HIV-Associated Nephropathy (HIVAN)

1. HIVAN (collapsing FSGS):

• Heavy nephrotic-range proteinuria
• Rapid fall in eGFR
• Large echogenic kidneys (USS)
• Biopsy: collapsing FSGS, microcystic tubular dilatation, tubuloreticular inclusions on EM
• Almost all patients have West African ancestry + two APOL1 risk variants

2. Hiv Immune Complex Kidney Disease (Hivick)

• 'Lupus-like' immune complex GN
• Proteinuria + haematuria
• Mixed picture on biopsy (membranous, MPGN, IgA, fibrillary)
• Less ART-responsive than HIVAN

3. Thrombotic Microangiopathy (Tma)

• Mostly in uncontrolled HIV with low CD4
• AKI + MAHA + thrombocytopenia
• Treat HIV + plasma exchange ± eculizumab (selected)

4. Co-infection Gn

• HBV → membranous nephropathy
• HCV → cryoglobulinaemic MPGN
• Hep C now largely curable with DAAs

5. Drug-induced

• Tenofovir (TDF) — proximal tubulopathy, Fanconi
• Atazanavir — crystal nephropathy and stones
• Cotrimoxazole, dapsone — AIN
• Acyclovir — crystal AKI if rapid IV bolus

6. Conventional CKD

• Diabetes, hypertension, atherosclerotic disease — increasingly the dominant cause as the HIV population ages

Baseline For Every Patient With Hiv

• eGFR every 6-12 months on stable ART
• Urine ACR every 6-12 months
• BP at every visit
• Bone profile if on TDF
• Renal ultrasound if abnormal screen

When To Biopsy

• Persistent ACR >70 mg/mmol
• Unexplained CKD with eGFR <60
• Falling eGFR not explained by drugs
• Active urinary sediment
• Atypical features

Additional Tests

• HIV viral load, CD4 count
• ART history (especially TDF exposure)
• Hep B/C serology
• ANA, complement, immunoglobulins
• Serum free light chains (if myeloma considered)
• Urine PCR/ACR, microscopy
• APOL1 genotyping in West African ancestry (research/specialist centre)

Uss

• HIVAN: large kidneys (>13 cm), increased echogenicity
• Other causes: variable

Hivan

• ART (combination antiretroviral therapy) — the single most important step
• ACE inhibitor or ARB — reduce proteinuria
• Statin
• BP target <130/80
• Steroids — limited evidence; consider 1 mg/kg prednisolone for 2-11 weeks in unresponsive cases (specialist)
• SGLT2 inhibitor — emerging role, use as in non-HIV CKD if eGFR ≥20 and proteinuria persists
• Dialysis or transplant if progresses to ESKD
• Kidney transplantation is now standard of care for ESKD in well-controlled HIV (undetectable VL >6 months, CD4 >200, no opportunistic infections); HIV-to-HIV transplant programmes exist (UK)

Hivick

• ART (less reliably effective than for HIVAN)
• ACE/ARB + statin
• Selected immunosuppression — biopsy guided

Tma

• Treat HIV
• Plasma exchange
• Eculizumab in selected aHUS-like cases

Drug-induced

• Switch TDF → TAF or abacavir (if HLA-B*5701 negative)
• Stop atazanavir if crystal nephropathy
• Manage tubulopathy: replace K, phosphate, bicarbonate
• Monitor — most TDF tubulopathy partially reverses with switch

General CKD Care

• Vaccinations (pneumococcal, hepatitis B, flu, COVID, shingles non-live)
• Cardiovascular risk: statin (most), aspirin if indicated
• Bone health: DXA if TDF exposure or RTA
• Mental health screen, social support, addiction support if relevant
• Multidisciplinary HIV + nephrology clinic — gold standard

Dose Adjustment

• Most ART drugs need dose adjustment in CKD — consult HIV pharmacist
• Use estimated GFR cautiously: dolutegravir, cobicistat raise serum creatinine without true GFR change (block tubular creatinine secretion); confirm true eGFR with cystatin C if uncertain

Dialysis

• Same modalities as non-HIV patients
• Haemodialysis or peritoneal dialysis both safe
• Standard precautions adequate; no isolation required
• Maintain ART through dialysis

Kidney Transplant

• Excellent outcomes if well-controlled HIV (UV <50, CD4 >200, no AIDS-defining illness in 12 months)
• Adjust immunosuppression for drug interactions (especially with PI-based ART → switch to integrase-inhibitor regimens like dolutegravir before transplant)
• Use cobicistat with caution — interacts heavily with tacrolimus
• HIV-to-HIV deceased donor transplant programmes operational in the UK
• Outcomes approaching non-HIV recipients in modern era

KEY MESSAGE: HIV is no longer a contraindication to renal replacement therapy or transplant in 2026. With suppressed virus and good CD4, kidney outcomes match the general population.