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The Kidney Shelters HIV

An unusual case suggests that the kidneys are a viral reservoir from the time of acute HIV infection forward.

Although the pathogenesis of HIV nephropathy is not fully understood, data indicate that it may be caused, at least in part, by direct viral infection of the kidney. A case report describing acute HIV infection complicated by acute renal failure supports this theory.

A 35-year-old man developed fever, rash, generalized lymphadenopathy, hypoalbuminemia, and massive proteinuria (17 g/day). HIV ELISA and Western blot, negative 4 months earlier, were positive, showing a viral load of more than 750,000 copies/ml and a CD4 count of 459 cells/mm³. Renal function deteriorated rapidly despite prompt initiation of combination antiretroviral drugs, and dialysis was begun. After 6 weeks of antiretroviral therapy, serum creatinine had returned to 1.4 mg/dl off dialysis, proteinuria had fallen to 1.5 g/day, and viral load was less than 50 copies/ml.

A renal biopsy done during the patient's acute illness before antiretroviral drugs were started showed widespread capillary collapse and focal glomerulosclerosis; other pathologic changes, seen on light and electron microscopy, were consistent with severe HIV nephropathy. A repeat biopsy after the patient had clinically improved with treatment showed resolution of most of these changes, and a pathologist unfamiliar with the details of the case interpreted the biopsy specimen to be consistent with mild, inactive HIV nephropathy.

A circular, unintegrated form of viral DNA, believed to indicate recent infection of cells, was present in the first biopsy specimen but not in the second. However, in situ hybridization for HIV messenger RNA (mRNA) was positive in renal tubular epithelial cells and glomerular podocytes in both specimens, with similar numbers of cells expressing viral mRNA before and during treatment.

This case describes a highly atypical presentation of HIV nephropathy, which generally occurs late in the course of infection and is seldom reversed by antiretroviral drugs. Still, the researchers suggest that its lessons can be generalized to many patients: Although antiretroviral agents may slow viral infection in the kidney and, in doing so, slow the course of HIV nephropathy, they do not completely eliminate this reservoir of infection.

— Abigail Zuger, MD

Published in AIDS Clinical Care August 1, 2001

Citation(s):

Winston JA et al. Nephropathy and establishment of a renal reservoir of HIV type 1 during primary infection. N Engl J Med 2001 June 28; 344:1979-84.

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