ASN95 Hot Topic: HIV in Nephrology

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 (PO/414) 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 prevented 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 pressures, 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 elevated 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 HIV 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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