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.

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HIV associated nephropathy (HIVAN)

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