HIV Nephropathy

Aka: HIV Nephropathy, AIDS associated Nephropathy, HIVAN

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II. Epidemiology

  1. HIV Nephropathy is associated with increased mortality in HIV

III. Pathophysiology

  1. HIV associated glomerulopathy
  2. HIV infects renal epithelial cells
    1. Promotes HIV gene expression (esp. Nef, Vpr) within renal cells
    2. Cellular organelle dysfunction (mitochondria, endolysosomes)
    3. Stress kinase activation

IV. Risk Factors

  1. Black race
  2. Older age
  3. Advanced Immunosuppression
    1. CD4 Count <200 cells/mm3
    2. HIV Viral Loads high
  4. Hepatitis C Virus coninfection
  5. Injection drug use
  6. APOL1-Mediated Kidney Disease (AMKD)

V. Findings

  1. Edema
  2. Hypertension (may be present)

VI. Labs

  1. Urinalysis and Urine Protein Quantification
    1. Proteinuria (nephrotic range)
    2. Nephrotic Syndrome
    3. Hematuria (may be present)
  2. Renal Function Tests (Serum Creatinine, Blood Urea Nitrogen)
    1. Azotemia (Rapidly progressive, irreversible)
  3. Renal Biopsy
    1. Focal Segmental Glomerulosclerosis (collapsing)

VII. Imaging

  1. Renal Ultrasound
    1. Increased Kidney size and echogenicity

VIII. Course

  1. End Stage Renal Disease develops in 4-16 weeks

IX. Differential Diagnosis

  1. See Nephrotic Syndrome
  2. Heroin-associated nephropathy
    1. In contrast, HIV Nephropathy lacks Severe Hypertension, Peripheral Edema, Anasarca

X. Diagnosis

  1. Renal Ultrasound
    1. Kidneys are usually enlarged in HIV Nephropathy
  2. Renal Biopsy confirms diagnosis

XI. Management

  1. No known specific treatment
  2. Antiretroviral therapy for HIV
  3. ACE Inhibitor or Angiotensin Receptor Blocker
    1. See ACE Inhibitors and ARBs in Diabetic Nephropathy
    2. Indicated for persistent Proteinuria
  4. Manage comorbidities
    1. See Prevention of Kidney Disease Progression
    2. See Diabetic Nephropathy
    3. Avoid Nephrotoxic Drug
    4. Manage Renal Osteodystrophy
  5. End Stage Renal Disease
    1. Hemodialysis
    2. Renal Transplant (risk of recurrent HIVAN)

XII. Prevention

  1. Screen for renal disease at time of HIV diagnosis and then every 6 months (more frequently if high risk)
  2. Avoid Nephrotoxic Drugs
    1. See Renal Manifestations of HIV
    2. See Nephrotoxic Drugs

XIII. References

  1. Baloor (2018) Exam Preparatory Manual for Undergraduates Medicine, Jaypee Brothers, India, p. 240
  2. Chu (2017) Am Fam Physician 96(3): 161-9 [PubMed]

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