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HIV nephropathy

Etiology: 1) fluid & electrolyte disorders a) hyponatremia b) SIADH 2) renal insufficiency a) pharmaceutical agents 1] amphotericin B 2] foscarnet 3] pentamidine 4] trimethoprim-sulfamethoxazole 5] non-steroidal anti-inflammatory drugs 3) nephrolithiasis a) indinavir b) high dose trimethoprim-sulfamethoxazole 4) nephrotic syndrome 5) rapidly progressive, irreversible azotemia 6) focal glomerulosclerosis Epidemiology: 1) more frequent in IV drug abusers than homosexuals [1] 2) occurs more frequently in blacks than whites [2] 3) may occur at any stage of HIV infection Pathology: 1) resembles focal segmental glomerulosclerosis 2) diffuse glomerular collapse & glomerulosclerosis 3) glomerular epithelial cell swelling 4) severe tubulointerstitial damage 5) microcystic dilatation of the renal tubules 6) opportunistic infections increase risk of acute renal failure Clinical manifestations: 1) progressive renal insufficiency with heavy proteinuria 2) rapidly progresses to end-stage renal disease 3) little or no edema or hypertension 4) disease progresses to end-stage renal disease in 4-16 weeks Laboratory: 1) heavy proteinuria, nephrotic syndrome 2) renal biopsy Radiology: large echogenic kidneys on renal ultrasound Differential diagnosis: (HIV-infected patients) 1) post-infectious glomerulonephritis 2) HIV-associated IgA nephropathy 3) membranoproliferative glomerulonephritis 4) membranous nephropathy 5) hemolytic uremic syndrome (HUS); thrombotic thrombocytopenic purpura (TTP) 6) nephrotoxic medications - pentamidine, aminoglycosides, Bactrim, NSAIDs Management: 1) some patients show improvement with glucocorticoids 2) anti-retroviral therapy (HAART) 3) plasmapheresis for HUS/TTP 4) recognize nephrotoxicity of antibiotics & anti-retroviral agents 5) ACE inhibitors diminish proteinuria & preserve renal function 6) ARB if ACE inhibitor not tolerated 7) renal transplantation [2]

General

complications in patients with HIV1 infection nephropathy

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 608
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 17 American College of Physicians, Philadelphia 1998, 2009, 2015
  3. Hartle PM, Carlo ME, Dwyer JP, Fogo AB. AKI in an HIV patient. J Am Soc Nephrol. 2013 Jul;24(8):1204-8. PMID: 23559580 Free PMC Article