Figure 723

Glomerulosclerosis associated with HIV. In the United States, HIV-associated focal segmental or global glomerulosclerosis was described originally in 1984 in large East Coast cities, particularly New York and Miami [157-159]. This entity initially was considered with skepticism because it was not seen in San Francisco, where most patients testing seropositive were white homosexuals [160,161]. In New York, patients with glomerulosclerosis were largely black intravenous (IV) drug abusers, a group of patients in whom heroin nephropathy was prevalent. Thus, concern existed that this entity merely represented the older heroin nephropathy now seen in HIV-infected IV drug abusers. However, in a Miami-based population of adult non-IV drug users with glomerular disease and HIV infection, 55% of Caribbean and American blacks had severe glomerulosclerosis, 9% had mild focal glomerulosclerosis, and 27% had diffuse mesangial hyperplasia. In contrast, two of 12 (17%) whites had a mild form of focal glomerulosclerosis, 75% had diffuse mesangial hyperplasia, and none had severe glomeru-losclerosis. These morphologic differences were reflected in more severe clinical presentations, with blacks more likely to manifest proteinuria in the nephrotic range (>3.5 g/24 h) and renal insufficiency (serum creatinine concentration (>3 mg/dL). Whites often had proteinuria under 2 g/24 h and serum creatinine values less than 2 mg/dL [162]. In blacks, glomerulosclerosis has been described in all groups at risk for HIV infection, including IV drug users, homosexuals, patients exposed to heterosexual transmission or to contaminated blood products, and children infected perinatally [163,164]. Subsequent reports confirmed the unique clinical and histopatho-logic manifestations of HIV-associated glomerulosclerosis and its striking predominance in blacks independent of IV drug abuse [165]. Racial factors explain the absence of HIV-associated glomerulosclerosis in whites and Asians. The cause of this strong racial predilection is unknown.

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