Table 3.

Clinical Recommendations in the Setting of Kidney Impairment

Condition	Recommendation
Proteinuria with preserved eGFR (>60 mL/min)	- Rule out glomerulonephritis, especially in the presence of high-grade proteinuria (>1 g/24 h) or concomitant hematuria. - Collect 24-hour urine to determine proximal tubular dysfunction - Consider with a nephrologist the indication of a renal biopsy. - Consider angiotensin-converting enzyme inhibitors to decrease proteinuria.
Progressive tubular dysfunction	- Evaluate and treat risk factors - Discontinue tenofovir with long-term follow-up (recovery often slow and incomplete).
Progressive eGFR decline	- Evaluate and treat risk factors. - Investigate the use of nephrotoxic agents. - Collect 24-hour urine to determine proximal tubular dysfunction. - Consider tenofovir discontinuation.
Chronic kidney disease with eGFR <60 mL/min	- Consider TDF discontinuation (especially if coadministered with boosted PI). - Adjust NRTI dose (required for all with the exception of abacavir) or maraviroc. No dose adjustment is necessary for NNRTI, PI, or integrase inhibitors).
End-stage kidney disease (eGFR <10 mL/min or dialysis)	- Similar management to that of HIV-uninfected individuals, with special consideration to avoidance of nephrotoxic agents, including TDF.
Kidney transplant	- Similar indications than in the general population in ART-treated patients without overt immunosuppression (ie, CD4+ T cells <200/mm3 or AIDS). - Similar survival rates after transplantation, although some have suggested higher incidence of acute rejection [93, 94]. - Consider switching ART to raltegravir, dolutegravir, and maraviroc-based regimens might be optimal ART choices given the narrow therapeutic index and interactions of most immunosuppressive agents and the need for dose adjustments

Abbreviations: AIDS, acquired immune deficiency syndrome; ART, antiretroviral therapy; eGFR, estimated glomerular filtration rate; HIV, human immunodeficiency virus; NNRTI, nonnucleoside reverse-transcriptase inhibitor; NRTI, nucleoside reverse-transcriptase inhibitors; PI, protease inhibitor; TDF, tenofovir disoproxil fumarate.