HIV nephropathy

Etiology

• fluid & electrolyte disorders
  • hyponatremia
  • SIADH
• renal insufficiency
  • pharmaceutical agents
    • amphotericin B
    • foscarnet
    • pentamidine
    • trimethoprim-sulfamethoxazole
    • non-steroidal anti-inflammatory drugs
• nephrolithiasis
  • indinavir
  • high dose trimethoprim-sulfamethoxazole
• nephrotic syndrome
• rapidly progressive, irreversible azotemia
• focal glomerulosclerosis

Epidemiology

• more frequent in IV drug abusers than homosexuals
• occurs more frequently in blacks than whites
• may occur at any stage of HIV infection

Pathology

• resembles focal segmental glomerulosclerosis
• diffuse glomerular collapse & glomerulosclerosis
• glomerular epithelial cell swelling
• severe tubulointerstitial damage
• microcystic dilatation of the renal tubules
• opportunistic infections increase risk of acute renal failure

Clinical manifestations

• progressive renal insufficiency with heavy proteinuria
• rapidly progresses to end-stage renal disease
• little or no edema or hypertension
• disease progresses to end-stage renal disease in 4-16 weeks

Laboratory

• heavy proteinuria, nephrotic syndrome
• renal biopsy

Radiology

large echogenic kidneys on renal ultrasound

Differential diagnosis

(HIV-infected patients)

• post-infectious glomerulonephritis
• HIV-associated IgA nephropathy
• membranoproliferative glomerulonephritis
• membranous nephropathy
• hemolytic uremic syndrome (HUS); thrombotic thrombocytopenic purpura (TTP)
• nephrotoxic medications
  • pentamidine, aminoglycosides, Bactrim, NSAIDs

Management

• some patients show improvement with glucocorticoids
• anti-retroviral therapy (HAART)
• plasmapheresis for HUS/TTP
• recognize nephrotoxicity of antibiotics & anti-retroviral agents
• ACE inhibitors diminish proteinuria & preserve renal function
• ARB if ACE inhibitor not tolerated
• renal transplantation

More general terms

• complications in patients with HIV1 infection
• nephropathy