Boswell Michael T, Rossouw Theresa M
Department of Medical Immunology, University of Pretoria, South Africa.
Nuffield Department of Medicine, University of Oxford, United Kingdom.
South Afr J HIV Med. 2017 Nov 28;18(1):714. doi: 10.4102/sajhivmed.v18i1.714. eCollection 2017.
HIV-infected patients have an increased risk of renal disease. Current first-line antiretroviral therapy contains tenofovir disoproxil fumarate (TDF), which has nephrotoxic potential, characterised by proximal tubular cell injury. This may result in acute kidney injury, chronic kidney disease or partial or complete Fanconi syndrome.
We reviewed the existing literature on acute kidney injury and TDF-associated nephrotoxicity with the aim of providing an approach to diagnosis and management, which is relevant to a general medical practitioner.
We performed a broad literature search of biomedical databases including PubMed and ScienceDirect. Our search terms included, but were not limited to, 'tenofovir', 'nephrotoxicity', 'HIV', 'acute kidney injury' and 'renal tubular acidosis'.Our aim was not to generate a systematic literature review with weighted evidence, but rather to provide a review of best practice from a variety of sources. Where published studies were not available from the above databases, we relied on relevant textbooks and professional guidelines.
Potential nephrotoxicity is not an impediment to the widespread use of TDF in treating HIV infection, because most patients will tolerate the medication well. However, patients with advanced disease, low body weight, advanced age, pre-existing kidney disease and concomitant use of other nephrotoxic medications are at increased risk of adverse renal events and may develop severe complications if not appropriately managed. These risk factors are unfortunately common in patients initiating antiretroviral therapy in South Africa.
Prevention of renal damage by means of careful screening and monitoring of high-risk patients is of paramount importance. Increased awareness of this problem and knowledge of how to manage kidney disease should be emphasised for general medical practitioners who work with HIV-infected patients.
HIV感染患者患肾病的风险增加。目前的一线抗逆转录病毒疗法包含替诺福韦酯（TDF），其具有肾毒性潜力，表现为近端肾小管细胞损伤。这可能导致急性肾损伤、慢性肾病或部分或完全性范科尼综合征。
我们回顾了关于急性肾损伤和TDF相关肾毒性的现有文献，旨在提供一种对普通医生有参考价值的诊断和管理方法。
我们对包括PubMed和ScienceDirect在内的生物医学数据库进行了广泛的文献检索。我们的检索词包括但不限于“替诺福韦”“肾毒性”“HIV”“急性肾损伤”和“肾小管酸中毒”。我们的目的不是进行有加权证据的系统文献综述，而是提供来自各种来源的最佳实践综述。如果上述数据库没有已发表的研究，我们则参考相关教科书和专业指南。
潜在的肾毒性并非TDF广泛用于治疗HIV感染的障碍，因为大多数患者对该药物耐受性良好。然而，患有晚期疾病、体重低、年龄大、已有肾病以及同时使用其他肾毒性药物的患者发生不良肾脏事件的风险增加，如果管理不当可能会出现严重并发症。不幸的是，这些风险因素在南非开始抗逆转录病毒治疗的患者中很常见。
通过仔细筛查和监测高危患者来预防肾损害至关重要。对于治疗HIV感染患者的普通医生，应提高对该问题的认识以及对如何管理肾病的了解。
