Introduction
The human immunodeficiency virus is an important public health concern that is related to kidney disease. Due to advances in treatment modality, the life expectancy of people living with HIV has greatly increased. However, the risk of kidney disease and other comorbidities has increased due to improved survival. HIV-associated nephropathy and immune complex kidney disease were the most common complications associated with HIV. Several antiretroviral drugs cause damage to the kidney cells and increase kidney dysfunction. Thus, it is necessary to have specialized kidney care for individuals with HIV to overcome the issues caused by the virus, antiretroviral therapy, and other comorbidities.
What Are the Factors That Cause Kidney Disease in HIV?
Numerous elements play a significant role in kidney diseases associated with HIV. These include HIV infection, antiretroviral therapy, comorbidities, and immune dysregulation.
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Nephrotoxicity of Antiretroviral Therapy: Antiretroviral therapy is essential to control the multiplication of the virus and the progression of the disease. However, certain drugs have disadvantageous effects on kidney cells, causing injury and reducing kidney function. Nucleotide reverse transcriptase inhibitors (Tenofovir disoproxil fumarate (TDF)) and some older protease inhibitors are more common antiretroviral drugs frequently associated with kidney damage. The novel drug Tenofovir alafenamide (TAF) has a similar antiretroviral effect but with decreased toxicity on kidney cells. However, more studies are required, and management of the condition still requires more attention.
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HIV Infection: HIV can invade the kidney epithelial cells and undergo replication inside them. This causes kidney damage, leading to diseases like HIV-associated nephropathy (HIVAN). However, with the commencement of ART, the incidence of HIV has tremendously reduced. This shows the importance of ART in HIV-infected people.
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Comorbidities: Another ongoing study is how HIV can cause kidney disease because of standard risk factors like diabetes and hypertension. Several epidemiological studies have confirmed the association of HIV and diabetes in promoting kidney-related illnesses.
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Immune Dysregulation: Infection with human immunodeficiency virus can cause immune dysfunction and progress in inflammation. These can cause damage to kidney cells resulting in kidney disease.
What Are the HIV-Associated Kidney Diseases?
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HIV-Associated Nephropathy: The most common condition linked with HIV is HIV-associated nephropathy. It is seen more in people of African descent people because of genetic predisposition. This condition occurs when HIV replicates in the renal epithelial cells, causing damage to the cells. HIVAN is characterized by FSGS (focal segmental glomerulosclerosis). FSGS is scarring of the kidney, particularly damaging the glomeruli of the kidneys. In this condition, the permeability of the glomerular membrane increases due to damage to podocytes (cells that maintain the integrity of the barrier membrane). This results in proteinuria (excess protein in the urine). Earlier treatment with antiretroviral therapy prevents the multiplication of viral cells and further damage to the kidney. This prevents the occurrence of HIV- associated nephropathy. ACE (angiotensin-converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are administered to reduce the protein loss in the urine. It also helps to lower blood pressure.
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Chronic Kidney Disease: Individuals with HIV are more at risk of developing chronic kidney disease. The standard risk factors that contribute to the occurrence of CKD are diabetes, hypertension, and dyslipidemia. When CKD is diagnosed in people with HIV, they must begin the ART promptly. In addition to this, risk factors like diabetes and hypertension must also be treated and kept under control to prevent the progression of the disease. Certain lifestyle changes should also be encouraged, which include low salt intake, exercise, and weight loss to reduce the risk of cardiac and other kidney diseases.
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HIV-Associated Immune Complex Kidney Disease (HIVICK): It is a group of kidney disorders seen in people with HIV. HIVICK occurs due to the deposition of immune complexes in glomeruli. The immune complex consists of HIV antigen and host antibody. These get deposited in the kidneys and lead to kidney dysfunction. The symptoms include proteinuria, decreased glomerular filtration rate, hypocomplementemia (low complement protein in blood), and unusual urinary sediment. HIVICK includes membranoproliferative glomerulonephritis (an immune-mediated kidney disease), IgA nephropathy (deposition of immunoglobulin A in renal glomeruli), post-infectious glomerulonephritis (kidney disease that occurs after a bacterial infection), and lupus-like glomerulonephritis (inflammation of the kidneys due to an autoimmune disease). Begin ART once HIV is diagnosed to reduce the formation of immune complexes and its deposition. Opt for less nephrotoxicity ART, as it may affect the kidney cells and progress the kidney disease. Treat co-occurring conditions like hepatitis B or C to reduce immune complex formation.
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Acute Kidney Injury: Acute kidney injury occurs in HIV due to prerenal, renal, or postrenal causes. It may cause an abrupt decline in kidney function, resulting in mild, temporary damage or a severe decline. Symptoms include oliguria, edema, nausea, vomiting, and tiredness. Certain drugs included in the ART regimen, including Tenofovir disoproxil fumarate (TDF), may also cause AKI. Treating acute kidney injury depends on various factors, such as what causes AKI and the degree of kidney impairment.
Is Dialysis Suitable for People With HIV?
People with HIV are more susceptible to kidney disease progression and develop end-stage kidney disease. This is more common in individuals with HIV infection. They are the candidates for dialysis. The life expectancy of PWH on dialysis is comparatively lower than PWH. Dialysis does the function of kidneys and helps remove waste products and excess fluids from the body. The precautionary measures to be followed are the same in dialysis to prevent the spread of infection to other patients and healthcare providers.
How to Prevent the Risk of Kidney Diseases in HIV-Positive Individuals?
The following steps may help reduce the risk -
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Take medications prescribed for HIV properly without fail.
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Include a diet rich in fruits, vegetables, and whole grains.
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Reduce the consumption of salt and sugar.
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Exercise every day for a minimum of 30 minutes.
Conclusion
People with human immunodeficiency virus are more susceptible to various kidney diseases. The factors that are responsible for HIV-associated kidney diseases are drug nephrotoxicity, immune complex formation, multiplication of virus in kidney epithelial cells, and comorbidities. Considering the wide range of diseases, nephrology care for HIV patients is of great importance to increase life expectancy and standard of living.
