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Optimizing antiretroviral regimens in chronic kidney disease

Hamzah, Lisaa; Jones, Rachaelb; Post, Frank A.c

Current Opinion in Infectious Diseases: February 2019 - Volume 32 - Issue 1 - p 1–7
doi: 10.1097/QCO.0000000000000509
HIV INFECTIONS AND AIDS: Edited by David Dockrell

Purpose of review To identify recent data that inform the management of individuals with HIV and chronic kidney disease.

Recent findings Several nonnucleoside reverse transcriptase, protease, and integrase strand transfer inhibitors inhibit tubular creatinine secretion resulting in stable reductions in creatinine clearance of 5–20 ml/min in the absence of other manifestations of kidney injury. Progressive renal tubular dysfunction is observed with tenofovir disoproxil fumarate in clinical trials, and more rapid decline in estimated glomerular filtration rate in cohort studies of tenofovir disoproxil fumarate and atazanavir, with stabilization, improvement or recovery of kidney function upon discontinuation. Results from clinical trials of tenofovir alafenamide (TAF) in individuals with chronic kidney disease suggest that TAF is well tolerated in those with mild to moderate renal impairment (creatinine clearance >30 ml/min) but results in very high tenofovir exposures in those on haemodialysis.

Summary Standard antiretroviral regimens remain appropriate for individuals with normal and/or stable, mildly impaired kidney function. In those with chronic kidney disease or progressive decline in estimated glomerular filtration rate, antiretrovirals with nephrotoxic potential should be avoided or discontinued. Although TAF provides a tenofovir formulation for individuals with impaired kidney function, TAF is best avoided in those with severe or end-stage kidney disease.

aGuy's and St Thomas’ Hospital NHS Foundation Trust

bChelsea and Westminster Hospital NHS Foundation Trust

cKing's College Hospital NHS Foundation Trust, London, UK

Correspondence to Professor Frank A. Post, MMed, FCP(SA), PhD, FRCP, King's College Hospital NHS Foundation Trust, Weston Education Centre (rm 2.53), Cutcombe Road, London SE5 9RJ, UK. Tel: +44 207 848 5779; fax: +44 207 848 5769; e-mail: frank.post@kcl.ac.uk

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