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Krawczyk CS, Holmberg SD, Moorman AC, Gardner LI, McGwin G. Factors associated with chronic renal failure in HIV-infected ambulatory patients. AIDS 2004; 18:2171-8. [PMID: 15577650 DOI: 10.1097/00002030-200411050-00009] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Renal disease is an increasingly common manifestation among HIV-positive persons, particularly during late stages of HIV disease. We performed a cohort-based, nested case-control study to examine the role of several factors in developing HIV-related chronic renal disease, including HIV viral load and CD4+ cell count. DESIGN Incident cases of chronic renal disease were identified from a cohort of 6361 prospectively followed HIV-1 positive persons. Controls were selected using incidence density sampling and matched 4:1 on age, race/ethnicity, and gender. METHODS Odds ratios (OR) and 95% confidence intervals (CI) were obtained using conditional logistic regression. RESULTS One hundred and eight cases of chronic renal disease were identified; 80 (74.1%) were eligible for the current analysis. Nadir CD4+ cell count < 200 x 10(6) cells/l (OR = 4.3; 95% CI, 2.1-8.7), highly active antiretroviral therapy (HAART) use for 56 days or more (OR = 0.5; 95% CI, 0.3-1.0), and hypertension [treated with angiotensin-converting enzyme (ACE) inhibitors: OR = 4.6; 95% CI, 1.8-11.6; treated with non-ACE inhibitors: OR = 2.5; 95% CI, 1.0-6.2; not treated: OR = 4.2; 95% CI, 0.8-21.6] were associated with disease. HAART use for 56 days or more modified the associations for nadir CD4+ cell count and hypertension. CONCLUSIONS Our findings suggest that advanced HIV-disease, as indicated by low CD4+ cell count, is associated with subsequently developing chronic renal disease and treatment with HAART may reduce the risk of developing chronic renal disease.
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Affiliation(s)
- Christopher S Krawczyk
- School of Public Health, Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
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Ray PE, Xu L, Rakusan T, Liu XH. A 20-year history of childhood HIV-associated nephropathy. Pediatr Nephrol 2004; 19:1075-92. [PMID: 15300477 DOI: 10.1007/s00467-004-1558-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2004] [Revised: 05/13/2004] [Accepted: 05/24/2004] [Indexed: 12/16/2022]
Abstract
In 1984, physicians in New York and Miami reported HIV-infected adult patients with heavy proteinuria and rapid progression to end-stage renal disease. These patients showed large edematous kidneys with a combination of focal segmental glomerulosclerosis (FSGS) and tubulointerstitial lesions. This renal syndrome, named HIV-associated nephropathy (HIVAN), was found predominantly in African Americans. Subsequent studies confirmed the presence of HIVAN in children, who frequently develop nephrotic syndrome in association with FSGS and/or mesangial hyperplasia with microcystic tubular dilatation. Since then, substantial progress has been made in our understanding of the etiology and pathogenesis of HIVAN. This article reviews 20 years of research into the pathogenesis of HIVAN and discusses how these concepts could be applied to the treatment of children with HIVAN. HIV-1 infection plays a direct role in the pathogenesis of childhood HIVAN, at least partially by affecting the growth and differentiation of glomerular and tubular epithelial cells and enhancing the renal recruitment of infiltrating mononuclear cells and cytokines. An up-regulation of renal heparan sulfate proteoglycans seems to play a relevant role in this process, by increasing the recruitment of heparin-binding growth factors (i.e., FGF-2), chemokines, HIV-infected cells, and viral proteins (i.e., gp120, Tat). These changes enhance the infectivity of HIV-1 in the kidney and induce injury and proliferation of intrinsic renal cells. Highly active anti-retroviral therapy (HAART) appears to be the most promising treatment to prevent the progression of childhood HIVAN. Hopefully, in the near future, better education, prevention, and treatment programs will lead to the eradication of this fatal childhood disease.
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Affiliation(s)
- Patricio E Ray
- Division of Nephrology, Children's National Medical Center, Washington, DC 20010, USA.
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Szczech LA, Hoover DR, Feldman JG, Cohen MH, Gange SJ, Goozé L, Rubin NR, Young MA, Cai X, Shi Q, Gao W, Anastos K. Association between renal disease and outcomes among HIV-infected women receiving or not receiving antiretroviral therapy. Clin Infect Dis 2004; 39:1199-206. [PMID: 15486845 DOI: 10.1086/424013] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2004] [Accepted: 05/17/2004] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The associations of proteinuria and an elevated creatinine level with progression to acquired immunodeficiency syndrome (AIDS) and death in the era of highly antiretroviral therapy (HAART) have not been fully described. METHODS This analysis includes 2038 human immunodeficiency virus (HIV)-infected women from the Women's Interagency HIV Study. Time to the development of a new AIDS-defining illness (ADI) and death was modeled using proportional hazards regression before the widespread availability of HAART and after initiation of HAART. RESULTS Of the 2038 subjects, the 14.1% of women with proteinuria had lower CD4 lymphocyte counts and higher viral loads (P<.0001 for all) at baseline and before initiation of HAART. Before the widespread availability of HAART, proteinuria was associated with an increased risk for development of ADI (hazard ratio [HR], 1.37; P=.005), and proteinuria and an elevated creatinine level were both associated with an increased risk of death (for proteinuria: HR, 1.35 [P=.04]; for creatinine: HR, 1.72 per decrease in the inverse unit [P=.02]). Among women initiating HAART, an elevated creatinine level remained associated with an increased risk of development of ADI (HR, 1.54 per decrease in the inverse unit; P=.03), and proteinuria and an elevated creatinine level were associated with an increased risk of death (for proteinuria: HR, 2.07 [P=.005]; for creatinine: HR, 1.96 per decrease in the inverse unit [P=.04]). CONCLUSIONS Proteinuria and an elevated creatinine level were associated with an increased risk of death and development of ADI. These associations may reflect the direct role of the kidney in modulating HIV disease, or they may act as markers of greater comorbidity.
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Affiliation(s)
- Lynda Anne Szczech
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Lucas GM, Eustace JA, Sozio S, Mentari EK, Appiah KA, Moore RD. Highly active antiretroviral therapy and the incidence of HIV-1-associated nephropathy: a 12-year cohort study. AIDS 2004; 18:541-6. [PMID: 15090808 DOI: 10.1097/00002030-200402200-00022] [Citation(s) in RCA: 213] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE to assess temporal changes in the incidence of human immunodeficiency virus-1-associated nephropathy (HIVAN), and the association with use of highly active antiretroviral therapy (HAART). METHODS HIVAN incidence and risk factors were assessed in 3976 HIV-1-infected individuals followed in clinical cohort in Baltimore, Maryland, USA from 1989 to 2001. The incidence of HIVAN, defined by biopsy or a conservative uniformly applied clinical coding protocol, was expressed in terms of person-years, and Poisson regression was used for multivariate analysis. RESULTS Ninety-four patients developed HIVAN over the course of the study for an incidence of 8.0 per 1000 person-years [95% confidence interval (CI), 6.5 to 9.8]. African American race and advanced immunosuppression were strongly associated with HIVAN risk. HIVAN incidence declined significantly in 1998-2001 compared with 1995-1997. Among patients with a prior diagnosis of AIDS, HIVAN incidence was 26.4, 14.4, and 6.8 per 1000 person-years in patients not receiving antiretroviral therapy, treated with nucleoside analogue therapy only, or treated with HAART, respectively (P < 0.001 for trend). In multivariate analysis, HIVAN risk was reduced 60% (95% CI, -30 to -80%) by use of HAART, and no patient developed HIVAN when HAART had been initiated prior to the development of AIDS. CONCLUSION HAART was associated with a substantial reduction in HIVAN incidence. Additional follow-up will be needed to determine if renal damage in susceptible individuals is halted or merely slowed by HAART, particularly when control of viremia is incomplete or intermittent.
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Affiliation(s)
- Gregory M Lucas
- Johns Hopkins University, Baltimore and the Good Samaritan Hospital, Baltimore, Maryland, USA.
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Wei A, Burns GC, Williams BA, Mohammed NB, Visintainer P, Sivak SL. Long-term renal survival in HIV-associated nephropathy with angiotensin-converting enzyme inhibition. Kidney Int 2003; 64:1462-71. [PMID: 12969167 DOI: 10.1046/j.1523-1755.2003.00230.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) is the most common cause of end-stage renal disease (ESRD) in HIV-infected patients. Angiotensin-converting enzyme (ACE) inhibition has previously shown a short-term benefit in HIVAN. This study examines the long-term effects of ACE inhibition on renal survival in HIVAN. METHODS In this single-center prospective cohort study, 44 patients with biopsy-proven HIVAN were enrolled prior to the onset of severe renal insufficiency (serum creatinine <or=2.0 mg/dL), throughout the study period of 1890 days (5.1 years). Twenty-eight patients received fosinopril, 10 mg/day, and 16 were followed as controls. End points included ESRD and death. Treatment effects on survival were evaluated with Kaplan-Meier product-limit estimates. Survival is also described as absolute median number of days. RESULTS Median renal survival of treated patients was 479.5 days, with only one patient developing ESRD. All untreated controls progressed to ESRD, with a median renal survival of 146.5 days (P < 0.0001). There were no significant differences between treatment and control groups in age, significant exposure to antiretroviral therapy, defined as >or=two antiviral drugs for >or=30 consecutive days, CD4 lymphocyte count, initial median serum creatinine concentration, or proteinuria. Risk of renal failure was reduced with ACE inhibitors (RR = 0.003, P < 0.0001). Exposure to antiretroviral therapy did not have a significant impact on the risk of renal failure. Of the ACE inhibitor-treated group, 87.5% survived compared with 21.4% of the control group (P < 0.001). CONCLUSION ACE inhibition initiated prior to severe renal insufficiency may offer long-term renal survival benefits in HIVAN. Diagnosis should be sought early in patients with clinical signs suggestive of HIVAN.
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Affiliation(s)
- Alice Wei
- Department of Medicine, Saint Vincent's Hospital and Medical Center, New York, New York 10011, USA.
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Weiner NJ, Goodman JW, Kimmel PL. The HIV-associated renal diseases: current insight into pathogenesis and treatment. Kidney Int 2003; 63:1618-31. [PMID: 12675837 DOI: 10.1046/j.1523-1755.2003.00901.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Since the description of a new renal syndrome in patients with the acquired immunodeficiency syndrome (AIDS) in the middle 1980s, much has been learned regarding the association of human immunodeficiency virus (HIV) infection and renal disease. The HIV-associated renal diseases represent a spectrum of clinical and histopathologic conditions. In this review, epidemiologic and clinical aspects of HIV-associated renal diseases are presented. Particular attention is placed on the pathologic and pathophysiologic mechanisms involved in HIV-associated focal glomerulosclerosis, immune complex-mediated disease, and thrombotic microangiopathies. Pharmaceutical treatment options, including the use of glucocorticoids, angiotensin-converting enzyme (ACE) inhibitors, and highly active antiretroviral therapy, are discussed. The therapeutic option of renal transplantation is presented, with insight into new clinical and basic research supporting a possible role of immunosuppressive therapy in this already immunocompromised patient population.
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Affiliation(s)
- Neil J Weiner
- Division of Renal Diseases and Hypertension, Department of Medicine, The George Washington University Medical Center, Washington, D.C. 20037, USA
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Abstract
Initially described in 1984, human immunodeficiency virus-associated nephropathy (HIVAN) has now become a common disease within the HIV-seropositive population. It is a focal segmental glomerulosclerosis causing rapid deterioration of renal function. It is the most common cause of chronic renal disease in HIV patients and occurs almost exclusively in blacks. Through murine and human studies, it is now clear that HIVAN is caused by a direct effect of infection of renal cells by HIV-1 and that the virus actively replicates within renal cells. How the virus causes disease within cells is not yet understood, but there is evidence for factors within infected cells causing both proliferation and apoptosis. Steroids, angiotensin converting enzyme (ACE) inhibitors, and highly active antiretroviral therapy (HAART) have been used for the treatment of HIVAN, with HAART, in particular, showing a dramatic improvement in both the pathologic changes and clinical course of HIVAN.
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Hedayati SS, Reddan DN, Szczech LA. HIV-associated nephropathy: a review of the epidemiology and clinical course in the HAART era. AIDS Patient Care STDS 2003; 17:57-63. [PMID: 12639288 DOI: 10.1089/108729103321150782] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- S Susan Hedayati
- Department of Medicine, Division of Nephrology, Duke University Medical Center, Durham, North Carolina 27710, USA
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HIV-Associated Nephropathy With Peripheral Edema, Arterial Hypertension, and Hyperlipidemia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2002. [DOI: 10.1097/01.idc.0000086418.30743.63] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cosgrove CJ, Abu-Alfa AK, Perazella MA. Observations on HIV-associated renal disease in the era of highly active antiretroviral therapy. Am J Med Sci 2002; 323:102-6. [PMID: 11863077 DOI: 10.1097/00000441-200202000-00009] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Renal disease in patients infected with HIV has evolved to include several lesions, including HIV-associated nephropathy (HIV-AN), which can promote progressive loss of renal function. Although angiotensin-converting enzyme inhibitors and corticosteroids are beneficial in selected patients, the effect of highly active antiretroviral therapy (HAART) on renal function is currently being explored. METHODS We undertook a retrospective study to determine the types of renal lesions present in patients infected with HIV with renal insufficiency and/or proteinuria during the era of HAART availability and the effect of HAART on renal outcomes in these patients. Patients with HIV infection referred to the renal clinic from July 1996 through December 2000 were evaluated. Patient characteristics and data were collected including CD4 count, viral load, serum creatinine, blood pressure, proteinuria, renal ultrasound, and biopsy results, and treatment with HAART. Study endpoints were doubling of serum creatinine, initiation of dialysis, or death. RESULTS Twenty-three patients met study criteria, 13 received HAART, and 10 did not. Baseline characteristics were similar except for renal function parameters, viral loads, and CD4 counts. A variety of lesions were noted on 12 renal biopsies. A clinical diagnosis of HIV-AN was made in the other 11 patients. Only 2 patients receiving HAART before renal evaluation were noted to have HIV-AN. In the HAART group, none of the patients, including those with HIV-AN, developed a doubling of serum creatinine. In the non-HAART group, all patients manifested a doubling of serum creatinine, 2 patients died, and 8 patients required dialysis. CONCLUSIONS A variety of renal lesions are noted in patients infected with HIV during the HAART era. Patients who received HAART maintained stable renal function, whereas patients who did not required dialysis therapy or died with advanced renal failure. It seems that HAART may improve renal outcomes in patients with HIV and renal disease.
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Szczech LA, Gange SJ, van der Horst C, Bartlett JA, Young M, Cohen MH, Anastos K, Klassen PS, Svetkey LP. Predictors of proteinuria and renal failure among women with HIV infection. Kidney Int 2002; 61:195-202. [PMID: 11786101 DOI: 10.1046/j.1523-1755.2002.00094.x] [Citation(s) in RCA: 160] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Glomerular disease with proteinuria and renal failure are complications of human immunodeficiency virus (HIV) infection. While studies suggest risk factors for both include black race and lower CD4 lymphocyte count, they have not been established in population-based cohorts. This study examines the risk factors for proteinuria and renal failure in a large cohort of HIV-infected women not selected for the presence of renal disease. METHODS This prospective cohort includes 2059 women enrolled in the Women's Interagency HIV study (WIHS). WIHS is a longitudinal study of the clinical course of HIV infection in which subjects are followed biannually with a detailed exam including urine analysis, serum creatinine, CD4 lymphocyte count, and HIV RNA level. Proteinuria was defined as > or =+1 on urine dipstick exam on at least two consecutive urine analyses, and renal failure was defined as a doubling of serum creatinine. Multivariable logistic regression was used to estimate the associations between clinical variables and the presence of proteinuria on initial evaluation in a cross-sectional analysis. Cox proportional hazards regression was used to estimate the associations between clinical variables and time to renal failure among study participants with proteinuria in a prospective longitudinal analysis. RESULTS Of 2057 HIV-positive women, 32% (N=671) had proteinuria on initial evaluation. Predictors of proteinuria include increasing (log) HIV RNA level [odds ratio (OR)=1.05], black race (OR=2.0), absolute CD4 lymphocyte count < or =200 cells/mm3 (OR=1.41), and the presence of hepatitis C antibody (OR=1.27; all P < 0.0001). Absolute CD4 lymphocyte count < or =200 cells/mm3 [hazard ratio (HR)=3.57, P=0.001], detectable HIV RNA level (HR=2.33, P=0.02), increasing systolic blood pressure (HR=1.02, P=0.002), and decreasing albumin (HR=3.33, P=0.0001) and increasing creatinine (1.67, P=0.0001) were all associated with the development of renal failure. CONCLUSIONS This analysis establishes the associations between both increasing HIV RNA level and decreasing CD4 lymphocyte count with the presence of proteinuria and occurrence of renal failure. Additionally, it demonstrates an association between proteinuria and a positive hepatitis C antibody. To lessen the presence and progression of renal disease among HIV-infected patients, future research should focus on suppression of the HIV RNA level and improvement in CD4 lymphocyte count.
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Affiliation(s)
- Lynda Anne Szczech
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Abstract
Renal manifestations are an important component of HIV disease. Renal disease significantly contributes to morbidity and mortality in patients with HIV. Great progress has been made in identifying specific glomerular lesions and its pathogenesis. Newer antiretroviral agents offer great promise in preventing renal disease and also in patients with established HIVAN. Survival of patients with HIV and ESRD (irrespective of cause) who are receiving RRT continues to improve over the years. Acute reversible renal failure, a preventable complication, is also declining in hospitalized HIV patients. More and more physicians, who in the past were reluctant to care for patients with HIV and renal failure because of grim prognosis, are now becoming familiar with the renal sequelae and are encouraged by recent favorable results. As knowledge about viruses is expanding, the proper use of newer highly effective antiretroviral and other agents in complicated patients should further improve both the survival and quality of life in patients with HIV infection and renal disease.
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Affiliation(s)
- T K Rao
- Renal Diseases Division of the State University of New York, Downstate Medical Center, Brooklyn, New York, USA.
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Szczech LA. Renal diseases associated with human immunodeficiency virus infection: epidemiology, clinical course, and management. Clin Infect Dis 2001; 33:115-9. [PMID: 11389504 DOI: 10.1086/320893] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2000] [Revised: 01/31/2001] [Indexed: 11/03/2022] Open
Abstract
Human immunodeficiency virus (HIV)--associated nephropathy (HIVAN) and other glomerular lesions (e.g., immunoglobulin A nephropathy and immune complex glomerulonephritis) are frequent complications of HIV infection. These renal diseases usually present as a nephrotic syndrome with progressive loss of renal function and an increased risk of mortality. The prevalence and epidemiology of these renal lesions remain largely undefined; however, most studies agree that black race is a major risk factor for HIVAN. Observational studies have suggested that antiretroviral medications and angiotensin-converting enzyme inhibitors have beneficial effects on slowing the progression of renal disease among patients with HIVAN; however, little is known about the effect of these therapies on other renal lesions. Future research should focus on gaining a better understanding of the distribution and determinants of renal disease among HIV-infected patients as well as on performing controlled studies to test treatment strategies.
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Affiliation(s)
- L A Szczech
- Department of Medicine, Division of Nephrology, Duke University Medical Center, Durham, NC 27710, USA.
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Abstract
HIV-associated nephropathy (HIVAN) is the most common cause of renal failure in patients infected with type 1 human immunodeficiency virus (HIV-1). The renal prognosis for HIVAN is poor and is typically associated with rapid progression to renal death. We report a patient with biopsy-proven HIVAN who was successfully treated with corticosteroids and review the currently available evidence supporting the specific treatments of this condition. A 34-year-old African-American male with a 2-year history of uncomplicated HIV disease developed progressive azotemia despite treatment with highly active antiretroviral therapy (HAART). He was treated with an uncomplicated 4-month course of prednisone, which improved his serum creatinine from 2.9 to 1.9 mg/dl and decreased his degree of proteinuria from 8 to 2.1 g/day. Two years post-steroid treatment his renal function remains stable. Increasing evidence supports that both ACE inhibitors and HAART are effective in preventing and in some cases of reversing HIVAN induced renal failure. In selected patients who progress despite these measures, a limited course of corticosteroid may achieve long-standing disease remissions. In general, with adequate supervision, corticosteroid therapy appears to be well tolerated and has an acceptable side effect profile. Although persuasive in view of the abysmal natural history of HIVAN, the currently available studies are subject to major methodological limitations. Appropriate randomized controlled trials are urgently required in order to further examine the efficacy, optimal timing, and potential side effects of these treatments.
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Affiliation(s)
- R Sothinathan
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland 21205, USA
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McComsey GA, Whalen CC, Mawhorter SD, Asaad R, Valdez H, Patki AH, Klaumunzner J, Gopalakrishna KV, Calabrese LH, Lederman MM. Placebo-controlled trial of prednisone in advanced HIV-1 infection. AIDS 2001; 15:321-7. [PMID: 11273211 DOI: 10.1097/00002030-200102160-00004] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the safety and the immunologic and virologic consequences of corticosteroid use in HIV-1 infection. METHODS A randomized, double-blinded, placebo-controlled trial of corticosteroid administration in 41 patients with advanced HIV-1 infection. Patients had a baseline median CD4 cell count of 131 x 10(6) cells/l at enrollment and 85% had a history of opportunistic infection. All but one of the patients had been taking stable antiretroviral regimen, including a protease inhibitor in 36, for a median duration of 158 days. Patients were randomized to 8 weeks of prednisone 0.5 mg/kg daily or placebo. RESULTS No AIDS-defining events occurred; two patients in each group developed oral candidiasis, and two patients on prednisone developed mild herpes simplex flares. None who developed oral candidiasis or herpes simplex was receiving prophylaxis and each responded promptly to therapy. In the prednisone group, two patients developed hyperglycemia and one diabetic increased insulin requirements. CD4 cell counts and plasma HIV-1 RNA levels did not change, but plasma tumor necrosis factor alpha levels and CD38+ CD8+ cells decreased significantly in those taking prednisone. CONCLUSION Short-term prednisone administration is well tolerated and reasonably safe in advanced HIV-1 disease and decreases immune activation without effects on HIV-1 RNA levels or CD4 cell counts. These results suggest that, in stable HIV-1 disease, these immune activation markers are more likely consequences of but not inducers of HIV-1 replication.
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Affiliation(s)
- G A McComsey
- Case Western Reserve University and University Hospitals of Cleveland, Ohio, USA
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Kino T, Kopp JB, Chrousos GP. Glucocorticoids suppress human immunodeficiency virus type-1 long terminal repeat activity in a cell type-specific, glucocorticoid receptor-mediated fashion: direct protective effects at variance with clinical phenomenology. J Steroid Biochem Mol Biol 2000; 75:283-90. [PMID: 11282284 DOI: 10.1016/s0960-0760(00)00187-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Glucocorticoid administration and/or excess secretion have been associated with increased Human Immunodeficiency Virus Type-1 (HIV-1) replication and AIDS progression. The HIV-1 long terminal repeat (LTR) promoter contains glucocorticoid-responsive element (GRE)-like sequences that could mediate a positive effect of glucocorticoids on HIV-1. In addition, we recently demonstrated that the HIV-1 accessory protein Vpr is a potent coactivator of the glucocorticoid receptor, which, like the host coactivator p300, potentiates the effect of glucocorticoids on GRE-containing, glucocorticoid-responsive genes. Such an effect may increase the sensitivity of several host target tissues to glucocorticoids by several fold, and may, thus, contribute to a positive effect of glucocorticoids on the HIV-1-LTR in infected host cells. In this study, we determined the direct effect of glucocorticoids on HIV-1-LTR by examining the ability of dexamethasone to modulate the activity of this promoter coupled to the luciferase reporter gene in human cell lines. Dexamethasone markedly inhibited Tat-stimulated, p300- or Vpr-enhanced luciferase activities in a cell-type specific, dose-dependent, and glucocorticoid receptor-mediated fashion. This effect of dexamethasone was not potentiated by Vpr, was antagonized by the glucocorticoid receptor antagonist RU 486 and required the DNA-binding domain of the receptor. These data suggest that the inhibitory effect of glucocorticoids on the HIV-1-LTR may be exerted via non-GRE-dependent inhibition of the strongly positive host transcription factor NF-kappaB, which interacts with the DNA- and ligand-binding domains of the receptor. Alternatively, it is also possible that dexamethasone-activated glucocorticoid receptor competes with other transcription factors for their binding sites on the promoter region or squelches transcription factors shared by HIV-1-LTR and glucocorticoid-responsive promoters. We conclude that glucocorticoids suppress, rather than stimulate, the HIV-1 promoter, thus acting, protectively for the host. Their apparent negative clinical association with AIDS is most likely due to immunosuppression of the host.
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Affiliation(s)
- T Kino
- Pediatric and Reproductive Endocrinology Branch, National Institute of Child Health and Human Development, Building 10, Room 9D42, National Institutes of Health, 10 Center Drive MSC 1583, Bethesda, MD 20892, USA.
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Ross MJ, Klotman PE, Winston JA. HIV-associated nephropathy: case study and review of the literature. AIDS Patient Care STDS 2000; 14:637-45. [PMID: 11119430 DOI: 10.1089/10872910050206559] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Human immunodeficiency virus type 1 (HIV-1)-seropositive patients are at risk for the development of a variety of acute and chronic renal diseases. The most common cause of chronic renal failure in HIV-1-seropositive patients is HIV-associated nephropathy (HIVAN). HIVAN occurs almost exclusively in black patients and the majority of published cases are of patients who present with acquired immunodeficiency syndrome (AIDS). This disease is currently the third leading cause of end-stage renal disease in blacks aged 20-64. Because HIV-1-seropositive patients may develop a wide variety of acute and chronic renal diseases, definitive diagnosis requires renal biopsy. Emerging data suggest a direct role of HIV-1 infection of kidney cells in the pathogenesis of HIVAN. There have been no well-controlled clinical trials in the treatment of HIVAN. The therapeutic agents with the most promise are angiotensin-converting enzyme inhibitors and antiretroviral medications. Long-term renal prognosis may be changing in the setting of improved aggressive antiretroviral therapy. Patient survival is determined primarily by the stage of HIV-1 infection. In this article, we present the case history of a patient who developed HIVAN. We then review the current literature concerning the epidemiology, differential diagnosis, etiology, and treatment of HIVAN.
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Affiliation(s)
- M J Ross
- Department of Medicine, Division of Nephrology, Mount Sinai School of Medicine, New York, New York 10029, USA.
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Abstract
This review examines the interaction of steroid hormones, glucocorticoids and estrogen, and gp120, a possible causal agent of acquired immune deficiency syndrome-related dementia complex. The first part of the review examines the data and mechanisms by which gp120 may cause neurotoxicity and by which these steroid hormones effect cell death in general. The second part of the review summarizes recent experiments that show how these steroid hormones can modulate the toxic effects of gp120 and glucocorticoids exacerbating toxicity, and estrogen decreasing it. We then examine the limited in vivo and clinical data relating acquired immune deficiency syndrome-related dementia complex and steroid hormones and speculate on the possible clinical significance of these findings with respect to acquired immune deficiency syndrome-related dementia complex.
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Affiliation(s)
- S M Brooke
- Department of Biological Sciences, Stanford University, Stanford, California 94305, USA
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69
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Chemlal K, Nochy D, Kenouch S, Joly V, Carbon C. Dramatic improvement of renal dysfunction in a human immunodeficiency virus-infected woman treated with highly active antiretroviral therapy. Clin Infect Dis 2000; 31:805-6. [PMID: 11017834 DOI: 10.1086/314033] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a single case documenting substantial improvement in the course of human immunodeficiency virus (HIV)-associated, biopsy-proven nephropathy after introduction of highly active antiretroviral therapy. Our case report joins several others recording improvement or stabilization in the course of nephropathy following better control of HIV replication.
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Affiliation(s)
- K Chemlal
- Service de Médecine Interne, Hôpital Bichat, Paris, France.
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70
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Eustace JA, Nuermberger E, Choi M, Scheel PJ, Moore R, Briggs WA. Cohort study of the treatment of severe HIV-associated nephropathy with corticosteroids. Kidney Int 2000; 58:1253-60. [PMID: 10972688 DOI: 10.1046/j.1523-1755.2000.00280.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Human immunodeficiency virus-associated nephropathy (HIVAN) results in rapidly progressive azotemia. The effectiveness and safety of corticosteroids in the treatment of HIVAN, however, remains controversial. METHODS We conducted a retrospective cohort study of patients with biopsy-proven HIVAN and progressive azotemia who were eligible for corticosteroid treatment and who had no clinical or histologic evidence of an alternative cause of acute renal failure. Selected patients were treated with 60 mg of prednisone for one month, followed by a several-month taper. RESULTS Twenty-one eligible patients were identified. Thirteen subjects had received corticosteroid treatment, whereas eight had not. The mean serum creatinine was 6.2 and 6.8 mg/dL, respectively (P > 0.05). The relative risk (95% CI) for progressive azotemia with corticosteroid treatment at three months was 0.20 (0.05, 0.76, P < 0.05). This association remained significant despite adjustment in separate logistical regression analyses for baseline creatinine, 24-hour proteinuria, CD4 count, history of intravenous drug use, hepatitis B, and hepatitis C. In an additional logistic regression model, using backward stepwise selection of the previously mentioned covariates, only corticosteroid treatment (P = 0.02) and baseline serum creatinine (P = 0.10) were retained within the model. In the corticosteroid-treated group, the mean level of proteinuria decreased by 5.5 g/24 hour (P = 0.01). On long-term follow-up, there was no significant difference in the incidence of hospitalizations (1 per 2.1 vs. 1 per 2.3 patient months) or of serious infections (1 per 2.6 vs. 1 per 2.3 patient months), but there was a significantly longer duration of hospitalization in the corticosteroid-treated group (3.2 vs. 2 days per patient month). At six months, only one of the non-corticosteroid-treated patients but seven of the corticosteroid-treated group continued to have independent renal function (P = 0.06). Three of the corticosteroid-treated group continued to have independent function at two years of follow-up. CONCLUSION A limited course of corticosteroid therapy in selected patients was beneficial and safe. Further research is required for the role of corticosteroids in the treatment of HIVAN.
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Affiliation(s)
- J A Eustace
- Divisions of Nephrology and Infectious Disease, The Johns Hopkins University Hospital, Baltimore, Maryland, USA.
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71
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Bottieau E, Colebunders R, Bosmans JL. Favourable outcome of haemolytic uraemic syndrome in an HIV-infected patient treated only with prednisone. J Infect 2000; 41:108-9. [PMID: 10942646 DOI: 10.1053/jinf.2000.0659] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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72
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Abstract
Significant advances have been made in the understanding of the pathophysiology of HIV infection since the beginning of the epidemic. This knowledge has translated into the development of new therapies for HIV and opportunistic infections, laboratory advances in monitoring viral and immune status, and a better understanding of factors affecting patient outcome. Concomitantly, significant progress has been made in the medical management of children with HIV infection in the past 5 years. The number of children reported with AIDS in the United States is decreasing, and efforts are shifting from caring for children with advanced immunosuppression and severe opportunistic infections to early HAART, maintenance of the immune system, and prevention of opportunistic infections. Primary care physicians are now more involved and informed in the care of HIV-infected patients. Although published data are limited, physicians who have been working with this population have observed a dramatic improvement in the quality of life and length of survival of these patients. Unfortunately, this progress is not shared by developing countries where resources are minimal and antiretroviral agents are commonly unavailable. Although efforts to develop a vaccine to prevent HIV infection are ongoing, progress has been slow. Education and awareness continue to be the most powerful weapons against HIV.
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Affiliation(s)
- M Laufer
- Division of Pediatric Infectious Disease, University of Miami School of Medicine, Florida, USA
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73
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Viani RM, Dankner WM, Muelenaer PA, Spector SA. Resolution of HIV-associated nephrotic syndrome with highly active antiretroviral therapy delivered by gastrostomy tube. Pediatrics 1999; 104:1394-6. [PMID: 10585995 DOI: 10.1542/peds.104.6.1394] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
There is no consensus regarding the specific management of HIV-associated nephrotic syndrome. We report a child whose first manifestation of human immunodeficiency virus type 1 (HIV-1) infection was nephropathy and wasting syndrome associated with profound immunodeficiency. The patient had a dramatic clinical and immunologic response to triple antiretroviral therapy delivered through a gastrostomy tube, with complete resolution of nephrotic syndrome. A 51/2-year-old African-American girl presented with a 2-week history of cough, chest pain, vomiting, loose stools, abdominal distention, anorexia, and fever. In addition, she had recurrent oral thrush. Her weight and height were below the 5th percentile. She was chronically ill, appearing with oropharyngeal thrush and pitting edema in lower extremities. She had scattered rhonchi and decreased breath sounds on both lung bases. Her abdomen was distended and diffusely tender. A chest radiograph showed consolidation of the right upper and left lower lobes with bilateral pleural effusion. Admission laboratories were consistent with nephrotic syndrome. Streptococcus pneumoniae grew from the blood culture and the child responded well to treatment with intravenous ceftriaxone. She was found to be HIV-infected, her CD4(+) cell count was 3 cells/mcL and her plasma HIV-1 RNA was >750 000 copies/mL. A percutaneous gastrostomy tube was placed for supplemental nutrition. She was treated with stavudine, lamivudine, and nelfinavir via gastrostomy tube with good clinical response. Twenty-one months after instituting antiretroviral therapy, her weight and height had increased to the 50th and 10th percentile respectively, and she had complete resolution of her nephrotic syndrome. Her CD4(+) cell count increased to 1116 cells/mcL and her viral load has remained undetectable. HIV-1 associated nephrotic syndrome has been described in children with profound immunodeficiency. The course of untreated HIV-associated nephrotic syndrome is rapid progression to renal failure in up to 40% of the children. Regardless of the presence of renal insufficiency, if untreated, it is uniformly fatal. A modest improvement of HIV-1 associated nephrotic syndrome has been observed in patients treated with zidovudine. Steroid and cyclosporine treatment have resulted in improved renal function but long-term use of immunosuppressive therapy has raised concerns about safety. We have described, to our knowledge, the first child with HIV-associated nephrotic syndrome who had a remarkable clinical, immunologic, and virologic response to triple-drug combination therapy given by gastrostomy tube, with complete resolution of proteinuria and normalization of the serum albumin. She also had a striking improvement in weight, height, and quality-of-life. Whether the presence of a gastrostomy tube contributed to the excellent response because of improved compliance is unknown, but warrants systematic evaluation.
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Affiliation(s)
- R M Viani
- Department of Pediatrics, University of California, San Diego, La Jolla 92093-0672, USA
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74
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Laurinavicius A, Hurwitz S, Rennke HG. Collapsing glomerulopathy in HIV and non-HIV patients: a clinicopathological and follow-up study. Kidney Int 1999; 56:2203-13. [PMID: 10594796 DOI: 10.1046/j.1523-1755.1999.00769.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
UNLABELLED Collapsing glomerulopathy in HIV and non-HIV patients: A clinicopathological and follow-up study. BACKGROUND Collapsing glomerulopathy (CG) is a pattern of renal injury that is seen in association with HIV infection and that is increasingly recognized in non-HIV patients. METHODS A review of native kidney biopsies with CG that were diagnosed between 1979 and 1997 in 18 HIV and 42 non-HIV patients is provided. RESULTS HIV and non-HIV patients with CG were similar in terms of age, sex ratio, serum creatinine, proteinuria, the extent of collapsing and sclerosing glomerular lesions, and interstitial damage. A slight female predominance was found in both groups. In contrast to non-HIV patients, the HIV group was characterized by a high prevalence of blacks (94 vs. 57%), frequent tubuloreticular inclusions (76 vs. 29%), and microcystic tubular changes (72 vs. 40%). In 13 non-HIV patients, CG was associated with a systemic lupus erythematosus (SLE)-like disease (5), hepatitis C virus (HCV) infection (3), HTLV-I infection, MCTD, acute monoblastic leukemia, multiple myeloma, and cerebral arteritis. Overall, the renal survival of human immunodeficiency virus (HIV) and non-HIV patients with CG was not significantly different. Cox regression revealed that HIV infection had an adverse effect on short-term renal survival, with other significant risk factors being extensive interstitial fibrosis, high serum creatinine, proteinuria, and a low percentage of glomeruli with collapse. The slope of reciprocal creatinine was best predicted by the degree of proteinuria. Serum creatinine correlated with the extent of interstitial fibrosis, the male gender, and the percentage of glomeruli with collapse. Proteinuria was best predicted by the extent of effacement of podocyte foot processes. CONCLUSIONS CG shares many clinicopathological similarities in HIV and non-HIV patients. In some non-HIV patients, CG was associated with autoimmune diseases, lymphoproliferative disorders, and viral infections.
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Affiliation(s)
- A Laurinavicius
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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75
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Cohen AH, Cohen GM. Distinguished Scientists Lecture Series. HIV-associated nephropathy. Nephron Clin Pract 1999; 83:111-6. [PMID: 10516488 DOI: 10.1159/000045486] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
HIV-associated nephropathy is manifested by heavy proteinuria and renal insufficiency and characterized pathologically by the collapsing variant of focal and segmental glomerulosclerosis with acute tubular necrosis and mild interstitial inflammation. Untreated, it may result in end-stage renal disease in as little as 4 months. It may present in patients with any manifestation of HIV infection, and affects predominantly black individuals. Insights into pathogenesis have come from a transgenic mouse model, renal cell cultures, and from study of human biopsy material. Although the pathogenesis is not completely understood, current considerations revolve around the role of HIV or protein in renal epithelium and the effects of cytokines, including transforming growth factor-beta and basic fibroblast growth factor, on renal structures. Therapy with zidovudine, corticosteroids, or angiotensin-converting enzyme inhibitors has met with modest success; to date, protease inhibitors have not been assessed.
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Affiliation(s)
- A H Cohen
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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76
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Affiliation(s)
- P E Klotman
- Mt. Sinai School of Medicine, New York, New York 10029, USA
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77
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Winston JA, Klotman ME, Klotman PE. HIV-associated nephropathy is a late, not early, manifestation of HIV-1 infection. Kidney Int 1999; 55:1036-40. [PMID: 10027941 DOI: 10.1046/j.1523-1755.1999.0550031036.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Human immunodeficiency virus-associated nephropathy (HIVAN) can be the initial presentation of HIV-1 infection. As a result, many have assumed that HIVAN can occur at any point in the infection. This issue has important implications for appropriate therapy and, perhaps, for pathogenesis. Since the development of new case definitions for acquired immunodeficiency syndrome (AIDS) and better tools to assess infection, the relationship of HIVAN to the time of AIDS infection has not been addressed. In this study, we reassessed the stage of infection at the time of HIVAN diagnosis in 10 patients, and we reviewed all previously published cases applying the new case definitions to assess stage of infection. METHODS HIVAN was confirmed by kidney biopsy in HIV seropositive patients with azotemia and/or proteinuria. CD4+ cell count and plasma HIV-1 RNA copy number were measured. We also reviewed all published cases of HIVAN to determine if AIDS-defining conditions, by current Centers for Disease Control definitions, were present in patients with biopsy-proven HIVAN. RESULTS Twenty HIV-1 seropositive patients with proteinuria and an elevated creatinine concentration were biopsied. HIVAN was the single most common cause of renal disease. CD4+ cell count was below 200/mm3 in all patients with HIVAN, fulfilling Centers for Disease Control criteria for an AIDS-defining condition. HIV-1 plasma RNA was detectable in all patients with HIVAN. In reviewing previous reports, an AIDS-defining condition was present in virtually all patients with HIVAN. CONCLUSION HIVAN develops late, not early, in the course of HIV-1 infection following the development of AIDS. This likely accounts for the poor prognosis noted in previous publications and has implications for pathogenesis. In addition, given the detectable viral RNA levels, highly active antiretroviral therapy is indicated in HIVAN. Highly active antiretroviral therapy may improve survival as well as alter the natural history of HIVAN.
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Affiliation(s)
- J A Winston
- Division of Nephrology, Department of Medicine, Mount Sinai School of Medicine, New York, New York 10029,
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78
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Purgus R, Tamalet C, Poignard P, Spire B, George F, Robert A, Olmer M. Long-term nonprogressive human immunodeficiency virus-1 infection in a kidney allograft recipient. Transplantation 1998; 66:1384-6. [PMID: 9846526 DOI: 10.1097/00007890-199811270-00020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We report a unique case of a renal transplant patient with a long-term nonprogressive human immunodeficiency virus type-1 (HIV-1) infection and who is asymptomatic despite sustained immunosuppression. Renal function is normal, and HIV infection was probably acquired through blood transfusion before the transplant. Nonprogression may be due either to an effective immune control of HIV replication or to particular genetic aspects of the virus. Several virological investigations were carried out to verify if she is infected with an attenuated virus strain. Results show an unusual combination of high and stable CD4 count, ongoing viral replication and elevated viral loads. Attempts to isolate the virus from plasma were unsuccessful, but isolation was possible from peripheral blood mononuclear cells, and the virus was shown to be non-syncytium-inducing. Sequence analysis of the nef gene revealed no mutation. This exceptional lack of progression of HIV infection under immunosuppressive therapy requires further investigation.
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Affiliation(s)
- R Purgus
- Department of Nephrology, Hôpital Conception, Marseille, France
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79
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Williams DI, Williams DJ, Williams IG, Unwin RJ, Griffiths MH, Miller RF. Presentation, pathology, and outcome of HIV associated renal disease in a specialist centre for HIV/AIDS. Sex Transm Infect 1998; 74:179-84. [PMID: 9849552 PMCID: PMC1758112 DOI: 10.1136/sti.74.3.179] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To describe the presentation, pathology, and outcome of biopsy proved renal disease in HIV infected patients at a central London HIV unit from 1992 to 1996. METHODS Retrospective review of a computerised database and case notes to identify patients with renal disease confirmed by antemortem percutaneous renal biopsy or necropsy. RESULTS 17 patients were identified, 13 had biopsy and four necropsy confirmed renal disease. Abnormalities included HIV associated nephropathy (HIVAN) in seven (41%) patients, membranous glomerulonephritis (GN) in four (23%), haemolytic uraemic syndrome (HUS) in two (12%), and interstitial nephritis, rhabdomyolysis, IgA nephropathy, and membranoproliferative GN in one patient each. Although renal disease was the first presentation of HIV disease in six (35%) patients the majority had advanced HIV disease (median CD4 count 40 x 10(6)/l). The commonest presentation was acute renal failure (ARF) in 10 (59%) patients, chronic renal failure (CRF) in five (29%), and proteinuria alone in two (12%). Although the majority of patients died during the study period (9/13) only three deaths were attributable to their renal disease. Survival ranged in those with HIVAN from 0 to 31 (median 10) months and, in those with membraneous GN from 1 to 46 (median 29) months. CONCLUSIONS HIVAN was the commonest renal disease found in this group of patients; however, a variety of other pathologies were seen with variable outcomes. All cases of HIVAN were in patients of African or Afro-Caribbean origin and for the majority this was their first presentation of HIV disease. Nephrologists need to be aware of the possibility of HIV infection in patients presenting with renal disease.
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Affiliation(s)
- D I Williams
- Department of Sexually Transmitted Diseases, UCL Medical School, London
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Spital A. Should all human immunodeficiency virus-infected patients with end-stage renal disease be excluded from transplantation? The views of U.S. transplant centers. Transplantation 1998; 65:1187-91. [PMID: 9603166 DOI: 10.1097/00007890-199805150-00008] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-infected patients have generally been excluded from transplantation. Recent advances in the management and prognosis of these patients suggest that this policy should be reevaluated. METHODS To explore the current views of U.S. transplant centers toward transplanting asymptomatic HIV-infected patients with end-stage renal disease, a written survey was mailed to the directors of transplantation at all 248 renal transplant centers in the United States. RESULTS All 148 responding centers said they require HIV testing of prospective kidney recipients, and 84% of these centers would not transplant an individual who refuses HIV testing. The vast majority of responding centers would not transplant a kidney from a cadaveric (88%) or a living donor (91%) into an asymptomatic HIV-infected patient who is otherwise a good candidate for transplantation. Among the few centers that would consider transplanting an HIV-infected patient, not a single center had performed such a transplant in the year prior to the survey. Most centers fear that transplantation in the face of HIV infection would be harmful to the individual, and some believe that it would be a waste of precious organs. CONCLUSIONS The great majority of U.S. renal transplant centers will not transplant kidneys to HIV-infected patients with end-stage renal disease, even if their infection is asymptomatic. However, advances in the management of HIV infection and a review of relevant ethical issues suggest that this approach should be reconsidered.
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Affiliation(s)
- A Spital
- University of Rochester School of Medicine, New York, USA.
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Mattana J, Siegal FP, Schwarzwald E, Molho L, Sankaran RT, Gooneratne R, Ahuja TS, Singhal PC. AIDS-associated membranous nephropathy with advanced renal failure: response to prednisone. Am J Kidney Dis 1997; 30:116-9. [PMID: 9214410 DOI: 10.1016/s0272-6386(97)90573-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We report the case of a patient with acquired immunodeficiency syndrome (AIDS) who developed nephrotic syndrome and progressive renal failure mimicking human immunodeficiency virus (HIV)-associated focal segmental glomerulosclerosis (FSGS) who required initiation of hemodialysis and was found on renal biopsy to have membranous nephropathy. Hepatitis B and C serologies were negative. Although she required hemodialysis, she was treated with prednisone and experienced a progressive decline in her serum creatinine from 10.1 mg/dL to 1.9 mg/dL, which permitted the discontinuation of hemodialysis. After she abruptly discontinued prednisone, her creatinine level increased to 4.8 mg/dL, and she experienced marked worsening of her nephrotic syndrome. Resumption of prednisone resulted in normalization of serum creatinine and reduction in urine protein excretion. No adverse effects of prednisone occurred during this time. She remains off of hemodialysis for 1 year with a serum creatinine level of 1.0 mg/dL and urine protein excretion of 0.4 g/d. Although most patients with HIV infection, nephrotic-range proteinuria, and renal failure have FSGS, a minority may have membranous nephropathy. Although typically not a steroid-responsive lesion in the setting of advanced renal failure, membranous nephropathy may be a highly steroid-responsive lesion in the HIV-infected patient, and treatment may help avert the need for dialysis in a patient population that generally has a poor outcome on dialysis.
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MESH Headings
- Acquired Immunodeficiency Syndrome/complications
- Adult
- Anti-Inflammatory Agents/therapeutic use
- Diagnosis, Differential
- Female
- Glomerulonephritis, Membranous/complications
- Glomerulonephritis, Membranous/diagnosis
- Glomerulonephritis, Membranous/drug therapy
- Glomerulonephritis, Membranous/pathology
- Glomerulonephritis, Membranous/virology
- Glomerulosclerosis, Focal Segmental/diagnosis
- Humans
- Kidney Failure, Chronic/drug therapy
- Kidney Failure, Chronic/etiology
- Kidney Failure, Chronic/pathology
- Prednisone/therapeutic use
- Renal Dialysis
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Affiliation(s)
- J Mattana
- Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, NY 11040, USA
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83
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ASTHMA AND AIDS. Radiol Clin North Am 1997. [DOI: 10.1016/s0033-8389(22)00277-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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84
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Lin RY, Smith AJ. ASTHMA AND AIDS. Immunol Allergy Clin North Am 1997. [DOI: 10.1016/s0889-8561(05)70305-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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