Several lines of evidence point to renal disease becoming an important complication of HIV infection and therapy. The kidney is particularly exposed to toxic nephropathy because of the increasing number of drugs used for the purpose of treating what has become a chronic disease. Very few drugs exhibit severe intrinsic nephrotoxic properties but renal risk factors such as age (the number of HIV patients over the age of 65 has grown ten times in the past ten years), pre-existing chronic renal failure (glomerular filtration rate is below 60 ml/min/1.73 m2 in as much as 10% of HIV patients) and diabetes mellitus or hypertension are highly prevalent in HIV patients.
Drug-induced toxic nephropathy may manifest as acute or chronic renal failure, an isolated decrease in glomerular filtration rate or a selective defect in tubular functions, a nephrotic range albuminuria or a low level tubular proteinuria together with or without leucocyturia or hematuria. All segments of nephron may be involved. Diagnosis relies on close monitoring of renal parameters at diagnosis of HIV infection, before any therapeutic change and once a year or more often depending on initial screening and current treatment. Renal biopsy is the only gold standard tool to perform appropriate diagnosis, define prognosis and tailor therapy.
Patients with low CD4 cell count and high viral load are especially at high risk for acute renal failure often enhanced by the high prevalence of antiretroviral medication errors in this setting.
Lastly it seems critical to bear in mind that chronic kidney disease as emerged in the past few years as one of the top five major cardiovascular risk factors, putting chronic kidney disease on the front scene as a major comorbidity impacting outcome and survival.
There is no need to be a nephrologist to appropriately screen for renal disease, monitor renal parameters, carefully adapt drug dosage when mandatory and thus allow preservation of renal function in HIV patients.