obsolete HIV-associated nephropathy

HIV-associated Nephropathy (HIVAN): A Historical Perspective

HIV-associated nephropathy (HIVAN) was the first kidney disease to be classically associated with HIV infection, initially described in 1984 during the early AIDS epidemic. This unique condition was characterized by a subset of patients developing severe nephrotic syndrome, irreversible renal failure, and rapid progression to end-stage kidney disease (ESKD).

Key Features

• Collapsing Focal Segmental Glomerulosclerosis: HIVAN presented as a collapsing form of focal segmental glomerulosclerosis (FSGS), with segmental collapse of the capillary loops, occlusion of the lumen, and associated podocyte satellite hyperplasia.
• Predominantly Affects African Americans and Haitian Immigrants: Early reports from New York and Miami described an aggressive form of HIVAN in African Americans and Haitian immigrants with advanced HIV infection.
• Severe Nephrotic Syndrome and Rapid Progression to ESKD: Patients with HIVAN experienced severe nephrotic syndrome, irreversible renal failure, and rapid progression to end-stage kidney disease (ESKD).

Impact of Antiretroviral Therapy

The widespread introduction of combination antiretroviral therapy has had a significant impact on the natural history and epidemiology of HIVAN. As a result, this condition is now infrequently encountered in populations with access to effective antiretroviral treatment.

References: [1] [2] [3] [9] [10] [11]

Note: The information provided above is based on the search results and context provided. It describes the historical perspective of HIV-associated nephropathy, its key features, and the impact of antiretroviral therapy on its epidemiology.

HIV-associated Nephropathy (HIVAN) Signs and Symptoms

HIV-associated nephropathy, also known as HIVAN, is a kidney disease that was commonly seen in the early days of the HIV epidemic. Although it's now less frequently encountered, understanding its signs and symptoms can provide valuable insights into this condition.

Typical Presentation

Patients with HIVAN typically present with nephrotic range proteinuria, which means they have an excessive loss of protein in their urine. This is often accompanied by renal insufficiency, indicating a decline in kidney function [1].

Other Symptoms and Signs

In contrast to most proteinuric renal diseases, hypertension (high blood pressure) and hematuria (blood in the urine) are not always present in patients with HIVAN [2]. However, some individuals may experience pyuria (pus in the urine), eosinophilia (an increase in eosinophils, a type of white blood cell), fever, rash, or flank pain [3].

Key Points

• Nephrotic range proteinuria and renal insufficiency are common presentations.
• Hypertension and hematuria may not always be present.
• Other symptoms like pyuria, eosinophilia, fever, rash, or flank pain can occur.

These signs and symptoms were more commonly observed in the past when HIVAN was a significant concern. However, with advancements in antiretroviral therapy and changes in the natural history of HIV infection, this condition is now less frequently encountered [4].

References:

[1] Patients with HIVAN typically present with nephrotic range proteinuria and renal insufficiency. In contrast to most proteinuric renal diseases, hypertension and ... (Search Result 1)

[2] by CM Wyatt · 2017 · Cited by 134 — HIV-associated nephropathy (HIVAN) was the first kidney disease described in HIV-infected persons but is now infrequently encountered in populations with access ... (Search Result 2)

[3] by S Khan · 2006 · Cited by 16 — HIV-associated nephropathy became well recognized and soon was found to be the most common cause of chronic kidney failure and end-stage renal disease (ESRD) in ... (Search Result 3)

[4] by J Röling · 2006 · Cited by 291 — HIV-related renal impairment can present as acute or chronic kidney disease; it can be caused directly or indirectly by HIV and/or by drug-related effects that ... (Search Result 4)

Diagnostic Tests for Obsolete HIV-Associated Nephropathy

HIV-associated nephropathy (HIVAN) was a classic kidney disease associated with HIV infection, but its incidence has decreased significantly due to the advent of antiretroviral therapy. However, it is still essential to diagnose and manage this condition accurately.

Kidney Biopsy: The definitive diagnosis of HIVAN requires a kidney biopsy, which can be challenging in patients with active HIV infection. A renal biopsy is necessary to confirm the presence of collapsing glomerulopathy, a hallmark feature of HIVAN [3][4].

Microalbuminuria Screening: Microalbuminuria is an early marker for HIV-AN and screening for microalbuminuria is recommended for early diagnosis of HIV-AN [12]. However, this test may not be specific to HIVAN and can be positive in other conditions.

CD4 Count: A low CD4+ cell count is a risk factor for developing HIVAN. However, this test is not diagnostic but rather indicative of immune suppression [13].

Renal Function Tests: Renal function tests, such as serum creatinine and estimated glomerular filtration rate (eGFR), can help assess the severity of kidney impairment in patients with suspected HIVAN.

Imaging Studies: Imaging studies, like ultrasound, may show enlarged echogenic kidneys in patients with HIVAN. However, these findings are not specific to HIVAN and require a renal biopsy for confirmation [6].

It is essential to note that the diagnosis of HIVAN has become less frequent due to the widespread use of antiretroviral therapy. The current knowledge suggests that HIV immune complex kidney disease is being diagnosed more frequently than HIVAN, especially in patients with low CD4 counts and AIDS-defining diagnoses [14].

Management of Obsolete HIV-Associated Nephropathy (HIVAN)

The management of HIVAN has evolved over the years, and current treatment approaches focus on antiretroviral therapy (ART) to suppress HIV viremia. However, specific treatments for HIVAN itself are still being researched.

• Antiretroviral Therapy (ART): The primary goal of ART is to reduce HIV-associated morbidity and mortality by suppressing HIV RNA levels [7]. This can be achieved using highly active antiretroviral therapy (HAART) or other combination therapies.
• Immunosuppressive Therapy: In some cases, immunosuppressive therapy may be used to mitigate renal inflammation induced by immune complex deposition [4].
• Nonspecific Therapies: Observational data suggest that nonspecific therapies such as glucocorticoids and ACE inhibitors may be beneficial in treating HIVAN [5].

Important Considerations

• The use of antiretroviral agents, such as indinavir and tenofovir, has been associated with nephrotoxic drug effects that are usually reversible [2].
• Tenofovir therapy has also been linked to acute renal failure (ARF) and Fanconi syndrome in patients with HIV infection [10].

Current Recommendations

While specific treatment recommendations for HIVAN are limited, the use of DTG/3TC as a 2-drug regimen is currently recommended for initial therapy when HIV RNA levels are less than 500 copies/mL [8]. However, further research is needed to establish the optimal treatment approach for HIVAN.

References:

[1] Kofotolios I (2023) - Management of HIVICK remains controversial and mainly focuses on HIV viremia suppression with combined antiretroviral therapy. [2] Röling J (2006) - Antiretroviral agents have been associated with nephrotoxic drug effects that are usually reversible. [4] Kofotolios I (2023) - Immunosuppressive therapy may be used to mitigate renal inflammation induced by immune complex deposition. [5] The treatment of HIVAN is based on observational data, and includes nonspecific therapies such as glucocorticoids and ACE inhibitors. [7] Feb 3, 2011 - The primary goal of antiretroviral therapy is to reduce HIV-associated morbidity and mortality. [8] Gandhi RT (2023) - DTG/3TC is the only 2-drug regimen currently recommended for initial therapy when HIV RNA levels are less than 500 copies/mL. [10] Zimmermann AE (2006) - Tenofovir therapy has been associated with acute renal failure and Fanconi syndrome in patients with HIV infection.

Obsolescence of HIV-associated Nephropathy (HIVAN)

The concept of HIV-associated nephropathy (HIVAN) as a distinct kidney disease has largely become obsolete due to the advancements in antiretroviral therapy (ART). With the widespread use of ART, the incidence and prevalence of HIVAN have significantly decreased [1][2].

Current Understanding

In the era of effective ART, the primary renal complications associated with HIV infection are now more frequently attributed to immune complex kidney disease, rather than collapsing focal segmental glomerulosclerosis (FSGS), which was a hallmark of HIVAN [3]. This shift in understanding is reflected in the updated diagnostic criteria and guidelines for managing kidney diseases in patients with HIV.

Differential Diagnosis

The differential diagnosis for renal complications in HIV-infected individuals now includes:

• Immune complex kidney disease
• Thrombotic microangiopathy
• Focal segmental glomerulosclerosis (FSGS)
• Other causes of chronic kidney disease (CKD)

Key Points

• The obsolescence of HIVAN as a distinct entity is largely due to the effectiveness of antiretroviral therapy.
• Immune complex kidney disease has become a more common renal complication in HIV-infected individuals.
• A comprehensive differential diagnosis is essential for managing renal complications in patients with HIV.

References:

[1] Wyatt CM. (2017) HIV-associated nephropathy occurs less frequently in the era of antiretroviral therapy. [Source 2]

[2] Röling J. (2006) Acute and chronic HIV-associated renal disease, metabolic alterations and related nephropathies. [Source 3]

[3] Fine DM. (2008) Kidney biopsy is an essential tool for evaluating kidney disease in HIV-infected patients. [Source 4]