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Human immunodeficiency virus and dialysis

Paul E Klotman, MD
Christina M Wyatt, MD
Section Editors
Steve J Schwab, MD
Martin S Hirsch, MD
Deputy Editor
Alice M Sheridan, MD


Kidney disease is an important complication of human immunodeficiency virus (HIV) infection, particularly in African Americans [1]. A collapsing form of focal segmental glomerulosclerosis (FSGS) with associated tubular microcysts and interstitial inflammation is the classic form of HIV-related kidney disease, known as HIV-associated nephropathy (HIVAN). HIV infection has also been associated with other forms of kidney disease, in particular, immune complex disease [2]. With prolonged survival and aging of the population, HIV-positive patients are also at increasing risk for kidney disease due to comorbid conditions, such as diabetes and hypertension.

Some of these kidney diseases can result in end-stage renal disease (ESRD). Issues relating to HIV and dialysis will be reviewed here. HIV-related disorders of the kidney are discussed separately. (See "Overview of kidney disease in HIV-positive patients" and "HIV-associated nephropathy (HIVAN)".)


Compared with the general population, HIV-positive patients are at increased risk for end-stage renal disease (ESRD). In a population-based cohort study from Denmark, HIV-positive individuals had a fourfold higher risk of ESRD compared with age- and gender-matched controls [3]. Data from the Veterans Affairs (VA) healthcare system have demonstrated that the risk of ESRD is associated with both HIV-related factors (high HIV-RNA, low CD4, and hepatitis C virus coinfection) and traditional kidney disease risk factors (diabetes, hypertension, and cardiovascular disease) [4]. A subsequent study from the VA suggests that ESRD may occur at a younger age in HIV-positive versus HIV-negative veterans, although the difference is small [5].

Both HIV-related factors and traditional renal risk factors were also associated with a combined endpoint of ESRD and advanced chronic kidney disease in two large HIV cohort studies, D:A:D and EuroSIDA [6,7]. In a smaller, retrospective cohort study from Germany, injection drug use and black race were the only independent risk factors for ESRD in HIV-positive adults [8]. Over the 20-year study period, these authors observed a decline in the prevalence of ESRD among HIV-positive blacks and an increase in the prevalence of ESRD among HIV-positive whites, although the racial disparity in ESRD risk remained significant.

Data from the VA healthcare system and from the Johns Hopkins HIV cohort have also demonstrated a striking disparity in the risk of ESRD among HIV-positive blacks, who may have as much as a 30-fold increase in the risk of ESRD compared with HIV-positive whites [9-11]. In the VA cohort, the risk of ESRD among HIV-positive blacks was similar to that observed among diabetics [9]. Genetic variability in the APOL1 gene on chromosome 22 appears to account for a significant proportion of the racial disparity in ESRD risk, including the risk of HIV-associated nephropathy (HIVAN) and other forms of focal segmental glomerulosclerosis (FSGS) [12-14]. (See "Epidemiology, classification, and pathogenesis of focal segmental glomerulosclerosis", section on 'FSGS in African Americans'.)


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Literature review current through: Sep 2016. | This topic last updated: Mar 23, 2016.
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