HIV-Associated Glomerulonephritis (HIVAGN): "Lupus-Like" Proliferative Glomerulonephritis in an Untreated Patient with HIV

Introduction: HIV infected patients can develop varying types of kidney disease either secondary to HIV infection itself or from antiretroviral treatment (ART). Any part of the kidney can be involved. Glomerular involvement can result in podocytopathies or immune-complex mediated glomerular disease. We present a case of an HIV patient presenting with massive proteinuria, microscopic hematuria, and acute kidney injury (AKI), who was eventually diagnosed with HIVAGN. Case Description: A 61 year old female with uncontrolled diabetes (HbA1c; 14%), hypertension, and HIV not on ART presented with AKI (creatinine; 4 mg/dL from 0.9 mg/dL), with nephrotic and nephritic syndrome (UPCR; 20.4 g/g, albumin; 2.7 g/dL, urine RBCS; 22 /hpf). Work up showed high HIV viral load (~70K copies/mL). Complements and ANA were normal. Kidney biopsy (figure 1) revealed diffuse endocapillary hypercellularity and neutrophilic inflammation on light microscopy (LM), immunofluorescence (IF) with “full house” staining, and electron microscopy (EM) showed mesangial and subendothelial immune complexes. There were no features of diabetic kidney disease. Subsequently, the patient was diagnosed with lupus-like glomerulonephritis (GN) secondary to HIV, and was started on ART, prednisone and mycophenolate, with improvement of creatinine and proteinuria. Discussion: HIVAGN is a distinct renal pathology in HIV patients, presenting with diverse histopathologies, including Lupus-like GN that can occur without systemic lupus erythematosus features or serologies. Pathogenesis is poorly understood. Treatment data are limited: ART reduces viral load but does not halt renal progression, and immunosuppression (IS) is used in selected cases. Our patient was diagnosed with Lupus-like GN and responded well to ART and IS highlighting the value of IS in those patients despite HIV infection.