Renal pathology and vascular lesions in patients with HIV in Japan: a retrospective observational kidney biopsy study

Background The spectrum of kidney disease in people living with human immunodeficiency virus (PLWH) has shifted in the antiretroviral therapy (ART) era. Although the prevalence of human immunodeficiency virus (HIV)-associated nephropathy has declined, the pathological spectrum may vary by race and region. However, biopsy-based data from Japan remain scarce. Therefore, we aimed to characterize biopsy-proven kidney disease in PLWH in Japan. Methods We retrospectively studied PLWH undergoing native kidney biopsy at a Japanese center between 2010 and 2024. Kidney biopsy diagnoses were reviewed. Vascular lesions were graded using the Banff chronic vascular score and alternative arteriolar hyalinosis (AAH) score. Factors associated with a higher AAH score were examined using ordinal logistic regression. The primary multivariable model included ART duration, age, and hypertension. Results Data from 30 patients were analyzed. The median age was 49 years; 90% were male. Twenty-five (83%) were receiving ART (median duration, 10.9 years). Most common diagnoses were arteriosclerotic nephrosclerosis and immunoglobulin A nephropathy, followed by membranous nephropathy and minor glomerular abnormalities. HIV-associated nephropathy and immune complex kidney disease were identified in one patient each. In kidney biopsy specimens, arteriolar hyalinosis was frequently observed and represented a prominent vascular finding in this cohort. Among the 25 patients receiving ART, advanced arteriolar hyalinosis (AAH score of 2–3) was observed in 16 (64%). Longer ART duration was associated with a higher AAH score after adjustment for age and hypertension (adjusted OR, 1.15; 95% CI, 1.04–1.29; P = 0.007). Conclusions In this Japanese kidney biopsy cohort of PLWH, arteriosclerotic nephrosclerosis and immunoglobulin A nephropathy were the most frequent diagnoses. Longer ART duration was associated with a higher AAH score, although ART duration may reflect cumulative HIV and treatment history rather than a direct causal effect.