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Abdomen » Kidneys/Ureters
HIV associated nephropathy
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Presentation A 24-year-old HIV positive African-American man presents with hypertension.
 
 
 
Caption: Longitudinal image of the right kidney
Description: This image reveals an enlarged kidney, showing a diffuse increase in echogenicity. The cortico-medullary differentiation is maintained.
 
 
 
Caption: Transverse image of right kidney
Description: This image also reveals an enlarged and highly echogenic right kidney. The left kidney also showed a similar appearance.
 
Differential Diagnosis HIV associated nephropathy
 
Final Diagnosis HIV associated nephropathy
 
Discussion HIV associated nephropathy [HIVAN] is a common cause of chronic renal failure in HIV patients and affects the African-American male more frequently. Patients with HIVAN may or may not have clinical AIDS. Renal involvement in HIV patients may be related to either

1. Direct infection of the renal epithelium by the virus [postulated to be the cause of HIV nephropathy] or
2. Drug associated damage as the antiviral drugs are nephrotoxic.

Patients with HIVAN typically present with nephrotic syndrome [massive proteinura > 3gm/ 24 hours, edema and hypoalbuminemia]. These patients have progressive uremia and are generally not responsive to dialysis. Patients with HIVAN usually have a poor prognosis. Histologically, focal and segmental glomerulosclerosis is noted.

Imaging: From the various studies available in literature, the following ultrasound features have been noted in HIVAN:
1. Normal sized or enlarged kidneys. Reduced kidney size is highly unlikely.
2. The characteristic feature of HIVAN is the increase in renal echogenicity. This may manifest as patchy or spotty increase in echogenicity.  Advanced stages of HIVAN typically demonstrate a diffuse increase in renal echogenicity.
3. Pelvi-calyceal thickening.
According to a study by Di Fiori, et al advanced stages of HIVAN may also show:
4. A globular renal configuration
5. Decreased renal sinus fat
6. Decreased cortico-medullary differentiation and
7. Parenchymal heterogeneity

Other imaging modalities have a limited role in diagnosis of HIVAN. Biopsy of the sonographically enlarged and echogenic kidney is the usual choice to establish a final diagnosis of HIV associated nephropathy.
 
Case References 1. Di Fiori JL, Rodrigue D, Kaptein EM, Ralls PW. Diagnostic sonography of HIV-associated nephropathy: new observations and clinical correlation. AJR. 1998 Sep; 171(3):713-6.
2. Atta MG, Longenecker JC, et al. Sonography as a predictor of human immunodeficiency virus-associated nephropathy. J Ultrasound Med. 2004 May; 23(5):603-10; quiz 612-3.
3. N`Gbesso RD, Vakou D, Keita AK. Renal insufficiency with AIDS: ultrasonographic aspects. J Radiol. 1998 Apr;79(4):323-6.
4. Rao TK. Human immunodeficiency virus (HIV) associated nephropathy. Annu Rev Med. 1991; 42:391-401.
5. Bourgoignie JJ, Meneses R, Ortiz C, et al. The clinical spectrum of renal disease associated with human immunodeficiency virus. Am J Kidney Dis. 1988 Aug; 12(2):131-137.
6. Wachsberg RH, Obolevich AT, Lasker N. Pelvocalyceal thickening in HIV-associated nephropathy. Abdom Imaging. 1995 Jul-Aug; 20(4):371-5.
 
Follow Up This patient had a renal biopsy which confirmed the diagnosis of HIVAN.
 
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