Under what circumstances would you consider a kidney biopsy in an HIV patient with subnephrotic range proteinuria, microscopic hematuria, and stable renal function who has been on a tenofovir-based regimen?

Under what circumstances would you consider a kidney biopsy in an HIV patient with subnephrotic proteinuria, microscopic hematuria, and stable renal function on a tenofovir-based regimen?

• I rarely biopsy — subnephrotic proteinuria with stable renal function on tenofovir is likely drug-related and I manage empirically
• I biopsy when clinical features suggest an alternative diagnosis (e.g., IgA nephropathy, lupus nephritis, or other glomerular disease)
• I biopsy when the tenofovir exposure has been brief, making drug-related injury less likely
• I biopsy when the urinary findings are unexplained despite optimizing or switching the antiretroviral regimen
• I biopsy in most cases — histologic diagnosis guides management regardless of clinical suspicion
• Other