Naicker Saraladevi, Rahmanian Sadaf, Kopp Jeffrey B
Division of Nephrology, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa, and Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA.
Clin Nephrol. 2015;83(7 Suppl 1):32-8. doi: 10.5414/cnp83s032.
Chronic kidney disease (CKD) is a frequent complication of HIV infection, occurring in 3.5 - 48.5%, and occurs as a complication of HIV infection, other co-morbid disease and infections and as a consequence of therapy of HIV infection and its complications. The classic involvement of the kidney by HIV infection is HIV-associated nephropathy (HIVAN), occurring typically in young adults of African ancestry with advanced HIV disease in association with APOL1 high-risk variants. HIV-immune complex disease is the second most common diagnosis obtained from biopsies of patients with HIV-CKD. CKD is mediated by factors related to the virus, host genetic predisposition and environmental factors. The host response to HIV infection may influence disease phenotype through activation of cytokine pathways. With the introduction of antiretroviral therapy (ART), there has been a decline in the incidence of HIVAN, with an increasing prevalence of focal segmental glomerulosclerosis. Several studies have demonstrated the overall improvement in kidney function when initiating ART for HIV CKD. Progression to end stage kidney disease has been reported to be more likely when high grade proteinuria, severely reduced eGFR, hepatitis B and/C co-infection, diabetes mellitus, extensive glomerulosclerosis, and chronic interstitial fibrosis are present. Improved renal survival is associated with use of renin angiotensin system blockers and viral suppression. Many antiretroviral medications are partially or completely eliminated by the kidney and require dose adjustment in CKD. Certain drug classes, such as the protease inhibitors and the non-nucleoside reverse transcriptase inhibitors, are metabolized by the liver and do not require dose adjustment. HIV-infected patients requiring either hemo- or peritoneal dialysis, who are stable on ART, are achieving survival rates comparable to those of dialysis patients without HIV infection. Kidney transplantation has been performed successfully in HIV-infected patients; graft and patient survival appears to be similar to that of HIV-uninfected recipients. Early detection of kidney disease by implementation of screening on diagnosis of HIV infection and annual screening thereafter will have an impact on the burden of disease, together with access to ART to those who require it. Programs for prevention of HIV infection are essential to prevent this lethal disease.
慢性肾脏病（CKD）是HIV感染的常见并发症，发生率为3.5% - 48.5%，它作为HIV感染、其他合并疾病和感染的并发症出现，也是HIV感染及其并发症治疗的结果。HIV感染对肾脏的典型影响是HIV相关性肾病（HIVAN），通常发生在有APOL1高风险变异的非洲裔年轻成人中，且伴有晚期HIV疾病。HIV免疫复合物疾病是从HIV-CKD患者活检中得出的第二常见诊断。CKD由与病毒、宿主遗传易感性和环境因素相关的因素介导。宿主对HIV感染的反应可能通过细胞因子途径的激活影响疾病表型。随着抗逆转录病毒疗法（ART）的引入，HIVAN的发病率有所下降，局灶节段性肾小球硬化的患病率则不断上升。多项研究表明，对HIV CKD患者启动ART时，肾功能总体有所改善。据报道，当出现大量蛋白尿、估算肾小球滤过率（eGFR）严重降低、乙肝和/或丙肝合并感染、糖尿病、广泛的肾小球硬化和慢性间质纤维化时，进展为终末期肾病的可能性更大。使用肾素血管紧张素系统阻滞剂和病毒抑制与改善肾脏存活率相关。许多抗逆转录病毒药物部分或完全由肾脏清除，在CKD患者中需要调整剂量。某些药物类别，如蛋白酶抑制剂和非核苷类逆转录酶抑制剂，由肝脏代谢，不需要调整剂量。在ART治疗下病情稳定的需要血液透析或腹膜透析的HIV感染患者，其存活率与未感染HIV的透析患者相当。HIV感染患者已成功进行了肾脏移植；移植物和患者的存活率似乎与未感染HIV的受者相似。通过在诊断HIV感染时进行筛查并在此后每年进行筛查来早期发现肾脏疾病，将对疾病负担产生影响，同时为有需要的人提供ART。预防HIV感染的项目对于预防这种致命疾病至关重要。
