HIV-associated nephropathy, a type of nephrotic syndrome Overview of Nephrotic Syndrome Nephrotic syndrome is urinary excretion of > 3 g of protein/day due to a glomerular disorder plus edema and hypoalbuminemia. It is more common among children and has both primary and secondary... read more , seems to be more common among Black patients with HIV who are injection drug users or have been poorly adherent to their antiretroviral therapy regimen. Infection of renal cells with HIV may contribute.
Most clinical findings are similar to those of focal segmental glomerulosclerosis Symptoms and Signs Focal segmental glomerulosclerosis is scattered (segmental) mesangial sclerosis that begins in some but not all (focal) glomeruli and eventually involves all glomeruli. It is most often idiopathic... read more 
, but hypertension is less common and the kidneys remain enlarged.
Most patients experience rapid progression to end-stage kidney disease Chronic Kidney Disease Chronic kidney disease (CKD) is long-standing, progressive deterioration of renal function. Symptoms develop slowly and in advanced stages include anorexia, nausea, vomiting, stomatitis, dysgeusia... read more 
within 1 to 4 months.
Diagnosis of HIV-Associated Nephropathy
Renal biopsy
HIV-associated nephropathy is suspected in patients with nephrotic syndrome or nephropathy who have AIDS or symptoms of AIDS. HIV-associated nephropathy should be distinguished from the many other disorders that occur with higher frequency in HIV-infected patients and cause renal disease, such as thrombotic microangiopathy (hemolytic-uremic syndrome Hemolytic-Uremic Syndrome (HUS) Hemolytic-uremic syndrome (HUS) is an acute, fulminant disorder characterized by thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney injury. HUS usually occurs in children... read more 
and thrombotic thrombocytopenic purpura Thrombotic Thrombocytopenic Purpura (TTP) Thrombotic thrombocytopenic purpura (TTP) is an acute, fulminant disorder characterized by thrombocytopenia and microangiopathic hemolytic anemia. Other manifestations may include alterations... read more ), immune complex–mediated glomerulonephritis, and drug-induced interstitial nephritis (due to indinavir and ritonavir) and rhabdomyolysis Rhabdomyolysis Rhabdomyolysis is a clinical syndrome involving the breakdown of skeletal muscle tissue. Symptoms and signs include muscle weakness, myalgias, and reddish-brown urine, although this triad is... read more (due to statins).
Ultrasonography, if done, shows that the kidneys are enlarged and highly echogenic.
Renal biopsy typically is done. Light microscopy shows capillary collapse of varying severity (collapsing glomerulopathy) and differing degrees of increased mesangial matrix. Tubular cells show marked degenerative changes and tubular atrophy or microcytic dilation. Interstitial immune cell infiltrate, fibrosis, and edema are common. Tubular reticular inclusions, similar to those in systemic lupus erythematosus Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic, multisystem, inflammatory disorder of autoimmune etiology, occurring predominantly in young women. Common manifestations may include arthralgias and... read more 
, are found within endothelial cells but are now rare with more effective HIV therapy.
Focal segmental glomerulosclerosis with collapse of glomerular tufts and microcystic tubular changes is characteristic of HIV-associated nephropathy (Jones silver stain, ×100).
Image provided by Agnes Fogo, MD, and the American Journal of Kidney Diseases' Atlas of Renal Pathology (see www.ajkd.org).
HIV-associated nephropathy can be distinguished from focal segmental glomerulosclerosis by reticular inclusions in endothelial cell cytoplasm on transmission electron microscopy (×20,000). However, these reticular inclusions are now rare with use of highly active antiretroviral therapy.
Image provided by Agnes Fogo, MD, and the American Journal of Kidney Diseases' Atlas of Renal Pathology (see www.ajkd.org).
Normotension and persistently enlarged kidneys help to differentiate HIV-associated nephropathy from focal segmental glomerulosclerosis.
Treatment of HIV-Associated Nephropathy
Antiretroviral therapy (ART) and angiotensin inhibition
Control of the HIV infection may help minimize renal damage; in fact, HIV-associated nephropathy is rare in patients taking ART with well-controlled HIV infection. Angiotensin inhibition with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) is probably of some benefit. The role of corticosteroids is not well defined. At some centers, outcomes after kidney transplantation Kidney Transplantation Kidney transplantation is the most common type of solid organ transplantation. (See also Overview of Transplantation.) The primary indication for kidney transplantation is End-stage renal failure... read more have been excellent.
Drugs Mentioned In This Article
| Drug Name | Select Trade |
|---|---|
indinavir |
Crixivan |
ritonavir |
Norvir |
