Our knowledge of HIV-related renal issues was expanded by data
presented in abstract form at the 1995 ASN.
Rahman et al (430/1048) extended the previous report of
the efficacy of prednisone therapy of HIVAN to 19
patients, and were able to show an 80-90% response rate, including dramatic
decreases in serum creatinine and urine protein as well as delay of death
and ESRD. Some patients who relapsed off prednisone responded to a second
course; 4 patients were able to come off of dialysis with steroids. These
findings were confirmed by Briggs and colleagues (153/413).
In this report 3 of 5 patients
responded to steroids, including one patient in whom the post-treatment
biopsy showed marked improvement. Two abstracts reported successful
response of early HIVAN to ACE inhibitors. In the Burns' et al
study, 3 HIVAN patients
treated with fosinopril did not progress over one year, while 4 untreated
patients developed ESRD. Similarly Kimmel and coworkers
(2207/423) found captopril
disease progression in 5 five patients compared with 5 matched controls.
These observations clearly indicate that the time is ripe for prospective
randomized controlled studies of steroids and of ACE inhibitors in HIVAN. Until the
results of such studies are available, judicious use of these agents in
selected patients is warranted.
The clinical diagnosis of HIVAN may be complicated in patients with
concomitant hepatitis C infection, with or without cryoglobulinemia.
Hertel et al (155/421) reported on five cryoglobulinemic patients, two
of whom were
proved to have cryoglobulinemic GN; one patient refused therapy and the
other responded clinically to interferon-alpha and plasmapheresis; three
patients had HIVAN on biopsy. Stokes et al (2208/433)
reported on 14 HIV positive
patients with renal disease most of whom were coinfected with HCV
presenting with hematuria, hypertension, edema and low C3; many had
cryoglobulinemia. Membranoproliferative GN, mesangioproliferative GN,
membranous GN and glomerular sclerosis with mesangial immune deposits were
found on biopsy. These two reports emphasize the fact that HIV infected
patients can present with nephropathies other than HIVAN, especially if
cryoglobulinemia, low C3 or HCV coinfection are present; renal biopsy
should be performed in these instances if corticosteroid or interferon
therapy is being contemplated. Not surprisingly
Schoenfeld et al (169/562) reported
HCV infection to be much more prevalent in HIV positive hemodialysis
patients than in HIV negative ones (83% vs. 25%).
One interesting clinical aspect of HIVAN is the absence of edema in many
patients, despite nephrotic range proteinuria and hypoalbuminemia.
Perinbasekar (PO/399) found that patients with edema had higher blood
higher CD4 counts, less weight loss, less diarrhea and greater use of
anti-retroviral drugs; some of these factors may effect the presence of
edema by altering Starling forces. Guardia (157/419) reported that
globulin levels led to higher colloid oncotic pressures in HIVAN patients
without edema, which may also help explain this finding.
The prevalence of renal disease in HIV infected patients may be higher than
is generally appreciated, at least in inner-city African American
populations with high rates of IV drug use. Tunde (PO/405)
reported that 21% of
their clinic patients had a creatinine greater than 1.4 and 16% had 1+
proteinuria or more on dipstick. Furthermore the prevalence of HIVAN
causing ESRD may be grossly under reported. Winston
(PO/408) estimated 1500-200
unreported cases of ESRD from HIVAN from 1989-1992 and raises the specter
of an unrecognized "epidemic", with HIV causing 20% of ESRD in young
blacks. Greer (106/389) reviewed Medicare 2278 forms and found that
accounted for 12% of ESRD in young black men, which was considered an
underestimate given under reporting and restrictions on HIV testing.
Two final positive notes: Harrison (PO/532)
reported on their latest
hemodialysis survival for HIV infected patients which was 50%, 30% and 10%
at 1, 2 and 3 years respectively. Mortality was related, in general, to
complications of HIV. These data confirm that the survival of HIV patients
on dialysis is better than originally reported. Secondly, Rao and
Friedman (164/474) have
shown that the yearly incidence of acute renal failure in HIV positive
patients has dropped from 2% to 1% of hospital admissions over the recent
past, implying a greater awareness of the nephrotoxicity of prescribed
drugs as well as better overall care of patients infected with HIV.
(Stephen Pastan, Emory University, Atlanta, GA)
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