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Renal complications are common among HIV patients: up to 30% of HIV-positive individuals may have kidney dysfunction. However, it is difficult to estimate precisely how many people develop kidney disease because kidney dysfunction may be asymptomatic or may result in only vague symptoms, such as fatigue or general malaise. This makes it difficult to implement effective disease prevention or early intervention. Without specific symptoms, many patients are only diagnosed later in their disease course, reducing the efficacy of available treatments.
Given the risks associated with kidney disease, developing awareness of kidney function and getting the necessary tests are essential to maintaining good health with HIV. Serum creatinine and urine proteinuria tests are two parameters necessary in investigating kidney health, and should be performed simultaneously. Abnormalities in either blood or urine tests indicates renal concerns.
Primary kidney diseases, those that do not obviate from another disease in the body, can also be experienced by non-HIV-infected patients. The same is true of secondary kidney diseases, which can express as a result of systemic diseases, like diabetes mellitus.
Specific symptoms that may result from the presence of kidney disease or worsening of kidney function include:
- Elevations in blood pressure
- Edema of the lower extremities or face
- Discoloration in the urine or changes in urinary habits
Constitutional symptoms are quite nonspecific and can include:
- Fatigue
- Loss of appetite
- Weight loss
- Change in taste of foods or a bad taste in the mouth
The following table describes renal diseases commonly associated with HIV infection.
Diagnosis |
Pathology |
HIV-associated |
Likely a result of the direct infection of kidney cells by HIV. |
IgA nephropathy |
Antibodies (primarily IgA) are trapped in the areas of the kidney where filtering occurs. It is unclear whether this is related to a defect in the production of or a defect in the clearance of antibodies. |
Immune-complex glomerulonephritis |
All types of antibodies produced within the body are trapped in the areas of the kidney where filtering occurs. The deposition of antibodies triggers severe inflammation. Given that the filtering of blood with antigen-antibody complexes is a normal occurrence, it is not clear why certain individuals experience deposition in the kidney and the resultant inflammation. |
Minimal change disease |
Biopsy reveals little gross change in appearance of the kidney. Small changes apparent at very high magnifications indicate impaired ability of the kidney to maintain a barrier to keep protein from spilling into the blood. Potentially the result of a -cell mediated abnormality. |
Membranous nephropathy and membranoproliferative glomerulonephritis |
Two kidney diseases in which certain types of antibodies are trapped in areas where filtering occurs. These areas are not directly adjacent to blood flow; therefore, there is little inflammation. Both are associated with the loss of potentially large amounts of protein in the urine. |
Amyloidosis |
Abnormal proteins in the blood (thought to be related to the inflammation caused by a chronic infection, such as HIV) are trapped in the kidney, affecting renal function. Deposition of these proteins may occur in other areas of the body - including the blood vessels, heart, and intestine - and affect their function, as well. |
Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome |
Diseases in which the interior of the blood vessels is severely damaged. These syndromes can result in not only kidney failure, but also central nervous system changes, such as seizures, decreased platelet count, anemia, and fevers. |
INDICATION AND IMPORTANT SAFETY INFORMATION
VIRAMUNE is indicated for use in combination with other antiretroviral agents for the treatment of HIV-1 infection. This indication is based on one principal clinical trial that demonstrated prolonged suppression of HIV-RNA and two smaller supportive studies.
Life-threatening and fatal hepatotoxicity has occurred in patients receiving VIRAMUNE. Any patient can experience hepatic events; however, female gender and higher CD4 counts at initiation of therapy place patients at greater risk. Women, including pregnant women, with CD4+ cell counts >250 cells/mm3 are at the greatest risk. VIRAMUNE should not be initiated in adult females with CD4+ cell counts greater than 250 cells/mm3 or in adult males with CD4+ cell counts greater than 400 cells/mm3 unless the benefit outweighs the risk. Hepatic events are often associated with rash. Hepatic failure has also been reported in patients without HIV taking VIRAMUNE for post-exposure prophylaxis (PEP). Use of VIRAMUNE for occupational and non-occupational PEP is contraindicated.
Life-threatening and fatal skin reactions have also occurred, including Stevens-Johnson Syndrome, toxic epidermal necrolysis and hypersensitivity reactions characterized by rash, constitutional findings, and organ dysfunction.
Patients should be intensively monitored for hepatic and skin reactions for the first 18 weeks of therapy with extra vigilance during the first 6 weeks, which is the period of greatest risk. Frequent monitoring should be performed throughout therapy with VIRAMUNE.
VIRAMUNE should be discontinued and not restarted in patients who develop signs or symptoms of hepatitis, hypersensitivity, severe skin reactions or any rash accompanied by constitutional findings. In some cases, hepatic injury has progressed despite discontinuation of treatment.
Patients with either hepatic fibrosis or cirrhosis should be monitored carefully for evidence of drug induced toxicity. VIRAMUNE should not be administered to patients with moderate or severe (Child Pugh Class B or C, respectively) hepatic impairment.
Other common side effects include nausea, fatigue, fever, headache, vomiting, diarrhea, abdominal pain, and myalgia. Immune reconstitution syndrome has been reported in patients treated with combination ARV therapy.
The dose of VIRAMUNE for adults is one 200-mg tablet daily for the first 14 days (this has been shown to reduce the frequency of rash), followed by one 200-mg tablet twice daily. Any patient experiencing rash during the 14-day lead-in period should not increase dose until the rash has resolved. The lead-in dosing regimen should not be continued beyond 28 days.
Please see full Prescribing Information, including boxed WARNING, for VIRAMUNE.
