Delayed onset renal failure in a patient on tenofovir based antiretroviral regimen
The present case report is about a 56-year-old woman was diagnosed to have HIV 1 infection with pulmonary tuberculosis in 2002. Viral load was 127,717 copies/ml with a CD4 cell count of 221 cells/μl. She was started on zidovudine, lamivudine and efavirenz. As she developed zidovudine induced anemia, the drug was replaced with stavudine in 2003. The patient was on regular follow-up since then. During the follow-up, the viral load decreased to less than 20 copies/ml and CD4 cell count improved to 606 cells/μl. However after 5 years of first line ART, viral loads increased to 15548 copies/ml and CD4 count dropped to 286/μl. She was started on ritonavir, lopinavir along with tenofovir and emtricitabine. Subsequently, she wasdiagnosed to have hypertension, type 2 diabetes mellitus and hypothyroidism which were under control with treatment. She was on regular follow-up every 6 months. Complete blood counts, renal function tests were monitored and were found to be normal.\nIn December 2012 that is 6 years after second line antiretroviral therapy (ART) was initiated, she presented with nausea and loss of appetite and a serum creatinine of 4.2 mg/dl. Examination was normal except for obesity, pallor and buffalo hump. Fundus examination did not show evidence of diabetic retinopathy. Investigations showed hemoglobin 9 g/dl, HIV viral load <20 copies/ml and CD4 cell count was 814 cells/μl. Ultrasound abdomen showed grade 1 renal parenchymal changes. Urine culture and blood culture were sterile. ‘M’ spike was absent on serum protein electrophoresis and 24 h urinary protein was 500 mg/day.\nRenal biopsy [] showed normal glomeruli with changes of interstitium showing diffuse infiltrates of lymphocytes and few eosinophils and neutrophils on light microscopy. Many tubules showed simplification of their lining indicating acute injury and a few mildly dilated tubules showed hyaline casts and a few tubules showed leucocyte casts. All these features were suggestive of acute tubulointerstitial nephritis, probably induced by tenofovir.\nTenofovir was stopped and raltegravir was started along with lamivudine, ritonavir and lopinavir. After 1 month of stopping tenofovir serum creatinine improved to 1.4 mg/dl and patient was better thereafter.