Chronic Kidney Disease and Antiretroviral Therapy in HIV-Positive Individuals: Recent Developments
Chronic Kidney Disease and Antiretroviral Therapy in HIV-Positive Individuals: Recent Developments
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DOI：
10.1007/s11904-016-0315-y
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发表时间：
2016-06-01
影响因子：
4.6
通讯作者：
Wyatt, Christina M.
中科院分区：
文献类型：
--
作者：
Achhra, Amit C.;Nugent, Melinda;Wyatt, Christina M.
慢性肾脏病（CKD）已成为HIV阳性个体的一个重要健康问题。因此，预防抗逆转录病毒治疗的长期肾毒性至关重要。选定的抗逆转录病毒药物，特别是富马酸替诺福韦酯（TDF）和一些利托那韦增强的蛋白酶抑制剂（PI/rs），已与CKD的风险增加。然而，这些药物导致的CKD风险总体较小，尤其是在CKD基线风险较低且肾功能正常的患者中。通过及时识别肾功能恶化的患者和停用潜在的肾毒性药物，可以进一步降低HIV阳性患者的CKD风险。临床医生可以使用几种监测工具，包括D：A：D风险评分和估计肾小球滤过率（eGFR）和蛋白尿的常规测量，以确定可能需要干预的高风险个体。替诺福韦艾拉酚胺（TAF）是TDF的替代品，在TDF相关的肾脏和骨毒性方面更安全。虽然TAF的短期数据确实表明eGFR下降较低，蛋白尿风险较低（与TDF相比），但仍在等待TAF肾脏安全性的长期数据。最近关于替代性双重治疗抗逆转录病毒方案的试验也出现了有希望的结果，该方案排除了核苷（tide）逆转录酶类以及可能的PI/rs，从而降低了药物负担，并可能降低了毒性。然而，这些双重治疗方案的长期安全性或益处仍不清楚，需要在未来的前瞻性研究中进行研究。最后，解决高血压和糖尿病等风险因素在这一人群中仍然很重要。
Chronic kidney disease (CKD) has emerged as an important health concern in HIV-positive individuals. Preventing long-term kidney toxicity from an antiretroviral therapy is therefore critical. Selected antiretroviral agents, especially tenofovir disoproxil fumarate (TDF) and some ritonavir-boosted protease inhibitors (PI/rs), have been associated with increased risk of CKD. However, the CKD risk attributable to these agents is overall small, especially in those with low baseline risk of CKD and normal renal function. CKD risk in HIV-positive individuals can be further minimized by timely identification of those with worsening renal function and discontinuation of potentially nephrotoxic agents. Clinicians can use several monitoring tools, including the D:A:D risk score and routine measurements of estimated glomerular filtration (eGFR) and proteinuria, to identify high-risk individuals who may require an intervention. Tenofovir alafenamide (TAF), a TDF alternative, promises to be safer in terms of TDF-associated kidney and bone toxicity. While the short-term data on TAF does indicate lower eGFR decline and lower risk of proteinuria (vs. TDF), long-term data on renal safety of TAF are still awaited. Promising results have also emerged from recent trials on alternative dual-therapy antiretroviral regimens which exclude the nucleoside(tide) reverse transcriptase class as well as possibly the PI/rs, thereby reducing the drug burden, and possibly the toxicity. However, long-term safety or benefits of these dual-therapy regimens are still unclear and will need to be studied in future prospective studies. Finally, addressing risk factors such as hypertension and diabetes will continue to be important in this population.