Makindo Medical Notes

About

HIV-Associated Nephropathy (HIVAN) is a serious kidney disease seen in patients with HIV infection. It is most common in individuals of African descent (APOL1 variants) and, if untreated, can progress rapidly to end-stage renal disease (ESRD). Prompt diagnosis and initiation of ART are critical for improving renal and overall outcomes.

📌 Causes & Risk Factors

• Direct Viral Injury: HIV infects renal epithelial cells → podocyte injury and tubular damage.
• Genetic Risk: APOL1 gene variants (common in African descent) significantly ↑ risk.
• Immunosuppression: Low CD4 count, high viral load → higher risk of HIVAN.
• Other contributors: Drug nephrotoxicity, co-infections, and chronic systemic inflammation.

🩺 Symptoms

• Nephrotic features: Proteinuria, oedema.
• Nephritic features: Haematuria, reduced urine output, hypertension.
• Systemic: Fatigue, unintentional weight loss.

🔬 Diagnosis

• Bloods: U&E, creatinine, HIV viral load, CD4 count.
• Urinalysis: Proteinuria (often nephrotic range), haematuria.
• Imaging: Ultrasound → large, echogenic kidneys.
• Renal Biopsy:
  • Focal Segmental Glomerulosclerosis (FSGS, collapsing variant)
  • Microcystic tubular dilatation with proteinaceous casts
  • Crescents may be seen
  • Electron microscopy: tubuloreticular inclusions

💊 HAART can lead to dramatic improvement in renal function and proteinuria.

⚕️ Treatment

• ART: Cornerstone therapy → reduces viral replication and improves renal outcomes.
• ACE inhibitors / ARBs: Reduce proteinuria, control blood pressure, protect nephrons.
• Supportive: Manage hypertension, oedema, dietary salt restriction, optimise cardiovascular risk factors.
• Dialysis: For ESRD (same modalities as HIV-negative patients).
• Transplant: HIV-positive patients can receive renal transplantation if well-controlled on ART.

🛡️ Prevention

• Early ART initiation and adherence.
• Regular renal monitoring (U&E, urine dipstick, proteinuria checks).
• Avoid nephrotoxic drugs (e.g., NSAIDs, aminoglycosides).
• Genetic counselling: APOL1 screening in high-risk groups may help stratify risk.

📋 Key Exam Pearls

✅ HIVAN = collapsing FSGS + microcystic tubular dilatation.
✅ APOL1 gene variant strongly linked in patients of African descent.
✅ Always start ART regardless of CD4 count in HIVAN.
✅ ACEI/ARB reduce proteinuria and improve prognosis.