The most common HIV-related glomerulopathy is focal segmental glomerulosclerosis (FSGS). It accounts for 25% of causes of nephrotic syndrome in adults and is more common in African Americans.
FSGS has a fair to poor prognosis. Generally resistant to steroid therapy, patients develop renal insufficiency within 5 to 10 years of diagnosis, and the course is progressive. It can appear in patients whose other HIV markers (CD4 count and viral load) are normal. It presents with nephrotic range proteinuria, azotemia, and normal sized kidneys. The treatment regimen is controversial but remission has been achieved in some patients with cytotoxic agents, steroids, and immunosuppressive agents. Hypertension tends to be resistant to therapy.
Kodner reviews diagnosis and management of nephrotic syndrome in adults. Patients present with marked edema, proteinuria, hypoalbuminemia, and often hyperlipidemia. In adults, FSGS and membranous nephropathy are the most common primary causes. The most common secondary cause is diabetes. Renal biopsy is useful in some cases to confirm the diagnosis. Treatment should include fluid and sodium restriction, diuretics, and ACE inhibitors, and some may benefit from steroids.
Medapalli et al. discuss pathogenesis of HIV-associated nephropathy. HIV-associated nephropathy is characterized histologically by a collapsing form of focal segmental glomerulosclerosis, microcystic tubular dilation, interstitial inflammation, and fibrosis. Nef and Vpr, HIV viral genes, have been implicated in its pathogenesis. They infect the renal epithelium resulting in apoptosis.
Illustration A depicts the biopsy appearance in focal segmental glomerulosclerosis as compared to normal glomeruli.
Answer 1: This describes minimal change disease.
Answer 2: This describes amyloidosis.
Answer 3: This describes diabetic glomerulonephropathy.
Answer 4: This describes rapidly progressive (crescentic) glomerulonephritis.
Kodner C.Nephrotic syndrome in adults: diagnosis and management.Am Fam Physician. 2009 Nov 15;80(10):1129-34.
PMID: 19904897 (Link to Abstract)
Medapalli RK, He JC, Klotman PE.HIV-associated nephropathy: pathogenesis.Curr Opin Nephrol Hypertens. 2011 May;20(3):306-11. doi: 10.1097/MNH.0b013e328345359a.
PMID: 21358326 (Link to Abstract)