Antiretroviral therapy, immune suppression and renal impairment in HIV-positive persons

The purpose of this article is to review recent literature on antiretroviral treatment (ART) and immune suppression as risk factors for renal impairment in HIV-positive persons, and to discuss pending research questions within this field.

Several individual antiretroviral agents (ARVs) including tenofovir and several protease inhibitors have, in diverse study settings, been associated with renal impairment. Traditional renal risk factors are common among those experiencing adverse renal impairment to ARVs, but do not fully explain why only some develop these effects. Discontinuation of nephrotoxic ARVs is common with declining renal function, but has unknown long-term consequences. Immune suppression is a strong independent risk factor for renal impairment, and ongoing investigations will clarify whether initiating ARVs with nephrotoxic properties at higher CD4 cell counts will have net beneficial effects on renal function.

With improvements in survival, multiple risk factors have emerged for renal impairment in HIV-positive persons. Although certain ARVs may cause moderate renal impairment, effects on more severe renal impairment remain unresolved. Regular renal function monitoring allow for switching away from nephrotoxic ARVs in case of decreasing function. If such actions prove beneficial higher prevalence of ARV-associated severe renal impairment may emerge in populations without access to regular monitoring.