Clinicopathological correlation of kidney disease in HIV infection pre- and post-ART rollout

Abstract

The spectrum of HIV-associated kidney disease has expanded significantly with the introduction of antiretroviral therapy (ART). In the pre-ART era there was prominence of HIV-associated nephropathy (HIVAN). More recently, the spectrum of disease additionally reflects comorbid illness in the ageing HIV population and ART-related nephrotoxicity. We performed a clinicopathological correlation of kidney disease in HIV-positive individuals who underwent kidney biopsy between 1989 and 2014, utilizing the 2018 Kidney Disease Improving Global Outcomes pathologic classification. ART rollout began in 2004 in South Africa. Patients biopsied pre-ART rollout were compared to those biopsied post-ART rollout with respect to demographics, clinical parameters and histology. We assessed kidney survival in a cohort of these patients following biopsy. Six hundred and ninety biopsies were included, 99 (14.3%) were undertaken pre- and 591 (85.7%) post-ART rollout. Most patients were of Black African descent (97.5%). The post-ART rollout patients were older (p = 0.007), had higher eGFR at presentation (p = 0.016) and fewer presented with eGFR of less than 15ml/min/1.73m2 (p = 0.0008). There was a decrease in the prevalence of classic HIVAN (p = 0.00001); and an increase in FSGS (NOS) in the setting of HIV (p = 0.0022) and tubulointerstitial diseases (p = 0.009) post-ART rollout. Kidney function survival over 5 years was poorest in patients with classic HIVAN (p = 0.00005) and best in minimal change nephropathy (p = 0.0013). Kidney biopsy is crucial for the correct diagnosis and management of HIV-related kidney disease. ART rollout has shifted the spectrum of kidney disease away from classic HIVAN but has not eliminated it. Histological diagnosis prognosticates kidney survival.

Fig 1. Median CD4 count and annual incidence of classic HIVAN in HIV-positive patients who underwent a native kidney biopsy following ART rollout in 2004.

Fig 2. CD4 count at presentation among glomerular-dominant lesions in HIV-positive patients who underwent a native kidney biopsy.

Fig 3. Percentage of patients achieving viral load suppression among glomerular-dominant lesions in HIV-positive patients who underwent a native kidney biopsy.

Fig 4. eGFR at time of kidney biopsy among patients within the subgroup with a glomerular-dominant lesion in the 229 HIV-positive patients with serial kidney function measurement.

Fig 5. Kidney function survival by histological type in the 229 HIV-positive patients with serial renal function measurement.