Kidney Disease and HIV Infection

Kidney disease in HIV-infected persons manifests in a variety of ways, including acute kidney injury (AKI), HIV-associated kidney disease, comorbid chronic kidney disease (CKD), and treatment-related kidney toxicity. The burden of CKD and end-stage renal disease (ESRD) remains high in the HIVinfected population. There are several important caveats to consider when diagnosing and managing kidney disease in HIV-infected persons. Glomerular filtration rate (GFR) estimates are not well validated in this population. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, which incorporates serum creatinine level and demographic factors, appears to provide the most accurate estimates among HIV-infected persons who are stable on antiretroviral therapy. However, there are strengths and limitations for all currently used equations, and creatinine clearance by Cockcroft-Gault calculation remains the recommended kidney function estimate for drug dosing. Several antiretroviral and other medications (eg, dolutegravir, rilpivirine, trimethoprim, and the pharmacoenhancers cobicistat and ritonavir) can interfere with creatinine secretion without affecting true GFR. In addition, creatine supplements and diets high in animal protein can increase levels of serum creatinine, resulting in an inaccurate estimate of GFR. Cystatin C testing may be helpful in such situations but should be used with caution in patients with HIV infection. Although normal cystatin C test results can be reassuring, abnormal cystatin C test results could reflect a decrease in GFR or an increase in systemic inflammation.1-3