Renal disease is a relatively common complication in patients with human immunodeficiency

virus (HIV) disease.[1] HIV nephropathy can result from direct kidney infection with HIV or from
the adverse effects of antiretroviral drugs (see the image below).[2, 3] Further, patients with HIV
disease are at risk for developing prerenal azotemia due to volume depletion resulting from salt
wasting, poor nutrition, nausea, or vomiting.

Types of electrolyte abnormalities observed with some of the

drugs used to treat opportunistic infections in patients with human immunodeficiency virus
(HIV). ARF stands for acute renal failure.

HIV-associated nephropathy (HIVAN), formerly known as AIDS-associated nephropathy, is

characterized by the following findings:

 Nephrotic range proteinuria

 Azotemia
 Normal to large kidneys on ultrasound images
 Normal pressure
 Focal segmental glomerulosclerosis (FSGS) on renal biopsy findings

Although FSGS is the predominant glomerular lesion in HIVAN, other reported glomerular
lesions in patients with HIV include IgA nephropathy, cryoglobulinemia, amyloidosis, and a
lupuslike immune complex glomerulopathy.

In the preantiretroviral therapy era, HIVAN was characterized by rapid progression to renal
failure and end-stage renal disease (ESRD) leading to the need for dialysis. Highly active
antiretroviral therapy (HAART) has changed the natural course of this disease, increasing the
importance of prompt diagnosis and proper care. Baseline estimated glomerular filtration should
be obtained and renal function monitored during HAART.[4] Physicians must consider HIVAN in
patients who develop proteinuria.

For other discussions on management of HIV infection, see HIV Disease, Pediatric HIV
Infection, and Antiretroviral Therapy for HIV Infection.

For patient education information, see the Immune System Center and Sexually Transmitted
Diseases Center, as well as HIV/AIDS and Rapid Oral HIV Test.

Epidemiology
According to the US Renal Data System (USRDS), HIV-associated nephropathy (HIVAN)
accounts for approximately 1% of new end-stage renal disease (ESRD) cases in the United
States. HIVAN is observed in patients regardless of the route by which HIV was contracted.

HIVAN is observed predominantly among African Americans and is the third leading cause of
ESRD among blacks aged 20-64 years.[5, 6] Most patients with HIVAN are young black men, and
approximately 50% of patients with HIVAN are intravenous drug abusers.[7, 8] Overall, HIVAN
is observed more often in men than in women, with a male-to-female ratio of 10:1. The mean age
of persons with HIVAN is 33 years. HIVAN may occur in children.[9]

Pathophysiology
Experiments using transgenic mice have provided perhaps the strongest evidence for a direct role
by HIV type 1 (HIV-1) in the development of HIV-associated nephropathy (HIVAN).
Researchers created transgenic mice by inserting HIV DNA constructs into the mice's genomes.
The mice developed proteinuria and had a histologic picture similar to that observed in patients
with HIVAN.

A genetic or environmental cofactor that has not yet been identified is required for patients to
develop this disease. This unidentified factor might explain the predilection for HIVAN among
black persons.[5]

The cellular target in the development of HIVAN is probably the renal glomerular and tubular
epithelium. Using in situ hybridization and polymerase chain reaction assays to detect HIV-1
DNA and messenger ribonucleic acid (mRNA), investigators have shown that renal glomerular
and tubular epithelial cells are productively infected by HIV-1 in patients with HIVAN; this
argues strongly for localized replication of HIV-1 in the kidney and for the existence of a renal
viral reservoir.

Further, circularized viral DNA, a marker of recent nuclear import of full-length, reverse-
transcribed RNA, has been detected in kidney biopsy samples from patients with HIVAN,
suggesting active replication in renal tissue.[10] However, the mechanisms of virus-induced renal
injury remain undetermined.

Peculiar histopathologic features of HIVAN are the enhanced proliferation and the loss of
differentiation markers of glomerular epithelial cells. In one study, HIV-1 infection was shown
to kill renal tubular epithelial cells in vitro by triggering an apoptotic pathway involving caspase
activation and Fas up-regulation, suggesting that apoptosis of nonlymphoid cells can be directly
induced by HIV-1. The net and long-standing glomerular and tubular epithelial cell damage leads
to proteinuria, glomerulosclerosis, and tubulointerstitial scarring.

The role of cytokines has not been established, and although their presence is not essential for
the development of HIVAN, cytokines may modify the progression of infection or a patient's
susceptibility to infection. The levels of cytokines are increased in renal biopsy samples from
patients with HIVAN.
In one study, mesangial and tubular cell production of interleukin-6 and tumor necrosis factor–
alpha was shown to be a potent stimulus for HIV-1 expression in HIV-1–infected monocytes.[11]
Viral replication in response to cytokines may play an important role in the pathogenesis of
HIVAN.

Genetics

The reason behind the increased predilection among black persons for the development of HIV-
associated nephropathy is not clear.[5] In general, black persons have a higher incidence of other
renal diseases (eg, diabetic nephropathy, lupus); therefore, they may have an underlying genetic
predisposition to severe renal disease, regardless of the etiology. The type of host response to the
HIV infection itself may be what determines whether or not nephropathy develops in a specific
individual.

Kopp et al studied genetic variants predisposing to idiopathic and HIV-1–associated focal

segmental glomerulosclerosis (FSGS), and they concluded that genetic variation at the MYH9
locus substantially explains the increased burden of FSGS and hypertensive kidney disease
among African Americans. They carried out admixture-mapping linkage-disequilibrium genome
scanning on 190 African American individuals with FSGS and 222 controls and identified a
chromosome-22 region centered on MYH9, a functional candidate gene expressed in kidney
podocytes.[12]

Prognosis
In one study, the rate of progression from the initial presentation to ESRD was 2.5 months in the
pre-HAART (highly active antiretroviral therapy) era. With the introduction of HAART in 1996-
1997, the traditional natural history of rapid progression of HIV-associated nephropathy
(HIVAN) has been slowed significantly. HAART has been shown to retard the progression of
renal disease in persons with HIVAN, and treatment with angiotensin-converting enzyme
inhibitors may be beneficial.

Among patients with HIV infection and end-stage renal disease receiving hemodialysis, survival
has improved significantly compared with the uniformly dismal outcomes in the 1980s.[13]

Clinical Presentation
Patients with HIV-associated nephropathy (HIVAN) typically present with a nephrotic syndrome
consisting of nephrotic-range proteinuria (>3.5 g/d), azotemia, hypoalbuminemia, and
hyperlipidemia. Edema is uncommon in HIVAN, yet many authors think that this is a
characteristic of HIVAN. The salt-losing propensity and high oncotic pressure contributed by
marked hypergammaglobulinemia in these patients have been suggested as possible explanations
for this puzzling observation.

CD4+ T-cell count

The CD4+ T-cell count in patients with HIVAN is usually depressed below 200 cells/µL, but
HIVAN has been reported in patients with higher CD4 counts. The prognosis for renal survival is
worse in patients with AIDS, especially if their CD4 count is less than 50 cells/µL.

Ultrasound and CT scan

Patients with HIVAN are not typically hypertensive, even in the face of renal insufficiency, and
their kidneys are usually normal to large in size and highly echogenic on ultrasonograms, as well
as on CT scans. This may result from prominent interstitial expansion by cellular infiltrate and
markedly dilated tubules containing voluminous casts.

Urinalysis

Routine urinalysis may occasionally reveal findings of nonnephrotic proteinuria in patients being
evaluated for other medical conditions. The urinalysis reveals microhematuria, leukocytes,
hyaline casts, and oval fat bodies, but no cellular casts. Serum complement levels are normal.

SIADH

Electrolyte abnormalities, such as hyponatremia and hyperkalemia, may be observed in patients

with HIVAN and may reflect an increase in total body water (from nephrotic syndrome or
syndrome of inappropriate secretion of antidiuretic hormone [SIADH]) or from hyporeninemic
hypoaldosteronism, respectively.

SIADH may result from concomitant pulmonary infection or from persistent nausea from
medications or gastrointestinal disease. Hyporeninemic hypoaldosteronism, a cause of type IV
renal tubular acidosis manifesting as hyperkalemia with normal anion gap metabolic acidosis, is
much more common when renal insufficiency is present.

Renal Biopsy
The decision to obtain a biopsy sample is somewhat controversial in the general medical
community. Even if a patient presents with the classic clinical features of HIV-associated
neuropathy (HIVAN), clinical consideration is predictive of the biopsy diagnosis in only 55-60%
of patients.

Therefore, to distinguish HIVAN from other forms of renal disease (eg, immune complex
glomerulonephritis, immunoglobulin-A nephropathy), patients who are seropositive for HIV
require a renal biopsy. The typical practice is to obtain a renal biopsy specimen if the patient's
daily protein excretion is greater than 1 g.

Histology

Findings from light microscopy of kidney biopsy tissue are diagnostic in most cases. The most
common histologic light microscopy finding is a collapsing form of focal segmental
glomerulosclerosis.[14] The glomerular capillary tuft is collapsed (see the first image below) and
may be segmentally or globally sclerosed. Visceral epithelial cells are hypertrophied and form a
characteristic pseudocrescent in the Bowman space. Tubulointerstitial scarring, atrophy, and
marked dilatation of the tubules (microcystic dilatations) are usually present (see the second
image below).

Light microscopy with trichrome staining showing the collapse of

the glomerular tuft, with segmental glomerular and interstitial sclerosis (bluish staining). The

renal tubules are dilated and filled with proteinaceous material.

Light microscopy showing prominent microcystic dilatation of renal tubules filled with
proteinaceous material; this finding is characteristic of human immunodeficiency virus (HIV)–
associated nephropathy, although it may also be observed in chronic glomerulonephritis.

Immunofluorescent microscopy helps to identify positive staining for albumin and

immunoglobulin G in epithelial cells and for immunoglobulin M, C3, and, occasionally, A in
mesangial or sclerotic areas.

Electron microscopy reveals wrinkling of the basement membranes, epithelial cell proliferation,
and focal foot process effacement. Tubuloreticular structures in the glomerular endothelial cells
(consisting of ribonucleoprotein and membrane, the synthesis of which is stimulated by alpha
interferon) is highly predictive of HIVAN (see the image below).
 Electron microscopy showing a segment of the glomerular
basement membrane; foot process effacement (black arrow) and prominent tubuloreticular
inclusions (red arrow) are present.

Antiretroviral Drugs and Renal Function

Most HIV medications are well tolerated, even in the presence of renal insufficiency. The
(potential) toxicity of the nucleoside reverse transcriptase inhibitors (ie, zidovudine,[15]
didanosine, zalcitabine, stavudine, lamivudine, abacavir, emtricitabine) uniformly manifests as
type-B lactic acidosis. However, didanosine may cause electrolyte abnormalities, such as
hypokalemia, hyponatremia, hypermagnesemia, and hyperuricemia, and stavudine may cause
hyperuricemia.

Tenofovir is a nucleotide reverse transcriptase inhibitor (NRTI) with known renal toxicity and
hypophosphatemia, and therefore, dose adjustment is indicated when creatinine clearance is less
than 50 mL/min. Except for nevirapine, which may cause lactic acidosis, the nonnucleoside
reverse transcriptase inhibitors (ie, nevirapine, delavirdine, efavirenz, etravirine) have no
reported significant renal toxicity.

As a class, the protease inhibitors (PIs) (ie, saquinavir, ritonavir, indinavir, nelfinavir,
amprenavir, fosamprenavir, lopinavir, atazanavir, tipranavir, darunavir) may precipitate
nephrolithiasis. A classic form of this is indinavir crystalluria, which occurs independently of
renal function; however, the stones resolve after cessation of indinavir therapy. A study by
Rockwood et al found that the rate of kidney stones was 7.3 per 1000 patient-years in patients
receiving ritonavir-boosted atazanavir compared with 1.9 per 1000 patient years in patients
receiving other commonly used antivirals.[16]

Enfuvirtide (Fuzeon) is the first of a newer class of fusion inhibitors that targets the gp41 protein
on the surface of HIV and stops the virus from entering cells. Enfuvirtide has no known renal
effects for creatinine clearance of greater than 35 mL/min.

Maraviroc (Selzentry), approved in August 2007, is also a fusion inhibitor. It blocks the CCR5
coreceptor on CD4+ cells, preventing the virus from entering. Maraviroc does not require dose
adjustment for creatinine clearance greater than 50 mL/min.

Raltegravir (Isentress) is the first of a newer class of integrase strand transfer inhibitors. It does
not require dose adjustment in patients with abnormal renal function.
Dose adjustment should be made in patients receiving nucleoside reverse transcriptase inhibitors
(NRTI) when the glomerular filtration rate falls below 50 mL/min. Patients receiving
nonnucleoside reverse transcriptase inhibitors (NNRTIs) may also receive a dose adjustment
when the glomerular filtration rate falls below 50 mL/min. No dose adjustment is required for
patients taking protease inhibitors.

Some drugs used to treat opportunistic infections in HIV disease may also cause nephrotoxicity
or electrolyte abnormalities (see the image below).

Types of electrolyte abnormalities observed with some of the

drugs used to treat opportunistic infections in patients with human immunodeficiency virus
(HIV). ARF stands for acute renal failure.

Pharmacologic Therapy
Although there are no guiding clinical studies, some experts recommend consideration of therapy
in all patients with HIV-associated nephritis (HIVAN). Initiation or adjustment of antiretroviral
therapy may be indicated. See Antiretroviral Therapy for HIV Infection for specific information,
including recommendations for dosage adjustments for renal insufficiency.

Angiotensin-converting enzyme (ACE) inhibitors and corticosteroids have been studied for use
in HIVAN. Some reports on pediatric populations suggest that cyclosporine can be effective in
reducing proteinuria in persons with HIVAN. The usefulness of cyclosporine therapy for
HIVAN warrants further study. Researchers are pursuing several promising therapeutic
strategies. Patients who progress to end-stage renal disease (ESRD) require dialysis and
consideration of renal transplantation in carefully selected cases.

Angiotensin-Converting Enzyme Inhibitors

In patients with advanced renal insufficiency, captopril was noted to improve renal survival for a
mean length of 37-156 days.[17] In a subsequent prospective follow-up of 44 patients, the median
length of renal survival for patients who received fosinopril was 479.5 days, with only 1 patient
developing ESRD. All untreated control subjects progressed to ESRD, with a median length of
renal survival of 146.5 days.[18]

The exact mechanism of action of ACE inhibitors in HIVAN is unknown, but it may be related
to a hemodynamic effect, a reduction in the transglomerular passage of serum proteins, and an
antiproliferative effect mediated in part by the inhibition of transforming growth factor beta. Use
ACE inhibitors if patients do not have hyperkalemia.

Corticosteroids

A number of case reports have suggested that corticosteroids offer some short-term benefit in
HIVAN.[19] In one report, results from a pretreatment and posttreatment kidney biopsy suggested
that an improvement in renal function was associated with a reduced number of lymphocytes and
macrophages infiltrating the interstitium.

In another report, of 20 patients who were treated with prednisone, 60 mg/day for 2-11 weeks,
followed by a slow taper,[20] 8 patients required maintenance dialysis, 11 died from
complications, and 7 were alive and no longer had ESRD after a follow-up of 44 weeks.

Experimental therapeutic strategies

Animal research shows promising results for retarding renal disease progression in HIVAN. In
one study, the use of a cyclin-dependent kinase inhibitor decreased visceral epithelial cell
proliferation in HIV-infected mice.[21]

In another study, blocking nuclear factor kappa beta (a cell signaling pathway) in mice resulted
in increased lifespan and kidney and lean body mass preservation.[22] These benefits were
associated with a reduction in the number of CD45+ cells infiltrating the kidneys, amelioration of
the renal architecture, and a reduction in the level of circulating inflammatory cytokines. Further
studies are needed to determine the role of these inhibitors on human HIVAN.

End-Stage Renal Disease

The care of patients with HIV-associated nephropathy (HIVAN) who progress to end-stage renal
disease (ESRD) remains a clinical challenge. Physicians must anticipate progressive renal
disease in patients with HIVAN and plan the placement of an arteriovenous fistula in a timely
manner for future use in hemodialysis. In current practice, hemodialysis is the accepted modality
of ESRD therapy in these patients.

A study by Ifudu et al showed that during a 68-month observation period, 17 (50%) of 34

patients with HIV infection and ESRD died, compared with 65 (50%) of 131 patients with ESRD
alone.[23] Mean survival was equivalent between patients with both HIV infection and ESRD and
those with ESRD alone (47.4 mo and 50.2 mo, respectively).

Because of increased susceptibility to infections, peritoneal dialysis has not been widely
advocated. Similarly, immunosuppression after kidney transplantation is thought to pose a
substantive risk of opportunistic infections in patients with HIVAN.[24] Consequently, kidney
transplantation in these patients is performed with caution in compliant, stable patients with no
prior opportunistic infections who have an undetectable viral load and a CD4+ T-cell count of
more than 300 cells/µL.
Anecdotal reports drawn from small samples of this selected group of patients with HIVAN
suggest no extra risk of opportunistic infections. Until larger studies are performed, however,
transplantation in persons with HIVAN should be focused on stable patients.

In one study, 1- and 2-year actuarial patient survival was 85% and 82%, respectively, and graft
survival was 75% and 71%, respectively. Plasma HIV-1 RNA remained undetectable, and CD4
counts remained in excess of 400 cells/µL with no evidence of AIDS for up to 2 years. These
results were comparable to other high-risk populations receiving kidney transplantation.

In a prospective study of kidney transplantation in 150 HIV-infected patients, Stock et al

reported 1- and 3-year graft survival rates of 90.4% and 73.7%, respectively. The rejection rate
was higher than expected, however, with 1- and 3-year estimates of 31% and 41%, respectively.
Living-donor transplants were protective. Before transplantation, all patients had CD4 counts of
at least 200/µL and undetectable plasma HIV-1 RNA levels while being treated with a stable
antiretroviral regimen, and HIV remained well controlled after transplantation.[25]

In an analysis of the United Network for Organ Sharing (UNOS) database, Locke et al evaluated
39,501 patients undergoing renal transplantation between January 1, 2004, and June 30, 2006
and found no difference in patient survival among HIV-positive patients versus HIV-negative
patients (95.4% vs 96.2%, respectively).[13] However, death-censored 1-year graft survival was
significantly lower among HIV-positive patients (87.9% vs 94.6%).

Locke et al concluded that with proper donor selection and transplant recipient management,
including the avoidance of prolonged cold ischemic time, use of living donors, and determination
of optimal immunosuppression dosing before transplant, long-term graft survival comparable to
that in HIV-negative patients can be achieved.