PREDNISONE IMPROVES RENAL-FUNCTION AND PROTEINURIA IN HUMAN IMMUNODEFICIENCY VIRUS-ASSOCIATED NEPHROPATHY

PURPOSE: To determine if prednisone ameliorates the course of human im munodeficiency virus-associated nephropathy (HIV-AN). PATIENTS AND MET HODS: Twenty consecutive HIV-infected adults with biopsy-proven HIV-AN (n = 17) or clinical characteristics of HIV-AN (n = 3) with serum cre atinine concentrations >177 mu mol/L (2 mg/dL) or proteinuria >2.0 g/d or both went prospectively evaluated and treated with prednisone at a dose of 60 mg/d for 2 to 11 weeks, followed by a tapering course of p rednisone over a 2- to 26-week period. Serum creatinine concentration, 24-hour protein excretion, serum albumin, and steroid-related adverse effects were assessed before and after treatment. RESULTS: Nineteen p atients had serum creatinine concentrations >177 mu mol/L (2 mg/dL). T wo of them progressed to end stage renal disease (ESRD) in 4 to 5 week s. In 17 patients serum creatinine levels decreased from 717 +/- 103 m u mol/L (8.1. +/- 1.2 mg/dL) (mean +/- SE) to 262 +/- 31 mu mol/L (3.0 +/- 0.4 mg/dL) (P <0.001). Five patients relapsed after prednisone wa s discontinued and were retreated. In these 5 the serum creatinine dec lined from 728 +/- 107 mu mol/L (8.2 +/- 1.2 mg/dL) to 344 +/- 47 mu m ol/L (3.9 +/- 0.5 mg/dL) (P <0.01) in response to the second course of prednisone. Twelve of 13 tested patients showed a reduction in 24-hou r urinary protein excretion with an average decrement from 9.1 +/- 1.8 g/d to 3.2 +/- 0.6 g/d (P <0.005). Serum albumin increased from 24.4 +/- 3.6 g/L to 29.3 +/- 2.6 g/L (P =NS) in the 11 patients with paired 24-hour urine collections for whom pre- and posttreatment determinati ons were available. In one non-azotemic patient with nephrotic syndrom e, protein excretion declined from 15.2 to 2.2 g/day and the serum alb umin increased from 4.0 g/L to 31.0 g/L. The 20 patients have been fol lowed for a median of 44 weeks (range 8 to 107). Eight ultimately requ ired maintenance dialysis. Eleven died from complications of HIV disea se 14 to 107 weeks after institution of prednisone; none was receiving prednisone at the time of death. Seven are alive and free from ESRD a median of 25 weeks (range 8 to 81) from the initiation of prednisone therapy. Six patients developed a total of seven serious infections wh ile receiving prednisone, including Mycobacterium avium-complex infect ion in 2 and CMV retinitis in 3. CONCLUSION: Prednisone improves serum creatinine and proteinuria in a substantial proportion of adults with HIV-AN. Corticosteroid-related side effects are not prohibitive. A pr ospective, randomized controlled trial is required to confirm these pr eliminary results.