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Kidney function on Truvada
Mar 31, 2012

Hello Dr. Young, I'm 45. My creatinine is 1.2, GFR around 70 and stable. Latest urinalysis showed 20mg/dl of protein and a recent 24hr urine showed 300mg protein in 24hours (10mg/dl). Creatinine hasn't changed since starting Truvada Nov 2010 for primary infection but proteinuria is new. I don't have diabetes or hypertension. Should kidney function continue to be monitored every 3 months or should I change to something else and what would you recommend? I want to stay on Isentress. Thank you for all you do for everyone.

Scott

Response from Dr. Young

Hello and thanks for comments and for posting your relevant questions.

It's good to know that you're following your kidney function well- by estimate of your glomerular filtration rate (GFR) and urine protein. A simple way to track your GFR (as you're likely doing) is using a MDRD calculator.

These issues are getting increasing attention because of several kidney health factors, including the widespread longterm use of tenofovir (which is associated with risk of kidney injury) and the increasing age of the HIV population.

First, while your GFR is stable, it's not entirely normal (this is common among 40 and older-somethings), it's actually stage 2 kidney function, with GFR between 60 and 89 ml/min.

Next, your level of urinary protein is of somewhat greater concern, but still not very serious. For example, nephrotic syndrome (when this is much more serious) is defined by having 3500 grams of urinary protein/day).

Management for this mild-moderate level of kidney disfunction involves several things. First is the assessment and optimalization of things related to the kidney- this would include making sure that you blood pressure is normal (or treated), management of diabetes, assessment of heart and bone disease, to name a few. Some might recommend getting a consultation with a nephrologist (kidney specialist) would be reasonable at this point. Since this was your first abnormal test, I'd consider repeating a test not too far off, just to get confirmation (3 months seems reasonable). Once established, it's not necessary to monitor the urine protein more than every 6-12 months, since changes tend to occur slowly.

With your level of urinary protein, many would consider the use of certain types of blood pressure medications, called ACE-inhibitors. These well-toleraed once-daily medications both lower blood pressure, but appear to mitigate against further kidney injury.

Last, if appropriate for your treatment and drug-resistance history, and particularly if your trend in urinary protein worsens, I'd be thinking about a switch from a tenofovir-based treatment to an alternative antiretroviral. If your HLA-B5701 test is negative, one reasonable switch (and still keeping with US treatment guideline alternative regimens) would be to substitute abacavir/3TC (Epzicom) for your current Truvada. Abacavir is not associated with kidney injury and a switch might help prevent any further injury and perhaps reverse existing problems.

I hope that's helpful. Be well, BY



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