22-20: HIV-Associated Nephropathy

HIV-associated nephropathy usually presents with nephrotic syndrome and declining GFR in patients with active HIV infection. Most patients are of African descent, likely due to the association of APOL1 polymorphisms with increased risk for HIV-associated nephropathy. HIV-associated nephropathy is usually associated with low CD4 counts and AIDS, but it can also be the initial presentation of HIV disease. Patients with HIV are at risk for kidney disease other than HIV-associated nephropathy, such as toxicity from antiretroviral medications (eg, tenofovir disoproxil fumarate), vascular disease, and diabetes, or an immune complex–mediated glomerular disease (HIV-immune complex disease).

Classic HIV-associated nephropathy results in an FSGS pattern of injury with glomerular collapse; severe tubulointerstitial damage may also be present.

HIV-associated nephropathy is less common in the era of HIV screening and more effective antiretroviral therapy. Small, uncontrolled studies have shown that antiretroviral therapy slows progression of disease. ACE inhibitors or ARBs can be used to control blood pressure and proteinuria. Kidney biopsy is necessary for diagnosis and to rule out other causes of kidney dysfunction. Patients who progress to ESRD and are otherwise healthy are good candidates for kidney transplantation.