Causes

HIV may infect cells inside the kidneys and cause organ damage. When the
kidneys are damaged, they do not function as well, and symptoms of HIV-
associated nephropathy (HIVAN) develop.
Antiretrovirals (anti-HIV drugs) may cause kidney damage in HIV patients.
Certain classes of antiretrovirals, including nucleoside reverse transcriptase
inhibitors like tenofovir (Viread) and a protease inhibitor called indinavir
(Crixivan), have been shown to cause kidney damage in HIV patients. Patients
taking these drugs should undergo blood and urine tests each year to evaluate
kidney function.

Diagnosis
General: The Infectious Diseases Society of America recommends screening for
kidney disease with a urinalysis, creatine test, and/or blood urea nitrogen (BUN)
test when HIV is diagnosed. If laboratory tests suggest kidney damage, a kidney
biopsy is conducted to confirm a diagnosis of HIV-associated nephropathy
(HIVAN).

Complications
HIV-associated nephropathy (HIVAN) may lead to end-stage renal (kidney)
disease (ESRD), also called kidney failure. This occurs when the kidneys are no
longer able to perform functions necessary for daily living. The kidneys can no
longer remove toxins and waste products from the blood, regulate acid
concentration, or maintain water and electrolyte balance in the body. ESRD is
fatal, unless treated with dialysis or kidney transplantation.
Common symptoms of ESRD include unintentional weight loss, nausea or
vomiting, general feeing of discomfort, fatigue, decreased urination,
generalized itching, easy bruising or bleeding, blood in vomit or stools, muscle
twitching or seizures, darkening of the skin tone, brittle nails, headache,
frequent hiccups, and decreased feelings in the hands, feet, or other areas.
Treatment of HIV infection with antiretrovirals
Management of renal impairment dependant upon the severity of the renal
disease and the overall prognosis of the patient including:
Avoidance of medications that may contribute to further renal damage -
NSAID's, IV contrast
Smoking cessation - people who continue to smoke progress to end stage renal
failure sooner
Close management of high blood pressure, whether it is a cause or result of
renal disease
Use of ACE inhibitors - in patients both with and without proteinuria, has been
shown to slow the progression of renal failure
Dietary management
Protein restriction - may have a role in slowing the progress of renal failure,
and is important to manage uremic symptoms in advanced failure, but needs to
be managed carefully to avoid malnutrition
Salt and water restriction as necessary to manage fluid overload
Phosphate restriction
Potassium restriction as necessary
Erythropoietin agonists - for management of anaemia associated with chronic
renal failure
Phosphate binders - for management of hyperphosphatemia in chronic renal
failure
Calcium supplements - for hypocalcaemia associated with chronic renal failure
Calcitriol and other Vitamin D supplements - for hypocalcaemia and
hyperparathyroidism associated with chronic renal failure
Sodium bicarbonate - for acid-base disturbance
Diuretics - may be used in situation of volume overload
Renal dialysis - used when there are manifestations of uraemia and the GFR is
< 10mL/min

Abstract
Human immunodeficiency virus-associated nephropathy (HIVAN) is a distinct
clinico-pathological syndrome that occurs almost exclusively in black patients
with an AIDS defining diagnosis. It is characterized by rapidly progressive renal
failure with a severe nephrotic syndrome. The renal biopsy typically shows a
collapsing glomerular sclerosis and variable tubulo-interstitial nephritis. The
pathogenesis most likely involves infection of renal tubular and epithelial cells
with HIV. The use of ACE-inhibitors and steroids may slow down the
progression to end-stage renal failure. With the introduction of highly active
anti-retroviral therapy, HIVAN may now be treated effectively although clinical
data are so far limited to case-reports.
General: Treatment generally involves aggressive highly active antiretroviral
therapy (HAART), which suppresses HIV and has been shown to improve kidney
function. Corticosteroids may also be used to improve kidney function. Kidney
dialysis and/or transplantation may be necessary in cases of severe damage. If
the patient is taking antiretrovirals known to cause kidney damage, a healthcare
provider may recommend altering the medication or dose.
Altering HIV treatment: If the patient is taking antiretrovirals known to cause
kidney damage, a healthcare provider may recommend altering the medication
or dose.

Treatment
General: Treatment generally involves aggressive highly active antiretroviral
therapy (HAART), which suppresses HIV and has been shown to improve kidney
function. Corticosteroids may also be used to improve kidney function. Kidney
dialysis and/or transplantation may be necessary in cases of severe damage. If
the patient is taking antiretrovirals known to cause kidney damage, a healthcare
provider may recommend altering the medication or dose.
Altering HIV treatment: If the patient is taking antiretrovirals known to cause
kidney damage, a healthcare provider may recommend altering the medication
or dose.
Corticosteroids: Corticosteroids like prednisone (Deltasone, Orasone, or
Meticorten) may significantly improve kidney function in some patients with
HIVAN. Patients typically receive daily doses of corticosteroids for two to 11
weeks. In order to avoid symptoms of withdrawal, patients should not suddenly
stop treatment without talking to their healthcare providers. Instead, patients
should slowly taper off the medication under the supervision of their healthcare
providers.

After the kidney transplant, patients will need to take drugs called
immunosuppressants for the rest of their lives in order to prevent their bodies
from attacking the transplanted organs. The most commonly prescribed oral
immunosuppressants include tacrolimus (Prograf), mycophenolate mofetil
(CellCept), sirolimus (Rapamune), prednisone (Prednisone Intensol),
cyclosoporine (Neoral, Sandimmune or Gengraf), and azathioprine
(Imuran). In general, patients are typically prescribed two to three medications
for long-term immunosuppression.
Also, since kidney transplant recipients have only one functioning kidney after
surgery, they will need to alter their diets so the kidney is not overworked. For
instance, alcohol and caffeine should be avoided because these products
contain many toxins and wastes that are difficult for just one kidney to filter
from the blood.
However, not all kidney failure patients are suitable candidates for kidney
transplantation. The transplant must come from a donor whose body tissues
are a close biological match to the recipient. The donated kidney may come
from a living relative who is a match or from a deceased donor. In order to
receive an organ from a deceased donor, patients are added to a national
waiting list. There is no way to know how long a patient will wait. Some will wait
weeks, while others may wait years. It is estimated that 18 people on the organ
transplant waiting list die each day.
Until recently, people who had HIV were not considered suitable candidates for
organ transplantations. Many patients were denied transplants under the
assumption that they had shorter life expectancies and less favorable survival
rates than other patients in need of transplants. However, now that patients are
living longer lives, many groups are reconsidering whether HIV patients should
be transplant candidates. Although the United Network for Organ Sharing
(UNOS) does not consider HIV infection a contraindication for organ
transplantation, the decision to perform transplantation in an HIV-positive
individual varies according to policies at individual centers. Some centers will
not provide organ transplants to good candidates who are HIV-positive.

BACKGROUND
HIV-associated nephropathy (HIVAN) is a type of kidney disease that occurs in
patients who are infected with the human immunodeficiency virus (HIV). HIVAN
is characterized by high levels of protein in the urine, high levels of nitrogenous
(waste) products in the blood, and scarring or hardening of blood vessels in the
kidneys (focal segmental glomerulosclerosis). Patients with HIVAN often suffer
from symptoms such as increased urination, excessive thirst, and fatigue.

The kidneys, which are a pair of organs located on the left and right side of the
abdomen, are an essential component of the urinary tract. They remove toxins,
chemicals, and waste products from the blood. They also regulate acid
concentration and maintain water and electrolyte balance in the body by
excreting urine.

HIVAN occurs when the HIV virus infects cells inside the kidneys or the
medications used to treat HIV damage kidney cells. When the cells become
damaged, the kidneys do not function properly and symptoms of HIVAN
develop.

Prognosis of HIVAN patients varies. If the condition is left untreated, it can lead
to kidney failure and possibly death. According to the U.S. Renal Data System
(USRDS), HIVAN accounts for about one percent of new end-stage renal disease
(ESRD, also called kidney failure) cases in the United States. HIVAN is the third
leading cause of ESRD among African Americans ages 20-64 years old. An
estimated 90% of HIVAN patients are African American. It is unknown exactly
why African Americans are predisposed to kidney disease. About half of African
Americans with HIVAN are injection drug users. It is believed that injection drug
use damages the kidneys, making drug addicts more vulnerable to developing
kidney disease.

However, if diagnosed and treated early, HIVAN is curable. If HIV is infecting
kidney cells and causing damage, patients receive a combination of anti-HIV
drugs, called highly active antiretroviral therapy (HAART). This suppresses the
viruses and, in most cases, kidney damage is reversed. If HIV medications are
responsible for the kidney damage, a healthcare provider may recommend
alternative drugs or doses.

CAUSES
HIV may infect cells inside the kidneys and cause organ damage. When the
kidneys are damaged, they do not function as well, and symptoms of HIV-
associated nephropathy (HIVAN) develop.

Antiretrovirals (anti-HIV drugs) may cause kidney damage in HIV patients.
Certain classes of antiretrovirals, including nucleoside reverse transcriptase
inhibitors like tenofovir (Viread) and a protease inhibitor called indinavir
(Crixivan), have been shown to cause kidney damage in HIV patients. Patients
taking these drugs should undergo blood and urine tests each year to evaluate
kidney function.
Human beings produce antibodies against specific infections.
When HIV infection takes place, anti-HIV antibodies are produced but they do
not appear immediately. This is called the window effect.
In some cases, antibodies to HIV become detectable 4 to 6 weeks after
infection.
When HIV is in circulation, it invades several types of cells the lymphocytes,
macrophages, the Langerhans cells, and neurons within the CNS.
HIV attacks the bodys immune system.
The organism attaches to a protein molecule called CD4 which is found in the
surface of T4 cells.
Once the virus enters the T4, it inserts its genetic materials into the T4 cells
nucleus taking over the cell to replicate itself.
Eventually the T4 cell dies after having been used to replicate HIV.
The virus mutates rapidly making it more difficult for the bodys immune
system to recognize the invaders.
HIV infection progresses through several stages.
The clinical course of HIV infection begins when a person becomes infected
with HIV through:
sexual contact with infected person
injection of infected blood or blood products
Perinatal or vertical transmission.

Correct When the client is started on antiretroviral drugs for HIV, it
will be important for the nurse to teach the client which of the following?

Your Answer:

This drug will not cure the disease, but could extend the life expectancy.
Objective: Explain the purpose and expected outcomes of HIV
pharmacotherapy.
Rationale: Drug therapy has not produced a cure, but has resulted in a number
of therapeutic successes.
Cognitive Level: Comprehension
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Strategy: Use knowledge of treatment for HIV-AIDS to determine the correct
answer.
2.

Incorrect The ________ therapy goal is to reduce the plasma HIV RNA to its
lowest possible level.

Your Answer:

NINRT
Correct Answer:

HAART
Objective: Explain the advantages of HAART in the pharmacotherapy of
HIV infection.
Rationale: HAART therapy is nearly always initiated during the acute phase,
before severe symptoms occur.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
Strategy: Use knowledge of standard drug therapy for HIV-AIDS to determine
the correct answer.
3.

Incorrect The laboratory test that must be assessed while on drug therapy
for HIV-AIDS is:

Your Answer:

A clotting factor (PT/PTT).
Correct Answer:

A CD4 lymphocyte count.
Objective: For each of the classes listed in Drugs at a Glance, know
representative drugs, and explain the mechanisms of drug action, primary
actions, and important adverse effects.
Rationale: Two laboratory tests used to guide pharmacotherapy are an absolute
CD4 count and a measurement of the amount of HIV RNA.
Cognitive Level: Comprehension
Client Need: Physiological Integrity
Nursing Process: Assessment
Strategy: Use knowledge of blood tests used to guide pharmacotherapy to
determine the correct answer.
4.

Correct The client receiving drug therapy for HIV-AIDS should be aware
that:

Your Answer:

HIV RNA counts will be performed every 3-6 months.
Objective: Categorize drugs used in the treatment of viral infections
based on their classifications and mechanisms of action.
Rationale: HIV RNA and CD4 lymphocytes will be performed every 3-6 months
to assess the degree of success of drug therapy.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
Strategy: Use knowledge of pharmacotherapy for HIV-AIDS to determine the
correct answer.
5.

Incorrect The standard drug therapy for antivirals for HIV-AIDS can include
which of the following?

Your Answer:

Interferon alpha-2b (Intron A)
Correct Answer:

Zidovudine (Retrovir, AZT)
Objective: Explain the advantages of HAART in the pharmacotherapy of
HIV infection.
Rationale: Aggressive treatment with as many as four drugs concurrently, a
regimen called highly active antiretroviral therapy, is used to reduce the plasma
level of HIV to its lowest possible level. This treatment is called HAART.
Cognitive Level: Knowledge
Client Need: Physiological Integrity
Nursing Process: Assessment
Strategy: Use knowledge of HIV-AIDS pharmacotherapy to determine the correct
answer.
6.

Incorrect When providing client and family education for the nucleoside
reverse transcriptase inhibitor drug for HIV-AIDS, the nurse would include
instructions:

Your Answer:

To take the medicine on a full stomach.
Correct Answer:

To take the medicine on an empty stomach.
Objective: Use the nursing process to care for clients receiving drug
therapy for viral infections.
Rationale: The medicine should be taken on an empty stomach, for absorption.
Cognitive Level: Application
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Strategy: Use knowledge of proper medication administration to determine the
correct answer.
7.

Incorrect A client is concerned about contracting influenza. The best
response by the nurse would be:

Your Answer:

"You would only need to be vaccinated if you are over 50 years of age."
Correct Answer:

"After the vaccination, you will be protected in about two weeks."
Objective: Use the nursing process to care for clients receiving drug
therapy for viral infections.
Rationale: Adequate immunity is achieved about two weeks after vaccination.
Cognitive Level: Application
Client Need: Psychosocial Integrity
Nursing Process: Implementation
Strategy: Use knowledge of transmission of influenza to determine the correct
answer.
8.

Incorrect A client wants to be vaccinated against hepatitis. The nurse would
inform the client that the vaccine available is for:

Your Answer:

Hepatitis B only.
Correct Answer:

Hepatitis A and B.
Objective: Categorize drugs used in the treatment of viral infections
based on their classifications and mechanisms of action.
Rationale: The best treatment for viral hepatitis is prevention through
immunization, which is available for HAV and HBV.
Cognitive Level: Comprehension
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
Strategy: Use knowledge of types of hepatitis to determine the correct answer.