# Advances in Chronic Kidney Disease in Africa
## 9 What Is New in HIV and CKD in SSA
It inhibits the organic cation transporter 2, thereby inducing an increase in serum creatinine of up to 0.4 mg/dL (44 mmol/L) and a drop in eGFR of 10-15 mL/min per 1.73 m\({}^{2}\) without altering the actual GFR [111; 112]. Most regions in SSA have no formal transplantation programs or, if available, are focused on living-related donation, with the operation occurring outside of their own country. PWH were initially not enrolled into transplantation programmes due to the perceived poor outcomes [113]. There is now robust evidence supporting positive outcomes in both HIV-negative donors to HIV-positive recipients and positive donors to positive recipients. South Africa reported on 15 years of experience of HIV-positive donors to HIV-positive recipients. The 5-year overall survival and graft survival of 83.3% and 78.7%, respectively, are similar to the 3-year overall survival [114] and graft survival observed among HIV-positive patients who received an organ from an HIV-negative donor in the United States (88.2% and 73.7%, respectively) [115]. However, there is the additional complexity of drug interactions. Managing ART and immunosuppression can make drug level monitoring challenging. There is also increased risk of rejection, similar to that described in the HIV-negative to HIV positive cohort. The South African cohort recently described a concerning signal for increased rejection rates in those on a protease-inhibitor-based regimen [116]. A heterogeneous spectrum of immune complex-mediated glomerular diseases has been reported in PWH [117; 118; 119]. These include mesangiocapillary GN (MCGN), membranous GN, post-infectious GN, \"lupus-like GN\", and IgA nephropathy. The pathogenesis and natural history of these GNs is not currently clarified. Key questions remain including the role of HIV infection in the pathogenesis, the efficacy of ART in the prevention and treatment, and the difference in the outcomes between those without HIV. A study from Cape Town aimed to determine the kidney outcomes of MCGN in PWH, and, without HIV, there was no difference in the composite outcome of either doubling of the serum creatinine or ESKD between PWH and HIV negative patients 45.0% versus 25.4%, respectively; \(p\) = 0.10 [120]. There was also no difference in mortality between the groups. Due to late presentation, kidney outcomes remained poor, regardless of the HIV status. Due to the increased genetic, infection, and drug risks for kidney disease in PWH, the monitoring of kidney function is essential. This is recommended at the ART initiation and when modifying ART, as well as yearly after that. However, those high-risk groups, including those of the Black ethnicity, CD4 cell counts < 200 cells/L, viral loads > 4000 copies/mL, or those with additional comorbid conditions such as diabetes mellitus, hypertension, or hepatitis C virus coinfection, require more frequent monitoring. Due to the changing spectrum of kidney disease since the ART rollout, additional attention needs to be given to traditional risk factors of CKD, ART, and opportunistic infections, particularly TB in high-risk regions. The overall positive outcomes of PWH with ESKD should not influence candidacy for KRT.