Outcome of severe acute renal failure in patients with acquired immunodeficiency syndrome

Abstract

Among a spectrum of renal disorders encountered in patients infected with the human immunodeficiency virus (HIV), the lesion studied most often has been the glomerular disease known as HIV-associated nephropathy. Of the other coincidental renal perturbations reported, the most significant are a heterogeneous group encompassing potentially reversible acute renal failure (ARF), primarily acute tubular necrosis. While HIV-associated nephropathy may frequently be seen in asymptomatic HIV-seropositive individuals, acute tubular necrosis almost always is encountered in patients with clinical acquired immunodeficiency syndrome (AIDS). We analyzed our decade's experience in the management of 146 HIV disease patients with ARF (132 AIDS patients and 14 HIV-seropositive patients) and compared it with a contemporaneous group of 306 non-HIV subjects with ARF. All patients evaluated for ARF between January 1984 and December 1993 by the Renal Division at Kings County Hospital Center, Brooklyn, NY, were reviewed. Only those patients with ARF who reached a serum creatinine concentration of 530 μmol/L or higher were included in the analysis. Ninety-one percent of 146 HIV disease patients with ARF were less than 50 years old compared with only 33% of the 306 non-HIV subjects ( P < 0.001). Septicemia was directly or indirectly responsible for 75% of patients with ARF in the AIDS group and for 39% in the non-HIV subjects ( P < 0.006). Urinary tract obstruction was the cause of ARF in 54 of 306 (17%) non-HIV patients compared with none in the HIV group ( P < 0.00001). While 36% of AIDS subjects were terminally ill and could not be treated by aggressive dialysis, the comparable rate in the much older non-HIV group was 18% ( P < 0.003). In treated patients in both groups, the renal recovery and mortality rates were similar. We conclude that HIV disease patients with ARF (the majority with AIDS) are younger and sicker, and many are agonal, limiting aggressive intervention. Despite widespread deployment of antiretroviral and chemoprophylactic agents in the management of HIV infection in recent years, septic complications continue to be a major cause of ARF in HIV disease. Recovery of renal function and mortality in ARF were determined by the patient's hemodynamic situation and not by HIV infection status. In both groups of patients, the mortality rate from ARF is still unacceptably high.