Spectrum of Biopsy-Proven Kidney Diseases in People with HIV in the Modern Era: The Bronx Experience

Background: People with HIV (PWH) have a diverse spectrum of kidney diseases affecting the glomerulus, tubulointerstitium and vascular compartments. In the antiretroviral therapy (ART) era, the prevalence of HIV-associated nephropathy (HIVAN) has declined, while immune complex glomerulonephritis (ICGN) and tubulointerstitial disease (TID) have become more common. We aimed to characterize the histopathologic spectrum and clinical outcomes of HIV-related kidney disease in a contemporary U.S. cohort, comparing patterns before and after changes in HIV treatment guidelines. Methods: We conducted an observational study of PWH who underwent native kidney biopsy between 2008–2023 at a large urban health system in the Bronx, NY. Diagnoses were classified using the KDIGO pathological classification. Histologic patterns were compared between 2008–2015 and 2016–2023, reflecting adoption of WHO guidelines recommending ART regardless of CD4 count. Clinical characteristics were compared by diagnosis. Dialysis-free survival was estimated using the Kaplan–Meier method from time of biopsy to dialysis, censoring for death or last follow-up. Results: Among 94 PWH who underwent biopsy, 74.5% had glomerular-predominant disease. The most common diagnoses were ICGN (24.5%), focal segmental glomerulosclerosis (21.3%), and diabetic nephropathy (18%). No significant changes in biopsy patterns were observed pre- and post-guideline change. HIVAN was identified in 5 individuals, all Black, with severe nephrotic syndrome, low CD4 counts (median 106 cells/mm), and high viral loads (median >300,000 copies/mL). In contrast, those with ICGN, FSGS, or diabetic nephropathy were more likely to be virally suppressed and have comorbidities such as hepatitis C and hypertension. TID was more common in those receiving tenofovir disoproxil fumarate (33%). Overall, 51% progressed to end-stage kidney disease within a median of 1.8 years. HIVAN and thrombotic microangiopathy carried the worst prognosis; ICGN and interstitial nephritis had better outcomes. Conclusion: HIV-related kidney disease remains heterogeneous in the ART era. ICGN and comorbidity-associated lesions are now more prevalent, while HIVAN is rare. Histologic patterns are influenced by ART use, viral suppression and comorbidity burden. These findings support the role of biopsy in diagnosis and management of PWH with kidney disease.