Differential Diagnosis of Renal Dysfunction and HIV

Tubular Microcyst with Proteinaceous cast

 

This week we had an interesting patient that present several months ago with HIV/AIDS with very low CD4 count off HAART for the last several years. The patient presents with nephrotic syndrome with lower extremity edema, normal renal function, and 13 grams proteinuria/day. Renal biopsy was done and showed membranoproliferative pattern with “full house” of immune complexes with IgA, IgG, and IgM, as well as C1q. We decided that this was HIV associated MPGN and referred to ID for initation of HAART therapy. The patient present to clinic for f/u one several months later with viral load in the 50s and CD4 of 250. So we decided to re-evaluate our diagnosis as patient still has 3 grams of proteinuria despite a decreased viral load with therapy. So here is a review of the differential diagnosis or renal dysfunction in patients with HIV, to help you not fall into the trap of HIV + kidney disease = HIVAN (FSGS, collapsing variant). Of course we see collapsing variant of FSGS in patients of African descent, nephrotic proteinuria, high viral load and CD4 count < 200. If HIV RNA is less 400 copies/ml another diagnosis is likely, see below.

Glomerular

  • Collapsing FSGS glomerulopathy
  • Immune complex GN
  • Thrombotic microangiopathy (TMA)
  • Membranoproliferative GN
  • Membranous nephropathy
  • Fibrallary and immunotactoid glomerulopathies
  • Amyloid (AA) nephropathy
  • Minimal change disease

Tubular

  • ATN
  • Proximal tubule injury (Fanconi syndrome)
  • Diabetes insipidus
  • Chronic tubular injury
  • Crystalluria with nephropathy
    • Seen with indinavir, atazanavir;sulfadiazine, cipro, and rapidly infused IV acyyclovir

Interstitial

  • Interstitial nephritis

As seen above antiviral therapy can nephrotoxic itself. Specifically the classes of Protease Inhibitors , Reverse Transcriptase Inhibitors, and cidofovir/adefovir.

Adrian

Image Source: Comprehensive Clinical Nephrology 4th Edition Copyright © 2013 Elsevier Inc.

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