Monitoring of Kidney Function in HIV-Positive Patients
Urine ACR, preferably in a first morning void, is used to estimate urine albumin excretion and is categorized as < 30, 30–300 and > 300 mg/g (or < 3, 3–30 and > 30 mg/mmol; normal to mildly increased, moderately increased, and severely increased, respectively). Albuminuria reflects glomerular pathology, and, while the PCR may provide an indication of glomerular protein leak, the median urine ACR to PCR ratio (APR) in HIV-positive patients with low-level proteinuria tends to be low (9.9% in a recent study); PCR is thus a relatively nonspecific marker of glomerular disease, especially in patients with mild proteinuria. In one study, the incidence of proteinuria (positive dipstick analysis on two consecutive specimens) was 82 per 1000 person-years for patients not receiving tenofovir, and 132 per 1000 person-years for those on tenofovir. The incidence of albuminuria in HIV-positive patients has not been reported; prevalence studies suggest that 11–20% of patients have albuminuria – mostly < 300 mg/24 h. Factors associated with albuminuria include reduced eGFR, older age, diabetes, hypertension, cardiovascular disease, hepatitis C virus coinfection, low CD4 cell count and high HIV RNA level. Albuminuria (or proteinuria) is an independent risk factor for kidney disease progression and cardiovascular events.
Albuminuria is highly prevalent in HIV-positive patients and identifies a population at increased risk of death, cardiovascular morbidity and kidney disease progression. Benefit of albuminuria reduction has not been established in HIV-positive patients. Nonetheless, cardiovascular and renal risk factors should be optimized. In patients with severe albuminuria or proteinuria (ACR > 300 and PCR > 500 mg/g, respectively), referral to a nephrologist may be indicated to establish the kidney disease aetiology. Hypertension should be managed with a renin-angiotensin-system inhibitor (i.e. an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker) as per KDIGO guidance for the general population. Simultaneous assessment of ACR and PCR may be useful in distinguishing between glomerular and tubular pathology; a low APR is suggestive of tubulopathy. Although the optimal frequency of albuminuria monitoring is unknown, annual assessment should suffice in the majority of patients stable on cART with ACR < 300 or PCR < 500 mg/g.
Albuminuria
Urine ACR, preferably in a first morning void, is used to estimate urine albumin excretion and is categorized as < 30, 30–300 and > 300 mg/g (or < 3, 3–30 and > 30 mg/mmol; normal to mildly increased, moderately increased, and severely increased, respectively). Albuminuria reflects glomerular pathology, and, while the PCR may provide an indication of glomerular protein leak, the median urine ACR to PCR ratio (APR) in HIV-positive patients with low-level proteinuria tends to be low (9.9% in a recent study); PCR is thus a relatively nonspecific marker of glomerular disease, especially in patients with mild proteinuria. In one study, the incidence of proteinuria (positive dipstick analysis on two consecutive specimens) was 82 per 1000 person-years for patients not receiving tenofovir, and 132 per 1000 person-years for those on tenofovir. The incidence of albuminuria in HIV-positive patients has not been reported; prevalence studies suggest that 11–20% of patients have albuminuria – mostly < 300 mg/24 h. Factors associated with albuminuria include reduced eGFR, older age, diabetes, hypertension, cardiovascular disease, hepatitis C virus coinfection, low CD4 cell count and high HIV RNA level. Albuminuria (or proteinuria) is an independent risk factor for kidney disease progression and cardiovascular events.
Albuminuria is highly prevalent in HIV-positive patients and identifies a population at increased risk of death, cardiovascular morbidity and kidney disease progression. Benefit of albuminuria reduction has not been established in HIV-positive patients. Nonetheless, cardiovascular and renal risk factors should be optimized. In patients with severe albuminuria or proteinuria (ACR > 300 and PCR > 500 mg/g, respectively), referral to a nephrologist may be indicated to establish the kidney disease aetiology. Hypertension should be managed with a renin-angiotensin-system inhibitor (i.e. an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker) as per KDIGO guidance for the general population. Simultaneous assessment of ACR and PCR may be useful in distinguishing between glomerular and tubular pathology; a low APR is suggestive of tubulopathy. Although the optimal frequency of albuminuria monitoring is unknown, annual assessment should suffice in the majority of patients stable on cART with ACR < 300 or PCR < 500 mg/g.
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