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Kidney Week

Abstract: TH-PO171

Atazanavir Crystal-Induced Chronic Granulomatous Interstitial Nephritis

Session Information

Category: Trainee Case Report

  • 2102 CKD (Non-Dialysis): Clinical, Outcomes, and Trials

Authors

  • Varghese, Vipin, University of Queensland - Ochsner Clinical School, New Orleans, Louisiana, United States
  • Velez, Juan Carlos Q., Ochsner Clinic Foundation, New Orleans, Louisiana, United States
Introduction

Atazanavir (ATZV) is a protease inhibitor used in the treatment of human immunodeficiency virus (HIV) infection. Highly active antiretroviral therapy (HARRT)-related nephrotoxicity is primarily linked to tenofovir (TFV) or to the no-longer-used drug, indinavir. We describe a case of biopsy-proven atazanavir crystal-induced chronic granulomatous interstitial nephritis (CGIN) and review previously reported cases.

Case Description

A 51-year-old black man with HIV infection presented to renal clinic for evaluation of worsening kidney function. He was asymptomatic. He denied NSAID use and was on ritonavir (RTV), ATZV, abacavir and lamivudine. Physical examination was unremarkable. Laboratory data showed a serum creatinine (sCr) 2.7 mg/dL (3 months prior 1.7 mg/dL; 9 months prior 1.2 mg/dL). CD4 count was 327 and HIV-1 RNA viral load was undetectable. Hepatitis B and C were negative. Complements, lupus serology and serum protein electrophoresis were within normal limits. Urinalysis showed 20-30 white blood cells/hpf. Urine protein-creatinine ratio (UPCR) was 450 mg/g. Urine culture was negative. Renal ultrasound was normal. One month later, sCr rose to 3.3 mg/dL. A kidney biopsy was performed and the specimen showed: interstitial mononuclear infiltrate with numerous eosinophils, a granulomatous process with central necrosis, crystal-like material and neutrophils, moderate interstitial fibrosis, and 9/15 obsolescent glomeruli. ATZV was stopped and prednisone was begun. After 8 months, sCr gradually improved to a new baseline of 2.0 mg/dL. Our case is only the 10th reported (see Table

Discussion

ATZV must be considered as a potential cause of chronic progressive nephropathy in patients on HAART and can present as CGIN and acute interstitial nephritis (AIN).

Comparison of ATZV nephropathy case reports
CaseViglietti et al.Izzedine et al.Hara et al.Kanzaki et al.Coelho et al.Brewster and PerazellaSchmid et al.Schmid et al.Schmid et al.Varghese and Velez
sCr at biopsy (mg/dL)2.23.62.22.07.111.110.33.47.03.3
UPCR (g/g)N/A0.30.250.38N/AN/A0.750.51.00.45
Pyuria+---++-+-+
ATZV duration4.1 yearsN/A5.6 years3.5 years8 months4 weeks3 months6 weeks4 months3.5 years
Select HAARTRTVRTVRTVRTV, TFVRTV, TFV-RTV, TFVRTV, TFVRTV, TFVRTV
PathologyCGINCGINCGINCGINAINAINAINAINAINCGIN