Red blood cells

The Infectious Diseases Society of America recently issued updated guidelines for the management of a common problem in people with HIV—chronic kidney disease (CKD). The document, “Clinical Practice Guideline for the Management of Chronic Kidney Disease in Patients Infected With HIV: 2014 Update by the HIV Medicine Association of the Infectious Diseases Society of America​,” covers a wide range of topics, much of it relevant to laboratorians.

Specifically, clinicians should order tests to monitor the patient’s estimated glomerular filtration rate (GFR) when he or she starts antiretroviral therapy (ART), or if that therapy is changed. Patients who are considered stable should have their eGFRs determined at least twice per year, and clinicians should look for trends over time. Some patients may require more frequent testing, especially if they have additional risk factors for kidney disease.

The guidelines also recommend checking for kidney damage using urinalysis or a quantitative measure of albuminuria/proteinuria when ART is started, or if the regimen is changed. This should also be done at least once per year in stable patients.

When evaluating patients who have new-onset or just-diagnosed CKD, testing should include “serum chemistry panel; complete urinalysis; quantitation of albuminuria (albumin-to-creatinine ratio from spot sample or total albumin from 24-hour collection); assessment of temporal trends in estimated GFR, blood pressure, and blood glucose control (in patients with diabetes); markers of proximal tubular dysfunction (particularly if treated with tenofovir); a renal sonogram; and review of prescription and over-the-counter medications for agents that may cause kidney injury or require dose modification for decreased kidney function,” according to the guidelines.

It’s also best to refer patients with HIV and kidney disease to a nephrologist for evaluation when “there is a clinically significant decline in GFR (.ie., GFR decline by >25% from baseline and to a level <60 mL/minute/1.73 m2) that fails to resolve after potential nephrotoxic drugs are removed, there is albuminuria in excess of 300 mg per day, hematuria is combined with either albuminuria/proteinuria or increasing blood pressure, or for advanced CKD management (GFR <30 mL/minute/1.73 m2) ,” the authors wrote.

Children and adolescents prescribed ART should be monitored for kidney disease using eGFR, whether or not there is reason to suspect renal problems, at the start of therapy, and if there is a change in therapy. At a minimum, they should be tested at least annually, with more frequent monitoring done in those with additional risk factors for kidney disease.