Hope for kidney transplantation in candidates with human immunodeficiency virus

Table 1 Summary of different classes of medications used in human immunodeficiency virus antiretroviral therapy and considerations in renal transplantation

Drug class	Examples	Mechanism of action	Renal transplant considerations	Ref.
Protease inhibitors	Atazanavir; darunavir; fosamprenavir; nelfinavir; tipranavir	Inhibition of the last step in HIV virus maturation that renders assembled immature viral particles noninfectious	Potent inhibitors of CYP 3A4 with major interaction with CNIs. Should be avoided, if possible, in transplantation	[60,65]
Nucleoside(tide) reverse transcriptase inhibitors	Abacavir; emtricitabine; lamivudine; tenofovir (tenofovir alafenamide or tenofovir disoproxil fumarate); zidovudine	Inhibition of HIV viral replication process by mimicry of nucleoside(tides) thus blocking viral reverse transcriptase and ending the DNA elongation step in HIV-1 and HIV-2 infection life cycle	Tenofovir disoproxil fumarate can cause renal toxicity and proximal tubulopathies requiring close monitoring	[63-65]
Nonnucleoside reverse transcriptase inhibitors	Efavirenz; etravirine; nevirapine	Blocking of DNA prolongation through binding the HIV-1 viral reverse transcriptase at a separate allosteric site	Inducers of CYP 3A4 with major interaction with CNIs. Should be avoided, if possible, in transplantation	[62,65]
Integrase strand inhibitors	Raltegravir; dolutegravir; bictegravir	Inhibition of the integration of transcribed viral DNA into the host genome	Potential for decreasing creatinine excretion, increasing serum creatinine and decreasing estimated glomerular filtration without impacting measured glomerular filtration. Regimens generally preferred in transplantation	[65,67]
Boosters	Ritonavir (e.g., in ritonavir-boosted lopinavir). Cobsistat (e.g., in elvitegravir boosted with cobicistat)	Pharmacokinetic enhancer by potent and selective inhibition of cytochrome P450 3A enzymes	Potent inhibitors of CYP 3A4 with major interaction with CNIs. Should be avoided, if possible, in transplantation	[60,65]

CNIs: Calcineurin inhibitors; HIV: Human immunodeficiency virus; CYP 3A4: Cytochrome P450 3A4; DNA: Deoxyribonucleic acid.