ZIDOVUDINE IS BENEFICIAL IN HUMAN-IMMUNODEFICIENCY-VIRUS ASSOCIATED NEPHROPATHY

Human immunodeficiency virus associated nephropathy (Hivan) is a disti nct renal disease described in patients infected with the human immuno deficiency virus (HIV). Hivan is characterized by a nephrotic syndrome , enlarged kidneys, a histologic finding of focal and segmental glomer ulosclerosis, and a very rapid progression to end-stage renal disease (ESRD). No therapeutic intervention has been shown, in a prospective e valuation, to either alter the course of established Hivan or to influ ence the emergence of Hivan in HIV-infected patients. We conducted a p rospective study on 23 consecutively selected patients seen between 19 89 and 1992 who were infected with the HIV, 14 (61%) of whom had signi ficant proteinuria (greater than or equal to 2+). Percutaneous kidney biopsy was performed in 5 (36%) of the 14 subjects who had Significant proteinuria, and histologic examination of the kidney tissue revealed focal and segmental glomerulosclerosis in all 5 cases. Of the 14 subj ects with proteinuria, 8 (57%) also had azotemia (serum creatinine lev el greater than or equal to 1.3 mg/dl). Nine (39%) of 23 subjects admi tted intravenous drug use, while 9 (39%) of 23 subjects have had an op portunistic infection before enrollment in the study. The known durati on of HIV infection before initiation of zidovudine therapy was 10.3 /- (SD) 8 months. The mean CD4 count before zidovudine therapy was 195 .9 +/- 117 (range 21-654) cells/mm(3). The mean dose of zidovudine adm inistered was 543 +/- 117 (range 400-800) mg daily for a period of 20. 4 +/- 11 (range 6-38) months. The clinical course of renal disease in the study subjects was compared to that of a control cohort of 28 HIV- infected patients with the nephrotic syndrome, presenting in ESRD for initiation of renal replacement therapy during the study period, who h ad never been treated with zidovudine or any other antiretroviral drug . Of 28 control patients, 14(50%) admitted intravenous drug use; the k nown duration of HIV infection before onset of ESRD was 14.6 +/- 8.6 m onths. These 28 control patients had been seen at an outpatient facili ty between 1989 and 1992 for anasarca and proteinuria without azotemia . The mean serum creatinine concentration of the 23 study subjects bef ore zidovudine therapy was 1.2 +/- 0.4 (range 0.8-2.1) mg/dl. By contr ast, 8 (35%) of 23 subjects who stopped zidovudine due to noncomplianc e progressed to ESRD within a mean of 8 +/- 2 (range 4-12) weeks, and each was begun on renal replacement therapy. Of these 8 patients, 2 di ed 10 and 12 weeks: respectively, after initiation of maintenance hemo dialysis. These 8 patients had been on zidovudine therapy for a mean o f 9 +/- 3 months before discontinuing the drug. Reinstituted zidovudin e therapy had no obvious effect on their renal function. None of the 1 5 zidovudine-compliant subjects developed ESRD or worsening azotemia. The mean se:rum creatinine concentration at the end of the study perio d was 0.93 +/- 0.2 mg/dl. All patients initially free of proteinuria r emained so. In the control patients, the interval from presentation wi th anasarca and proteinuria to onset of ESRD was 5.9 +/- 2.3 months. N one of the control group were on any medication known to cause renal f ailure. Fourteen (50%) of 28 control patients died within 10 months af ter initiation of hemodialysis at a mean time of 3.8 +/- 2.1 months. W e conclude that zidovudine is beneficial in HIV-associated nephropathy , and that discontinuing zidovudine treatment in HIV-infected patients with nephropathy may result in irreversible and accelerated loss of r enal function.