Antiretroviral therapy in people with HIV and end-stage kidney disease

Abstract

Objective: To summarize antiretroviral therapy (ART) use in the setting of end-stage kidney disease (ESKD).

Design: Cross-sectional analysis.

Methods: Descriptive analysis of ART regimens and dose of nucleoside/nucleotide reverse-transcriptase inhibitors (NRTI) in people with HIV and ESKD [dialysis, kidney transplantation, or estimated glomerular filtration rate (eGFR) <15 ml/min/1.73 m 2 ] receiving HIV and renal care at five London centres. Exposures of interest were use of dual/unboosted ART regimens and higher than recommended doses of renally cleared NRTI.

Results: A total of 157 participants were included (median age 55 years, 66% men, 84% black ethnicity, median CD4 + cell count 382 cells/μl, 99% HIV RNA <200 copies/ml). Fifty-eight (37%) were on dual/unboosted ART regimens, mainly dolutegravir/lamivudine. Participants on dual/unboosted ART had similar rates of HIV suppression as those on triple ART. Two participants currently virologically controlled on triple-ART had previously failed to suppress on dual/unboosted ART [dolutegravir/rilpivirine and dolutegravir/lamivudine (50 mg)]. Lamivudine doses were higher than recommended in 75 (77%) and lower than recommended in 8 (8%) participants. Full-dose lamivudine (300 mg daily) was used by 24 (32%) participants with eGFR less than 30 ml/min/1.73m 2 . None of those currently on reduced-dose lamivudine had required dose reductions for previous toxicity concerns.

Conclusion: Dual/unboosted ART regimens, such as dolutegravir/lamivudine, provide robust viral efficacy in the setting of ESKD, and higher than recommended, including full-dose, lamivudine was well tolerated. The dolutegravir/lamivudine (300 mg) fixed-dose combination provides a single-tablet regimen for use across the eGFR spectrum, avoids under-exposure to lamivudine, and merits further evaluation in this population.

Keywords: HIV; antiretroviral therapy; end-stage kidney disease; kidney failure.