The Human Immunodeficiency Virus (HIV) is best known for weakening the immune system, but it can also silently damage another vital organ, the kidneys. Over the years, HIV-associated kidney disease (HIVAN) has become one of the significant causes of chronic kidney disease (CKD), particularly among patients who start treatment late or experience long-term effects of antiretroviral therapy (ART).

How HIV Affects the Kidneys

HIV can harm the kidneys in several ways. The virus may directly infect kidney cells, trigger immune-related inflammation, or cause injury through certain medications used to control HIV. These processes can lead to different kidney disorders such as focal segmental glomerulosclerosis (FSGS), immune complex disease, and tubulointerstitial nephritis.

As a result, many people with HIV develop a gradual loss of kidney function. If not treated on time, this can progress to end-stage kidney disease (ESKD), a stage where dialysis or a kidney transplant becomes the only option.

In India, where HIV affects an estimated 2.4 million people, kidney involvement is becoming increasingly recognized. The rise in diabetes and hypertension has further added to the burden, making HIV-related CKD a dual challenge for healthcare providers.

Studies suggest that around 10–15% of HIV-positive adults in India may show signs of kidney dysfunction during their lifetime, often going undiagnosed until late stages.

With the success of ART programs like the National AIDS Control Organisation (NACO) initiative, people with HIV are now living longer and healthier lives. However, this improved longevity means chronic diseases, such as CKD, are emerging as new health priorities.

Early detection remains key. Routine testing for urine protein (albumin) and kidney function (creatinine and eGFR) is crucial for identifying early kidney changes and preventing irreversible damage.

Management of ESRD in HIV Patients

For HIV-positive individuals who progress to end-stage renal disease (ESRD), renal replacement therapy (RRT) is essential to sustain life. With proper infection control and ART management, both dialysis and transplantation can be safely offered.

1. Maintenance Hemodialysis (MHD)

MHD remains the most common form of renal replacement therapy in HIV-positive patients.

• Safety: With universal precautions and dedicated dialysis protocols, HIV patients can safely undergo hemodialysis alongside other patients.

• Considerations: Regular monitoring of ART–drug interactions, nutritional status, and infection risk is crucial.

• Challenges: Vascular access infections and anemia are more common, requiring proactive management.

2. Peritoneal Dialysis (CAPD/APD)

Continuous Ambulatory Peritoneal Dialysis (CAPD) and Automated Peritoneal Dialysis (APD) are excellent home-based alternatives, especially for patients with stable HIV and good hygiene practices.

• Advantages: Offers independence, avoids vascular access complications, and minimizes exposure in hospital dialysis units.

• Precautions: Strict aseptic technique and regular follow-up are key to prevent peritonitis.

• Suitability: CAPD/APD may be preferred in areas with limited dialysis facilities or for patients with difficult vascular access.

3. Integration with ART

• ART should continue uninterrupted during dialysis.

• Dose adjustments for certain drugs (especially tenofovir and protease inhibitors) are necessary depending on kidney function and dialysis modality.

• Coordination between nephrologists and infectious disease specialists ensures optimal outcomes.

Can HIV-Positive Patients Receive Kidney Transplants?

Yes, and this is one of the most promising advances in HIV care.
Earlier, HIV was considered a contraindication for organ transplantation. Today, thanks to effective ART and improved infection control, HIV-positive individuals in India can undergo successful kidney transplantation if they meet certain criteria:

• On stable ART for at least 3–6 months

• CD4 count above 200 cells/mm³

• No active opportunistic infections

• Willingness for lifelong follow-up and medication adherence

While kidney transplantation for HIV-positive patients is still limited to select centers in India, outcomes have been encouraging, with graft and patient survival rates comparable to HIV-negative recipients.

Managing Life After Transplant

Post-transplant management is more complex in HIV-positive patients because some ART drugs interact with immunosuppressants. Experienced multidisciplinary teams, nephrologists, infectious disease specialists, and transplant physicians, play a crucial role in adjusting doses and preventing complications.

Preventive medications and vaccinations (against hepatitis, influenza, pneumococcus, and tuberculosis) are strongly recommended before transplant to reduce infection risk.

HIV-related kidney disease is a growing yet manageable concern in India. Early screening, appropriate ART, and regular follow-up can prevent most complications. For those who develop advanced kidney failure, transplantation now offers a safe and effective path to recovery.

With increasing awareness and specialized care, HIV no longer needs to be a barrier to living a healthy, fulfilling life, even after kidney disease.