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Kidney Disease in HIV: An Update for Ryan White Providers

Kidney Disease in HIV: An Update for Ryan White Providers. Christina M. Wyatt, MD Assistant Professor Mount Sinai School of Medicine New York, New York. FORMATTED: 11/16/2015. New Orleans, Louisiana: December 15-17, 2015. Caveats for Diagnosis in HIV.

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Kidney Disease in HIV: An Update for Ryan White Providers

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  1. Kidney Disease in HIV:An Update for Ryan White Providers Christina M. Wyatt, MD Assistant Professor Mount Sinai School of Medicine New York, New York FORMATTED: 11/16/2015 New Orleans, Louisiana: December 15-17, 2015

  2. Caveats for Diagnosis in HIV • GFR estimates are not well validated • CKD-EPI appears to be the best • Cystatin C should not be used alone • Several antiretrovirals& co-meds interfere with creatininesecretion • Don’t forget about creatine Inker et al JAIDS 2012 Gagneux-BrunonAIDS 2013 Bhasinet al PLoS ONE 2013

  3. Acute Kidney Injury in HIV • More common in HIV-infected individuals • Associated with adverse outcomes • Detailed data on etiology are outdated • Sepsis remains a risk factor for severe AKI • Other associated factors reflect aging of the HIV population: DM, HTN, CKD, liver disease Nadkarni et al, JAIDS 2015

  4. HIV-Associated Disease • May present with either AKI or CKD • HIV-associated nephropathy (HIVAN) • Immune complex kidney disease (HIVICK) • Thrombotic microangiopathy (rare)

  5. HIVAN: Classic Presentation • Rapid progression to ESRD • Advanced HIV disease • First-line treatment is ART • Almost exclusively in blacks • Strong linkage to SNPs in APOL1 Raoet al. NEJM 1984 Pardoet al. Annals 1984 Genovese et al. Science 2010

  6. HIVICK • Immune complex disease (without HCV/ HBV) • Causal relationship to HIV is less clear • Most data for IgA nephropathy • Role of ART is less clear • More indolent course than HIVAN Gerntholtzet al. KI 2006 Kimmel et al. NEJM 1992 Foy et al. CJASN 2013

  7. Changing Spectrum of CKD • Decline in biopsies with classic HIVAN • Recognition of other HIV-related diseases • More comorbid kidney disease • Potential for treatment toxicity Berliner et al. Am J Nephrol2008

  8. Comorbid CKD in HIV • CKD risk factors are overrepresented • Black race • Diabetes/ hypertension • Hepatitis C virus (HCV) • Difficult to distinguish contribution of HIV from that of comorbid risk factors

  9. Tenofovir in 2016 • Combination with drugs that inhibit tubular creatinine secretion • Combination with new anti-HCV drugs • Ledipasvir/ sofosbuvirtenofovir levels in patients with or without concomitant PI/r • Use for pre-exposure prophylaxis • Tenofoviralafenamide (TAF)

  10. TenofovirAlafenamideFumarate • Switch studies show improvement in proteinuria and tubular biomarkers with TDFTAF • Limited data on hard clinical outcomes • Approved as E/C/F/TAF on November 5 • Approved for CrCl > 30 mL/min

  11. HIV & ESRD in 2016 • Candidates for hemodialysis, peritoneal dialysis, and transplant • Early planning to avoid HD catheter use • Upcoming study will evaluate the use of HIV+ donor kidneys in HIV+ recipients Stock et al, NEJM 2010 Muller et al, NEJM 2015

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