pyrimethamine, and 25mg folinic acid three times failure; nephrotoxicity; crystals; AIDS weekly. At day 0 of this antitoxoplasmic treatment, serum creatinine was ...
Nephrol Dial Transplant (1998) 13: 750–753
Nephrology Dialysis Transplantation
Case Report
Indinavir crystal deposits associated with tubulointerstitial nephropathy Frank Martinez1, Herve´ Mommeja-Marin1, Laurence Estepa-Maurice2, He´le`ne Beaufils3, Marie Bochet4, Michel Daudon2, Gilbert Deray1 and Christine Katlama4 With the technical assistance of C. Jouanneau and G. Le Naour 1Service de Ne´phrologie, Groupe Hospitalier Pitie´-Salpeˆtrie`re, 2Service de Biochimie A, Hoˆpital Necker Enfants Malades, 3INSERM U 423, Hoˆpital Necker Enfants Malades, 4Service des Maladies Infectieuses et Tropicales, Groupe Hospitalier Pitie´-Salpeˆtrie`re, Paris, France
Key words: indinavir; HIV protease inhibitor; renal failure; nephrotoxicity; crystals; AIDS
Introduction During phase II and phase III studies of HIV-protease inhibitors, renal failure has not emerged as a sideeffect. However, indinavir is distinguishable from other HIV-protease inhibitors by its ability to induce crystalluria and urolithiasis [1,2]. One case of acute renal failure associated with crystal deposits was recently reported in a patient given indinavir therapy [3]. However, definite conclusions were difficult to draw from this observation because of failure to identify the crystals found in the kidney. We report here two cases of tubulointerstitial nephropathy in patients treated with indinavir. Analysis of the renal biopsy samples showed extensive interstitial fibrosis and for the first time, allowed identification of monohydrated indinavir crystals inside the collecting tubules.
Case report 1 A 40-year-old white man, who had been HIV positive since 1987 was admitted to our institution in November 1996 for mental confusion. He had no history of personal or familial kidney disease. In May 1996 his prior antiretroviral treatment comprising zidovudine and zalcitabine had been switched to 150 mg lamivudine twice daily, 30 mg stavudine twice daily, and 800 mg indinavir three times daily. On admission, panencephalic magnetic resonance imaging (MRI ) showed an intracerebral abscess with a perilesional oedema. Toxoplasma gondii serodiagnosis was positive and therapy with the following drug combination was Correspondence and offprint requests to: Dr Gilbert Deray, Service de Ne´phrologie, Groupe Hospitalier Pitie´-Salpeˆtrie`re, 83 Boulevard de l’Hoˆpital, F-75013 Paris, France.
started: 4 g per day sulphadiazine, 50 mg per day pyrimethamine, and 25 mg folinic acid three times weekly. At day 0 of this antitoxoplasmic treatment, serum creatinine was 0.9 mg/dl (80 mmol/l ) and proteinuria was negative. No concomitant alkaline supplements were given during the sulphadiazine therapy. Between days 0 and 30 of treatment, serum creatinine rose progressively from 0.9 to 1.9 mg/dl (80–180 mmol/l ). Because of its potential nephrotoxicity, sulphadiazine was discontinued and clindamycin (2.4 g/day) introduced. Lamivudine, stavudine, and indinavir were continued at the daily doses stated above. At day 45 the serum creatinine level was 2.4 mg/dl (215 mmol/l ). Urinalysis revealed tubular type proteinuria of 0.7 g/day and aseptic leukocyturia (25 000 leukocytes per millilitre) without haematuria. Routine microscope analysis of urine did not show the presence of crystals. Renal sonography showed two normal kidneys without pyelocalyceal distension or urinary lithiasis. Serum and urine immunoelectrophoresis were negative for monoclonal components. Complete immunological and infectious screening disclosed only asymptomatic cytomegalovirus viraemia. On day 45 indinavir was stopped. On day 75 serum creatinine was 2.3 mg/dl (204 mmol/l ), and a percutaneous kidney biopsy was performed. On day 135 (3 months after the discontinuation of indinavir) serum creatinine was still high at 1.7 mg/dl (151 mmol/l ).
Case report 2 A 40-year-old Asian man with an HIV-l infection diagnosed 8 years previously was referred to our hospital in February 1997 for acute headaches. Except for varicella 5 months before admission, he was free of any AIDS-related illnesses. Between November 1996 and February 1997 his treatment had consisted of 160 mg co-trimoxazole, 150 mg lamivudine and 40 mg stavudine twice daily, and 800 mg indinavir three times a day. During the same period, serum creatinine had gradually risen from 1.1 to 1.35 mg/dl
© 1998 European Renal Association–European Dialysis and Transplant Association
Indinavir crystal deposits associated with tubulointerstitial nephropathy
(100–120 mmol/l ) and the patient had no urinary symptoms. At day 0 of admission he presented with grand mal seizures, which prompted us to perform a CT scan and brain MRI. These imaging tests led us to conclude that the patient probably had cerebral varicella zoster virus vasculitis. Lumbar puncture was normal except for protein (2.7 g/l ). On day 3 treatment with i.v. acyclovir (15 mg/kg twice daily) was initiated, and the patient’s neurological status improved during the days that followed. Between days 0 and day 10, his serum creatinine rose from 1.35 to 1.9 mg/dl (120–170 mmol/l ). Hypertension, which was 190/100 mmHg and had not previously been diagnosed, was treated with nicardipine. No renal arterial stenosis was found on abdominal aortic MRI. Haptoglobin, lactate dehydrogenase, and schistocytes were normal or absent. Urinalysis revealed low-level proteinuria (0.42 g/24 h), aseptic leukocyturia (50 000 leukocytes per milliliter) and haematuria (10 000 RBC per millilitre). Routine microscope analysis of urine showed the presence of unidentified crystals. Ultrasound examination showed normal kidneys with no pyelocalyceal distension. At day 23, 10 days after acyclovir had been discontinued, serum creatinine was still 1.8 mg/dl (160 mmol/l ). Indinavir was stopped and a percutaneous renal biopsy was performed. One and two months after this biopsy, serum creatinine levels slowly declined to 1.7 and 1.35 mg/dl respectively (150 and 120 mmol/l ).
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Montluc¸on, France). FTIRM allowed the recording of spectra without any transfer [4,5].
Results Histological and immunohistological findings Patient 1 Cortical renal tissue showed marked interstitial fibrosis with a moderately dense inflammatory infiltrate, severe tubular atrophy, and a thickened Bowman’s capsule in four of eight glomeruli (Figures 1 and 2). Numerous collecting ducts were dilated and contained crystal prints and histiocytes (Figures 2 and 3). A few peritubular giant cells were present. By immunofluorescence with human antisera, only small, non-specific, irregular mesangial deposits of IgM and C3 were observed. Polarization examination of hydric and alcohol staining slides was negative, but birefringent crystalline images were present on unstained frozen sections.
Methods Histological and immunohistological procedures Renal biopsy specimens were examined by light-microscopy, immunofluorescence, electron scanning-microscopy (SEM ) and Fourier transform infrared microscopy. Briefly, Carnoyfixed paraffin-embedded sections were stained with H & E, trichrome with light green, periodic acid–Schiff (PAS) and Jones. Snap frozen sections were cut in a cryostat and stained with fluorescein-conjugated anti-human immunoglobulins and complement sera (Dako, Trappes, France). Snap-frozen sections were examined by light-microscopy with polarization, with or without alcohol methylene blue staining.
Fig. 1. (Patient 1) Diffuse interstitial fibrosis with tubular atrophy (Silver Jones, ×120).
Scanning electron-microscopy (SEM) Snap-frozen section were air-dried and the glass slides were cemented to specimen stubs with conductive silver paste and coated with a thin layer of vacuum evaporated metal to form an electrically conductive surface. Gold and palladium, which are highly effective in generating secondary electrons, were applied to specimens in order to prevent thermal and electrical injuries during examination. Crystal deposits were observed by SEM, using a Hitachi H430 microscope at 20 kV.
Crystals analyses Crystal deposits were identified by Fourier transform infrared microscopy (FTIRM ): accordingly, frozen sections 10 mm thick were spread out on a CaF2 window (Interchim,
Fig. 2. Patient 1. Thickening of tubular basement membranes and Bowman’s capsule. Presence of a dilated collecting tubule containing crystal prints (PAS, ×250).
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Fig. 3. Patient 1. Crystals prints and histiocytes in a collecting tubule (PAS, ×350).
Fig. 5. Patient 2. Indinavir crystals observed by SEM (×2400).
Patient 2 Renal biopsy showed a diffuse fibro-oedema with moderate cellular infiltration and extensive tubular lesions (Figure 4). Numerous tubules were atrophic, with thickened basement membranes; others were dilated and contained histiocytes and crystals. Glomerular lesions were discontinuous: some Bowman capsules were thickened and some capillary walls wrinkled, but there were no collapsing glomeruli, hyperplastic visceral epithelial cells, or sclerosis. Vessel examination revealed arteriolosclerosis and fibrous endarteritis. As in patient 1, immunohistology was non-specific, and crystals were present on unstained frozen sections. Scanning electron-microscopy findings In both patients, examination of frozen sections by SEM confirmed the presence of polyhedric crystals, which were confined to the distal tubules. These crystals have various forms, often rectangular and less frequently were needle shaped ( Figure 5).
Fig. 4. Patient 2. Interstitial fibrosis with atrophic and dilated tubules. Presence of crystal prints in one dilated collecting tubule (Masson trichrome with light green, ×250).
Crystal analyses Polarizing microscopy confirmed the presence of these crystals in the renal biopsy of both patients ( Figure 6). Secondarily, FTIRM provided a spectrum with characteristic absorption bands at 705, 751, 1152, 1302, 1365, 1455, 1525 and 1656 cm−1 without the specific absorption bands of either sulphadiazine (941 and 1678 cm−1) or acyclovir [1,5].
Discussion The present case reports concerned two patients with tubulointerstitial nephropathy who were treated with indinavir therapy. For these patients, other drugs (i.e. sulphadiazine and acyclovir) had a nephrotoxic potential, and are known to be associated with crystalluria [6–8]. In a recent review of sulphadiazine-associated nephrotoxicity [8], Becker et al. pointed out the usually excellent outcome for patients with this drug-related side-effect. This is in contrast to our first case, in which serum creatinine remained elevated at day 135 despite
Fig. 6. Patient 1. Crystals of monohydrate indinavir observed by polarizing microscopy (×600).
Indinavir crystal deposits associated with tubulointerstitial nephropathy
the withdrawal of sulphadiazine 4 months previously. Similarly, in case 2, the slowness of the decrease in serum creatinine after acyclovir had been discontinued suggested that the protease inhibitor has a nephrotoxic role. In the seven studies of acyclovir-associated acute renal failure reviewed by Becker et al. [7], serum creatinine returned to baseline value within 10 days of acyclovir cessation. Further evidence that indinavir has a nephrotoxic role was obtained by infrared microscopy and spectral analysis, which indicated the presence of indinavir monohydrated crystals only, inside the lumen of the collecting tubules. The morphological and spectral characteristics of all these crystals were clearly different from those of crystals composed of sulphadiazine, N-acetyl sulphadiazine (a major metabolite of sulphadiazine) or acyclovir [2,5,6 ]. In addition, the renal biopsy findings excluded the other main causes of renal failure in HIV-infected patients, i.e. collapsing glomerulopathy, lupus-like nephropathy, haemolytic–uraemic syndrome, and infectious renal diseases [9]. Indinavir (CrixivanB) is a new antiretroviral agent for HIV-infected patients. The occurrence of kidney stones composed of monohydrated indinavir has been reported in about 3% of patients taking indinavir [2]. In a recently published case of acute renal dysfunction which was attributed to indinavir, the crystals found in the tubules were not structurally identified [3]. Furthermore, in this case the potential nephrotoxicity of amoxicillin, which was administered together with indinavir, could not be ruled out, as amoxicillin is known to induce urinary crystals or immunoallergic nephropathy. Seven cases of acute renal dysfunction of unknowm aetiology have been reported in patients taking ritonavir with or without saquinavir, which are both HIVprotease inhibitors [10–12]. Note that in six of these seven patients, baseline serum creatinine values were elevated (from 1.2 to 2.2 mg/dl ) and five of them were concomitantly taking, or had previously taken, either acyclovir or foscarnet, both of which are known to induced crystal-related acute renal failure [6,13]. As reported for kidney myeloma, tubular obstruction and tubular cell lesions induced by abnormal intraluminal content may trigger inflammatory reaction, such as the reaction to a foreign compound as well as fibrogenic processes that lead to extensive renal interstitial fibrosis [14]. It is important to note that sulphadiazine and indinavir are soluble under opposite conditions, as sulphadiazine dissolve more easily in alkaline solutions, whereas indinavir preferably dissolves in acid aqueous solutions. In our patients, sulphadiazine and acyclovir might have slowed urinary outflow and/or increased urine supersaturation,
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thereby favouring indinavir crystallization inside the tubules. In both cases reported here tubulointerstitial nephropathy appeared during indinavir treatment. In the kidney biopsy specimens, indinavir crystals associated with inflammatory cells were authenticated inside collecting tubules but the specimens were free of acyclovir and sulphadiazine crystals. However, in both cases, these two concomitantly administered drugs could have promoted indinavir crystal formation and deposition capable of inducing inflammatory reactions, fibrosis, and renal dysfunction. On the basis of our observations and of previous reports concerning the nephrotoxic potential of ritonavir, we suggest that renal function should be closely monitored when HIV protease inhibitors are administered together with other nephrotoxic drugs. Ample hydration should be recommended in order to prevent both indinavir-induced urolithiasis and the present new form of renal failure associated with crystal deposition.
References 1. Daudon M, Estepa L, Viard JP, Joly D, Jungers P. Urinary stones in HIV-1 patients treated with indinavir. Lancet 1997; 349: 1294–1295 2. Kopp JB, Miller KD, Mican AM et al. Crystalluria and urinary tract abnormalities associated with indinavir. Ann Intern Med 1977; 127: 119–125 3. Tashima KT, Horowitz JD, Rosen S. Indinavir nephropathy. N Engl J Med 1997; 336: 138–140 4. Estepa-Maurice L, Hennequin C, Marfisi C, Bader C, Lacour B, Daudon M. Fourier transform infrared microscopy identification of crystal deposits in tissues. Am J Clin Pathol 1996; 105: 576–582 5. Daudon M. Me´thodes d’analyse des calculs et des cristaux urinaires. Classification morpho-constitutionnelle des calculs. In: Jungers P, Daudon M, Le Duc A. Lithiase Urinaire. Flammarion Me´decine Sciences, Paris, 1989; 35–113 6. Sawyer MH, Webb DE, Balow JE, Straus SE. Acyclovir-induced renal failure: clinical course and histology. Am J Med 1988; 84: 1067–1075 7. Becker BN, Fall P, Hall C et al.. Rapidly progressive acute renal failure due to acyclovir: case report and review of the literature. Am J Kidney Dis 1993; 22 : 611–615 8. Becker K, Jablonowski H, Haussinger D. Sulfadiazineassociated nephrotoxicity in patients with the acquired immunodeficiency syndrome. Medicine 1996; 75: 185–194 9. D’Agati V, Appel CB. HIV infection and the kidney. J Am Soc Nephrol 1997; 8: 138–152 10. Chugh S, Bird R, Alexander EA. Ritonavir and renal failure. N Engl J Med 1997; 336: 138 11. Duong M, Sgro C, Grappin M, Biron F, Boibieux A. Renal failure after treatment with ritonavir. Lancet 1996, 348: 693–694 12. Witzke O, Plentz A, Scha¨fers RF, Reinhardt W, Heeman U, Philipp T. Side-effects of ritonavir and its combination with saquinavir with special regard to renal function. AIDS 1997; 11: 836–838 13. Beaufils H, Deray C, Katlama C et al. Foscarnet and crystals in glomerular capillary lumens. Lancet 1990, 336: 755 14. Solomon A, Weiss DT, Kattine AA. Nephrotoxic potential of Bence Jones proteins. N Engl J Med 1991; 324: 1845–1851 Received for publication: 15.10.97 Accepted: 22.10.97
