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Page 29 of 39 Guideline

If renal dysfunction is severe or renal function deteriorates ÿ Integrase strand transfer inhibitors; and NNRTI drugs do
with TDF, then 3TC monotherapy or other drugs with anti- not require dose adjustment.
HBV activity should be considered. ÿ Atazanavir concentrations are reduced in patients on
haemodialysis to a greater extent than LPV concentrations.
° Common pitfalls: Lopinavir/ritonavir requires a twice-daily dosing in
° Not continuing with TDF + 3TC (or FTC) ÿ patients on haemodialysis.
combination when switching to second-line ART. ÿ Antiretroviral therapy drugs taken once daily, or the
The second-line ART regimen should be shaped evening doses of drugs taken twice daily, should be given
around these two drugs. after the haemodialysis session on dialysis days to
° Using 3TC without including TDF in the treatment prevent the drug from being dialysed out.
of HIV/HBV co-infected patients. ÿ Patients on chronic haemodialysis should be reviewed by
a clinician experienced in ART management at least
21. Renal disease 6 monthly to monitor treatment efficacy and side effects

Antiretroviral drug dose adjustment in renal and to adjust the regimen when needed.
disease Recommendations for antiretroviral therapy for patients
Key points on chronic haemodialysis

ÿ Renal function is estimated by the modified Cockgraft– We recommend the following first-line option for patients on
Gault formula or modification of diet in renal disease chronic haemodialysis: ABC (600 mg daily) + 3TC (50 mg first
(MDRD) formula. dose and thereafter 25 mg daily) + DTG (50 mg daily). On the
ÿ For haemodialysis, the ART prescribed should be taken days when haemodialysis is performed, the drugs should be
after dialysis. given after the haemodialysis session.
• Common pitfall: Not giving daily doses or the evening
In HIV-positive patients on chronic haemodialysis, there are a doses of a twice-daily regimen after the haemodialysis
number of important ART considerations. The NRTI class is session on dialysis days to prevent the drug from being
eliminated through the kidneys; thus, most NRTIs require dialysed out.
dose adjustment as shown in Table 25. 86,87,88 For suggested TDF
dosing in patients with chronic hepatitis B, see section 20. Antiretroviral therapy in patients with acute
kidney injury
Antiretroviral drug choice and dosing in patients Key points
on chronic haemodialysis
Key points ÿ In patients with AKI, NRTI dose adjustments should be
implemented based on estimated CrCl calculation.
ÿ Patients with HIV may develop end-stage renal failure ÿ Tenofovir disoproxil fumarate should be interrupted
owing to HIV-associated nephropathy or an HIV- even if it is not thought to be the cause of the AKI.
unrelated cause, necessitating chronic haemodialysis. ÿ Re-challenge with TDF may be considered in patients
ÿ Tenofovir disoproxil fumarate can be used in patients on 1-month post-resolution of AKI if TDF was not the cause
chronic haemodialysis, but with once-weekly dosing and renal function returns to normal.
which can be difficult for patients to remember. ÿ In patients with AKI who have not yet received ART,
ÿ Zidovudine is generally avoided because of anaemia initiation is preferably deferred until AKI has resolved.
associated with renal failure. But avoid significant delays.
TABLE 25: Antiretroviral drug dose adjustments in renal failure. 86,87,88
Drug CrCl†,§ Haemodialysis (dosage after dialysis) Peritoneal dialysis
10–50 mL/min < 10 mL/min
TDF Avoid Avoid 300 mg once weekly Unknown
ABC Unchanged Unchanged Unchanged Unchanged
3TC 150 mg daily 50 mg daily¶ 50 mg first dose, thereafter 25 mg daily¶ 50 mg first dose, thereafter 25 mg daily¶
AZT Unchanged 300 mg daily 300 mg daily 300 mg daily
NNRTIs Unchanged Unchanged Unchanged Unchanged
PIs Unchanged Unchanged Unchanged Unchanged
InSTIs Unchanged Unchanged Unchanged Unchanged
Source: Bartlett JG, Gallant JE, Pham PA (eds). Medical management of HIV infection. 15th ed. Baltimore, MD: John Hopkins University Press, 2009–2010; 556 pp; Gilbert DN, Moellering RC,
Eliopoulos GM, et al. (eds). The Sanford Guide to antimicrobial therapy. 42nd ed. Sperryville, Virginia: Antimicrobial Therapy, Inc., 2012; 232 pp; HIV Medicine Association of the Infectious Diseases
Society of America. Clinical practice guideline for the management of chronic kidney disease in patients infected with HIV: 2014 update. Clin Infect Dis. 2014;59(9):e96–e138.
3TC, lamivudine; ABC, abacavir; ART, antiretroviral therapy; AZT, zidovudine; CrCl, creatinine clearance rate; d4T, stavudine; ddI, didanosine; eGFR, estimated glomerular filtration rate; InSTIs,
integrase strand transfer inhibitors; MDRD, modification of diet in renal disease; NNRTIs, non-nucleoside reverse transcriptase inhibitors; PIs, protease inhibitors; NRTIs, nucleoside reverse
transcriptase inhibitors; sCr, serum creatinine; TDF, tenofovir disoproxil fumarate.
†, Many laboratories report the eGFR calculated using a variation of the MDRD formula. This result can be used (in place of the calculated CrCl) to make decisions regarding the use of TDF and for
modification of the dose of other NRTIs based on this table.
¶, Some experts recommend that the lowest available tablet dose of 150 mg 3TC daily should be used in patients with advanced renal disease (CrCl < 10 mL/min) and patients on dialysis so as to
avoid having to use the liquid formulation of 3TC, and because of the favourable safety profile and lack of data to suggest 3TC dose-related toxicity. This is particularly relevant if the 3TC liquid
formulation is unavailable or not tolerated.
§, The modified Cockgraft–Gault equation: CrCl = (140 – age × ideal weight) ÷ sCr. For women, multiply the total by 0.85.

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