From the Guidelines
The most common cause of chronic kidney disease (CKD) in HIV-infected individuals is HIV-associated nephropathy (HIVAN), as supported by the 2018 Kidney Disease: Improving Global Outcomes (KDIGO) controversies conference 1. This condition primarily affects individuals of African descent and is characterized by collapsing focal segmental glomerulosclerosis, tubular microcyst formation, and interstitial inflammation. The key management approach for HIVAN is effective antiretroviral therapy (ART), which should be initiated promptly regardless of CD4 count, as recommended by the 2013 KDOQI US commentary on the 2012 KDIGO clinical practice guideline for glomerulonephritis 1. Typical ART regimens include integrase inhibitors like dolutegravir or bictegravir combined with two nucleoside reverse transcriptase inhibitors, with dose adjustments based on kidney function, and ACE inhibitors or ARBs are often added to reduce proteinuria and slow disease progression, as suggested by the 2005 guidelines for the management of chronic kidney disease in HIV-infected patients 1. Regular monitoring of kidney function through serum creatinine, estimated glomerular filtration rate (eGFR), and urinalysis is essential. HIVAN develops due to direct HIV infection of kidney epithelial cells and the expression of viral proteins, particularly Nef and Vpr, which disrupt normal cellular function. Without treatment, HIVAN can progress rapidly to end-stage renal disease, but early ART intervention can significantly improve outcomes and even lead to partial reversal of kidney damage. It is also important to consider the potential nephrotoxicity of antiretroviral therapy, particularly tenofovir disoproxil fumarate (TDF), and to monitor kidney function closely in patients receiving these medications, as highlighted in the 2018 study on kidney disease in the setting of HIV infection 1. Overall, the management of HIVAN requires a comprehensive approach that includes effective ART, careful monitoring of kidney function, and timely intervention to prevent disease progression.
From the Research
Causes of CKD in HIV
- HIV-associated nephropathy (HIVAN) is a common cause of chronic kidney disease (CKD) in HIV patients, particularly in those of African ancestry 2.
- HIVAN is a focal segmental glomerulosclerosis that causes rapid deterioration of renal function and is the most common cause of CKD in HIV patients 2.
- Other causes of CKD in HIV patients include HIV-immune complex disease, which is the second most common diagnosis obtained from biopsies of patients with HIV-CKD 3, 4.
- Antiretroviral therapy (ART) itself can also contribute to the development of CKD, particularly tenofovir disoproxil fumarate (TDF), which can cause nephrotoxicity 5, 6.
Risk Factors for CKD in HIV
- Comorbid hypertension, diabetes, and hepatitis B or C co-infection are risk factors for CKD in HIV patients 5, 3.
- The use of certain antiretroviral medications, such as TDF, in combination with a ritonavir-boosted protease inhibitor, can also increase the risk of CKD 5.
- Advanced HIV disease and low CD4 cell count are also risk factors for CKD in HIV patients 3, 4.
Diagnosis and Management of CKD in HIV
- Early detection of kidney disease through screening and annual monitoring is essential for preventing and managing CKD in HIV patients 3, 4, 6.
- The use of renin-angiotensin system blockers and viral suppression can improve renal survival in HIV patients with CKD 3.
- Antiretroviral medications may need to be adjusted or switched in patients with CKD, and referral to a nephrologist may be necessary in cases of severe CKD 5, 3.