The use of antiretroviral agents in patients with renal insufficiency

Novel Antiretroviral Drugs in Patients with Renal Impairment: Clinical and Pharmacokinetic Considerations

Highly active antiretroviral therapy (HAART) has dramatically increased the survival of HIV-infected patients from Western countries reducing the incidence of opportunistic infections and AIDS-related malignancies, and improving the patients' quality of life compared with the pre-HAART era. HIV is thus now considered in the West as a chronic disease, with the majority of HIV-infected patients successfully reaching an optimal immune and virological outcome a few months after starting HAART. However, this switch from acute to chronic disease has been accompanied by an increased incidence of chronic kidney disease (CKD), reported in up to 60% of HIV-infected patients. Tenofovir disoproxil fumarate (TDF) is considered to play a significant role in the development of CKD in these patients. It has been proposed that tenofovir alafenamide (TAF), a prodrug formulation able to providing lower systemic and renal drug exposure, could potentially contribute to reduce the development of CKD in HAART-treated patients. On the other hand, the pharmacokinetics of some components of HAART can be significantly altered in HIV-infected patients developing CKD. TDF- or TAF-based antiretroviral regimens should be avoided in patients with a creatinine clearance of less than 50 or 30 mL/min, respectively. This review focuses on the pharmacokinetic changes of novel antiretroviral drugs in HIV-infected patients with renal impairment or requiring renal replacement therapy, and provides some suggestions on how to change drug doses in these clinical settings.

Indinavir/ritonavir remains an important component of HAART for the treatment of HIV/AIDS, particularly in resource-limited settings

For over a decade, indinavir has been approved for the treatment of HIV/AIDS; however, following the introduction of new protease inhibitors (PIs) with improved safety and pharmacologic profiles, its use in developed countries has become almost obsolete. In contrast, in resource-limited settings where the majority of people living with HIV/AIDS reside, indinavir is part of the most affordable PI-based highly active antiretroviral treatment regimen. A major drawback of indinavir use is renal toxicity, but low-dose indinavir plus ritonavir (400/100 mg) twice daily is both efficacious and tolerable. Similar low dosing levels in children have also proven successful, but data in pregnant women remains limited. Due to its low cost and proven efficacy indinavir remains a key component of HIV/AIDS treatment in resource-limited settings.