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 creatinine secretion
Don’t forget about creatine
Inker et al JAIDS 2012
Gagneux-Brunon AIDS 2013
Bhasin et 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Detailed data on etiology are outdated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
Data from
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
Rao et al. NEJM 1984
Pardo et 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
Gerntholtz et 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 Nephrol 2008

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
Tenofovir alafenamide (TAF)

10. Tenofovir Alafenamide Fumarate
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