Pharmacotherapy and treatment options for HIV-associated nephropathy

Abstract

Human immunodeficiency virus (HIV) remains a worldwide disease with significant mortality and morbidity. There are a multitude of HIV-related kidney diseases including HIV-associated nephropathy (HIVAN) most prominently. The risk of developing HIVAN increases with decreasing CD4 count, higher viral load, and based on genetic factors. The mortality rate for those with HIVAN-end stage renal disease (ESRD) remains 2.5-3 times higher than ESRD patients without HIVAN. Areas covered: The epidemiology of HIVAN, particularly risk assessment, will be explored in this review. Further, the pathogenesis of HIVAN, from viral-specific renal expression to the role of genetics as well as characteristic renal pathology will be described. Diagnosis and management of HIVAN will be addressed, with an emphasis on various treatment strategies including medication, dialysis, and kidney transplantation. Expert opinion: HIVAN is associated with a high risk for progression to ESRD and increased mortality. The backbone of HIVAN therapy remains combined anti-retroviral therapy (cART), while adjunctive therapies including RAAS blockade and prednisone, should be considered. In those who progress to ESRD, dialysis remains the mainstay of management, though increasing evidence has demonstrated that kidney transplantation can be effective in those with controlled HIV disease.

Torque Teno Virus plasma level as novel biomarker of retained immunocompetence in HIV-infected patients

“…Accordingly, multiple factors need to be considered and collectively illustrate the complexity of individualized HIV therapy. While the characteristics of drugs and the virus are well studied and mostly considered in treatment options [ 5 , 6 ], host characteristics are less well understood [ 7 ].…”

Discontinuation of Intermittent Hemodialysis in HIV-Associated Nephropathy Following Initiation of Antiretroviral Therapy

“…The main therapeutic options for the management of HIVAN are ART, proteinuria control with angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers, and may involve steroid therapy for the suppression of inflammation [ 11 , 14 ]. Given that the development of HIVAN can happen at any stage, treatment with ART remains the mainstay of therapy regardless of the CD4 count [ 14 ]. Several cases in the literature have been reported with evidence of improvement of renal function after the initiation of ART [ 3 ].…”

APOL1 risk variants and the development of HIV‐associated nephropathy

“…Regardless of the effect of APOL1 on the progression of HIVAN, treating the HIV will prevent the development of HIVAN; even if HIVAN is confirmed on biopsy, ART can still delay progression to ESRD [2]. Before the use of ART, ACE inhibitors (ACEi) and angiotensin receptor blockers (ARBs) were used to delay ESRD in HIVAN in Black patients [87]. APOL1 variants were unknown at the time, so it is unknown whether this subpopulation will respond similarly.…”

“…Given the possible importance of NF-jΒ signaling in upregulating APOL1, there may be a role for glucocorticoids in immunologically well-controlled patients with an undetectable viral load who still have renal disease progression despite ART. Although recent studies have not evaluated the use of glucocorticoids as adjunctive therapy in APOL1 variant patients, older studies have found a potential benefit to using glucocorticoids in reducing the inflammatory response within podocytes [87].…”