Pediatric Nephrology

, Volume 26, Issue 6, pp 973–977 | Cite as

HIV-associated nephropathy in the setting of maximal virologic suppression

  • Shivaram Hegde
  • Cheentan Singh
  • Bernadette Óhare
Brief Report

Abstract

Human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) is most frequently seen as a late manifestation in adult patients with a high viral load and low T-helper cell (CD4) counts. We report a case of HIVAN in a black Zimbabwean teenager in whom the disease activity was well suppressed for years following highly active antiretroviral therapy (HAART). Proteinuria was absent at 9 years of age when he presented with vertically transmitted HIV infection. Within a few months of HAART, the viral load became undetectable and CD4 count was normalised. Nephrotic range proteinuria, with preserved renal function, developed approximately 4 years later despite excellent HIV disease suppression. Renal biopsy showed non-collapsing focal segmental glomerular sclerosis changes compatible with HIVAN. Although the role of other unknown factors in the disease pathogenesis could not be totally excluded, this case demonstrates that HIVAN can still occur in HIV-infected children despite excellent HAART and that the disease manifestations and outcome may differ from those reported in previous studies.

Keywords

HIV HIV-associated nephropathy Proteinuria Nephrotic syndrome Non-collapsing focal segmental glomerulosclerosis Viral load CD4 count Proteinuria HAART 

References

  1. 1.
    Gupta SK, Eustace JA, Winston JA, Boydstun II, Ahuja TS, Rodriguez RA, Tashima KT, Roland M, Franceschini N, Palella FJ, Lennox JL, Klotman PE, Nachman SA, Hall SD, Szczech LA (2005) Guidelines for the management of chronic kidney disease in HIV-infected patients: recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 40:1559–1585PubMedCrossRefGoogle Scholar
  2. 2.
    Ray PE, Rakusan T, Loechelt BJ, Selby DM, Liu XH, Chandra RS (1998) Human immunodeficiency virus (HIV)-associated nephropathy in children from the Washington, D.C. area: 12 years' experience. Semin Nephrol 18:396–405PubMedGoogle Scholar
  3. 3.
    Strauss J, Abitbol C, Zillerruelo G, Scott G, Paredes A, Malaga S, Montane B, Mitchell C, Parks W, Pardo V (1989) Renal disease in children with acquired immunodeficiency syndrome. N Engl J Med 321:625–630PubMedCrossRefGoogle Scholar
  4. 4.
    Winston JA, Burns GC, Klotman PE (1998) Human immunodeficiency virus (HIV) epidemic and HIV associated nephropathy. Semin Nephrol 18:373–377PubMedGoogle Scholar
  5. 5.
    Ahuja TS, Abbott KC, Pack L, Kuo YF (2004) HIV-associated nephropathy and end-stage renal disease in children in the United States. Pediatr Nephrol 19:808–811PubMedCrossRefGoogle Scholar
  6. 6.
    Winston JA, Klotman ME, Klotman PE (1999) HIV-associated nephropathy is a late, not early, manifestation of HIV-1 infection. Kidney Int 55:1036–1040PubMedCrossRefGoogle Scholar
  7. 7.
    Izzedine H, Wirden M, Launay-Vacher V (2005) Viral load and HIV-associated nephropathy. N Engl J Med 353:1072–1074PubMedCrossRefGoogle Scholar
  8. 8.
    Szczech LA, Gupta SK, Habash R, Guasch A, Kalayjian R, Appel R, Fields TA, Svetkey LP, Flanagan KH, Klotman PE, Winston JA (2004) The clinical epidemiology and course of the spectrum of renal diseases associated with HIV infection. Kidney Int 66:1145–1152PubMedCrossRefGoogle Scholar
  9. 9.
    Gavin PJ, Yogev R (2002) The role of protease inhibitor therapy in children with HIV infection. Paediatr Drugs 4:581–607PubMedGoogle Scholar
  10. 10.
    D’Agati V, Appel GB (1998) Renal pathology of human immunodeficiency virus infection. Semin Nephrol 18:406–421PubMedGoogle Scholar
  11. 11.
    D’Agati V, Suh JI, Carbone L, Cheng JT, Appel G (1989) Pathology of HIV-associated nephropathy: A detailed morphologic and comparative study. Kidney Int 35:1358–1370PubMedCrossRefGoogle Scholar
  12. 12.
    Wyatt CM, Morgello S, Katz-Malamed R, Wei C, Klotman ME, Klotman PE, D'Agati VD (2009) The spectrum of kidney disease in patients with AIDS in the era of antiretroviral therapy. Kidney Int 75:428–434PubMedCrossRefGoogle Scholar
  13. 13.
    Ray PE (2009) Taking a hard look at the pathogenesis of childhood HIV-associated nephropathy. Pediatr Nephrol 24:2109–2119PubMedCrossRefGoogle Scholar
  14. 14.
    Albaqumi M, Soos TJ, Barisoni L, Nelson PJ (2006) Collapsing glomerulopathy. J Am Soc Nephrol 17:2854–2863PubMedCrossRefGoogle Scholar
  15. 15.
    Wyatt CM, Klotman PE, D'Agati VD (2008) HIV-associated nephropathy: clinical presentation, pathology, and epidemiology in the era of antiretroviral therapy. Semin Nephrol 28:513–522PubMedCrossRefGoogle Scholar
  16. 16.
    McElrath MJ, Pruett JE, Cohn ZA (1989) Mononuclear phagocytes of blood and bone marrow: Comparative roles as viral reservoirs in human immunodeficiency virus type 1 infections. Proc Natl Acad Sci USA 86:675–679PubMedCrossRefGoogle Scholar
  17. 17.
    Wong JK, Gunthard HF, Havlir DV, Zhang ZQ, Haase AT, Ignacio CC, Kwok S, Emini E, Richman DD (1997) Reduction of HIV-1 in blood and lymph nodes following potent antiretroviral therapy and the virologic correlates of treatment failure. Proc Natl Acad Sci USA 94:12574–12579PubMedCrossRefGoogle Scholar
  18. 18.
    Bruggeman LA, Ross MD, Tanji N, Cara A, Dikman S, Gordon RE, Burns GC, D'Agati VD, Winston JA, Klotman ME, Klotman PE (2000) Renal epithelium is a previously unrecognized site of HIV-1 infection. J Am Soc Nephrol 11:2079–2087PubMedGoogle Scholar
  19. 19.
    Winston JA, Bruggeman LA, Ross MD, Jacobson J, Ross L, D'Agati VD, Klotman PE, Klotman ME (2001) Nephropathy and establishment of a renal reservoir of HIV type 1 during primary infection. N Engl J Med 344:1979–1984PubMedCrossRefGoogle Scholar
  20. 20.
    Marras D, Bruggeman LA, Gao F, Tanji N, Mansukhani MM, Cara A, Ross MD, Gusella GL, Benson G, D'Agati VD, Hahn BH, Klotman ME, Klotman PE (2002) Replication and compartmentalization of HIV-1 in kidney epithelium of patients with HIV-associated nephropathy. Nat Med 8:522–526PubMedCrossRefGoogle Scholar
  21. 21.
    Cantor ES, Kimmel PL, Bosch JP (1991) Effect of race on expression of acquired immunodeficiency syndrome-associated nephropathy. Arch Intern Med 151:125–128PubMedCrossRefGoogle Scholar
  22. 22.
    Ray PE, Tassi E, Liu XH, Wellstein A (2006) Role of fibroblast growth factor-binding protein in the pathogenesis of HIV-associated hemolytic uremic syndrome. Am J Physiol Regul Integr Comp Physiol 290:R105–R113PubMedCrossRefGoogle Scholar
  23. 23.
    Izzedine H, Deray G (2007) The nephrologist in the HAART era. AIDS 21:409–421PubMedCrossRefGoogle Scholar
  24. 24.
    McCulloch MI, Ray PE (2008) Kidney disease in HIV-positive children. Semin Nephrol 28:585–594PubMedCrossRefGoogle Scholar
  25. 25.
    Porter K, Babiker A, Bhaskaran K, Darbyshire J, Pezzotti P, Porter K, Walker AS, Collaboration CASCADE (2003) Determinants of survival following HIV-1 seroconversion after the introduction of HAART. Lancet 362:1267–1274PubMedCrossRefGoogle Scholar
  26. 26.
    Gibb DM, Duong T, Tookey PA, Sharland M, Tudor-Williams G, Novelli V, Butler K, Riordan A, Farrelly L, Masters J, Peckham CS, Dunn DT, NSHPC and CHIPS study (2003) Decline in mortality, AIDS, and hospital admissions in perinatally HIV-1 infected children in the United Kingdom and Ireland. Br Med J 327:1019–1031CrossRefGoogle Scholar
  27. 27.
    Schwartz EJ, Szczech LA, Ross MJ, Klotman ME, Winston JA, Klotman PE (2005) Highly active antiretroviral therapy and the epidemic of HIV + end-stage renal disease. J Am Soc Nephrol 16:2412–2420PubMedCrossRefGoogle Scholar
  28. 28.
    Lucas GM, Eustace JA, Sozio S, Mentari EK, Appiah KA, Moore RD (2004) Highly active antiretroviral therapy and the incidence of HIV-1-associated nephropathy: a 12-year cohort study. AIDS 18:541–546PubMedCrossRefGoogle Scholar
  29. 29.
    Kirchner JT (2002) Resolution of renal failure after initiation of HAART: 3 cases and a discussion of the literature. AIDS Read 12(103–105):110–112Google Scholar
  30. 30.
    Wali RK, Drachenberg CI, Papadimitriou JC, Keay S, Ramos E (1998) HIV-1-associated nephropathy and response to highly active antiretroviral therapy. Lancet 352:783–784PubMedCrossRefGoogle Scholar
  31. 31.
    Chaparro A, Mitchell C, Abitbol C, Wilkinson J, Baldarrago G, Lopez E, Zilleruelo G (2008) Proteinuria in Children Infected with the Human Immunodeficiency Virus. J Pediatr 152:844–849PubMedCrossRefGoogle Scholar
  32. 32.
    Han TM, Naicker S, Ramdial RK, Assounga AG (2006) A cross-sectional study of the HIV- seropositive patients with varying degrees of proteinuria in South Africa. Kidney Int 69:2243–2250PubMedCrossRefGoogle Scholar
  33. 33.
    Smith MC, Austen JL, Carey JT, Emancipator SN, Herbener T, Gripshover B, Mbanefo C, Phinney M, Rahman M, Salata RA, Weigel K, Kalayjian RC (1996) Prednisone improves renal function and proteinuria in human immunodeficiency virus-associated nephropathy. Am J Med 101(1):41–48PubMedCrossRefGoogle Scholar
  34. 34.
    Wei A, Burns GC, Williams BA, Mohammed NB, Visintainer P, Sivak SL (2003) Long-term renal survival in HIV-associated nephropathy with angiotensin-converting enzyme inhibition. Kidney Int 64(4):1462–1471PubMedCrossRefGoogle Scholar

Copyright information

© IPNA 2011

Authors and Affiliations

  • Shivaram Hegde
    • 1
  • Cheentan Singh
    • 1
  • Bernadette Óhare
    • 2
  1. 1.Department of Paediatric NephrologyUniversity Hospital of WalesCardiffUK
  2. 2.Department of PaediatricsUniversity Hospital of WalesCardiffUK

Personalised recommendations