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Algorithm
Dr. Patrice JunodClinique médicale l’Actuel
This activity is supported byan educational grant from:
1- Algorithm Nephropathy
Advisory Committee on the clinical management of people living with HIV
2- HIV and Renal Health – Management tool
National Development Committee – Supported by Janssen
Algorithm
− Nephropathy −
Advisory Committee on the Clinical Management of Persons Living with HIV
PERIODIC HEALTH EXAMINATION OF ADULTS LIVING WITH HIV (HUMAN
IMMUNODEFICIENCY VIRUS)
Screening schedule based on risk factors for kidney disease (EACS 2011)
Untreated HIV+ patients
Treated HIV+ patients
Without TDF With TDF
Assessment of risk factors for CKD* Annual Annual 6–12 months
Urinalysis or urine dipstick Annual
Annual6 months if GFR < 60
3-6 months
eGFR 6-12 months 3-6 months 3-6 months
Phosphorus As needed As needed Optional3-6 months
* Risk factors for CKD:Diabetes, hypertension, CVD, viral hepatitis, concomitant nephrotoxic drugs, family history of CKD, black African ethnicity
Advisory Committee on the Clinical Management of Persons Living with HIV
Screening for Kidney Problems
GFR using CKD-EPI or MDRD
ACR and MAU
Refer to proteinuria algorithm
(next page)
Referral to nephrologist or internist
< 60 cc/min* < 30 cc/min*
CaPO4 Renal
ultrasound
> 60 and < 90 cc/min
Increase in Cr > 20%
for > 3 months**
Repeat CKD-EPI or
MDRD calculation
Refer to algorithms (next pages)
GFR < 90
Glucose+Protein+HypoPO4
GFR > 90
Regular follow-up
Follow up every
3 months
* If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications
** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir
GFR using CKD-EPI or MDRD
ACR and MAU
Refer to proteinuria algorithm
(next page)
Referral to nephrologist or internist
< 60 cc/min* < 30 cc/min*
CaPO4 Renal
ultrasound
> 60 and < 90 cc/min
Increase in Cr > 20%
for > 3 months**
Repeat CKD-EPI or
MDRD calculation
Refer to algorithms (next pages)
GFR < 90
Glucose+Protein+HypoPO4
GFR > 90
Regular follow-up
Follow up every
3 months
* If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications
** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir
* If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications
** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir
> 60 and < 90 cc/min
Increase in Cr > 20%for > 3
months**
Repeat CKD-EPI or MDRD
calculation
Refer to algorithms (next pages)
GFR < 90
Glucose+Protein+HypoPO4
GFR > 90
Regular follow-up
Follow up every
3 months
GFR using CKD-EPI or MDRD
GFR using CKD-EPI or MDRD
ACR and MAU
Refer to proteinuria algorithm
(next page)
Referral to nephrologist or internist
< 60 cc/min* < 30 cc/min*
CaPO4 Renal
ultrasound
> 60 and < 90 cc/min
Increase in Cr > 20%
for > 3 months**
Repeat CKD-EPI or
MDRD calculation
Refer to algorithms (next pages)
GFR < 90
Glucose+Protein+HypoPO4
GFR > 90
Regular follow-up
Follow up every
3 months
* If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications
** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir
GFR using CKD-EPI or MDRD
ACR and MAU
Refer to proteinuria algorithm
(next page)
Referral to nephrologist or
internist
< 60 cc/min* < 30 cc/min*
CaPO4 Renal ultrasound
* If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications
** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir
Urinalysis or urine dipstick
Glucose > 0
Glycosuria
DB +
Glycosuria
DB –
DB follow-up
Fasting glucose+
Rule out diabetes
Repeat 1x
Glycosuria
DB –
Referral to nephrologist or internist
ACR ≤ 0.05 g/mmol and MAU <
2.1 mg/mmol
Normal
- Renal ultrasound- Ascertain the risk
factors- Referral to nephrologist
or internist, or to urologist for isolated
hematuria
Protein ≥ 1 + or 0.25 g/L
Repeat at next appt.
Protein < 1+ or 0.25
g/L
Protein ≥ 1+ or 0.25
g/L
NormalACR and
MAU
ACR > 0.05 g/mmolor
MAU > 2.1 mg/mmolor
hematuria (> 2 RBC/HPF)
Urinalysis or urine dipstick
Glucose > 0
Glycosuria
DB +
Glycosuria
DB –
DB follow-up
Fasting glucose+
Rule out diabetes
Repeat 1x
Glycosuria
DB –
Referral to nephrologist or internist
ACR ≤ 0.05 g/mmol and MAU <
2.1 mg/mmol
Normal
- Renal ultrasound- Ascertain the risk
factors- Referral to nephrologist
or internist, or to urologist for isolated
hematuria
Protein ≥ 1 + or 0.25 g/L
Repeat at next appt.
Protein < 1+ or 0.25
g/L
Protein ≥ 1+ or 0.25
g/L
NormalACR and
MAU
ACR > 0.05 g/mmolor
MAU > 2.1 mg/mmolor
hematuria (> 2 RBC/HPF)
Urinalysis or urine dipstick
Glucose > 0
Glycosuria
DB +
Glycosuria
DB –
DB follow-up
Fasting glucose+
Rule out diabetes
Repeat 1x
Glycosuria
DB –
Referral to nephrologist or internist
Urinalysis or urine dipstick
Glucose > 0
Glycosuria
DB +
Glycosuria
DB –
DB follow-up
Fasting glucose+
Rule out diabetes
Repeat 1x
Glycosuria
DB –
Referral to nephrologist or internist
ACR ≤ 0.05 g/mmol and MAU <
2.1 mg/mmol
Normal
- Renal ultrasound- Ascertain the risk
factors- Referral to nephrologist
or internist, or to urologist for isolated
hematuria
Protein ≥ 1 + or 0.25 g/L
Repeat at next appt.
Protein < 1+ or 0.25
g/L
Protein ≥ 1+ or 0.25
g/L
NormalACR and
MAU
ACR > 0.05 g/mmolor
MAU > 2.1 mg/mmolor
hematuria (> 2 RBC/HPF)
Urinalysis or urine dipstick
ACR ≤ 0.05 g/mmol and MAU <
2.1 mg/mmol
Normal
- Renal ultrasound- Ascertain the risk
factors- Referral to nephrologist
or internist, or to urologist for isolated
hematuria
Protein ≥ 1 + or 0.25 g/L
Repeat at next appt.
Protein < 1+ or 0.25
g/L
Protein ≥ 1+ or 0.25
g/L
NormalACR and
MAU
ACR > 0.05 g/mmolor
MAU > 2.1 mg/mmolor
hematuria (> 2 RBC/HPF)
Serum phosphorus
< normal levels
Repeat and if < normal levels
PTH assay25-OH Vit D Albumin-corrected Ca
< 50: deficiency< 75: insufficiency
> 75
Vit D Rx Normal
Abnormal Normal
Referral to nephrologist or internist
Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist
Abnormal Normal
Referral to nephrologist or internist
0.65 – normal level
0.32 – 0.65 mmol/L
< 0.32 mmol/L
Repeat in 3 months
Repeat in 1 month
Treat immediatelyReferral to
nephrologist
Serum phosphorus
< normal levels
Repeat and if < normal levels
PTH assay25-OH Vit D Albumin-corrected Ca
< 50: deficiency< 75: insufficiency
> 75
Vit D Rx Normal
Abnormal Normal
Referral to nephrologist or internist
Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist
Abnormal Normal
Referral to nephrologist or internist
0.65 – normal level
0.32 – 0.65 mmol/L
< 0.32 mmol/L
Repeat in 3 months
Repeat in 1 month
Treat immediatelyReferral to
nephrologist
Serum phosphorus
< normal levels
Repeat and if < normal levels
Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist
0.65 – normal level
0.32 – 0.65 mmol/L
< 0.32 mmol/L
Repeat in 3 months
Repeat in 1 month
Treat immediatelyReferral to
nephrologist
Serum phosphorus
< normal levels
Repeat and if < normal levels
PTH assay25-OH Vit D Albumin-corrected Ca
< 50: deficiency< 75: insufficiency
> 75
Vit D Rx Normal
Abnormal Normal
Referral to nephrologist or internist
Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist
Abnormal Normal
Referral to nephrologist or internist
0.65 – normal level
0.32 – 0.65 mmol/L
< 0.32 mmol/L
Repeat in 3 months
Repeat in 1 month
Treat immediatelyReferral to
nephrologist
Serum phosphorus
< normal levels
Repeat and if < normal levels
PTH assay25-OH Vit D Albumin-corrected Ca
< 50: deficiency< 75: insufficiency
> 75
Vit D Rx Normal
Abnormal Normal
Referral to nephrologist or internist
Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist
Abnormal Normal
Referral to nephrologist or internist
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