Spectrum of CKD in patients with HIV infection.
| CKD | Characteristics |
|---|---|
| HIVAN | > Almost exclusively African/Caribbean patients > Often low CD4 count at presentation > Nephrotic range proteinuria common, often little oedema despite low albumin > Classical ‘collapsing’ glomeruli on biopsy with tubular microcystic changes > Disease may stabilise with initiation of cART |
| HIV-ICKD | > Patients may be of any ethnicity or HIV risk group > Less likely to be severely immunodeficient/viraemic compared to HIVAN > Proteinuria +/– haematuria +/– creatinine – may be nephrotic range proteinuria > Often clinically indistinguishable from HIVAN – biopsy required > Benefit of cART less clear cut; most would initiate regardless of CD4 count |
| IgA nephropathy | > Clinical and histological features identical to general population > HIV antigens have been found in renal IgA immune complexes but pathogenical role of virus unclear > Role for cART in modifying disease uncertain |
| FSGS (non-collapsing variant) | > More commonly seen in African/Caribbean patients > Epidemiology similar to HIVAN > Proportion of cases may represent HIVAN (eg collapsed glomeruli not seen due to sampling error) |
| Chronic tubulointerstitial nephritis | > Progressive CKD, often with little proteinuria or haematuria > Range of causes including drug exposures (eg indinavir), infections (eg tuberculosis), neoplasms (eg lymphoma) and inflammatory disease (eg sarcoid) > Presence or absence of granulomas on biopsy may aid differential diagnosis > Treatment is removal of offending agent or treatment of underlying cause |
| AA amyloid | > Nephrotic syndrome, progressive CKD – often relentlessly so > Typically seen in intravenous drugs users – likely due to recurrent suppurative skin infection |
| Diabetic nephropathy | > Increasingly common in the cART era as the HIV population ages > Typically causes proteinuria (up to nephrotic range) and progressive CKD > More likely if end-organ disease elsewhere (eg retinopathy) |
cART = combination antiretroviral therapy; CKD = chronic kidney disease; HIVAN = HIV-associated nephropathy; HIV-ICKD = HIV immune-complex kidney disease; MCGN = mesangio-capillary glomerulonephritis; NOS = not otherwise specified; VL = viral load.