Recent developments in HIV and the kidney

Recent developments in HIV and the kidney
Current Opinion in Infectious Diseases. 22(1):43-48, February 2009.
ISSN: 0951-7375 • Frequency: 6/year • Impact Factor: 4.35 • Subscribe Now

World AIDS Day provides an opportunity to focus on the reality of HIV/AIDS today. For those who have come forward to be diagnosed, combination antiretroviral therapy (cART) is now within reach in many parts of the world, and its use reduces the risk of severe AIDS-defining infectious and neoplastic complications, and dramatically improves survival. Recent epidemiological and clinical studies have highlighted the association between chronic, uncontrolled HIV replication and cardiovascular, hepatic, renal and neurological disease. It has become apparent that the period previously referred to as "clinical latency" is in fact characterised by heightened immune activation and inflammation, and that this plays a central role in the pathogenesis of these non-infectious complications. Use of cART can reduce HIV-associated inflammation, and earlier cART initiation is being investigated as a strategy to improve health outcomes.

The effects of HIV on the kidney have long been recognised. Our article summarises recent progress in our understanding, and focuses on acute renal failure, which remains common among "late presenters" - those in whom HIV is diagnosed once significant immunodeficiency has occurred, and chronic kidney disease. Its most severe manifestation, end-stage renal failure, fortunately remains relatively rare, although black patients are at particular risk due to genetic susceptibility. Chronic kidney disease is present in 15-20% of HIV infected patients and an important risk factor for cardiovascular morbidity. cART may improve renal function in those with subnormal renal function at baseline, and data is emerging that cART use is associated with renal tubular dysfunction. Sever tubular dysfunction may manifest as renal tubular acidosis, Fanconi syndrome or osteomalacia, and this is almost exclusively observed in those taking tenofovir. Screening for these and other renal abnormalities are progressively implemented as part of HIV care, and treatment strategies with nucleoside/nucleotide sparing regimens to reduce cART toxicity are being investigated. Prevention of cardiovascular and renal complications through blood pressure control, lipid lowering therapy and smoking cessation are of increasing importance as people living with HIV infection survive into old age.

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