T. K. Sreepada Rao

Natural History of Heroin-Associated Nephropathy

Abstract Of 14 black heroin addicts with massive proteinuria, 12 manifested a typical syndrome including edema, hypoalbuminemia and hypercholesterolemia. Renal biopsies obtained in 13 patients showed focal and segmental glomerular sclerosis in 11, typically (seven of 11 patients) associated with focal glomerular deposition of IgM and β1C/β1A globulin. Deterioration of renal function was continuous and rapid, so that in all eight patients with follow-up examinations, uremia developed in six to 48 months. Although focal sclerosis may have other as yet unidentified causes (especially in children), its occurrence in 11 of 13 nephrotic heroin addicts biopsied in the absence of other systemic or renal disease indicates a causal relation to heroin abuse. The combination of focal glomerular sclerosis and IgM and β1C/β1A globulin localization in glomeruli is otherwise unusual, having been noted in only two of 400 adult renal biopsies originating from a general nephrology service. An undefined response of the addic...

Outcome of severe acute renal failure in patients with acquired immunodeficiency syndrome

Among a spectrum of renal disorders encountered in patients infected with the human immunodeficiency virus (HIV), the lesion studied most often has been the glomerular disease known as HIV-associated nephropathy. Of the other coincidental renal perturbations reported, the most significant are a heterogenous group encompassing potentially reversible acute renal failure (ARF), primarily acute tubular necrosis. While HIV-associated nephropathy may frequently be seen in asymptomatic HIV-seropositive individuals, acute tubular necrosis almost always is encountered in patients with clinical acquired immunodeficiency syndrome (AIDS). We analyzed our decades experience in the management of 146 HIV disease patients with ARF (132 AIDS patients and 14 HIV-seropositive patients) and compared it with a contemporaneous group of 306 non-HIV subjects with ARF. All patients evaluated for ARF between January 1984 and December 1993 by the Renal Division at Kings County Hospital Center, Brooklyn, NY, were reviewed. Only those patients with ARF who reached a serum creatinine concentration of 530 mumol/L or higher were included in the analysis. Ninety-one percent of 146 HIV disease patients with ARF were less than 50 years old compared with only 33% of the 306 non-HIV subjects (P < 0.001). Septicemia was directly or indirectly responsible for 75% of patients with ARF in the AIDS group and for 39% in the non-HIV subjects (P < 0.006). Urinary tract obstruction was the cause of ARF in 54 of 306 (17%) non-HIV patients compared with none in the HIV group (P < 0.00001).(ABSTRACT TRUNCATED AT 250 WORDS)

Uremia Therapy in Patients With End-Stage Renal Disease and Human Immunodeficiency Virus Infection: Has the Outcome Changed in the 1990s?

We conducted a cross-sectional survey to determine the relative course of patients with end-stage renal disease (ESRD) and human immunodeficiency virus (HIV) infection sustained on maintenance hemodialysis. All 34 patients with ESRD and HIV infection receiving hemodialysis in one hospital-based and three community-based outpatient hemodialysis facilities in Brooklyn, NY, were studied. We documented their known duration of HIV infection, duration of ESRD, and hemodialysis prescription, and noted the presence of clinical acquired immunodeficiency syndrome (AIDS). Total CD4 count, serum albumin concentration, and percent reduction of urea (predialysis blood urea nitrogen minus postdialysis blood urea nitrogen, divided by predialysis blood urea nitrogen x 100) were measured. The 34 study subjects (26 men and eight women) included 31 blacks (91%) and three Hispanics (9%) with a mean age of 42 +/- 7.5 years, 29 (85%) of whom had AIDS. Twenty subjects (59%) had a history of intravenous drug abuse. Only six subjects (18%) were receiving an antiretroviral drug (zidovudine = five, dideoxyinosine = one). In 23 subjects (68%), AIDS was diagnosed prior to ESRD and was presumed to be the cause of renal failure (HIV-associated nephropathy). The mean known duration of HIV infection was 50.5 +/- 34 months (median, 48 months); the mean duration of ESRD was 57 +/- 50 months, the mean total CD4 count was 140 +/- 150 cells/microL (median, 70 cells/microL), the mean hematocrit was 28% +/- 5%, and the mean serum albumin concentration was 3.5 +/- 0.37 g/dL. All subjects were receiving erythropoietin for anemia correction. The mean length of the prescribed thrice-weekly hemodialysis sessions was 3.5 +/- 0.4 hours. Our results suggest that the survival of many ESRD patients with HIV infection receiving hemodialysis has improved compared with the uniformly dismal survival rate reported in the 1980s. Decisions on whether to initiate renal replacement therapy in patients with AIDS and advanced renal failure should be individualized because the combination of ESRD and HIV infection does not necessarily signal near-term death.

Severity of AIDS and the response to EPO in uremia

To determine the factors that govern their response to erythropoietin (EPO), we conducted a cross-sectional study of all patients in four outpatient hemodialysis facilities in Brooklyn, NY, who had end-stage renal disease (ESRD) and human immunodeficiency virus (HIV) infection and were receiving recombinant EPO. We also compared the hematocrit and EPO requirements of these patients to those of a control group of hemodialysis patients without HIV infection. We documented known duration of HIV infection, and total CD4 count was measured once. In both groups, hematocrit was measured weekly for 5 weeks and a mean value calculated for each subject. Transferrin saturation was measured twice and a mean value calculated for each subject. Intensity of hemodialysis was assessed by measuring both percent reduction of urea and serum albumin concentration twice; mean values were calculated for each subject. Twenty-nine (88%) of 33 study subjects had acquired immunodeficiency syndrome. Mean known duration of HIV infection was 49 +/- 32.5 months (median, 48 months), and mean total CD4 count was 143 +/- 152.4 cells/mm3 (median, 72 cells/mm3). Mean hematocrit in the study subjects was 27.4% +/- 4.7% compared with 27.6% +/- 3.7% in the controls (P = 0.69). Mean thrice-weekly EPO dose was higher in the study subjects (90 +/- 52 U/kg body weight) than in the controls (62 +/- 36 U/Kg body weight) (P = 0.001). Among the study subjects, hematocrit had direct univariate correlations with serum albumin concentration (r = 0.43; P = 0.02), transferrin saturation (r = 0.4; P = 0.03), and percent reduction of urea (r = 0.4; P = 0.02), but not with total CD4 count (r = -0.05; P = 0.8) or known duration of HIV infection (r = -0.11; P = 0.55). There was an inverse correlation between hematocrit and dose of EPO (r = -0.5; P = 0.003). Multiple regression analysis showed that transferrin saturation (P = 0.01) and percent reduction of urea (P = 0.003) had direct correlations with hematocrit after adjustment for other factors. There was an inverse relationship between hematocrit and dose of EPO (P = 0.0006). We conclude that in patients with ESRD and HIV infection receiving hemodialysis, the response to EPO (hematocrit) is modulated by the dose of EPO, quantity of hemodialysis, and transferrin saturation, but not by the severity of HIV disease. Hemodialysis patients infected with HIV receive a higher dose of EPO than those without HIV infection.

Noncompliance frustrates formulae in maintenance dialysis patients

The leading causes of morbidity and mortality in patients with end stage renal disease (ESRD) who are treated by maintenance dialysis include cardiovascular diseases, renal osteodystrophy, infections (vascular access related and other systemic), and inadequate dialysis delivery. Many recent publications have focused on these issues, demonstrated various parameters to identify indices for poor patient survival, and have outlined steps to reduce morbidity and mortality [1–6]. One issue which has not received much attention is the role of, or lack thereof, patient’s participation in his own care, and adherence to prescribed treatment regimen, in contributing to morbidity and mortality. Many urban dialysis centers are obliged to care for an increasing number of patients with renal failure who are intravenous drug addicts (IVDA), infected with the Human immunodeficiency virus (HIV), prisoners, undocumented aliens, homeless individuals, indigent patients with little or no family support. In such a clinical setting, noncompliance to prescribed therapy due to a variety of reasons is another major factor in limiting the ability of nephrologists to achieve the goals of renal replacement therapy in ESRD subjects.

Acute renal failure in human immunodeficiency virus disease

In patients infected with the human immunodeficiency virus (HIV), renal manifestations are frequent, and diverse in nature. They include many co-incidental disorders, and specific glomerular syndromes. Fluid-electrolyte, acid-base derangements, and a spectrum of diseases leading to potentially reversible acute renal failure (ARF), are the major coincidental disorders relevant to clinicians. HIV associated nephropathy is an unusual form of glomerular disease characterized by nephrotic syndrome, focal and segmental glomerulosclerosis, and a rapid fulminant progression to end stage renal disease. In addition, some HIV infected patients may develop chronic renal failure from unrelated diseases such as diabetes mellitus, polycystic kidney disease and others. The primary focus in this communication will be the spectrum of ARF encountered in patients with HIV disease.

Heroin Addiction and Nephropathy

Excerpt To the editor: The study of glomerular focal sclerosis by Matalon and associates (1) adds further support to previous reports (2-5) indicating an association of heroin addiction and nephrop...