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The progression of kidney disease in patients with HIV.

Q: What are the chronic kidney disease considerations in caring for patients with human immunodeficiency virus (HIV)?

A: Human immunodeficiency virus (HIV) has be come a chronic illness, with episodes of exacerbation and recovery similar to heart failure, chronic obstructive pulmonary disease, and dementia. However, since the introduction of highly active antiretroviral therapy (HAART), the prevalence of renal disease, and acute or chronic renal failure that are often not directly related to underlying HIV disease, has increased over the past two decades (Kalim, Szczech, & Wyatt, 2008).

Renal disease is a common and significant complication in patients infected with HIV, and it accounts for significant morbidity and mortality in these patients (Bickel et al., 2013). Renal disease in patients with HIV can be caused by the harmful effects of HIV on the nephrons in the kidneys, infection, the medications used to treat HIV, diabetes, hypertension, recreational drug use, and hepatitis C--all causing a decline in kidney function. In addition, about 25% of people living with HIV in the United States are co-infected with hepatitis C virus (HCV), an inflammation of the liver that causes chronic infection. HCV is associated with several types of kidney disease (U.S. Department of Health & Human Services [DHHS],

2013). According to Bickel and colleagues (2013), renal disease of any stage is a common complication in patients infected with HIV, affecting up to 30% of patients, and is associated with increased morbidity and mortality.

In a 2012 study, renal involvement in patients who were HIV-positive was more common in males. In addition, those with increased age, minority ethnicity (especially African Americans), and patients with a CD4 count less than 350 and a high viral load had a higher rate of ESRD (Vali, Ismal, Gowrishankar, & Sahay, 2012). Research by Franceschini, Napravnik, Eron, Szczech, and Finn (2005) illustrated that acute kidney injury (AKI) is frequent in patients with HIV who are ambulatory, even in the HAART era, with an incidence of 5.9 cases per 100 patient-years.

Updated Therapies

Therapy for patients with chronic kidney disease (CKD) in the context of HIV infection focuses on reducing viral replication and control of traditional risk factors for kidney disease progression, including hypertension, hyperglycemia, and hyperlipidemia (Cohen, Kopp, Cathro, & Kimmel, 2014). HIV-associated nephropathy (HIVAN) is an important cause of end stage renal disease (ESRD) in this population. Although HIVAN may be prevented and treated with HAART, kidney disease remains an important issue in this population. Multiple drugs are used together with HAART in regimens called "cocktails" (Ignativicius & Workman, 2013). These regimens consist of combinations of different types of antiretroviral agents. Overall, HAART is showing good results as measured by reduced viral load and improved CD4+ T-cell counts.

Several factors contribute to the development of drug resistance to HAART, with the most important being missed doses of drugs. When doses are missed, the blood drug concentrations become lower, and the organism can replicate and produce new organisms that are resistant to the drugs being used. It is critical to ensure that HAART drugs are not missed, delayed, or administered in lower-than-prescribed doses in the inpatient setting. Although compliance is an issue, patients must be taught the importance of taking their drugs exactly as prescribed to maintain the effectiveness of HAART drugs. However, the patients must be made aware that some drugs can damage the kidneys and have adverse effects--lipodystrophy, hyperlipidemia, heart disease, and diabetes (Ignativicius & Workman, 2013). Therefore, it is important that patients work with their physician/healthcare provider to monitor their HIV treatment.

Assessment, Diagnostics, and Clinical Manifestations of Kidney Disease

CKD, which is progressive and irreversible, is of increasing importance in the HAART era. In order to identify the disease early, it is recommended that risk-factor assessment, screening for existing kidney disease, and early referral begin at the time of HIV diagnosis to improve short-term outcomes.

When taking a history from a patient with suspected CKD, the focus is on its manifestations. The patient's weight and height need to be accurately measured, and usual weight and recent weight gain or loss need to be determined. Weight gain may indicate fluid retention caused by poorly functioning kidneys. The nurse should obtain a complete history of known renal or urologic disorders, long-term health problems (e.g., hypertension and/or diabetes), drug use, and current health problems, as well as history of kidney infection or stones (Ignativicius & Workman, 2013).

The patient needs to have creatinine, blood urea nitrogen (BUN), glomerular filtration rate (GFR), sodium, potassium, calcium, phosphate, bicarbonate, hemoglobin, and hematocrit, as well as urinalysis, values determined to assess trends. In the early stages of CKD, urinalysis may show excessive protein, glucose, red blood cells (RBCs), and white blood cells (WBCs), as well as decreased or fixed specific gravity. If CKD progresses suddenly, a kidney ultrasound or computed tomography (CT) scan without contrast medium may be used to rule out an obstruction (Ignativicius & Workman, 2013).

The nurse should document the use of current and past prescription, and over-the-counter drugs because many drugs have the potential to be nephrotoxic. Examine the patient's dietary habits, and ask about the patient's energy level and his or her daily routine as a possible indicator of fatigue. Lastly, discuss urine elimination in detail, including frequency of urination, appearance of the urine, and any difficulty starting or controlling urination (Ignativicius & Workman, 2013).

Challenges in Providing Care

Kidney function is abnormal in up to 30% of HIV-infected patients (Ryom et al., 2014). The most common complication is HIVAN, a disease characterized by massive nephrotic proteinuria (often more than 10 grams/day), absence of edema, and large echogenic kidneys seen on ultrasound. If left untreated, HIVAN can progress to renal failure in 1 to 2 years. HIVAN is almost always seen in patients with advanced immunosuppression (a CD4 cell count under 100) (Ryom et al., 2014). The loss of kidney function affects many body systems, such as the cardiovascular, respiratory, gastrointestinal, skeletal, urinary, hematologic, neurologic, and integumentary, and reproductive systems.

It is important that patients with CKD be referred early to a nephrologist for the management of complications and for the transition to renal replacement therapy (hemodialysis, peritoneal dialysis, renal transplantation). According to Salifu, Ifudu, Batuman, Aronoff, and Talavera (2015), disease progression can be slowed by various maneuvers, including aggressive control of diabetes, hypertension, and proteinuria, and dietary protein and phosphate restriction.

It is imperative that staff and patients be properly educated on the effects of HIV and renal disease. It is also important to teach the effects of protein, sodium, potassium, phosphorus in the diet, targeting ideal body weight, exercise, and progression of CKD. According to Kirton (2014), nurses should also monitor patients for abnormalities in glucose metabolism or hypertension, which are common risk factors for renal disease.

Discussion

CKD is of increasing importance in the HAART era. Its increasing prevalence can be largely attributed to non-HIV-related kidney disease (Gardner et al., 2003). In order to identify the disease early, it is recommended that risk-factor assessment and screening for existing kidney disease begin at the time of HIV diagnosis.

HIV medications can also cause renal dysfunction. Tenofovir, the most widely prescribed HAART medication and the preferred drug in treatment, can cause tubular injury that leads to renal tubular dysfunction and a decrease in the GFR (Cooper et al., 2010). Patients may, however, have concurrent illnesses that affect the kidneys (for example through dehydration), but it is hard to be certain that any one drug alone is responsible for renal disease. Some HAART medications may also precipitate nephrolithiasis. Many drugs administered as part of treatment or used to prevent opportunistic infections, (such as trimethoprim/sulfamethoxazole for pneumonia jiroveci prevention) are nephrotoxic (Cooper et al., 2010).

Implications for Nephrology Nursing Practice

The healthcare team providing care to these patients must assess the acuity of the disease and distinguish between HIV-related and non-HIV-related causes of CKD. In addition, the physician/health care provider must properly manage kidney disease in patients infected with HIV, including accurate and rapid identification and diagnosis. It is important that patients with CKD have early referral to a nephrologist for the management of complications and for the transition to possible renal replacement therapy. Some evidence suggests that early referral of patients with CKD improves short-term outcomes. Proper selection and dose-adjustment of antiretrovirals and other commonly used drugs for patients with kidney disease are important components of care for patients with HIV (Winston et al., 2008).

Current guidelines recommend starting HAART in all HIV-infected patients, regardless of CD4 cell count (DHHS, 2014). Nurses play a critical role when the decision is made to start a patient on HAART. Before patients are started on a new HAART regimen, the nursing assessment should include a comprehensive evaluation of patient readiness. Therapy with these medications is lifelong, and once started, generally continues without interruption. Nurses need to teach patients that these medications must be taken exactly as prescribed. Patients must be aware that all HAART medications have adverse effects, including lipodystrophy, hyperlipidemia, heart disease, diabetes, and changes in body image (DHHS, 2014).

The role of the nurse is to continue to provide care and educate patients with HIV who are at risk for CKD or have CKD. The primary goals are to manage the clinical manifestations; control exposure to nephrotoxic drugs, chemicals, and contrast dye; prevent prolonged episodes of hypotension and hypovolemia; and monitor input/output, and protein, sodium, and potassium intake.

Conclusion

The HIV population is at high risk for kidney disease. Screening for kidney disease is recommended in all patients with newly diagnosed HIV infection. The identification and definitive diagnosis of HIV-related and unrelated kidney disease is critical to patient management. Nurses and the interdisciplinary team must educate the patient and family about the medication regimen, dose adjustments for medications used in treatment of HIV, blood pressure and glucose control, dietary and fluid management, avoidance of nephrotoxins, and kidney replacement therapy.

Key Words: Immunodeficiency, HIV, kidney disease.

The Clinical Consult department is designed to provide answers to questions concerning clinical problems and to report innovative clinical practices. Readers are invited to submit questions to be answered by a guest consultant. Questions should provide background information and state specific information requested. Answers will be referenced. Manuscripts that address clinical problems or present innovative ideas are also invited. These should be between 400 and 600 words and contain one to three references. Address correspondence to: Charlotte Szromba, Clinical Consult Department Editor, through the ANNA National Office; East Holly Avenue/Box 56; Pitman NJ 08071-0056; (856) 256-2320. The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses' Association.

Jami Smith Brown, DHEd, RN, CNN, is an Assistant Professor, University of Tennessee Health Science Center, College of Nursing, Memphis, TN, and a member of ANNA's Memphis Blues Chapter. She may be contacted directly via email at Jsmit36l@uthsc.edu

References

Bickel, M., Marben, W., Betz, C., Khaykin, P., Gute, P., Habert, A., ... Jung, O. (2013). End-stage renal disease and dialysis in HIV-positive patients: Observations from a long-term cohort study with a follow-up of 22 years. HIV Medicine, 74(3), 127-135. doi: 10.1111/j.1468-1293.2012.01045.x

Cohen, S., Kopp, J., Cathro, H., & Kimmel, P. (2014) Human immunodeficiency vims infection and chronic kidney disease. In P.L. Kimmel & M.E. Rosenberg (Eds.), Chronic renal disease (pp. 534-543). San Diego, CA: Elsevier, Inc.

Cooper, R., Wiebe, N., Smith, N., Keiser, R, Naicker, S., & Tonelli, M. (2010). Systematic review and meta-analysis: Renal safety of tenofovir disoproxil fumarate in HIV-infected patients. Clinical Infectious Diseases, 51(5), 496-505. doi: 10.1086/655681

Franceschini, N., Napravnik, S., Eron, J., Szczech, L., & Finn, W. (2005). Incidence and etiology of acute renal failure among ambulatory HIV-infected patients. Kidney International, 57(4), 1526-1531. doi: 10.1111/j.1523-1755.2005.00232.x

Gardner, L., Klein, R., Szczech, L., Phelps, R., Tashima, K., Rompalo, A., ... Scott, D. (2003). Rates and risk factors for condition-specific hospitalizations in HIV-infected and uninfected women. Journal of Acquired Immune Deficiency Syndromes, 34, 320-330. doi: 10.1097/00126334-20031101000011

Ignativicius, D.D., & Workman, M.L. (2013). Medical surgical nursing: Patient centered collaborative care (7th ed.). St. Louis, MO: Elsevier Saunders.

Kalim, S., Szczech, L.A., & Wyatt, C.M. (2008). Acute kidney injury in HIV-infected patients. Seminars in Nephrology, 28(6), 556-562. doi: 10.1016/j.semnephrol.2008.08.008

Kirton, A. (2014). HIV infection and its implication for nurse leaders. Nursing Management, 45(16), 24-31. Retrieved from http://www.nursingcenter.com/lnc/CEArticle?an=000062 47-201410000-00008

Ryom, L., Mocroft, A., Kirk, O., Ross, M., Reiss, R, Fux, C., ... Lundgren, J. (2014). Predictors of advanced chronic kidney disease and end-stage renal disease in HIV-positive persons. AIDS, 28(2), 187-199. doi:10.1097/QAD.()000000000000042

Salifu, M., Ifudu, O., Batuman, V., Aronoff, G.R., & Talavera, F. (2015). Azotemia treatment and management. Medscape. Retrieved from http://emedicine.medscape.com/article/238545-treatment

U.S. Department of Health and Human Services (DHHS) .(2013). Staying healthy with HIV/AIDS: Potential related health problems: Kidney disease. Retrieved from https://www.aids. gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potentialrelated-health-problems/kidney-disease

U.S. Department of Health and Human Services (DHHS). (2014). Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Retrieved from http://aids info.nih.gov/contentfiles/lvguidelines/AdultandAdolescent GL.pdf

Vali, P., Ismal, K., Gowrishankar, S., & Sahay, M. (2012). Renal disease in human immunodeficiency virus--Not just HIV-associated nephropathy. Indian Journal of Nephrology, 22(2), 98-102. doi: 10.4103/0971-4065.97117

Winston, J., Deray, G., Hawkins, T., Szczech., Wyatt, C., & Young, B. (2008). Kidney disease in patients with HIV infection and AIDS. Clinical Infectious Diseases, 47, 1449-1457. doi: 10.1086/593099

Charlotte Szromba, Department Editor
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Title Annotation:Clinical Consult
Author:Brown, Jami Smith
Publication:Nephrology Nursing Journal
Date:May 1, 2015
Words:2270
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