1. Algorithm Dr. Patrice Junod Clinique médicale l’Actuel This activity is supported by an educational grant from:

2. 1- Algorithm Nephropathy Advisory Committee on the clinical management of people living with HIV 2- HIV and Renal Health – Management tool National Development Committee – Supported by Janssen Algorithm

3. − Nephropathy − Advisory Committee on the Clinical Management of Persons Living with HIV PERIODIC HEALTH EXAMINATION OF ADULTS LIVING WITH HIV (HUMAN IMMUNODEFICIENCY VIRUS)

4. Screening schedule based on risk factors for kidney disease (EACS 2011) Untreated HIV+ patients Treated HIV+ patients Without TDFWith TDF Assessment of risk factors for CKD* Annual 6–12 months Urinalysis or urine dipstick Annual 6 months if GFR < 60 3-6 months eGFR6-12 months3-6 months PhosphorusAs needed Optional 3-6 months * Risk factors for CKD: Diabetes, hypertension, CVD, viral hepatitis, concomitant nephrotoxic drugs, family history of CKD, black African ethnicity Advisory Committee on the Clinical Management of Persons Living with HIV Screening for Kidney Problems

5. GFR using CKD-EPI or MDRD ACR and MAU Refer to proteinuria algorithm (next page) Refer to proteinuria algorithm (next page) Referral to nephrologist or internist < 60 cc/min* < 30 cc/min* CaPO4 Renal ultrasound > 60 and < 90 cc/min Increase in Cr > 20% for > 3 months** Increase in Cr > 20% for > 3 months** Repeat CKD-EPI or MDRD calculation Refer to algorithms (next pages) Refer to algorithms (next pages) GFR < 90 Glucose+ Protein+ HypoPO4 GFR > 90 Regular follow-up Regular follow-up Follow up every 3 months Follow up every 3 months * If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications ** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir

6. GFR using CKD-EPI or MDRD ACR and MAU Refer to proteinuria algorithm (next page) Refer to proteinuria algorithm (next page) Referral to nephrologist or internist < 60 cc/min* < 30 cc/min* CaPO4 Renal ultrasound > 60 and < 90 cc/min Increase in Cr > 20% for > 3 months** Increase in Cr > 20% for > 3 months** Repeat CKD-EPI or MDRD calculation Refer to algorithms (next pages) Refer to algorithms (next pages) GFR < 90 Glucose+ Protein+ HypoPO4 GFR > 90 Regular follow-up Regular follow-up Follow up every 3 months Follow up every 3 months * If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications ** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir

7. * If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications ** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir > 60 and < 90 cc/min Increase in Cr > 20% for > 3 months** Increase in Cr > 20% for > 3 months** Repeat CKD-EPI or MDRD calculation Refer to algorithms (next pages) Refer to algorithms (next pages) GFR < 90 Glucose+ Protein+ HypoPO4 GFR > 90 Regular follow-up Regular follow-up Follow up every 3 months Follow up every 3 months GFR using CKD-EPI or MDRD

8. ACR and MAU Refer to proteinuria algorithm (next page) Refer to proteinuria algorithm (next page) Referral to nephrologist or internist < 60 cc/min* < 30 cc/min* CaPO4 Renal ultrasound > 60 and < 90 cc/min Increase in Cr > 20% for > 3 months** Increase in Cr > 20% for > 3 months** Repeat CKD-EPI or MDRD calculation Refer to algorithms (next pages) Refer to algorithms (next pages) GFR < 90 Glucose+ Protein+ HypoPO4 GFR > 90 Regular follow-up Regular follow-up Follow up every 3 months Follow up every 3 months * If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications ** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir

9. GFR using CKD-EPI or MDRD ACR and MAU Refer to proteinuria algorithm (next page) Refer to proteinuria algorithm (next page) Referral to nephrologist or internist < 60 cc/min* < 30 cc/min* CaPO4 Renal ultrasound * If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications ** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir

10. Urinalysis or urine dipstick Glucose > 0 Glycosuri a DB + Glycosuri a DB + Glycosuri a DB – Glycosuri a DB – DB follow-up Fasting glucose + Rule out diabetes Fasting glucose + Rule out diabetes Repeat 1x Glycosuri a DB – Glycosuri a DB – Referral to nephrologist or internist ACR ≤ 0.05 g/mmol and MAU < 2.1 mg/mmol Normal - Renal ultrasound - Ascertain the risk factors - Referral to nephrologist or internist, or to urologist for isolated hematuria - Renal ultrasound - Ascertain the risk factors - Referral to nephrologist or internist, or to urologist for isolated hematuria Protein ≥ 1 + or 0.25 g/L Repeat at next appt. Protein < 1+ or 0.25 g/L Protein ≥ 1+ or 0.25 g/L Normal ACR and MAU ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF) ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF)

11. Urinalysis or urine dipstick Glucose > 0 Glycosuri a DB + Glycosuri a DB + Glycosuri a DB – Glycosuri a DB – DB follow-up Fasting glucose + Rule out diabetes Fasting glucose + Rule out diabetes Repeat 1x Glycosuri a DB – Glycosuri a DB – Referral to nephrologist or internist ACR ≤ 0.05 g/mmol and MAU < 2.1 mg/mmol Normal - Renal ultrasound - Ascertain the risk factors - Referral to nephrologist or internist, or to urologist for isolated hematuria - Renal ultrasound - Ascertain the risk factors - Referral to nephrologist or internist, or to urologist for isolated hematuria Protein ≥ 1 + or 0.25 g/L Repeat at next appt. Protein < 1+ or 0.25 g/L Protein ≥ 1+ or 0.25 g/L Normal ACR and MAU ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF) ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF)

12. Urinalysis or urine dipstick Glucose > 0 Glycosuri a DB + Glycosuri a DB + Glycosuri a DB – Glycosuri a DB – DB follow-up Fasting glucose + Rule out diabetes Fasting glucose + Rule out diabetes Repeat 1x Glycosuri a DB – Glycosuri a DB – Referral to nephrologist or internist

13. Urinalysis or urine dipstick Glucose > 0 Glycosuri a DB + Glycosuri a DB + Glycosuri a DB – Glycosuri a DB – DB follow-up Fasting glucose + Rule out diabetes Fasting glucose + Rule out diabetes Repeat 1x Glycosuri a DB – Glycosuri a DB – Referral to nephrologist or internist ACR ≤ 0.05 g/mmol and MAU < 2.1 mg/mmol Normal - Renal ultrasound - Ascertain the risk factors - Referral to nephrologist or internist, or to urologist for isolated hematuria - Renal ultrasound - Ascertain the risk factors - Referral to nephrologist or internist, or to urologist for isolated hematuria Protein ≥ 1 + or 0.25 g/L Repeat at next appt. Protein < 1+ or 0.25 g/L Protein ≥ 1+ or 0.25 g/L Normal ACR and MAU ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF) ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF)

14. Urinalysis or urine dipstick ACR ≤ 0.05 g/mmol and MAU < 2.1 mg/mmol Normal - Renal ultrasound - Ascertain the risk factors - Referral to nephrologist or internist, or to urologist for isolated hematuria - Renal ultrasound - Ascertain the risk factors - Referral to nephrologist or internist, or to urologist for isolated hematuria Protein ≥ 1 + or 0.25 g/L Repeat at next appt. Protein < 1+ or 0.25 g/L Protein ≥ 1+ or 0.25 g/L Normal ACR and MAU ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF) ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF)

15. Serum phosphorus < normal levels Repeat and if < normal levels PTH assay 25-OH Vit D Albumin- corrected Ca < 50: deficiency < 75: insufficiency < 50: deficiency < 75: insufficiency > 75 Vit D Rx Normal Abnorma l Normal Referral to nephrologist or internist Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist Abnorma l Normal Referral to nephrologist or internist 0.65 – normal level 0.32 – 0.65 mmol/L < 0.32 mmol/L Repeat in 3 months Repeat in 1 month Treat immediately Referral to nephrologist Treat immediately Referral to nephrologist

16. Serum phosphorus < normal levels Repeat and if < normal levels PTH assay 25-OH Vit D Albumin- corrected Ca < 50: deficiency < 75: insufficiency < 50: deficiency < 75: insufficiency > 75 Vit D Rx Normal Abnorma l Normal Referral to nephrologist or internist Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist Abnorma l Normal Referral to nephrologist or internist 0.65 – normal level 0.32 – 0.65 mmol/L < 0.32 mmol/L Repeat in 3 months Repeat in 1 month Treat immediately Referral to nephrologist Treat immediately Referral to nephrologist

17. Serum phosphorus < normal levels Repeat and if < normal levels Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist 0.65 – normal level 0.32 – 0.65 mmol/L < 0.32 mmol/L Repeat in 3 months Repeat in 1 month Treat immediately Referral to nephrologist Treat immediately Referral to nephrologist

18. Serum phosphorus < normal levels Repeat and if < normal levels PTH assay 25-OH Vit D Albumin- corrected Ca < 50: deficiency < 75: insufficiency < 50: deficiency < 75: insufficiency > 75 Vit D Rx Normal Abnorma l Normal Referral to nephrologist or internist Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist Abnorma l Normal Referral to nephrologist or internist 0.65 – normal level 0.32 – 0.65 mmol/L < 0.32 mmol/L Repeat in 3 months Repeat in 1 month Treat immediately Referral to nephrologist Treat immediately Referral to nephrologist

19. Serum phosphorus < normal levels Repeat and if < normal levels PTH assay 25-OH Vit D Albumin- corrected Ca < 50: deficiency < 75: insufficiency < 50: deficiency < 75: insufficiency > 75 Vit D Rx Normal Abnorma l Normal Referral to nephrologist or internist Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist Abnorma l Normal Referral to nephrologist or internist

20. Algorithm