Update on current management of chronic kidney disease in patients with HIV infection

Abstract

The prevalence of HIV-associated chronic kidney disease (CKD) varies geographically and depends on the definition of CKD used, ranging from 4.7% to 38% globally. The incidence, however, has decreased with the use of effective combined antiretroviral therapy (cART). A wide variety of histological patterns are seen in HIV-associated kidney diseases that include glomerular and tubulointerstitial pathology. In resource-rich settings, there has been a plateau in the incidence of end-stage renal disease secondary to HIV-associated nephropathy (HIVAN). However, the prevalence of end-stage renal disease in HIV-positive individuals has risen, mainly due to increased longevity on cART. There is a disparity in the occurrence of HIVAN among HIV-positive individuals such that there is an 18- to 50-fold increased risk of developing kidney disease among HIV-positive individuals of African descent aged between 20 and 64 years and who have a poorer prognosis compared with their European descent counterparts, suggesting that genetic factors play a vital role. Other risk factors include male sex, low CD4 counts, and high viral load. Improvement in renal function has been observed after initiation of cART in patients with HIV-associated CKD. Treatment with an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker is recommended, when clinically indicated in patients with confirmed or suspected HIVAN or clinically significant albuminuria. Other standard management approaches for patients with CKD are recommended. These include addressing other cardiovascular risk factors (appropriate use of statins and aspirin, weight loss, cessation of smoking), avoidance of nephrotoxins, and management of serum bicarbonate and uric acid, anemia, calcium, and phosphate abnormalities. Early diagnosis of kidney disease by screening of HIV-positive individuals for the presence of kidney disease is critical for the optimal management of these patients. Screening for the presence of kidney disease upon detection of HIV infection and annually thereafter in high-risk populations is recommended.

Keywords: HIV infection; chronic kidney disease; current management.

Figure 1

HIVAN (silver methenamine, ×200). Note: Collapsing glomerulopathy with tubular microcysts and interstitial inflammation and scarring (Courtesy of Dr Pulane Mosiane, Department of Anatomical Pathology, University of the Witwatersrand, Johannesburg, South Africa). Abbreviation: HIVAN, HIV-associated nephropathy.

Figure 2

HIVICD (silver methenamine, ×400). Note: Mild mesangial expansion and subepithelial immune complex deposits with a basement membrane reaction (blue arrows) (Courtesy of Dr Pulane Mosiane, Department of Anatomical Pathology, University of the Witwatersrand, Johannesburg, South Africa). Abbreviation: HIVICD, HIV immune complex disease.