HIV NEPHROPATHY Done By GhadaAnkawi Medical Resident, KAAUH
Causes • HIV-related. • Secondary to infections. • Secondary to nephrotoxic medications. (HAART, opportunistic infections treatment)
HIV Related Focal segmental sclerosis -Most common (80%). -Pathogenesis: HIV infect endothelial/mesangial & tubular cells. -Epidemiology: 2-10% before HAART. common in men & blacks.
Focal Segmental Glomerulosclerosis (cont.) -Clinical picture: Nephrotic syndrome (heavy proteinuria, oedema, decreased albumin, few red/white cell cast in urinary sediment). -Diagnosis: US enlarged, hyperechoec kidney. BX collapsing FGS & severe tubulointerstitial damage.
Focal Segmental Glomerulosclerosis (cont.) Indications for biopsy 1-High risk, seropositive patients. 2-Proteinuria >1 gm/day. Treatment 1-HAART (should be started regardless of the CD4count). 2-ACE-Inhibitors/ ARB. 3-BP< 130/80. 4-Corticosteroids. 5-Cyclophosphamide (uncertain, risk of infection vs benefit should be balanced).
HIV Related Memberanous GN In HCV/HBV/Syphillis patients. Membranoproliferative GN Associated with HCV/ mixed cryoglobulinemia. Immune complex GN IgA related. Interstitial nephritis CMV associated or reaction to cotrimoxazole. Amyloidosis Due to chronic infection. TTP mechanism is not understood.
Secondary To Infections Generally approached the same as in non-HIV infected patients.
Nephrotoxic Medications Direct injury HAART Ritonavir (protease inhibitor). Tenofovir (nucleotide reverse transcriptase inhibitor). NB: nucleoside reverse transcriptase inhibitors are much less nephrotoxic.
Nephrotoxic Medications As treatment for opportunistic infections -Pentamedine (PCP). -Foscarnet (CMV retinitis, resitatant HSV). -Cidofovir (CMV retinitis, Hepatitis C). -Amphotericin B (wide range of fungal infections). -Adevovir (HBV). -Aminoglycosides.
Nephrotoxic Medications Renal failure with intratubular obstruction Due to crystals deposition. Seen with: -IV acyclovir. -Sulfadiazine (used with pyremethamine for toxoplasmosis treatment).
Nephrotoxic Medications Causing renal calculi Indinavir (protease inhibitor). Causing interstitial nephritis Trimethopriumsulfamethoxazole.
References -Harrison. -Up-to-date.