Immune reconstitution inflammatory syndrome and acute granulomatous interstitial nephritis

Acute poststreptococcal glomerulonephritis: a manifestation of immune reconstitution inflammatory syndrome

Immune reconstitution inflammatory syndrome (IRIS) is a well-described complication of initiation of highly active antiretroviral therapy in HIV-infected patients. As the immune system recovers, an inappropriate inflammatory response often occurs that causes significant disease. It is most commonly seen in patients naïve to therapy with CD4+ T-lymphocyte counts <100 cells/cmm and usually presents as a flare of mycobacterial, cytomegalovirus, or herpes zoster infections. Less commonly, this syndrome occurs in response to noninfectious triggers and results in autoimmune or malignant disease. Here we present the first case of acute poststreptococcal glomerulonephritis associated with varicella zoster virus and IRIS in an adolescent with perinatally acquired HIV and hepatitis C virus infections. Our patient was not naïve to therapy but was starting a new regimen of therapy because of virologic failure and had a relatively high CD4+ T-lymphocyte count. This case report indicates that IRIS remains a concern after initiation of a new highly active antiretroviral therapy regimen in HIV-infected patients with high viral loads, even in the presence of CD4+ T-lymphocyte counts >100 cells/cmm. It may present as infectious, malignant, or autoimmune conditions including poststreptococcal glomerulonephritis.

Immune reconstitution renal-limited sarcoidosis presenting as acute kidney injury

An HIV-infected asymptomatic woman developed acute kidney injury six weeks after initiation of combination antiretroviral therapy (cART). A renal biopsy revealed both renal-limited sarcoidosis and HIV nephropathy. The acute renal injury reversed with glucocorticoid therapy.

A case of acute renal failure in a patient recently treated with clozapine and a review of previously reported cases

Clozapine has been reported to cause acute renal failure due to acute interstitial nephritis. We discuss a case of clozapine-induced acute renal failure and compare it to 7 other cases reported in the literature. We review the signs and symptoms of the hypersensitivity response, such as fever and eosinophilia, caused by clozapine and make recommendations for early detection. Early detection and prompt discontinuation of clozapine can prevent renal damage, as can the avoidance of other nephrotoxic drugs like antibiotics.

HIV care and the incidence of acute renal failure

BACKGROUND

The clinical epidemiology of acute renal failure (ARF) in human immunodeficiency virus (HIV)-infected patients remains poorly defined.

METHODS

We conducted a retrospective analysis of patients who developed ARF while attending King's College Hospital (London, United Kingdom) during January 1998-December 2005. Serum creatinine level and estimated glomerular filtration rate were used to identify ARF. ARF episodes were classified as early onset if they occurred <3 months after initiation of HIV care and as late onset if they occurred > or =3 months after initiation of HIV care.

RESULTS

During the study period, 130 (5.7%) of 2274 patients developed 144 episodes of ARF. The incidences of early-onset and late-onset ARF were 19.3 episodes per 100 person-years (95% confidence interval [CI], 15.4-24.1 episodes per 100 person-years) and 1.1 episodes per 100 person-years (95% CI, 0.83-1.49 episodes per 100 person-years), respectively (rate ratio, 17.4; P<0.001). In multivariate analysis, nadir CD4 T cell count <100 x 10(9) cells/L (odds ratio [OR], 6.7; 95% CI, 2.5-18.3) and acquired immunodeficiency syndrome (OR, 6.7; 95% CI, 3.4-13.3) were associated with early-onset ARF, whereas injection drug use (OR, 4.8; 95% CI, 1.3-17.7), hepatitis C virus coinfection (OR, 3.4; 95% CI, 1.3-8.6), and nadir CD4 T cell count <100 x 10(9) cells/L (OR, 5.8; 95% CI, 2.5-13.4) were associated with late-onset ARF.

CONCLUSIONS

ARF was common and was associated with advanced immunodeficiency. The incidence of ARF decreased >10-fold in patients who had received HIV care for > or =3 months.

Nephrotoxicity associated with antiretroviral therapy in HIV-infected patients

BACKGROUND

With the success of modern antiretroviral therapies in increasing longevity of patients with HIV infection, chronic conditions including renal disease have assumed a greater importance in patient management. Some antiretroviral therapies have themselves been identified to have clinically significant nephrotoxicity.

OBJECTIVE

To review the risk factors and mechanisms for renal toxicity of antiretroviral drugs, and their impact on the clinical management of patients with HIV.

METHODS

Current literature and HIV treatment guidelines are reviewed.

RESULTS/CONCLUSIONS

Background rates of renal disease and associated risk factors are significant in the HIV clinic population, and renal function should be assessed in all HIV-infected patients. Modern HIV treatment regimens have a relatively low but clinically significant nephrotoxic potential; therefore, renal function should be evaluated on an ongoing basis in patients receiving antiretroviral therapy.

Acute Kidney Disease Due to Immune Reconstitution Inflammatory Syndrome in an HIV-Infected Patient With Tuberculosis

This study reports the case of an HIV-infected patient with disseminated tuberculosis who presented an immune reconstitution inflammatory syndrome (IRIS) revealed by an acute kidney disease 45 and 15 days after initiation of antituberculosis therapy and HAART, respectively. Prednisone therapy and the transient withdrawal of HAART improved the renal function and the clinical condition of this patient. All published case reports of IRIS revealed by acute renal failure in HIV-infected patients are also reviewed.