Prednisone Improves Renal Function and Proteinuria in Human Immunodeficiency Virus-associated Nephropathy

Purpose To determine if prednisone ameliorates the course of human immunodeficiency virus-associated nephropathy (HIV-AN). Patients and Methods: Twenty consecutive HIV-infected adults with biopsy-proven HIV-AN (n = 17) or clinical characteristics of HIV-AN (n = 3) with serum creatinine concentrations >177 μmol/L (2 mg/dL) or proteinuria >2.0 g/d or both were prospectively evaluated and treated with prednisone at a dose of 60 mg/d for 2 to 11 weeks, followed by a tapering course of prednisone over a 2- to 26-week period. Serum creatinine concentration, 24-hour protein excretion, serum albumin, and steroidrelated adverse effects were assessed before and after treatment. Results Nineteen patients had serum creatinine concentrations >177 μmol/L (2 mg/ dL). Two of them progressed to end stage renal disease (ESRD) in 4 to 5 weeks. In 17 patients serum creatinine levels decreased from 717 ±103 μmol/L (8.1 ± 1.2 mg/dL) (mean ± SE) to 262 ± 31 μmol/L (3.0 ± 0.4 mg/dL) (P <0.001). Five patients relapsed after prednisone was discontinued and were retreated. In these 5 the serum creatinine declined from 728 ± 107 μmol/L (8.2 ± 1.2 mg/dL) to 344 ± 47 μmol/L (3.9 ± 0.5 mg/ dL) (P <0.01) in response to the second course of prednisone. Twelve of 13 tested patients showed a reduction in 24-hour urinary protein excretion with an average decrement from 9.1 ± 1.8 g/d to 3.2 ± 0.6 g/d (P <0.005). Serum albumin increased from 24.4 ± 3.6 g/L to 29.3 ± 2.6 g/L (P =NS) in the 11 patients with paired 24-hour urine collections for whom pre- and posttreatment determinations were available. In one non-azotemic patient with nephrotic syndrome, protein excretion declined from 15.2 to 2.2 g/ day and the serum albumin increased from 4.0 g/L to 31.0 g/L. The 20 patients have been followed for a median of 44 weeks (range 8 to 107). Eight ultimately required maintenance dialysis. Eleven died from complications of HIV disease 14 to 107 weeks after institution of prednisone; none was receiving prednisone at the time of death. Seven are alive and free from ESRD a median of 25 weeks (range 8 to 81) from the initiation of prednisone therapy. Six patients developed a total of seven serious infections while receiving prednisone, including Mycobacterium aviumcomplex infection in 2 and CMV retinitis in 3. Conclusion Prednisone improves serum creatinine and proteinuria in a substantial proportion of adults with HIV-AN. Corticosteroidrelated side effects are not prohibitive. A prospective, randomized controlled trial is required to confirm these preliminary results.