HIV-ASSOCIATED NEPHROPATHY

Background: Patients with HIV-1 infection are at risk for developing r enal diseases with diverse etiologies. Acute renal failure occurs in u p to 20% of hospitalized patients with HIV infection, and chronic rena l disease of diverse etiology has been reported. The single most commo n cause of chronic renal insufficiency in HIV-1+ patients is HIV-assoc iated nephropathy (HIVAN). Typical morphologic features include enlarg ed kidneys, microcystic tubule dilatation, tubulointerstitial inflamma tion, and focal and segmental glomerulosclerosis. Methods: The pathoge nesis, epidemiology, and treatment options for HIVAN are discussed. In studying the epidemiology of the disease, we reviewed several renal d isease databases, including the United States Renal Data Systems and N ew York State End Stage Renal Disease Network. We have previously repo rted our experience with HIVAN at Mount Sinai Medical Center. Results: The exact cause of the renal disease remains unknown. The importance of a direct effect of HIV-I viral protein(s) or renal HIV-1 gene expre ssion in disease pathogenesis is supported in the murine model of HIVA N, but definitive proof of renal cell infection in humans is lacking. Further study is required to clarify this issue. We estimate that HIVA N is the fourth leading cause of end-stage renal disease (ESRD) among Blacks between the ages of 20 and 64 years, only slightly behind hyper tension, diabetes, and chronic glomerulonephritis. At Mount Sinai Hosp ital HIVAN accounts for 20% of newly diagnosed ESRD in young black adu lts. It has become the third leading cause of ESRD in this group, afte r hypertension and diabetes. Conclusions: In seropositive patients wit h renal disease, renal biopsies should be performed to confirm the dia gnosis and determine the true incidence. Special attention should be d irected toward understanding the underlying cause(s) of HIVAN. A multi center trial to explore the potential for antiviral therapy in this di sease should be initiated.