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Algorithm Dr. Patrice Junod Clinique médicale l’Actuel This activity is supported by an educational grant from:

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Presentation on theme: "Algorithm Dr. Patrice Junod Clinique médicale l’Actuel This activity is supported by an educational grant from:"— Presentation transcript:

1 Algorithm Dr. Patrice Junod Clinique médicale l’Actuel This activity is supported by an educational grant from:

2 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

3 − Nephropathy − Advisory Committee on the Clinical Management of Persons Living with HIV PERIODIC HEALTH EXAMINATION OF ADULTS LIVING WITH HIV (HUMAN IMMUNODEFICIENCY VIRUS)

4 Screening schedule based on risk factors for kidney disease (EACS 2011) Untreated HIV+ patients Treated HIV+ patients Without TDFWith TDF Assessment of risk factors for CKD* Annual 6–12 months Urinalysis or urine dipstick Annual 6 months if GFR < months eGFR6-12 months3-6 months PhosphorusAs needed Optional 3-6 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

5 GFR using CKD-EPI or MDRD ACR and MAU Refer to proteinuria algorithm (next page) 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** Increase in Cr > 20% for > 3 months** Repeat CKD-EPI or MDRD calculation Refer to algorithms (next pages) Refer to algorithms (next pages) GFR < 90 Glucose+ Protein+ HypoPO4 GFR > 90 Regular follow-up Regular follow-up Follow up every 3 months 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

6 GFR using CKD-EPI or MDRD ACR and MAU Refer to proteinuria algorithm (next page) 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** Increase in Cr > 20% for > 3 months** Repeat CKD-EPI or MDRD calculation Refer to algorithms (next pages) Refer to algorithms (next pages) GFR < 90 Glucose+ Protein+ HypoPO4 GFR > 90 Regular follow-up Regular follow-up Follow up every 3 months 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

7 * 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** Increase in Cr > 20% for > 3 months** Repeat CKD-EPI or MDRD calculation Refer to algorithms (next pages) Refer to algorithms (next pages) GFR < 90 Glucose+ Protein+ HypoPO4 GFR > 90 Regular follow-up Regular follow-up Follow up every 3 months Follow up every 3 months GFR using CKD-EPI or MDRD

8 ACR and MAU Refer to proteinuria algorithm (next page) 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** Increase in Cr > 20% for > 3 months** Repeat CKD-EPI or MDRD calculation Refer to algorithms (next pages) Refer to algorithms (next pages) GFR < 90 Glucose+ Protein+ HypoPO4 GFR > 90 Regular follow-up Regular follow-up Follow up every 3 months 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

9 GFR using CKD-EPI or MDRD ACR and MAU Refer to proteinuria algorithm (next page) 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

10 Urinalysis or urine dipstick Glucose > 0 Glycosuri a DB + Glycosuri a DB + Glycosuri a DB – Glycosuri a DB – DB follow-up Fasting glucose + Rule out diabetes Fasting glucose + Rule out diabetes Repeat 1x Glycosuri a DB – Glycosuri a 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 - 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 Normal ACR and MAU ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF) ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF)

11 Urinalysis or urine dipstick Glucose > 0 Glycosuri a DB + Glycosuri a DB + Glycosuri a DB – Glycosuri a DB – DB follow-up Fasting glucose + Rule out diabetes Fasting glucose + Rule out diabetes Repeat 1x Glycosuri a DB – Glycosuri a 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 - 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 Normal ACR and MAU ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF) ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF)

12 Urinalysis or urine dipstick Glucose > 0 Glycosuri a DB + Glycosuri a DB + Glycosuri a DB – Glycosuri a DB – DB follow-up Fasting glucose + Rule out diabetes Fasting glucose + Rule out diabetes Repeat 1x Glycosuri a DB – Glycosuri a DB – Referral to nephrologist or internist

13 Urinalysis or urine dipstick Glucose > 0 Glycosuri a DB + Glycosuri a DB + Glycosuri a DB – Glycosuri a DB – DB follow-up Fasting glucose + Rule out diabetes Fasting glucose + Rule out diabetes Repeat 1x Glycosuri a DB – Glycosuri a 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 - 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 Normal ACR and MAU ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF) ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF)

14 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 - 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 Normal ACR and MAU ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF) ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF)

15 Serum phosphorus < normal levels Repeat and if < normal levels PTH assay 25-OH Vit D Albumin- corrected Ca < 50: deficiency < 75: insufficiency < 50: deficiency < 75: insufficiency > 75 Vit D Rx Normal Abnorma l Normal Referral to nephrologist or internist Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist Abnorma l 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 immediately Referral to nephrologist Treat immediately Referral to nephrologist

16 Serum phosphorus < normal levels Repeat and if < normal levels PTH assay 25-OH Vit D Albumin- corrected Ca < 50: deficiency < 75: insufficiency < 50: deficiency < 75: insufficiency > 75 Vit D Rx Normal Abnorma l Normal Referral to nephrologist or internist Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist Abnorma l 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 immediately Referral to nephrologist Treat immediately Referral to nephrologist

17 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 immediately Referral to nephrologist Treat immediately Referral to nephrologist

18 Serum phosphorus < normal levels Repeat and if < normal levels PTH assay 25-OH Vit D Albumin- corrected Ca < 50: deficiency < 75: insufficiency < 50: deficiency < 75: insufficiency > 75 Vit D Rx Normal Abnorma l Normal Referral to nephrologist or internist Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist Abnorma l 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 immediately Referral to nephrologist Treat immediately Referral to nephrologist

19 Serum phosphorus < normal levels Repeat and if < normal levels PTH assay 25-OH Vit D Albumin- corrected Ca < 50: deficiency < 75: insufficiency < 50: deficiency < 75: insufficiency > 75 Vit D Rx Normal Abnorma l Normal Referral to nephrologist or internist Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist Abnorma l Normal Referral to nephrologist or internist

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