Treatment of HIV-Associated Nephropathies

In patients with HIV, the use of highly active antiretroviral therapy has improved life expectancy. At the same time, this increase in life expectancy has been associated with a higher frequency of chronic kidney disease due to factors other than HIV infection. Besides HIV-associated nephropathy, a number of different types of immune complex and non-immune complex-mediated processes have been identified on kidney biopsies, including vascular disease (nephrosclerosis), diabetes, and drug-related renal injury. In this setting, renal biopsy needs to be considered in order to obtain the correct diagnosis in individual patients with HIV and kidney impairment. Many issues regarding the optimal treatment of the different pathological processes affecting the kidneys of these patients have remained unresolved. Further research is needed in order to optimize treatment and renal outcomes in patients with HIV and kidney disease. Copyright © 2011 S. Karger AG, Basel Published online: February 3, 2011 Fernando C. Fervenza, MD, PhD Division of Nephrology and Hypertension Mayo Clinic College of Medicine 200 First Street, SW, Rochester, MN 55901 (USA) Tel. +1 507 266 7083, E-Mail fervenza.fernando @ mayo.edu © 2011 S. Karger AG, Basel 1660–2110/11/1184–0346$38.00/0 Accessible online at: www.karger.com/nec Treatment of HIV-Associated Nephropathies Nephron Clin Pract 2011;118:c346–c354 c347 uria predicted HIVAN in 67% of cases, while a CD4+ count ! 200 cells/ l had a sensitivity and specificity for HIVAN of 74 and 67%, respectively, with positive and negative predictive values of 58 and 82%, respectively [10] . Untreated, HIVAN rapidly progresses to end-stage renal disease (ESRD). In addition to HIVAN, a number of other HIV-associated kidney diseases have been described [3, 6, 11] . Regardless of the specific histologic lesion, it is clear that persons with kidney disease have a greater risk of death and cardiovascular events when compared with a community-based population without CKD [12] . The same is true for patients with HIV and CKD, where the presence of proteinuria and/or decreased kidney function is associated with increased mortality and worse outcomes [13] . However, little is known regarding the prevalence of proteinuria in HIV patients and the effects of highly active antiretroviral therapy (HAART) on proteinuria. As will be discussed below, the limitations in the available data highlight the need for good quality prospective controlled studies to address the effects of interventions for treating patients with HIVAN and other HIV-associated glomerular diseases. Although placebo-controlled trials are not ethically appropriate given the strong evidence that HIV-associated end-organ disease is improved with HIV viral control, long-term follow-up is needed to determine if kidney damage in susceptible individuals correlates with the level of viral replication, or immunologic response after treatment with HAART, particularly when control of viremia is incomplete or intermittent. Further evaluation of the effects of angiotensin II blockade (ACE inhibitors, angiotensin II receptor blockers, or renin inhibitors), both in terms of kidney function and proteinuria effects in patients with HIVAN and other HIV-mediated kidney diseases, is required. There is also a need for further delineation regarding the role of immunosuppressive agents commonly used in HIV-negative patients with parenchymal diseases (e.g. corticosteroids), either alone or in combination with HAART in the treatment of HIV-associated kidney diseases. These points have been highlighted in an excellent recent review [14] . HIV-Infected Patients with Kidney Disease other