Figure 719

Causes of acute renal failure. Acute renal failure is related to complications of AIDS, its treatment, or the use of diagnostic agents in about 20% of patients [129,130]. Acute tubular necrosis occurs with a prevalence of 8% to

30%, most often in patients with AIDS and prerenal azotemia from hypovolemia, hypotension, severe hypoalbuminemia, superimposed sepsis, or drug nephrotoxicity (radiocontrast dyes, fos-carnet, acyclovir, pentamidine, cidofovir, amphotericin B, nonsteroidal anti-inflammatory drugs, and antibiotics) [129-138]. The clinical presentation, laboratory findings, and course of acute tubular necrosis do not differ in patients with AIDS and those in other clinical settings. Prevention includes correction of fluid and electrolyte abnormalities and dosage adjustments of potentially nephrotic drugs. Identification and withdrawal of the offending agents usually result in recovery of renal function. Dialysis may be needed before renal function improves. Less frequent causes of acute renal failure include allergic acute interstitial nephritis; complicating treatments with trimethoprim and sulfamethoxazole, rifampin, or acyclovir; and acute obstructive nephropathy, resulting from the intrarenal precipitation of crystals of sulfadiazine, acyclovir, urate, or protease inhibitors [134,139-146]. Obstructive uropathy without hydronephrosis also may develop in patients with lymphoma as a result of lymphomatous ureteropelvic infiltration or retroperitoneal fibrosis [147-149]. Rhabdomyolysis with myoglo-binuric acute renal failure usually occurs in the setting of cocaine use [150]. Instances of acute renal failure associated with intravascular coagulation related to thrombotic thrombocytopenic purpura (TTP) or hemolytic uremic syndrome (HUS) have been reported (vide infra). Rare causes of acute renal failure include disseminated microsporidian infection or histoplasmosis [151,152]. A clinical presentation of acute renal failure also can be seen in patients with acute immunocomplex postinfectious glomerulonephritis, crescentic glomerulonephritis, or fulminant HIV-associated glomerulosclerosis.

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