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Renal Impairment – Causes


In general, reversible causes are sought first when diagnosing the cause of kidney disease.1

Acute renal failure (ARF) in HIV-infected people can be caused by:

  • antiretroviral therapy (ART)
  • treatments for HIV-associated opportunistic infections

Chronic kidney disease (CKD) can be caused by multiple pathophysiological mechanisms, including HIV-associated nephropathy (HIVAN).2

Diabetes mellitus and hypertension are the commonest causes of CKD in the general population, and the prevalence of these conditions is increasing in HIV-infected people.1

Table 1: Causes of ARF in HIV3 

Reproduced with permission from the International AIDS Society – USA. 

Some antiretrovirals have been associated with renal damage/impairment presenting as ARF, tubular necrosis, kidney stones or CKD.2 

For details of potentially nephrotoxic antiretrovirals, antifungals, antivirals, and antibiotics, find out more on screening for HIV-related renal disease.3

Most documented cases of ARF due to ARVs were associated with the use of indinavir and/or tenofovir, although ritonavir has occasionally been reported to cause reversible ARF.2,4 

Table 2: Drug-associated nephrotoxicity5

i. UP/C in spot urine: urine protein/creatinine ratio in mg/mmol, detects total urinary protein including protein of glomerular or tubular origin. The urine dipstick analysis primarily detects albuminuria as a marker of glomerular disease and is inadequate to detect tubular disease.
ii. eGFR: estimated glomerular filtration rate, according to the abbreviated MDRD formula (Modification of Diet in Renal Disease).
iii. See EACS online table for Indications and tests for proximal renal tubulopathy.
iv. Microscopic haematuria is usually present.
v. Atazanavir may cause decline in eGFR – also without clinical detected nephrolithiasis – but exact pathology and clinical significance remains unclear.

Reproduced with permission from the European AIDS Clinical Society Guidelines Version 6.0.

It should be noted that with both indinavir and tenofovir, renal failure usually appears to improve upon discontinuation of the drug.4  



  1. Winston J, Deray G, Hawkins T, et al. Kidney disease in patients with HIV infection and AIDS. Clin Infect Dis. 2008;47:1449–1457.
  2. Röling J, Schmid H, Fischereder M, et al. HIV-associated renal diseases and highly active antiretroviral therapy-induced nephropathy. Clin Infect Dis. 2006;42:1488–1495.
  3. Fine DM. Renal disease and toxicities: issues for HIV care providers. Top HIV Med. 2007;14:164–169.
  4. Gupta SK, Eustace JA, Winston JA, et al. Guidelines for the Management of Chronic Kidney Disease in HIV-Infected Patients: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2005;40:1559–1585.
  5. European AIDS Clinical Society (EACS). Guidelines. Version 6.0. Accessed 4 July 2012.