Kudose Satoru, Santoriello Dominick, Bomback Andrew S, Stokes M Barry, Batal Ibrahim, Markowitz Glen S, Wyatt Christina M, D'Agati Vivette D
Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA.
Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA.
Kidney Int. 2020 May;97(5):1006-1016. doi: 10.1016/j.kint.2020.01.018. Epub 2020 Feb 4.
HIV-associated kidney disease is evolving rapidly. Few North American studies have addressed modern trends and none has applied the 2018 Kidney Disease Improving Global Outcomes (KDIGO) pathologic classification. Therefore we performed a retrospective clinical-pathologic analysis of all HIV-positive patients with kidney biopsy interpreted at Columbia University from 2010-2018 using the KDIGO classification. The biopsy cohort of 437 HIV-positive patients had median age 53 years, including 66% males, 80% on anti-retroviral therapy, 57% with hypertension, 31% with diabetes, 27% with hepatitis C and 6% with hepatitis B co-infections. Race, known in 308 patients, included 58% black, 25% white and 17% Hispanic. Pathologic diagnoses were surprisingly diverse. Immune complex glomerulonephritis (ICGN) and diabetic nephropathy each outnumbered HIV-associated nephropathy, followed by tenofovir nephrotoxicity, FSGS- not otherwise specified (NOS) and global sclerosis (NOS). HIV-associated nephropathy was the most common disease in patients not on anti-retroviral therapy, and 94% were black. The association of FSGS (NOS) with black race (68%) and anti-retroviral therapy use (77%) suggests some cases may represent attenuated HIV-associated nephropathy. The most common ICGNs were IgA nephropathy and membranous glomerulopathy, both associating with anti-retroviral therapy (over 90%), followed by hepatitis C-associated proliferative ICGN. Among the 16 cases of uncharacterized ICGN lacking identifiable etiology, 69% were not on anti-retroviral therapy, possibly representing true HIV-associated immune complex kidney disease. Dual diseases occurred in 17% of patients, underscoring lesion complexity. Thus, anti-retroviral therapy has shifted the landscape of HIV-associated kidney disease toward diverse ICGN, diabetic nephropathy, and non-collapsing glomerulosclerosis, but has not eradicated HIV-associated nephropathy.
HIV相关性肾病正在迅速演变。北美很少有研究涉及现代趋势，且没有一项研究应用2018年改善全球肾脏病预后组织（KDIGO）的病理分类。因此，我们对2010年至2018年在哥伦比亚大学接受肾活检解读的所有HIV阳性患者进行了回顾性临床病理分析，采用KDIGO分类。437例HIV阳性患者的活检队列中位年龄为53岁，其中66%为男性，80%接受抗逆转录病毒治疗，57%患有高血压，31%患有糖尿病，27%合并丙型肝炎，6%合并乙型肝炎。在308例已知种族的患者中，58%为黑人，25%为白人，17%为西班牙裔。病理诊断出人意料地多样。免疫复合物性肾小球肾炎（ICGN）和糖尿病肾病的病例数均超过了HIV相关性肾病，其次是替诺福韦肾毒性、未另作说明的局灶节段性肾小球硬化（FSGS-NOS）和全球硬化（NOS）。HIV相关性肾病是未接受抗逆转录病毒治疗患者中最常见的疾病，94%为黑人。FSGS（NOS）与黑人种族（68%）和抗逆转录病毒治疗的使用（77%）之间的关联表明，一些病例可能代表减轻的HIV相关性肾病。最常见的ICGN是IgA肾病和膜性肾小球病，两者均与抗逆转录病毒治疗相关（超过90%），其次是丙型肝炎相关的增殖性ICGN。在16例缺乏可识别病因的未分类ICGN病例中，69%未接受抗逆转录病毒治疗，可能代表真正的HIV相关性免疫复合物性肾病。17%的患者出现双重疾病，突出了病变的复杂性。因此，抗逆转录病毒治疗已使HIV相关性肾病的格局转向多样的ICGN、糖尿病肾病和非塌陷性肾小球硬化，但尚未根除HIV相关性肾病。
