Chronic kidney disease in HIV — fellow's quick read

Personal study digest for a new ID fellow. Recommendations (with GRADE strength/quality, e.g. strong, moderate) are from the 2014 HIVMA/IDSA guideline. The “What’s changed since 2014” section is reviewer synthesis of newer evidence — much of it postdates the guideline and is separately cited. Not a substitute for the full guideline.

In one line

People with HIV get CKD at high rates (in African ancestry, HIV confers ESRD risk like diabetes). Screen eGFR + albuminuria, keep them on ART (it protects the kidney and is underused), watch tenofovir, and treat HIVAN with ART + an ACE inhibitor/ARB. The modern twists: TAF, the creatinine “pseudo-rise,” and HIV-to-HIV transplant.

◆How do I screen, and how often?

Kidney function — eGFR at least twice yearly, and at every ART initiation or change (strong, low). Use the same estimating equation each time to track trends.
Kidney damage — urinalysis or a quantitative albuminuria/proteinuria at baseline, at ART start/change, and at least annually (weak, low).
Monitor more often with added risk factors: diabetes, hypertension, Black race, HCV coinfection, low CD4, or a nephrotoxic regimen.

◆New kidney disease — the workup, and when to call nephrology

Evaluate with a serum chemistry panel, complete urinalysis, quantified albuminuria (spot ACR or 24-h), temporal trends in eGFR/BP/glucose, proximal tubular markers if on tenofovir (glucosuria with normal glucose, phosphaturia), a renal sonogram, and a med review for nephrotoxins/dose adjustments (strong, low).
Refer to nephrology when: eGFR falls >25% from baseline AND to <60 and doesn’t recover after stopping nephrotoxins; albuminuria >300 mg/day; hematuria + albuminuria/proteinuria or rising BP; or eGFR <30 (strong, low).
Protect future access early: establish an AV fistula or PD catheter before dialysis; avoid PICCs and subclavian lines in anyone who may need hemodialysis (strong, moderate) — they scar veins and burn access options.

◆ART and drug dosing in CKD — HIVMA/IDSA 2014

Core message: keep patients on ART — it lowers mortality and is underused in CKD/ESRD (strong, moderate). Don’t let a low eGFR become a reason to stop HIV treatment.

Dose ART by kidney function using the CKD-EPI equation or Cockcroft–Gault (strong, moderate).
HIVAN → ART to cut progression to ESRD (strong, moderate); the biopsy lesion is collapsing FSGS, classically with low CD4.
Tenofovir (TDF): avoid at eGFR <60 along with other nephrotoxins (e.g. NSAIDs) when feasible (strong, low). If a TDF-treated patient has a confirmed GFR drop >25% and to <60 — especially with proximal tubular dysfunction — substitute off tenofovir (strong, low).

◆Slowing progression & cutting cardiovascular risk

Intervention	Who	Strength
ACE inhibitor / ARB	Confirmed or suspected HIVAN, or clinically significant albuminuria (>30 mg/d diabetic; >300 mg/d non-diabetic)	strong, high
Statin	Pre-ESRD CKD in the highest CVD-risk group (e.g. >7.5% 10-yr risk)	strong, high
Aspirin 75–100 mg	Consider for CVD prevention — weigh against bleeding risk	weak, high
BP <140/90	CKD with normal-to-mild albuminuria (<30 mg/d)	strong, moderate
BP <130/80	CKD with moderate-to-severe albuminuria (>30–300 mg/d)	weak, low

◆HIVAN steroids & transplant

Corticosteroids: may be considered as an adjunct to ART + ACEi/ARB in biopsy-confirmed HIVAN (weak, low) — not routine, and not for children with HIVAN.
Kidney transplant: assess every patient with ESRD or imminent ESRD for candidacy (strong, moderate). After transplant, dose-adjust and monitor immunosuppressants for interactions with ART (e.g. cobicistat/ritonavir boosting raises calcineurin-inhibitor levels), and pick ART that minimizes those interactions (strong, moderate).
Peds: avoid TDF first-line in prepubertal children (Tanner 1–3) — tubular and bone toxicity (weak, low).

What's changed since 2014

Reviewer synthesis of newer evidence — NOT the 2014 guideline. Each claim cited. The 2014 HIVMA/IDSA guideline has not been formally updated.

TAF replaced TDF as the tenofovir of choice for kidneys. Tenofovir alafenamide (approved 2015–16) delivers ~90% lower plasma tenofovir → much less proximal tubulopathy, proteinuria, and bone loss, and is generally usable down to eGFR ≥30. The guideline’s “avoid/stop tenofovir if GFR <60” advice was written for TDF — today you switch TDF→TAF (or a TDF-sparing regimen) rather than reflexively drop tenofovir. Reviewer synthesis; TAF renal-safety literature
The creatinine “pseudo-rise” from modern ART. Cobicistat, dolutegravir, rilpivirine, bictegravir (and TMP-SMX) inhibit tubular creatinine secretion (OCT2/MATE1) → serum creatinine rises ~0.1–0.2 mg/dL and eGFR dips in the first weeks without a true GFR change. Don’t mistake it for nephrotoxicity or stop the drug; it plateaus and reverses on discontinuation. J Antimicrob Chemother 2021;76:1046
INSTI-based regimens are now first-line (DHHS) — bictegravir/TAF/FTC and dolutegravir-based regimens, plus TDF-sparing 2-drug (DTG/3TC) and long-acting CAB/RPV options — which reshapes how you build a kidney-sparing regimen. DHHS ART guidelines
HIV-to-HIV kidney transplant is now evidence-based. Under the HOPE Act, transplanting kidneys from donors with HIV into recipients with HIV was noninferior to HIV-negative donors (adjusted HR 1.00, 95% CI 0.73–1.38; 1-yr survival 94% vs 95%) — expanding the donor pool. The 2014 guideline predates it. Durand/Massie, N Engl J Med 2024;391:1390–1401; PMID 39413376
Race-free eGFR. The 2021 CKD-EPI creatinine equation (NKF/ASN Task Force) dropped the Black-race coefficient and is now the US standard — it shifts CKD staging and ART-dosing thresholds vs the race-based equation the guideline assumed. NKF/ASN 2021
SGLT2 inhibitors — a new pillar of proteinuric CKD. KDIGO 2024 recommends an SGLT2 inhibitor for CKD with eGFR ≥20 and ACR ≥200 mg/g (or heart failure), regardless of diabetes — a nephroprotective class layered onto RAAS blockade that didn’t exist in the 2014 ACEi/ARB-only paradigm. KDIGO 2024 CKD guideline
Statin evidence strengthened — REPRIEVE. Pitavastatin cut major adverse cardiovascular events 35% (HR 0.65, 95% CI 0.48–0.90) in low-to-moderate-risk people with HIV, lowering the threshold to treat. Grinspoon, N Engl J Med 2023;389:687–699; PMID 37486775
Still current from 2014: screen eGFR + albuminuria at ART start/change and periodically; dose ART by CKD-EPI/Cockcroft–Gault; treat HIVAN with ART + ACEi/ARB; the nephrology-referral triggers; protect veins (no PICC/subclavian) and build an AVF before dialysis; assess ESRD patients for transplant.

◆Anki cards minted this run

3 cards added to Bugs and Drugs Clinicals after a live findNotes dedup. Tags: Guideline::HIVMA_IDSA::CKD_HIV + Subject::Infectious_Disease.

HOPE Act — HIV-positive → HIV-positive kidney transplant is noninferior to HIV-negative donors (NEJM 2024).
HIV-CKD monitoring cadence — eGFR ≥ twice yearly, urinalysis/albuminuria ≥ annually, and both at every ART start/change.
TDF → TAF in CKD — avoid TDF at eGFR <60; TAF is far less nephrotoxic and usable to eGFR ≥30.

Not carded — already in the deck: the ART creatinine pseudo-rise (OCT2/MATE), TAF “less renal/bone toxicity,” tenofovir → Fanconi, HIVAN → ART + ACEi/ARB, and APOL1 → collapsing FSGS.

Sources: Lucas GM, Ross MJ, Stock PG, et al. Clinical Practice Guideline for the Management of Chronic Kidney Disease in Patients Infected With HIV: 2014 Update by the HIV Medicine Association of the IDSA. Clin Infect Dis 2014;59(9):e96–e138. doi:10.1093/cid/ciu617. — Currency: Durand CM, Massie AB, et al. Safety of Kidney Transplantation from Donors with HIV. N Engl J Med 2024;391:1390–1401 (PMID 39413376; doi:10.1056/NEJMoa2403733). Grinspoon SK, et al. Pitavastatin to Prevent Cardiovascular Disease in HIV (REPRIEVE). N Engl J Med 2023;389:687–699 (PMID 37486775; doi:10.1056/NEJMoa2304146). KDIGO 2024 CKD Guideline. Kidney Int 2024;105(4S):S117–S314. NKF/ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease, 2021. Creatinine-secretion inhibition: J Antimicrob Chemother 2021;76:1046.