勞拉‧奧爾邁爾 / 2024 年 4 月 / 愛滋病地圖

關鍵點：

• HIV 會增加腎臟疾病的風險。但最常見的兩個原因是糖尿病和高血壓。

• 生活方式的改變有助於控制腎臟疾病。

• 您的愛滋病毒診所將定期監測您的腎功能。

腎臟是過濾血液的器官，有助於維持體內鹽分和礦物質的最佳平衡。腎臟過濾血液中的廢物並透過尿液排出，同時保留身體所需的物質。腎臟也會釋放調節血壓、刺激紅血球形成並幫助身體調節保持骨骼強健所需的鈣儲存的荷爾蒙。

當腎臟衰竭時，體內會積聚過多的液體和廢物。這會讓您感覺不適、體重增加、呼吸困難以及手腳腫脹。

• 「腎臟疾病」一詞是指任何腎功能異常，即使只有輕微損傷。

• 急性腎損傷是指在幾小時或幾天內發生的腎功能突然喪失。

• 慢性腎病變 (CKD) 是指腎功能長期持續喪失。

• 末期腎病是指腎功能幾乎完全喪失，如果不進行透析或腎臟移植等替代治療，就會導致死亡。

• 您可能會聽到醫生談論腎臟疾病或腎臟問題。這與腎臟疾病相同。

腎臟疾病的兩個最重要的原因是糖尿病和高血壓。這兩種情況通常都可以成功預防或治療。

在糖尿病中，血液中過量的葡萄糖（一種型態的糖）會損害腎臟內稱為腎單位（一種過濾單位）的微小結構。高血壓會損害這些腎單位周圍的小血管。在這兩種情況下，這都會使腎臟更難將廢物與應重新吸收到體內的物質分開。

您的生活方式和腎臟疾病

改變生活方式可以降低糖尿病和高血壓或病情惡化的風險。這反過來又有助於預防腎臟疾病。

如果您超重，請減肥。

經常運動。

不要吸煙。

吃健康、均衡的飲食。吃低鈉和高鉀的食物（例如香蕉）可以幫助降低血壓。

限制藥物和酒精的攝取。

如果您被診斷出患有腎臟疾病，同樣的生活方式改變將有助於控制病情。您的醫生或營養師可能會為您提供有關食物和飲料的具體建議。一般來說，你應該選擇少鹽的食物，少吃富含蛋白質的食物，並吃對心臟健康的食物。

誰會有危險？

50 歲以上的人，包括愛滋病毒感染者，罹患慢性腎臟病的風險更大。由於遺傳因素，如果近親患有腎臟疾病，或者您有南亞、西非或加勒比海血統，您面臨的風險會更大。

糖尿病、高血壓、膽固醇升高（血液中的一種脂肪）、B型肝炎和C型肝炎都會增加腎臟問題的可能性。使用一些娛樂性藥物（包括搖頭丸、可卡因、K他命和海洛因）和大量飲酒可能會導致腎臟問題。長期使用一些非處方止痛藥（包括ibuprofen布洛芬）、蛋白質補充劑和一些草藥產品也會損害腎臟。如果您使用任何這些產品，值得告訴您的醫生，以便他們可以監測您的腎功能。

愛滋病毒感染者的腎臟疾病

慢性腎臟病是愛滋病毒感染者常見的疾病。

原因之一是有效的愛滋病毒治療意味著愛滋病毒感染者的壽命更長。隨著年齡的增長，他們更有可能出現老年典型症狀。

愛滋病毒本身也會增加腎臟病的風險，即使對於愛滋病毒控制良好的人也是如此。雖然原因尚不清楚，但可能與免疫系統對愛滋病毒反應引起的發炎有關。

CD4 數量低、病毒量高以及在晚期被診斷出感染 HIV 都會增加慢性腎臟病的風險。

感染愛滋病毒還會增加慢性腎病更快惡化的風險。

愛滋病毒感染者腎病變發生率高的另一個原因是，許多愛滋病毒陽性者有吸菸和高血壓等腎臟疾病危險因子。

整體而言，愛滋病毒治療可以保護腎臟。特別是，它可以保護您免受愛滋病毒特異性腎臟疾病的侵害。現在，大多數愛滋病毒感染者都接受愛滋病毒治療，這些形式的腎臟疾病已經很少見。有時，在晚期被診斷出感染愛滋病毒的人身上也會出現這種情況。

然而，有些抗愛滋病毒藥物可以歸因於少數人的腎臟問題。因此，愛滋病毒診所會定期監測接受愛滋病毒治療的人的腎功能。如果出現任何問題的跡象，您的醫生可能會建議改用不同的治療方法。

• 替諾福韋二吡呋酯 (Tenofovir disoproxil , Viread) 是一種廣泛使用的藥物，也包含在組合藥 Truvada、Atripla、Stribild 和 Eviplera 中。這種藥物對大多數人都有效，但偶爾也會引起一系列腎臟問題。

•利托那韋增強的蛋白酶抑制劑 (Ritonavir-boosted protease inhibitors) ，包括阿扎那韋（Reyataz）、洛匹那韋（在 Kaletra）和茚地那韋（Crixivan，現在很少使用）有時會引起腎結石（藥物在腎臟內硬塊中積聚）和其他形式的腎病腎臟病.

• 如果HIV 治療同時含有替諾福韋二吡呋酯和利托那韋或考比司他 (tenofovir disoproxil and ritonavir or cobicistat)，則患腎病的風險會增加。

症狀

腎臟疾病可能存在多年而不引起任何症狀。這是因為身體通常能夠應對腎功能的顯著下降。

人們通常只有在腎臟疾病處於晚期時才會出現症狀。

這些可能包括疲勞和睡眠困難；腳踝或腳腫脹；肌肉痙攣；癢感；呼吸急促；噁心和嘔吐；體重減輕和食慾不佳；尿液中有血；以及排尿的需求增加，尤其是在晚上。

如果不加以控制，腎臟疾病會導致多種併發症，並導致心臟病、骨骼脆弱和性問題。

診斷和監測

您的愛滋病毒診所將定期監測您的腎功能。因此，腎功能的任何下降都可能會被及時注意到。對尿液和血液樣本進行測試。

如果尿液檢查發現尿液中蛋白質含量較高，這可能是腎臟問題的徵兆。同樣，血液中一種稱為肌酸酐的廢物含量過高可能表示腎功能喪失。健康的腎臟保留血液中的蛋白質並透過尿液排出肌酸酐。當腎臟受損時，它可能會起到相反的作用。

血液檢查的結果應根據您的年齡和性別進行調整。這些提供了一種稱為腎小球濾過率（GFR）的測量方法，這是用於監測腎功能的主要測量方法。

您的 GFR 結果以 1 到 5 的階段形式給出：

• 第1階段：GFR 高於 90；腎功能正常（前提是其他檢查沒有發現其他腎臟疾病的跡象）。

• 第2階段：GFR在60至89之間；輕度腎臟疾病。

• 第3階段：GFR在30至59之間；中度腎臟疾病。

• 第 4 階段：GFR 在 15 至 29 之間；嚴重的腎臟疾病。

• 第5階段：GFR 低於 15；末期腎臟疾病。

可以進行其他測試來評估腎臟受損的程度。腎臟超音波檢查是一種安全無痛的檢查，使用聲波拍攝腎臟影像，顯示其結構。在腎臟切片過程中，會取出一小部分腎組織樣本，同時對該區域進行局部麻醉。然後可以在顯微鏡下檢查細胞。

治療與管理

如果腎臟疾病的根本原因是糖尿病、高血壓或高膽固醇，那麼治療腎臟疾病的一個重要部分就是控制這些疾病。由於患有腎臟疾病會增加未來心臟問題的風險，因此您還需要採取措施改善心臟健康。

透過改變生活方式並服用藥物來控制這些狀況，可以限制腎臟損傷。生活方式的改變包括戒菸、健康飲食和體能活動。

您可能需要服用藥物來降低血壓（ACE 抑制劑或血管緊張素受體阻斷劑）、降低膽固醇水平（他汀類藥物）、控制貧血（促紅血球生成素或鐵補充劑）或緩解腫脹（利尿劑）。

接受愛滋病毒治療也有助於控制腎臟疾病。

由於腎臟損傷會損害身體清除藥物的能力，因此您的醫生可能需要調整一些抗愛滋病毒藥物和其他藥物的劑量。

如果您正在服用任何可能導致腎臟疾病的藥物（例如tenofovir disoproxil，替諾福韋二吡呋酯），則可能需要更改這些藥物。

替諾福韋艾拉酚胺 (Tenofovir alafenamide) 是替諾福韋二吡呋酯的替代品，自2015 年起上市。對腎臟更安全。如果您患有腎臟疾病或有腎臟疾病的風險，您的醫生可能會推薦這種藥物用於治療。

一種稱為 SGLT2 抑制劑的新型藥物也有助於預防慢性腎臟病的進展。它也常用於治療糖尿病。

如果您的腎臟完全停止工作，您將需要替代治療，例如透析或腎臟移植。

透析涉及使用一根管子將您的身體連接到透析機，每週持續幾天，每天持續幾個小時。透析機可作為人工腎，清除體內的廢物和多餘液體。

以前不建議愛滋病毒感染者進行腎臟移植，但自從引入有效的愛滋病毒治療以來，這種情況發生了變化。

儘管您的身體在移植後第一年排斥新腎臟的風險稍高，但您與未感染愛滋病毒的人一樣有可能透過透析或腎臟移植獲得良好的健康結果。因此，不應因為您的愛滋病毒狀況而拒絕您接受這兩種治療。

專門研究腎臟疾病和腎臟醫學的醫生稱為腎臟病專家。您的全科醫生也可能參與管理您的病情。

治療您的腎臟疾病和愛滋病毒的醫生最好就您的醫療保健事宜進行聯絡。為了實現這一點，您需要允許他們分享您的醫療資訊。您也可以要求您的醫生和藥劑師檢查您正在服用的不同藥物之間是否有任何藥物交互作用。

其他資訊來源如需了解更多信息，您可能會發現國家腎臟聯合會的網站很有幫助：www.kidney.org.uk。您也可以撥打 0800 169 09 36 聯絡他們在英國的求助專線團隊。

Chronic kidney disease and HIV

Laura Ohlmeier / April 2024 / aidsmap

Key points

• HIV can contribute to the risk of kidney disease. But the two most common causes are diabetes and high blood pressure.
• Lifestyle changes can help keep kidney disease under control.
• Your HIV clinic will monitor your kidney function regularly.

The kidneys are organs that filter blood and help maintain the optimal balance of salts and minerals in the body. The kidneys filter waste products out of blood and get rid of them in the urine, while keeping substances the body needs. The kidneys also release hormones that regulate blood pressure, stimulate red blood cell formation and help the body regulate the calcium stores that we need to keep bones strong.

When the kidneys fail, too much fluid and waste products build up in the body. This can make you feel unwell, gain weight, become breathless and develop swollen hands and feet.

• The term ‘kidney disease’ refers to any abnormal kidney function, even if there is only slight damage.
• Acute kidney injury refers to a sudden loss of kidney function that happens within a few hours or days.
• Chronic kidney disease (CKD) refers to a loss of kidney function that continues for a long period of time.
• End-stage kidney disease describes a near-complete loss of kidney function, which would result in death without replacement therapy such as dialysis or a kidney transplant.
• You may hear doctors talk about renal disease or renal problems. This is the same as kidney disease.

The two most important causes of kidney disease are diabetes and high blood pressure. Both conditions can often be successfully prevented or treated.

In diabetes, excess glucose (a type of sugar) in the blood injures tiny structures inside the kidneys called nephrons (a kind of filtering unit). High blood pressure damages the small blood vessels that surround these nephrons. In both cases, this makes it harder for the kidneys to sort waste from substances that should be reabsorbed into the body.

Your lifestyle and kidney disease

Changes to your lifestyle can reduce the risk of diabetes and high blood pressure developing or getting worse. This will, in turn, help prevent kidney disease.

Lose weight if you’re overweight.

Exercise regularly.

Don’t smoke.

Eat a healthy, balanced diet. Eating foods low in sodium and high in potassium (for example bananas) can help lower your blood pressure.

Limit your intake of drugs and alcohol.

If you have been diagnosed with kidney disease, the same lifestyle changes will help manage the condition. Your doctor or dietitian may give you specific advice about food and drink. In general, you should choose foods with less salt, have smaller quantities of foods that are rich in protein, and eat foods that are healthy for your heart.

Who is at risk?

People over the age of 50, including people living with HIV, are at greater risk of chronic kidney disease. Because of genetic factors, you are at greater risk if a close family member has had kidney disease or if you have south Asian, west African or Caribbean heritage.

Diabetes, high blood pressure, raised cholesterol (a type of fat in your blood), hepatitis B and hepatitis C all make kidney problems more likely. Use of some recreational drugs (including ecstasy, cocaine, ketamine and heroin) and heavy drinking can contribute to kidney problems. Long-term use of some over-the-counter painkillers (including ibuprofen), protein supplements and some herbal products can also damage the kidneys. It’s worth telling your doctor if you use any of these products so that they can monitor your kidney function.

Kidney disease in people living with HIV

Chronic kidney disease is a common condition amongst people living with HIV.

One reason for this is that effective HIV treatment has meant that people with HIV are living longer. With ageing, they’re more likely to develop conditions typical for older age.

HIV itself can also contribute to the risk of kidney disease, even in people living with well-controlled HIV. While the reasons for this are unclear, it may relate to inflammation caused by the immune system’s response to HIV.

Having a low CD4 count, high viral load and being diagnosed with HIV at a late stage all increase your risk of developing chronic kidney disease.

Having HIV also increases the risk of chronic kidney disease getting worse more quickly.   

Another reason for high rates of kidney disease in people living with HIV is that many HIV-positive people have risk factors for kidney disease such as smoking and high blood pressure.

Overall, HIV treatment protects the kidneys. In particular, it will protect you from HIV-specific forms of kidney disease. Now that most people living with HIV receive HIV treatment, these forms of kidney disease are rare. They still sometimes occur in people who are diagnosed with HIV at a late stage.

However, some anti-HIV drugs can contribute to kidney problems in a small number of people. For this reason, HIV clinics monitor the kidney function of people taking HIV treatment regularly. If there is any sign of a problem, your doctor may suggest switching to a different treatment.

• Tenofovir disoproxil (Viread) is a widely used drug that is also included in the combination pills Truvada, Atripla, Stribild and Eviplera. The drug works well for most people but occasionally can cause a range of kidney problems.
• Ritonavir-boosted protease inhibitors, including atazanavir (Reyataz), lopinavir (in Kaletra) and indinavir (Crixivan, now rarely used) can occasionally cause kidney stones (an accumulation of the drug in a hard lump inside the kidney) and other forms of kidney disease.
• The risk of kidney disease increases if treatment for HIV contains both tenofovir disoproxil and ritonavir or cobicistat.  

Symptoms

Kidney disease can be present for years without causing symptoms. This is because the body is usually able to cope with a significant reduction in kidney function.

People usually have symptoms only when kidney disease is at a late stage.

These can include tiredness and trouble sleeping; swollen ankles or feet; muscle cramps; itching; shortness of breath; nausea and vomiting; weight loss and poor appetite; blood in your urine; and an increasing need to urinate, especially at night.

If left unmanaged, kidney disease can cause a wide range of complications and contribute to heart disease, fragile bones and sexual problems.

Diagnosis and monitoring

Your HIV clinic will monitor your kidney function regularly. As a result, any decline in kidney function is likely to be noticed in good time. Tests are done on samples of urine and blood.

Basic information on health checks for people with HIV

If a urine test finds higher levels of protein in urine this may be a sign of kidney problems. Similarly, high levels of a waste product called creatinine in the blood may indicate a loss of kidney function. A healthy kidney retains protein in blood and excretes creatinine in urine. When the kidney is damaged, it may do the opposite.

The results of the blood test should be adjusted for your age and sex. These provide a measure called glomerular filtration rate (GFR) which is the main measure used to monitor kidney function.

Your GFR result is given as a stage from 1 to 5:

• Stage 1: GFR above 90; normal kidney function (provided there are no other signs of kidney disease from other tests).
• Stage 2: GFR between 60 and 89; mild kidney disease.
• Stage 3: GFR between 30 and 59; moderate kidney disease.
• Stage 4: GFR between 15 and 29; severe kidney disease.
• Stage 5: GFR below 15; end-stage kidney disease.

Other tests may be done to assess the level of damage to your kidneys. A renal ultrasound is a safe and painless test that uses sound waves to make images of the kidneys, showing their structure. During a kidney biopsy, a small sample of kidney tissue is removed while the area is numbed with a local anaesthetic. Then the cells can be examined under a microscope.

Treatment and management

If the underlying cause of your kidney disease is diabetes, high blood pressure or high levels of cholesterol, an important part of treating kidney disease is managing these conditions. Because having kidney disease raises the risk of heart problems in the future, you will also need to take steps to improve your heart health.

By making lifestyle changes and taking medications to control these conditions, kidney damage can be limited. Lifestyle changes include stopping smoking, healthy eating and physical activity.

You may need to take medication to lower blood pressure (ACE inhibitors or angiotensin receptor blockers), to lower cholesterol levels (statins), to control anaemia (erythropoietin or iron supplements) or to relieve swelling (diuretics).

Taking HIV treatment will also help keep kidney disease under control.

Because kidney damage impairs the body’s ability to remove drugs, your doctor may need to adjust the doses of some of your anti-HIV drugs and other medications.

If you are taking any medication which could contribute to kidney disease (for example, tenofovir disoproxil), these may need to be changed.

Tenofovir alafenamide is an alternative to tenofovir disproxil that has been available since 2015. It is included in the combination pills Biktarvy, Descovy, Genvoya, Odefsey and Symtuza and has been found to be safer for the kidneys than the older version. Your doctor may recommend this drug for your treatment if you have, or are at risk of developing, kidney disease.

A new type of medications called SGLT2 inhibitors can also help to prevent the progression of chronic kidney disease. It’s also commonly used to treat diabetes.

If your kidneys stop working completely, you will need replacement therapy such as dialysis or a kidney transplant.

Dialysis involves using a tube to connect your body to a dialysis machine for several hours a day on several days each week. The dialysis machine acts as an artificial kidney, removing waste and extra fluids from the body.

Kidney transplants were previously not recommended for people living with HIV, but this has changed since effective HIV treatment was introduced.

You are just as likely to experience good health outcomes from dialysis or kidney transplantation as someone who isn’t living with HIV, although there is a slightly higher risk of your body rejecting your new kidney in the first year following transplantation. Therefore, you should not be denied access to either of these treatments based on your HIV status.

Doctors specialising in kidney disease and renal medicine are called nephrologists. Your GP may also be involved in managing your condition.

It’s best for the doctors treating your kidney disease and your HIV to liaise about your health care. In order for this to happen, you need to give your permission for them to share your medical information. You can also ask your doctors and pharmacists to check that there are not any drug-drug interactions between the different medicines you are taking.

Other sources of information

For more information, you may find the website of the National Kidney Federation helpful: www.kidney.org.uk. You can also contact their helpline team in the UK on 0800 169 09 36.