Abstract: TH-PO171
Atazanavir Crystal-Induced Chronic Granulomatous Interstitial Nephritis
Session Information
- Drug Events Trainee Case Reports
November 07, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
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
Case | Viglietti et al. | Izzedine et al. | Hara et al. | Kanzaki et al. | Coelho et al. | Brewster and Perazella | Schmid et al. | Schmid et al. | Schmid et al. | Varghese and Velez |
sCr at biopsy (mg/dL) | 2.2 | 3.6 | 2.2 | 2.0 | 7.1 | 11.1 | 10.3 | 3.4 | 7.0 | 3.3 |
UPCR (g/g) | N/A | 0.3 | 0.25 | 0.38 | N/A | N/A | 0.75 | 0.5 | 1.0 | 0.45 |
Pyuria | + | - | - | - | + | + | - | + | - | + |
ATZV duration | 4.1 years | N/A | 5.6 years | 3.5 years | 8 months | 4 weeks | 3 months | 6 weeks | 4 months | 3.5 years |
Select HAART | RTV | RTV | RTV | RTV, TFV | RTV, TFV | - | RTV, TFV | RTV, TFV | RTV, TFV | RTV |
Pathology | CGIN | CGIN | CGIN | CGIN | AIN | AIN | AIN | AIN | AIN | CGIN |