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Wearne N, Davidson B. HIV-associated kidney disease: the changing spectrum and treatment priorities. Curr Opin Nephrol Hypertens 2024:00041552-990000000-00182. [PMID: 39155827 DOI: 10.1097/mnh.0000000000001018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
PURPOSE OF REVIEW This review examines the impact of HIV on kidney disease, which remains significant despite advances in antiretroviral therapy (ART). The review is timely due to the shifting epidemiology of kidney disease in people with HIV (PWH), driven by increased ART access, noncommunicable diseases, and region-specific opportunistic infections like tuberculosis. RECENT FINDINGS The literature highlights a decline in HIV-associated nephropathy (HIVAN) and a rise in tubulointerstitial diseases and noncommunicable diseases among PWH. Studies from the United States and South Africa report decreased HIVAN prevalence and increased rates of tubulointerstitial diseases linked to tenofovir disoproxil fumarate (TDF) toxicity and tuberculosis (TB). Immune complex glomerulonephritis (ICGN) and diabetic kidney disease (DKD) are also prevalent. SUMMARY The findings underscore the need for improved diagnostic tools for opportunistic infections, management of ART-related complications, and strategies to address noncommunicable diseases in PWH. There is a need to centralize care to address all health needs simultaneously. Future research should focus on APOL1-targeted therapies and the role of SGLT2 inhibitors in CKD. Enhanced transplantation outcomes and the development of guidelines for managing DKD in PWH are critical for advancing clinical practice and improving patient outcomes.
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Affiliation(s)
- Nicola Wearne
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, South Africa
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McCutcheon K, Nqebelele U, Murray L, Thomas TS, Mpanya D, Tsabedze N. Cardiac and Renal Comorbidities in Aging People Living With HIV. Circ Res 2024; 134:1636-1660. [PMID: 38781295 PMCID: PMC11122746 DOI: 10.1161/circresaha.124.323948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Contemporary World Health Organization data indicates that ≈39 million people are living with the human immunodeficiency virus. Of these, 24 million have been reported to have successfully accessed combination antiretroviral therapy. In 1996, the World Health Organization endorsed the widespread use of combination antiretroviral therapy, transforming human immunodeficiency virus infection from being a life-threatening disease to a chronic illness characterized by multiple comorbidities. The increased access to combination antiretroviral therapy has translated to people living with human immunodeficiency virus (PLWH) no longer having a reduced life expectancy. Although aging as a biological process increases exposure to oxidative stress and subsequent systemic inflammation, this effect is likely enhanced in PLWH as they age. This narrative review engages the intricate interplay between human immunodeficiency virus associated chronic inflammation, combination antiretroviral therapy, and cardiac and renal comorbidities development in aging PLWH. We examine the evolving demographic profile of PLWH, emphasizing the increasing prevalence of aging individuals within this population. A central focus of the review discusses the pathophysiological mechanisms that underpin the heightened susceptibility of PLWH to renal and cardiac diseases as they age.
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Affiliation(s)
| | - Unati Nqebelele
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, Western Cape, South Africa (U.N.)
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Western Cape, South Africa (U.N.)
| | - Lyle Murray
- Division of Infectious Diseases, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand and the Charlotte Maxeke Johannesburg Academic Hospital, South Africa (L.M.)
| | - Teressa Sumy Thomas
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand and the Chris Hani Baragwanath Academic Hospital, Johannesburg, Gauteng, South Africa (T.S.T.)
| | - Dineo Mpanya
- Division of Cardiology, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa (D.M., N.T.)
| | - Nqoba Tsabedze
- Division of Cardiology, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa (D.M., N.T.)
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Diana NE, Naicker S. The changing landscape of HIV-associated kidney disease. Nat Rev Nephrol 2024; 20:330-346. [PMID: 38273026 DOI: 10.1038/s41581-023-00801-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/27/2024]
Abstract
The HIV epidemic has devastated millions of people globally, with approximately 40 million deaths since its start. The availability of antiretroviral therapy (ART) has transformed the prognosis of millions of individuals infected with HIV such that a diagnosis of HIV infection no longer automatically confers death. However, morbidity and mortality remain substantial among people living with HIV. HIV can directly infect the kidney to cause HIV-associated nephropathy (HIVAN) - a disease characterized by podocyte and tubular damage and associated with an increased risk of kidney failure. The reports of HIVAN occurring primarily in those of African ancestry led to the discovery of its association with APOL1 risk alleles. The advent of ART has led to a substantial decrease in the prevalence of HIVAN; however, reports have emerged of an increase in the prevalence of other kidney pathology, such as focal segmental glomerulosclerosis and pathological conditions associated with co-morbidities of ageing, such as hypertension and diabetes mellitus. Early initiation of ART also results in a longer cumulative exposure to medications, increasing the likelihood of nephrotoxicity. A substantial body of literature supports the use of kidney transplantation in people living with HIV, demonstrating significant survival benefits compared with that of people undergoing chronic dialysis, and similar long-term allograft and patient survival compared with that of HIV-negative kidney transplant recipients.
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Affiliation(s)
- Nina E Diana
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Saraladevi Naicker
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Hanser S, Choshi J, Mokoena H, Mabhida SE, Mchiza ZJR, Moetlediwa MT, Muvhulawa N, Nkambule BB, Ndwandwe D, Nqebelele U, Kengne AP, Dludla PV. A systematic review assessing the potential use of cystatin c as a biomarker for kidney disease in people living with HIV on antiretroviral therapy. Front Med (Lausanne) 2024; 11:1295217. [PMID: 38566923 PMCID: PMC10985183 DOI: 10.3389/fmed.2024.1295217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/26/2024] [Indexed: 04/04/2024] Open
Abstract
The introduction of antiretroviral therapy (ART) has significantly prolonged the lifespan of people living with human immunodeficiency virus (PLWH). However, the sustained use of this drug regimen has also been associated with a cluster of metabolic anomalies, including renal toxicity, which can lead to the development of kidney diseases. In this study, we reviewed studies examining kidney disease in PLWH sourced from electronic databases such as PubMed/MEDLINE, Scopus, and Google Scholar, as well as gray literature. The narrative synthesis of data from these clinical studies demonstrated that the serum levels of cystatin C remained unchanged or were not affected in PLWH on ART, while the creatinine-based glomerular filtration rate (GFR) fluctuated. In fact, some of the included studies showed that the creatinine-based GFR was increased in PLWH taking tenofovir disoproxil fumarate-containing ART, perhaps indicating that the use of both cystatin C- and creatinine-based GFRs is vital to monitor the development of kidney disease in PLWH. Clinical data summarized within this study indicate the potential detrimental effects of tenofovir-based ART regimens in causing renal tubular injury, while highlighting the possible beneficial effects of dolutegravir-based ART on improving the kidney function in PLWH. However, the summarized literature remains limited, while further clinical studies are required to provide insights into the potential use of cystatin C as a biomarker for kidney disease in PLWH.
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Affiliation(s)
- Sidney Hanser
- Department of Physiology and Environmental Health, University of Limpopo, Sovenga, South Africa
| | - Joel Choshi
- Department of Physiology and Environmental Health, University of Limpopo, Sovenga, South Africa
| | - Haskly Mokoena
- Department of Physiology and Environmental Health, University of Limpopo, Sovenga, South Africa
| | - Sihle E. Mabhida
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Zandile J. R. Mchiza
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | | | - Ndivhuwo Muvhulawa
- Department of Biochemistry, North-West University, Mmabatho, South Africa
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Bongani B. Nkambule
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Duduzile Ndwandwe
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Unati Nqebelele
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - André P. Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Phiwayinkosi V. Dludla
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Department of Biochemistry and Microbiology, University of Zululand, KwaDlangezwa, South Africa
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Wearne N, Davidson B, Blockman M, Jones J, Ross IL, Dave JA. Management of Type 2 Diabetes Mellitus and Kidney Failure in People with HIV-Infection in Africa: Current Status and a Call to Action. HIV AIDS (Auckl) 2023; 15:519-535. [PMID: 37700755 PMCID: PMC10493098 DOI: 10.2147/hiv.s396949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/13/2023] [Indexed: 09/14/2023] Open
Abstract
There is an increasing global burden of diabetes mellitus (DM) and chronic kidney disease (CKD), coupled with a high burden of people with HIV (PWH). Due to an increased lifespan on ART, PWH are now at risk of developing non-communicable diseases, including DM. Africa has the greatest burden of HIV infection and will experience the greatest increase in prevalence of DM over the next two decades. In addition, there is a rising number of people with CKD and progression to kidney failure. Therefore, there is an urgent need for the early identification and management of all 3 diseases to prevent disease progression and complications. This is particularly important in Africa for people with CKD where there is restricted or no access to dialysis and/or transplantation. This review focuses on the epidemiology and pathophysiology of the interaction between HIV infection and DM and the impact that these diseases have on the development and progression of CKD. Finally, it also aims to review the data on the management, which stems from the growing burden of all three diseases.
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Affiliation(s)
- Nicola Wearne
- Division of Nephrology and Hypertension, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Bianca Davidson
- Division of Nephrology and Hypertension, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Marc Blockman
- Division of Clinical Pharmacology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Jackie Jones
- Medicines Information Centre, Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ian L Ross
- Division of Endocrinology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Joel A Dave
- Division of Endocrinology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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Kalyesubula R, Wearne N, Kubo M, Hussey N, Naicker S. HIV and Associated TB: A Lethal Association for Kidney Health? Semin Nephrol 2023; 43:151470. [PMID: 38245391 DOI: 10.1016/j.semnephrol.2023.151470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
Human immunodeficiency virus (HIV) and tuberculosis (TB) are the leading infectious causes of death globally. The combined brunt of these diseases is experienced mainly in low-income and lower-middle-income countries. HIV/TB have devastating effects on the kidneys, leading to accelerated decline of kidney function as well as mortality. Managing the triad of TB/HIV and kidney disease is challenging. We discuss the epidemiology of HIV/TB coinfection and the kidney and the key mechanisms of kidney disease including genetic susceptibility. The clinical presentation and pathology, as well as the challenges of diagnosing CKD in these patients, also are discussed. The strategies to prevent and manage HIV/TB-related kidney disease such as proper assessment, avoiding nephrotoxic regimens, drug dose adjustments, kidney function monitoring, avoidance of drug-drug interactions, and other interventions are explored. We also briefly discuss the complexities around HIV/TB patients on dialysis and kidney transplantation. HIV/TB coinfection presents an increased risk for kidney-related morbidity and mortality; patients with this triad need to be given special consideration for future research and management.
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Affiliation(s)
- Robert Kalyesubula
- Department of Physiology and Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Nicola Wearne
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Mary Kubo
- Department of Clinical Medicine and Therapeutics, East African Kidney Institute, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya.
| | - Nadia Hussey
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Saraladevi Naicker
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Thomas KL, Davies M. Survival outcomes of HIV-positive adults on peritoneal dialysis at Helen Joseph renal unit. South Afr J HIV Med 2023; 24:1471. [PMID: 37293605 PMCID: PMC10244927 DOI: 10.4102/sajhivmed.v24i1.1471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/10/2023] [Indexed: 06/10/2023] Open
Abstract
Background HIV is a risk factor for the development of chronic kidney disease. People with chronic kidney disease in the state sector are likely to be prescribed continuous ambulatory peritoneal dialysis (CAPD). Previous studies have raised concern about the safety of CAPD in people living with HIV (PLWH) compared to HIV-negative patients. Objectives To compare the risk of peritonitis, and modality and patient survival by HIV status in patients receiving CAPD at Helen Joseph Hospital. Method A retrospective study of patients receiving CAPD between 01 January 2007 and 31 December 2017 was undertaken. Five-year patient and modality survival were modelled for PLWH and HIV-negative subgroups and analysed using the log-rank test; the effect of CD4 count, HIV viral load, and duration of antiretroviral therapy on these parameters in PLWH were additionally modelled using the Cox Proportional Hazards technique. Results Eighty-four patients, comprising of 21 PLWH and 63 HIV-negative patients, were analysed. No difference was observed in the proportion of patients who had at least one episode of peritonitis between PLWH (61.2%) and HIV-negative patients (63.5%) (P = 0.547). A trend towards increased risk of peritonitis due to Gram-negative organisms in PLWH was noted (odds ratio: 3.20, 95% confidence interval: 0.86-11.9, P = 0.083). No difference was observed in 5-year patient or modality survival on CAPD between PLWH (log-rank P = 0.161) and HIV-negative patients (log-rank P = 0.240). Conclusion People living with HIV should not be excluded from CAPD as a mode of kidney replacement therapy (KRT).
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Affiliation(s)
- Kagisho L Thomas
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Malcolm Davies
- Renal Department, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Wearne N, Manning K, Price B, Rayner BL, Davidson B, Jones ESW, Spies R, Cunningham C, Omar A, Ash S, Bohmer R, Kennedy L, Post F. The Evolving Spectrum of Kidney Histology in HIV-Positive Patients in South Africa. Kidney Int Rep 2023; 8:1087-1096. [PMID: 37180521 PMCID: PMC10166739 DOI: 10.1016/j.ekir.2023.02.1076] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/24/2023] [Accepted: 02/13/2023] [Indexed: 02/25/2023] Open
Abstract
Introduction Sub-Saharan Africa remains challenged by the highest burden of human immunodeficiency virus (HIV), an epidemic of tuberculosis (TB), and increasing number of people with HIV (PWH) on antiretroviral therapy (ART), all of which may result in kidney injury. Methods This observational cohort study describes the spectrum of kidney disease in PWH in South Africa, between 2005 and 2020. Kidney biopsies were analyzed in 4 time periods as follows: early ART rollout (2005-2009), tenofovir disoproxil (TDF) introduction (2010-2012), TDF-based fixed dose combination (2013-2015), and ART at HIV diagnosis (2016-2020). Logistic regression was used to identify factors associated with HIV-associated nephropathy or focal segmental glomerulosclerosis (HIVAN/FSGS) and tubulointerstitial disease (TID). Results We included 671 participants (median age 36, interquartile range, 21-44 years; 49% female; median CD4 cell count 162 [interquartile range, 63-345] cells/mm3). Over time, ART (31%-65%, P < 0.001), rate of HIV suppression (20%-43%, P < 0.001), nonelective biopsies (53%-72%, P < 0.001), and creatinine at biopsy (242-449 μmol/l, P < 0.001) increased. A decrease in HIVAN (45%-29% P < 0.001) was accompanied by an increase in TID (13%-33%, P < 0.001). Granulomatous interstitial nephritis accounted for 48% of TID, mostly because of TB. Exposure to TDF was strongly associated with TID (adjusted odds ratio 2.99, 95% confidence interval 1.89-4.73 P < 0.001). Conclusion As ART programs intensified and increasingly used TDF, the spectrum of kidney histology in PWH evolved from a predominance of HIVAN in the early ART era to TID in recent times. The increase in TID is likely due to multiple exposures that include TB, sepsis, and TDF as well as other insults.
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Affiliation(s)
- Nicola Wearne
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Kathryn Manning
- Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Brendon Price
- Division of Anatomical, Department of Pathology, National Health Laboratory Service and University of Cape Town, Cape Town, South Africa
| | - Brian L. Rayner
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Bianca Davidson
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Erika SW Jones
- Division of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Kidney and Hypertension Research Unit, University of Cape Town, Cape Town, South Africa
| | - Ruan Spies
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Carol Cunningham
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Aadil Omar
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Samantha Ash
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Raphaela Bohmer
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Luca Kennedy
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Frank Post
- Department of HIV Medicine, Kings College Hospital NHS Foundation Trust, London, UK
- School of Immunology and Microbial Sciences, King’s College London, London, UK
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Hung RKY, Winkler CA, Post FA. Host factors predisposing to kidney disease in people with HIV. Curr Opin HIV AIDS 2023; 18:87-92. [PMID: 36722197 DOI: 10.1097/coh.0000000000000784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW To highlight advances in understanding of host factors, in particular host genetics, in the development of chronic kidney disease (CKD) in people with HIV. RECENT FINDINGS In Black populations, the G1 and G2 variants of the apolipoprotein L1 (APOL1) gene predispose to HIV-associated nephropathy (HIVAN). The risk of HIVAN is mostly confined to individuals with two APOL1 variants (kidney-risk genotypes). APOL1 kidney-risk genotypes are present in approximately 80% of patients with HIVAN and account for nearly half the burden of end-stage CKD in people of African ancestry with HIV. Progress has been made in elucidating the mechanisms of kidney injury in APOL1 nephropathy, and several targeted molecular therapies are being investigated in clinical trials. Genome- and epigenome-wide association studies are identifying additional genes and pathways that may be involved in the pathogenesis of CKD in people with HIV. SUMMARY Genetic variants of APOL1 are strongly associated with severe CKD and contribute to the high rates of CKD in Black populations with HIV. Most individuals with APOL1 kidney-risk genotypes, however, do not develop kidney disease and further studies are required to understand the role of additional genetic and environmental factors that may affect CKD risk in this population.
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Affiliation(s)
| | - Cheryl A Winkler
- Frederick National Laboratory for Cancer Research and the National Cancer Institute, Frederick, USA
| | - Frank A Post
- King's College London, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
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