Update on kidney transplantation in human immunodeficiency virus infected recipients

Table 1 Causes of kidney disease in human immunodeficiency virus infected patients

Cause	Characteristics
HIVAN	Collapsing glomerulopathy in the setting of high grade HIV viremia
	Affects almost exclusively African Americans
	Manifests with high-grade proteinuria in the absence of hypertension
	Treated with antiretroviral therapy
HIV-immune complex	Manifests with hematuria and sub-nephrotic range proteinuria
	Variable presentation with AKI
	Poorly understood
Diabetic nephropathy	Similar presentation to patients without HIV. Proteinuria followed by decreased GFR
Hypertension	Similar presentation to patients without HIV
Thrombotic microangiopathy	Typically presents with AKI, subnephrotic range proteinuria with hematuria along with features of microagiopathic hemolytic anemia
IgA nephropathy	Hematuria with variable degree of proteinuria and decreased GFR
Tenofovir toxicity	Variable degree of decreased GFR with features of proximal tubular injury
Immune-complex membrano-proliferative glomerulonephritis and cryoglobulinemia in the setting of HCV co-infection	Nephritic syndrome picture with positive cryoglobulin and hypocomplementemia

HIV: Human immunodeficiency virus; HIVAN: HIV-associated nephropathy; AKI: Acute kidney injury; HCV: Hepatitis C virus.

Table 2 Inclusion criteria for kidney transplant listing in human immunodeficiency virus positive patients

Meet standard criteria for placement on transplant waiting list for kidney transplantation plus the following

Well-controlled HIV disease with viral load < 50 copies/mL and CD4 count > 200 cells/mm3

Absence of opportunistic infections or neoplasms

Stable antiretroviral regimen

Psycho-social clearance with demonstration of no active history of drug and/or alcohol use. Patients on stable methadone maintenance program can be considered

HIV: Human immunodeficiency virus.

Table 3 Key points

Kidney transplantation in patients with HIV infection is a viable therapeutic option

Ideal immunosuppressive regimen remains uncertain

Higher rates of rejection are reported in clinical trials

Immunosuppressive therapy does not seem to negatively impact the course of HIV infection

Some immunosuppressive drugs may exert antiretroviral actions

Special attention should be paid to the potential interaction between ART and immunosuppressive drugs

A close collaboration between infectious disease specialists and transplant professionals is mandatory in order to optimize transplantation outcomes in these patients

Transplantation from HIV+ donors to HIV+ is currently being researched

HIV: Human immunodeficiency virus.