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Common causes of Acute Kidney Injury in HIV
What are the common causes of Acute Kidney Injury in HIV patients?
Approximately 5% to 10% of hospitalized patients with HIV will experience AKI, with a mortality risk that is five times higher than the general AKI population without HIV. The most important approach in the assessment of AKI in a patient with HIV requires answers to the following questions:
- • Is the patient receiving cART?
- • What is the viral control of HIV?
The approach to AKI will be different based on the answers to these questions. If a patient is not receiving cART and has uncontrolled HIV viremia, the most common causes of kidney injury are related to systemic infection and volume depletion leading to prerenal azotemia and possible acute tubular necrosis (ATN). Uncontrolled infectious diarrhea with fever and large insensible fluid losses is a common presenting scenario in a patient with HIV who is cART naïve. Patients with HIV frequently develop sepsis from pneumonia and other opportunistic infections complicated by hypotension, which may also lead to ATN. In patients with infection who are cART-naïve, multiple antibiotics are often used to cover bacterial, viral, fungal, and atypical infectious agents. Many of these antibiotics can result in AKI, as summarised in the below table.
Antibiotics Can Result in Acute Kidney Injury
| ANTIBIOTIC | KIDNEY SYNDROME(S) |
|---|---|
| Amphotericin | ATN, type I kidney tubular acidosis |
| Trimethoprim-sulfamethoxazole | Crystal-induced ATN, allergic interstitial nephritis |
| Penicillin/cephalosporin agents | Allergic interstitial nephritis |
| Aminoglycosides | ATN |
| Foscarnet | ATN |
| Pentamidine | ATN |
| Vancomycin | ATN |
| Ciprofloxacin | Crystal-induced ATN, allergic interstitial nephritis |
| Acyclovir | Crystal-induced ATN, allergic interstitial nephritis |
| Azole class antifungals | Potentiate NRTI and calcineurin-induced nephrotoxicity |
ATN , Acute tubular necrosis; NRTI , nucleaside reverse transcriptase inhibitors.
If the patient is receiving cART therapy with a controlled viral load, then the development of AKI may be secondary to drug-induced tubular dysfunction. Patients on cART have been shown to have a significantly higher risk of AKI, particularly in the setting of volume depletion. It is essential that all physicians treating patients with HIV be familiar with the potential nephrotoxicity of cART.
