Figure 735

Treatment of glomerulosclerosis. There have been no prospective controlled randomized trials of any therapy in patients with nephropa-thy associated with HIV infection. Thus, the optimal treatment is unknown. Individual case reports and studies, often retrospective, on a small number of patients suggest a beneficial effect of monotherapy with azidothymidine (AZT) on progression of renal disease [177-179]. No reports exist on the effects of double or triple antiretroviral therapy on the incidence or progression of renal disease in patients with HIV who have modest proteinuria or nephrotic syndrome. The incidence of HIV-associated glomeruloscle-rosis may be declining as a result of prophylaxis with AZT, trimethoprim and sulfamethoxazole, or other drugs. Using logistic regression analysis, Kimmel and colleagues [180] demonstrated an improved outcome related specifically to antiretroviral therapy.

Steroids usually have been ineffective on proteinuria or progression of renal disease in adults and children. Recently, 20 adult patients with HIV-associated glomerulosclerosis or mesangial hyperplasia with proteinuria over 2 g/24 h and serum creatinine over 2 mg/dL were studied. These patients showed impressive decreases in pro-teinuria and serum creatinine when given 60 mgd of prednisone for 2 to 6 weeks [181]. Complications of steroid therapy, however, were common. These include development of new opportunistic infections, steroid psychosis, and gastrointestinal bleeding. The short-term improvement in renal function may correlate with an improvement in tubulointerstitial mononuclear cell infiltration [182]. In a single report of three children with perinatal AIDS, HIV-associated glomerulosclerosis, and normal creatinine clearance, cyclosporine induced a remission of the nephrotic syndrome [183]. This report has not been confirmed, and the use of cyclosporine in adults with HIV-associated glomerulosclerosis has not been studied.

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