What glomerular diseases are seen in patients with HIV?
Proteinuria in patients with HIV is often a sign of glomerular disease, even if it is not within the nephrotic range, since it depends on when during an HIV infection the proteinuria is measured. HIV-related glomerular disease goes through an initial phase of microalbuminuria (30 to 300 mg/24 hours) followed by macroalbuminuria (>300 mg/24 hours), culminating in nephrotic syndrome. Any level of proteinuria in a patient with HIV would be considered highly suspicious for one of the glomerular lesions described below:
• HIV-associated nephropathy (HIVAN): collapsing variant of focal segmental glomerular sclerosis (FSGS)
• HIV immune complex disease of the kidney (HIVICK): membranous nephropathy (MN), immunoglobulin (Ig)A nephropathy, diffuse proliferative glomerulonephritis
• HCV-related membranoproliferative glomerulonephritis (MPGN) associated with cryoglobulinemia: Approximately 30% of patients with HIV are co-infected with HCV and may develop glomerular disease from HCV-related immune complex disease
• HBV-associated MN: Approximately 10% to 20% of HIV are co-infected with HBV and can manifest typical HBV glomerular syndromes
• Thrombotic microangiopathy; typically seen in advanced untreated HIV patients
• FSGS: This is the typical perihilar or tip form of FSGS seen in the general population
• Diabetic nephropathy; diabetes is a frequent complication of cART, and since HIV patients are living 10 to 20 years with controlled HIV disease, contemporary biopsy series now show an increasing burden of diabetic nephropathy
• Infection-related glomerulonephritis: immune complex proliferative glomerular disease from opportunistic infections such as Streptococci, Staphylococci, Gram-negative bacteria, etc.
When developing a differential diagnosis of glomerular disease in a patient with HIV, the following questions are important to ask:
• Does the patient have active HIV viremia? If yes, consider HIVAN or HIVICK.
• Is the patient co-infected with HCV or HBV? If yes, consider MPGN or MN, respectively.
• Is the patient on cART and well controlled? If yes, consider typical FSGS, especially in black patients.
• Is the patient receiving cART with secondary diabetes? If yes, consider diabetic nephropathy.
• Is the patient septic? If yes, consider an infection-related glomerulonephritis.
