1. Case D 1 Age 37 M HIV for 17 years 1 week history of diarrhoea and fever Abrupt onset of oedema and oliguria Homosexual Teenage drug abuse

2. Case D 2 BP 127/70, Bilateral leg oedema. Otherwise normal Long standing anti-retroviral treatment INVESTIGATIONS Creatinine 787  mol/L, serum albumin 14 G/L, urine albumin 2.0 g/24 hr. CrCl 7, ANA -ve, Cardiolipin antibodies +ve Hep B and C positive

3. Case D 3 U/S normal sized kidneys. Increased echogenicity Renal biopsy Dialysis dependent

6. Case D 4 Treatment 3TC 150 mg bd Indinavir 800 mg bd Ritornavir 200 mg bd Pravastatin 20 mg daily Viral load low stable

7. HIV ASSOCIATED GLOMERULONEPHRITIS 1 1.May be early or late 2. Proteinuria, nephrotic syndrome, renal impairment 3. In USA more common in blacks 4. Usually rapid evolution to renal failure 5. Viral genome in tubular and glomerular epithelia

8. HIV ASSOCIATED GLOMERULONEPHRITIS 2 1. Focal segmental glomerulosclerosis with collapse of the glomerular tuft 2. Rarely IgA nephropathy, MCGN, Membranous nephropathy 3. Immune deposits of IgM and C3 4. Often an interstitial infiltrate of plasma cells and lymphocytes

9. HIV ASSOCIATED GLOMERULONEPHRITIS 3 4. Often an interstitial infiltrate of plasma cells and lymphocytes 5. Microcystic tubular dilatation with casts 6. Tubuloreticular inclusion bodies in glomerular endothelial cells

10. HIV RENAL PATHOLOGY- THAILAND ïNo collapsing glomerulopathy ïMesangial proliferative glomerulonephritis ïIgA nephropathy ïMembranous nephropathy ïMembranoproliferative glomerulonephritis Praditpornnsilpa et al. 1999. AJKD;33:282-6

11. TREATMENT HIVAN Captopril enhanced renal survival (uncontrolled) Anecdotal evidence that steroids improve clinical course oh HIVAN 20% actuarial survival of renal function at 5 years Risk of renal death increased by heavy proteinuria, renal impairment, interstitial nephritis and fibrosis