Introduction HIV infection in children is seen much more commonly seen in the UK. HIV associated nephropathy (HIVAN), is commonly considered as a late manifestation in adults having longstanding HIV infection with high viral-load and low T-helper cell (CD4) counts. The authors report a case of HIVAN in a teenager who was already on highly active antiretroviral therapy (HAART) with well suppressed disease activity.
Case A Zimbabwe-born 9-year-old boy was diagnosed with miliary tuberculosis and vertically transmitted HIV infection. He was started on anti tuberculosis medications and HAART. Within few months of HAART therapy his viral-load became undetectable and CD4 count got normalised. He successfully completed the treatment of miliary tuberculosis, but 4 years later, he developed nephrotic range proteinuria (7.5 gm/day). He was not hypertensive or oedematous. His urine showed no sediments, serum albumin was low, cholesterol was elevated, with normal creatinine and complement levels, and negative autoimmune screen. Ultrasound revealed echogenic normal sized kidneys. CD4 counts were still normal and viral-load remained undetectable. Drug related causes of nephropathy were ruled out by reviewing the list of medication that he was previously on. Kidney biopsy showed non-collapsing focal segmental glomerular sclerosis suggestive of HIVAN.
Treatment Along with regular HAART, he received 8 weeks of prednisolone and was put on enalapril (angiotensin-converting enzyme inhibitor), which markedly improved the proteinuria. His renal function subsequently has remained stable.
Conclusion This is a very interesting and unique case not reported in literature till now. Contrary to common belief it has made us postulate that HIVAN can occur at any stage in HIV infection, even in those with HAART induced stable state with undetectable viral-load and normal CD4 count. It has been suggested that renal epithelial cells act as reservoir for HIV-1 and intracellular expression of viral RNA could persist despite HAART. Improved survival following introduction of HAART has resulted in more patients being at-risk of developing kidney diseases.
Suggestion As HIVAN can remain asymptomatic in early stages, children with HIV infection should be regularly screened for kidney disease even if they are clinically asymptomatic and on adequate HAART regimen.