HIV-associated kidney diseases: progress, gaps, and future directions

SUMMARY With improved uptake and earlier initiation of effective antiretroviral therapy (ART), the landscape of chronic kidney disease (CKD) among people with HIV (PWH) has substantially evolved. HIV-driven kidney diseases, particularly HIV-associated nephropathy (HIVAN), have largely disappeared in regions with widespread ART availability. However, CKD remains an important comorbidity among PWH because of the increased prevalence of age-related conditions such as diabetes and hypertension, which are established CKD risk factors. Whether contemporary ART regimens that have lower metabolic and kidney toxicity will lower this burden over time remains unclear. In low-resourced areas, these age-related conditions are compounded by persistent disparities in access to ART, co-infections, and limited resources for CKD screening and management. Early detection and management of CKD are crucial to slowing CKD progression and averting its related cardiovascular complications. The past several years have ushered in several new therapies that both lower the risk for CKD progression and adverse cardiovascular events, underscoring the importance of kidney function and albuminuria testing in those at high risk of CKD or CKD progression. For PWH who unfortunately progress to end-stage kidney disease, kidney transplantation now offers improved survival but requires careful management of immunosuppressive regimens and infectious complications. This review will discuss the current understanding of the epidemiology, pathogenesis, diagnosis, and management of kidney diseases in PWH.