HIV: Renal Involvement

Key points

• HIV-associated kidney disease may result directly from HIV, from antiretroviral therapy or from other infections/drugs/comorbidities. Indinavir can cause crystalluria and intratubular obstruction; current ART has reduced the incidence of classic HIV-associated nephropathy.
• HIV-associated nephropathy (HIVAN) classically presents with heavy proteinuria, often nephrotic-range, and progressive renal dysfunction.
• HIVAN often has normal-to-enlarged kidneys , particularly early in disease.
• HIVAN classically shows collapsing focal segmental glomerulosclerosis with tubular microcystic change on biopsy.
• Renal dysfunction causes elevated creatinine/urea; HIVAN risk is particularly associated with uncontrolled HIV/high viral load and APOL1 risk variants. ART is central to management, with renal dosing/avoidance of nephrotoxic ART when appropriate.
• MRCP discriminator: HIV + heavy proteinuria + enlarged kidneys + collapsing FSGS → HIVAN.
• Drug trap: indinavir → crystal nephropathy; tenofovir DF can cause proximal tubular injury/Fanconi syndrome and requires renal-function consideration.