algorithm dr. patrice junod clinique médicale l’actuel this activity is supported by an...
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![Page 1: Algorithm Dr. Patrice Junod Clinique médicale l’Actuel This activity is supported by an educational grant from:](https://reader035.vdocuments.site/reader035/viewer/2022062621/551be995550346b4588b624a/html5/thumbnails/1.jpg)
Algorithm
Dr. Patrice JunodClinique médicale l’Actuel
This activity is supported byan educational grant from:
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1- Algorithm Nephropathy
Advisory Committee on the clinical management of people living with HIV
2- HIV and Renal Health – Management tool
National Development Committee – Supported by Janssen
Algorithm
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− Nephropathy −
Advisory Committee on the Clinical Management of Persons Living with HIV
PERIODIC HEALTH EXAMINATION OF ADULTS LIVING WITH HIV (HUMAN
IMMUNODEFICIENCY VIRUS)
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Screening schedule based on risk factors for kidney disease (EACS 2011)
Untreated HIV+ patients
Treated HIV+ patients
Without TDF With TDF
Assessment of risk factors for CKD* Annual Annual 6–12 months
Urinalysis or urine dipstick Annual
Annual6 months if GFR < 60
3-6 months
eGFR 6-12 months 3-6 months 3-6 months
Phosphorus As needed As needed Optional3-6 months
* Risk factors for CKD:Diabetes, hypertension, CVD, viral hepatitis, concomitant nephrotoxic drugs, family history of CKD, black African ethnicity
Advisory Committee on the Clinical Management of Persons Living with HIV
Screening for Kidney Problems
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GFR using CKD-EPI or MDRD
ACR and MAU
Refer to proteinuria algorithm
(next page)
Referral to nephrologist or internist
< 60 cc/min* < 30 cc/min*
CaPO4 Renal
ultrasound
> 60 and < 90 cc/min
Increase in Cr > 20%
for > 3 months**
Repeat CKD-EPI or
MDRD calculation
Refer to algorithms (next pages)
GFR < 90
Glucose+Protein+HypoPO4
GFR > 90
Regular follow-up
Follow up every
3 months
* If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications
** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir
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GFR using CKD-EPI or MDRD
ACR and MAU
Refer to proteinuria algorithm
(next page)
Referral to nephrologist or internist
< 60 cc/min* < 30 cc/min*
CaPO4 Renal
ultrasound
> 60 and < 90 cc/min
Increase in Cr > 20%
for > 3 months**
Repeat CKD-EPI or
MDRD calculation
Refer to algorithms (next pages)
GFR < 90
Glucose+Protein+HypoPO4
GFR > 90
Regular follow-up
Follow up every
3 months
* If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications
** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir
![Page 7: Algorithm Dr. Patrice Junod Clinique médicale l’Actuel This activity is supported by an educational grant from:](https://reader035.vdocuments.site/reader035/viewer/2022062621/551be995550346b4588b624a/html5/thumbnails/7.jpg)
* If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications
** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir
> 60 and < 90 cc/min
Increase in Cr > 20%for > 3
months**
Repeat CKD-EPI or MDRD
calculation
Refer to algorithms (next pages)
GFR < 90
Glucose+Protein+HypoPO4
GFR > 90
Regular follow-up
Follow up every
3 months
GFR using CKD-EPI or MDRD
![Page 8: Algorithm Dr. Patrice Junod Clinique médicale l’Actuel This activity is supported by an educational grant from:](https://reader035.vdocuments.site/reader035/viewer/2022062621/551be995550346b4588b624a/html5/thumbnails/8.jpg)
GFR using CKD-EPI or MDRD
ACR and MAU
Refer to proteinuria algorithm
(next page)
Referral to nephrologist or internist
< 60 cc/min* < 30 cc/min*
CaPO4 Renal
ultrasound
> 60 and < 90 cc/min
Increase in Cr > 20%
for > 3 months**
Repeat CKD-EPI or
MDRD calculation
Refer to algorithms (next pages)
GFR < 90
Glucose+Protein+HypoPO4
GFR > 90
Regular follow-up
Follow up every
3 months
* If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications
** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir
![Page 9: Algorithm Dr. Patrice Junod Clinique médicale l’Actuel This activity is supported by an educational grant from:](https://reader035.vdocuments.site/reader035/viewer/2022062621/551be995550346b4588b624a/html5/thumbnails/9.jpg)
GFR using CKD-EPI or MDRD
ACR and MAU
Refer to proteinuria algorithm
(next page)
Referral to nephrologist or
internist
< 60 cc/min* < 30 cc/min*
CaPO4 Renal ultrasound
* If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications
** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir
![Page 10: Algorithm Dr. Patrice Junod Clinique médicale l’Actuel This activity is supported by an educational grant from:](https://reader035.vdocuments.site/reader035/viewer/2022062621/551be995550346b4588b624a/html5/thumbnails/10.jpg)
Urinalysis or urine dipstick
Glucose > 0
Glycosuria
DB +
Glycosuria
DB –
DB follow-up
Fasting glucose+
Rule out diabetes
Repeat 1x
Glycosuria
DB –
Referral to nephrologist or internist
ACR ≤ 0.05 g/mmol and MAU <
2.1 mg/mmol
Normal
- Renal ultrasound- Ascertain the risk
factors- Referral to nephrologist
or internist, or to urologist for isolated
hematuria
Protein ≥ 1 + or 0.25 g/L
Repeat at next appt.
Protein < 1+ or 0.25
g/L
Protein ≥ 1+ or 0.25
g/L
NormalACR and
MAU
ACR > 0.05 g/mmolor
MAU > 2.1 mg/mmolor
hematuria (> 2 RBC/HPF)
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Urinalysis or urine dipstick
Glucose > 0
Glycosuria
DB +
Glycosuria
DB –
DB follow-up
Fasting glucose+
Rule out diabetes
Repeat 1x
Glycosuria
DB –
Referral to nephrologist or internist
ACR ≤ 0.05 g/mmol and MAU <
2.1 mg/mmol
Normal
- Renal ultrasound- Ascertain the risk
factors- Referral to nephrologist
or internist, or to urologist for isolated
hematuria
Protein ≥ 1 + or 0.25 g/L
Repeat at next appt.
Protein < 1+ or 0.25
g/L
Protein ≥ 1+ or 0.25
g/L
NormalACR and
MAU
ACR > 0.05 g/mmolor
MAU > 2.1 mg/mmolor
hematuria (> 2 RBC/HPF)
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Urinalysis or urine dipstick
Glucose > 0
Glycosuria
DB +
Glycosuria
DB –
DB follow-up
Fasting glucose+
Rule out diabetes
Repeat 1x
Glycosuria
DB –
Referral to nephrologist or internist
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Urinalysis or urine dipstick
Glucose > 0
Glycosuria
DB +
Glycosuria
DB –
DB follow-up
Fasting glucose+
Rule out diabetes
Repeat 1x
Glycosuria
DB –
Referral to nephrologist or internist
ACR ≤ 0.05 g/mmol and MAU <
2.1 mg/mmol
Normal
- Renal ultrasound- Ascertain the risk
factors- Referral to nephrologist
or internist, or to urologist for isolated
hematuria
Protein ≥ 1 + or 0.25 g/L
Repeat at next appt.
Protein < 1+ or 0.25
g/L
Protein ≥ 1+ or 0.25
g/L
NormalACR and
MAU
ACR > 0.05 g/mmolor
MAU > 2.1 mg/mmolor
hematuria (> 2 RBC/HPF)
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Urinalysis or urine dipstick
ACR ≤ 0.05 g/mmol and MAU <
2.1 mg/mmol
Normal
- Renal ultrasound- Ascertain the risk
factors- Referral to nephrologist
or internist, or to urologist for isolated
hematuria
Protein ≥ 1 + or 0.25 g/L
Repeat at next appt.
Protein < 1+ or 0.25
g/L
Protein ≥ 1+ or 0.25
g/L
NormalACR and
MAU
ACR > 0.05 g/mmolor
MAU > 2.1 mg/mmolor
hematuria (> 2 RBC/HPF)
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Serum phosphorus
< normal levels
Repeat and if < normal levels
PTH assay25-OH Vit D Albumin-corrected Ca
< 50: deficiency< 75: insufficiency
> 75
Vit D Rx Normal
Abnormal Normal
Referral to nephrologist or internist
Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist
Abnormal Normal
Referral to nephrologist or internist
0.65 – normal level
0.32 – 0.65 mmol/L
< 0.32 mmol/L
Repeat in 3 months
Repeat in 1 month
Treat immediatelyReferral to
nephrologist
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Serum phosphorus
< normal levels
Repeat and if < normal levels
PTH assay25-OH Vit D Albumin-corrected Ca
< 50: deficiency< 75: insufficiency
> 75
Vit D Rx Normal
Abnormal Normal
Referral to nephrologist or internist
Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist
Abnormal Normal
Referral to nephrologist or internist
0.65 – normal level
0.32 – 0.65 mmol/L
< 0.32 mmol/L
Repeat in 3 months
Repeat in 1 month
Treat immediatelyReferral to
nephrologist
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Serum phosphorus
< normal levels
Repeat and if < normal levels
Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist
0.65 – normal level
0.32 – 0.65 mmol/L
< 0.32 mmol/L
Repeat in 3 months
Repeat in 1 month
Treat immediatelyReferral to
nephrologist
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Serum phosphorus
< normal levels
Repeat and if < normal levels
PTH assay25-OH Vit D Albumin-corrected Ca
< 50: deficiency< 75: insufficiency
> 75
Vit D Rx Normal
Abnormal Normal
Referral to nephrologist or internist
Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist
Abnormal Normal
Referral to nephrologist or internist
0.65 – normal level
0.32 – 0.65 mmol/L
< 0.32 mmol/L
Repeat in 3 months
Repeat in 1 month
Treat immediatelyReferral to
nephrologist
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Serum phosphorus
< normal levels
Repeat and if < normal levels
PTH assay25-OH Vit D Albumin-corrected Ca
< 50: deficiency< 75: insufficiency
> 75
Vit D Rx Normal
Abnormal Normal
Referral to nephrologist or internist
Urinary fractional excretion of phosphorus if available (if > 20% or > 10% and hypophosphatemia: referral to a specialist
Abnormal Normal
Referral to nephrologist or internist
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Algorithm
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Algorithm
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Algorithm
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Algorithm
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Algorithm