Membranous nephropathy in patients with HIV: a report of 11 cases.

BACKGROUND: Membranous nephropathy (MN) has been recognized to occur in patients with human immunodeficiency virus (HIV) infection since the beginning of the HIV epidemic. The prevalence of phospholipase A2 receptor (PLA2R)-associated MN in this group has not been well studied. METHODS: We conducted a retrospective review of electronic pathology databases at three institutions to identify patients with MN and known HIV at the time of renal biopsy. Patients with comorbidities and coinfections known to be independently associated with MN were excluded. RESULTS: We identified 11 HIV-positive patients with biopsy-confirmed MN meeting inclusion and exclusion criteria. Patient ages ranged from 39 to 66 years old, and 10 of 11 patients (91%) were male. The majority of patients presented with nephrotic-range proteinuria, were on anti-retroviral therapy at the time of biopsy and had low or undetectable HIV viral loads. Biopsies from 5 of 10 (50%) patients demonstrated capillary wall staining for PLA2R. Measurement of serum anti-PLA2R antibodies was performed in three patients, one of whom had positive anti-PLA2R antibody titers. Follow-up data was available on 10 of 11 patients (median length of follow-up: 44 months; range: 4-145 months). All patients were maintained on anti-retroviral therapy (ARV) and 5 patients (52%) received concomitant immunosuppressive regimens. Three patients developed end-stage renal disease (ESRD) during the follow-up period. CONCLUSIONS: MN in the setting of HIV is often identified in the setting of an undetectable viral loads, and similar to other chronic viral infection-associated MNs, ~ 50% of cases demonstrate tissue reactivity with PLA2R antigen, which may be seen without corresponding anti-PLA2R serum antibodies.

The variable pathology of kidney disease after liver transplantation.

BACKGROUND: Chronic kidney disease is a frequent complication in orthotopic liver transplant (OLT) recipients, observed in 10% to 60% after 5 years. PATIENTS AND METHODS: We analyzed clinical and pathological data from 81 OLT recipients who developed impaired kidney function with a serum creatinine greater than or equal to 1.5 mg/dL or new proteinuria on dipstick urinalysis. All patients underwent percutaneous kidney biopsy. The most common reason for liver transplantation was hepatitis C virus infection. The mean time until biopsy was 4.89 years. At the time of biopsy, the mean serum creatinine was 2.0 mg/dL, Modified Diet of Renal Disease glomerular filtration rate was 38.7 mL/min, and 24-hr urine protein was 1.37 g. RESULTS: All biopsies demonstrated glomerular abnormalities, 42% showed primary glomerular diseases, and only 16% had evidence of calcineurin inhibitor toxicity. Electron microscopy was performed on 74 biopsies and podocyte effacement was detected in 88%. Mean postbiopsy follow-up was 20 months; eight patients progressed to end-stage renal disease. CONCLUSION: This study demonstrates universal glomerular abnormalities in kidney biopsies after OLT. The pathology is suggestive of diabetic nephropathy and hypertensive change, but there are also specific glomerular disease processes present. There is little calcineurin inhibitor toxicity in this group. These findings underscore the importance of understanding the causes of kidney disease in the constantly changing liver transplant population, and the need to change current management of these patients.

Routine use of ambulatory blood pressure monitoring in potential living kidney donors.

BACKGROUND AND OBJECTIVES: Most transplant centers exclude prospective living kidney donors with hypertension from donation. Centers routinely identify hypertension using BP measured in the clinic, but it is not clear that clinic BP accurately detects the presence or absence of hypertension in potential donors. We therefore conducted a prospective study to determine the impact of routine ambulatory BP monitoring on diagnosis of hypertension in potential donors and the value of other baseline characteristics in predicting ambulatory BP results. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We compared classification of hypertension status by clinic BP and by ambulatory BP monitoring in 178 potential living kidney donors. RESULTS: Of 63 individuals with hypertension by clinic BP, 62% had white-coat hypertension by ambulatory BP and were therefore eligible to donate. Of 115 individuals who were normotensive by clinic BP, 17% had masked hypertension by ambulatory BP and were excluded from donation. Individuals with masked hypertension were older, were more likely to be male, and had a somewhat higher clinic BP than individuals with sustained normotension. Individuals with white-coat hypertension had a somewhat lower clinic diastolic BP than individuals with sustained hypertension. CONCLUSIONS: Routine ambulatory BP monitoring may identify a large number of individuals with white-coat hypertension and a smaller but significant number of individuals with masked hypertension, ensuring adequate protection of potential donors and accurate assessment of donor risk. Differences in baseline characteristics are small and are not clinically useful in distinguishing individuals with masked hypertension from individuals with sustained normotension or individuals with white-coat hypertension from individuals with sustained hypertension, demonstrating the importance of ambulatory BP monitoring in this population.