Managing HIV/AIDS Therapy in Special Populations What are the special treatment needs for patients with renal insufficiency?
	Enlarged Version of Graphics Below	Dr. Bellos (OC): Actually, in this practice, we have treated a fair number of patients who were actually on dialysis. What has occurred is that these patients were candidates for transplant, and in the process of their transplant workup many years ago, were found to be HIV-positive, and were subsequently removed from the transplant list, placed on dialysis, and sent to me for treatment. Dr. Bellos (VO): I think the most important thing about those patients, especially now that we have the protease inhibitors, is that we need to realize is that we really don't need to dose-reduce protease inhibitors. The majority of them are hepatically metabolized, so they're not affected by dialysis or renal insufficiency, and those patients can be dosed normally.   See Slide Dr. Bellos (OC): I think the issue then becomes one of: What do we do with the nucleosides? And then, the IDSA recently published guidelines that specifically deal with the management of chronic renal failure in patients with HIV infection, and in that article, they actually list the dose reductions that are needed for the nucleoside analogues, and I would refer people to that article for specific doses. Dr. Bellos (VO): The important thing to remember about patients with renal insufficiency is that, A: Dose reduction does need to occur for the nucleosides; B: It does not need to occur for the protease inhibitors, that one can continue protease inhibitors on their standard dosing regimen, and I think that again, as mentioned in the IDSA guidelines, patients with HIV may have a higher propensity for the development of renal disease, because of their immunologic status, and that patients should probably be checked on a yearly basis, whether they have hypertension, diabetes, or other risk factors for renal insufficiency, and should at least have a dipstick urinalysis, to see if there's any protein in the urine. If there's any protein in the urine, then the creatinine clearance should probably be calculated, and if it is abnormal, then further evaluation of their renal function probably does need to occur.   See Slide Dr. Bellos (OC): The other thing is that as our patients are living longer and developing some of the greater complications associated with middle age, such as diabetes and hypertension, those patients are again increasing the risk for renal insufficiency, and those patients need to be monitored a little more closely as well, for developing signs of early renal insufficiency, such as proteinuria. Dr. Wohlfeiler (OC): So I think that the renal issues are really going to grow in importance. I think that we are probably underdiagnosing the degree of renal toxicity that is out there, probably at baseline, and then probably underdiagnosing the degree of renal impairment that's developing over time while on certain antiretroviral therapies. So I think that you're going to see renal issues becoming more and more important and more and more at the forefront of treatment concerns. Dr. Kwakwa (OC): That is why I am pleased to see the IDSA come out with these guidelines. I think that they raise the awareness, and sort of put the onus on us to do more than check a serum creatinine, and make decisions based on a serum creatinine, which, while it's not wrong, is grossly inadequate to measure the actual renal function, and so it is important with all of patients, really, to have an idea of what the GFR, or glomerular filtration rate, is, beyond just a serum creatinine, and that can be calculated; it can be measured, and it also goes beyond that to look at the different medications, and the potential impact on the kidneys as we use them, and cautions us in using some of these medications such as tenofovir in people with borderline renal function, particularly in those with higher risk for chronic kidney disease. Dr. Kwakwa (VO): Well, monitoring the medications that we give them, monitoring their renal function very carefully, regardless of the medications that they are on, but particularly if they are on a medication such as tenofovir or Truvada, and also monitoring the medications that they are on outside of their antiretroviral therapy. I can't begin to tell you how many patients I have on nonsteroidal anti-inflammatory drugs in an effort to keep off of narcotic medications, who may then be at increased risk of kidney disease because of that. It is also very important to keep such parameters as blood pressure, serum glucose in diabetics or prediabetics, under very good control, and in the setting of treating HIV, it is very easy to relegate that to a position of lower priority, but it is incredibly important.   See Slide
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