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The impact of early ART initiation (versus deferring) on kidney function has not been studied. START was a randomised comparison of immediate versus deferred ART initiation among HIV-positive persons with CD4 + (cells/mm 3 ) counts >500. Serum creatinine and urine dipstick protein were measured at Months 0, 1, 4, 8 and 12, and annually thereafter. The two arms were compared for changes in eGFR (mL/min/1.73 m 2 , calculated by CKD-EPI equation), over time using longitudinal mixed models. Of 4685 START participants, 4629 (2294 in immediate and 2335 deferred arm) were included. Median baseline CD4 + and eGFR were 651 and 111.5, respectively. ART was initiated in 2271 participants (99.0%) in the immediate and 1127 (48.3%) in the deferred arm, accounting for >94% and >19% of follow-up time, respectively. Overall, 89% started ART using a tenofovir-based regimen. Over 2.1 years median follow-up, mean eGFR was 0.56 (95% CI 0.003-1.11) higher in the immediate versus deferred arm, which was more prominent after adjustment for current tenofovir or bPI use (1.85, 95% CI 1.21-2.50) and in Black participants (30.1% overall) (3.90, 95% CI 2.84-4.97) versus non-Blacks (1.05, 95% CI 0.33-1.77) (P < 0.001 for interaction). Relative risk for proteinuria in the immediate versus deferred arm was 0.74 (95% CI 0.55-1.00) (P = 0.049). In the short-term, immediate ART initiation was associated with a modestly higher eGFR and lower proteinuria risk versus deferring ART (more pronounced in Black participants). Whether this early benefit translates into a lower risk of CKD requires further follow-up., (Copyright © 2017 Elsevier B.V. and International Society of Chemotherapy. All rights reserved.)

Background: FTC/TAF was shown to be noninferior to FTC/TDF with advantages in markers of renal and bone safety., Objective: To evaluate the efficacy and safety of switching to FTC/TAF from FTC/TDF by third agent (boosted protease inhibitor [PI] vs. unboosted third agent)., Methods: We conducted a 48-week subgroup analysis based on third agent from a randomized, double blind study in virologically suppressed adults on a FTC/TDF-containing regimen who switched to FTC/TAF vs. continued FTC/TDF while remaining on the same third agent., Results: We randomized (1:1) 663 participants to either switch to FTC/TAF (N = 333) or continue FTC/TDF (N = 330), each with baseline third agent stratifying by class of third agent in the prior treatment regimen (boosted PI 46%, unboosted third agent 54%). At week 48, significant differences in renal biomarkers and bone mineral density were observed favoring FTC/TAF over FTC/TDF (p < 0.05 for all), with similar improvements in the FTC/TAF arm in those who received boosted PI vs. unboosted third agents. At week 48, virologic success rates were similar between treatment groups for those who received a boosted PI (FTC/TAF 92%, FTC/TDF 93%) and for those who received an unboosted third agent (97% vs. 93%)., Conclusions: In virologically suppressed patients switching to FTC/TAF from FTC/TDF, high rates of virologic suppression were maintained, while renal and bone safety parameters improved, regardless of whether participants were receiving a boosted PI or an unboosted third agent. FTC/TAF offers safety advantages over FTC/TDF and can be an important option as an NRTI backbone given with a variety of third agents.

Background: Little is known about the progression of kidney disease in HIV-infected patients in developing countries in the era of antiretroviral therapy (ART)., Methods: HIV-infected patients were screened for kidney disease. Kidney biopsies were performed before and after initiation of ART to assess the clinical and histological response to treatment. Data were collected from all participants in accordance with the study protocol. The mean follow-up was 2.4 patient years on ART., Results: There was a rapid immunological and renal response to ART. The renal response was reflected by a significant rise in the estimated glomerular filtration rate (eGFR) and rapid regression of proteinuria. The histological patterns were highly variable, ranging from non-specific lesions such as mesangial hyperplasia and interstitial nephritis to HIV-immune complex disease (HIV-ICD) with or without features of HIV-associated nephropathy (HIVAN). In the follow-up biopsies, the histological response to treatment was variable with a combination of no change, progression or regression of lesions., Conclusions: This study demonstrated a spectrum of renal histological lesions in HIV-associated kidney disease. Initiation of ART produced a rapid and sustained clinical renal response in all participants, irrespective of the histology. Follow-up biopsies showed an inconsistent histological response of lesions to treatment. In lesions that regressed, there appeared to be a discrete lag in histological response when compared with the rapid clinical response.

Human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) is most frequently seen as a late manifestation in adult patients with a high viral load and low T-helper cell (CD4) counts. We report a case of HIVAN in a black Zimbabwean teenager in whom the disease activity was well suppressed for years following highly active antiretroviral therapy (HAART). Proteinuria was absent at 9 years of age when he presented with vertically transmitted HIV infection. Within a few months of HAART, the viral load became undetectable and CD4 count was normalised. Nephrotic range proteinuria, with preserved renal function, developed approximately 4 years later despite excellent HIV disease suppression. Renal biopsy showed non-collapsing focal segmental glomerular sclerosis changes compatible with HIVAN. Although the role of other unknown factors in the disease pathogenesis could not be totally excluded, this case demonstrates that HIVAN can still occur in HIV-infected children despite excellent HAART and that the disease manifestations and outcome may differ from those reported in previous studies.

Renal disease related to human immunodeficiency virus (HIV) has been a past and present burden on the HIV positive community, both in the United States and worldwide. Previously, focus has been on the impact of HIV-associated nephropathy (HIVAN) on the black population. This paper presents a large renal biopsy series of 108 HIV patients from an urban setting with early renal dysfunction. The purpose of the paper is to highlight clinical characteristics and epidemiological changes in HIV-related renal disease between 2 distinct time periods: pre- and postintroduction of highly active antiretroviral therapy. Our data show a persistence of HIVAN in the black HIV US population and, in addition, an increase in other renal diseases in that population. These findings are discussed in regard to current and future HIV renal disease management.

Background: The effect of antiretroviral therapy (ART) on the clinical course of patients with human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) is not well-established. This study was undertaken to further elucidate the potential benefit of ART in HIV-infected patients with documented HIVAN., Methods: A cohort of 263 consecutive HIV-infected patients referred to the Johns Hopkins renal clinic from 1995 to 2004 was examined. Patients were included if they had biopsy-proven HIVAN and did not require dialysis within 1 month of their kidney biopsy. The cumulative probability of renal survival was calculated using the Kaplan-Meier method. Multivariate analysis was performed using the Cox regression method., Results: Fifty-three patients among 152 biopsied patients had HIVAN. Among 36 patients who met the inclusion criteria, 26 were treated with ART (group I) and 10 patients were not (group II). Except for age, baseline demographics and clinical characteristics were similar in the two groups. Renal survival was significantly better in the group receiving ART by both univariate (P = 0.025) and multivariate analysis (overall adjusted hazard ratio = 0.30; 95% confidence interval 0.09-0.98; P < 0.05) for ART compared with no treatment., Conclusions: Patients with biopsy-proven HIVAN treated with ART had better renal survival compared with patients who did not receive ART. HIVAN should be considered as an indication to initiate ART.

We report about a patient with human immunodeficiency virus infection who developed acute renal failure after therapy with atazanavir. Renal biopsy showed acute interstitial nephritis. After discontinuing medication with atazanavir serum creatinine level decreased spontaneously without steroids. The different etiologies of acute renal failure in patients with human immunodeficiency infection are discussed.

Impaired renal function is a consequence of HIV infection, even without a defined AIDS syndrome. While collapsing focal and segmental glomerulosclerosis is the clinical entity that is associated most commonly with progressive disease, the spectrum of renal involvement in patients who are HIV positive is expanding. In addition, consequences of anti-retroviral therapy are well-documented in the literature. The current case illustrates an unusual primary renal pathology picture presumably related to his underlying HIV disease and compounded by the unexpected consequences of anti-retroviral therapy, noted long after discontinuation of the medication.

Human immunodeficiency virus-associated nephropathy (HIVAN) is a major complication of HIV infection with distinct pathological features, which may lead to end-stage renal disease. We describe a 32-year-old African man with HIVAN, to whom protease inhibitor-containing antiretroviral therapy was introduced and in whom stability of serum creatinine levels was observed for 60 weeks after the introduction. This report suggests useful application of highly active antiretroviral therapy into the patients with HIVAN to avoid the rapid progression of renal function, although the long-term effect of this therapy needs to be prospectively evaluated in a large number of cases.

Renal failure is a known complication of HIV infection. The most common form is HIV-associated nephropathy, or HIVAN. It is characterized by high-grade proteinuria with rapid progression to end-stage renal disease. The kidneys of affected patients appear enlarged on ultrasonography. Histopathologically, there is focal segmental glomerulosclerosis with glomerular collapse. Before the era of HAART, patients with HIVAN had limited survival, although in some cases this was prolonged if dialysis was instituted. Over the past few years, isolated case reports have shown that patients with HIVAN will recover renal function following initiation of HAART. We report 3 patients believed to have HIVAN who exhibited marked improvement in renal function after treatment with a regimen comprising 2 nucleoside reverse transcriptase inhibitors and a protease inhibitor.

HIV-associated nephropathy (HIVAN) is the most common cause of renal failure in patients infected with type 1 human immunodeficiency virus (HIV-1). The renal prognosis for HIVAN is poor and is typically associated with rapid progression to renal death. We report a patient with biopsy-proven HIVAN who was successfully treated with corticosteroids and review the currently available evidence supporting the specific treatments of this condition. A 34-year-old African-American male with a 2-year history of uncomplicated HIV disease developed progressive azotemia despite treatment with highly active antiretroviral therapy (HAART). He was treated with an uncomplicated 4-month course of prednisone, which improved his serum creatinine from 2.9 to 1.9 mg/dl and decreased his degree of proteinuria from 8 to 2.1 g/day. Two years post-steroid treatment his renal function remains stable. Increasing evidence supports that both ACE inhibitors and HAART are effective in preventing and in some cases of reversing HIVAN induced renal failure. In selected patients who progress despite these measures, a limited course of corticosteroid may achieve long-standing disease remissions. In general, with adequate supervision, corticosteroid therapy appears to be well tolerated and has an acceptable side effect profile. Although persuasive in view of the abysmal natural history of HIVAN, the currently available studies are subject to major methodological limitations. Appropriate randomized controlled trials are urgently required in order to further examine the efficacy, optimal timing, and potential side effects of these treatments.