Ureteral obstruction secondary to indinavir in the pediatric HIV population

Drug-Induced Urolithiasis in Pediatric Patients

Drug-induced nephrolithiasis is a rare condition in children. The involved drugs may be divided into two different categories according to the mechanism involved in calculi formation. The first one includes poorly soluble drugs that favor the crystallization and calculi formation. The second category includes drugs that enhance calculi formation through their metabolic effects. The diagnosis of these specific calculi depends on a detailed medical history, associated comorbidities and the patient's history of drug consumption. There are several risk factors associated with drug-induced stones, such as high dose of consumed drugs and long duration of treatment. Moreover, there are some specific risk factors, including urinary pH and the amount of fluid consumed by children. There are limited data regarding pediatric lithogenic drugs, and hence, our aim was to perform a comprehensive review of the literature to summarize these drugs and identify the possible mechanisms involved in calculi formation and discuss the management and preventive measures for these calculi.

Clinical Profile of Surgical Diseases with Emergence of New Problems in HIV+ Individuals

North Karnataka is one of the regions with the high prevalence of HIV+ individuals. Bijapur is a district in North Karnataka with high prevalence as per fact sheets of NACO of March 2012. Better awareness, access to health care, and antiretroviral therapy have improved survival and increase in number of people living with HIV/AIDS (PLHA). Improved survival has increased their attendance to hospitals with variety of surgical problems, some known and some less known. The percentage of HIV+ individuals was 1.64 % among all admissions. Of these individuals, 13.65 % (272) had surgical problems. Abscesses were the commonest. Abscesses at uncommon sites also were encountered. Anorectal pathologies, tuberculosis, lymphadenopathy, appendicitis, etc. commonly seen in HIV+ individuals were seen. Drug-induced pancreatitis due to anti retroviral therapy was one of the common problems encountered. Uncommon conditions like ureteric calculi, external iliac artery thrombosis, diaphragmatic eventration, and few more were observed. Even though literature on AIDS/HIV is abundant, there is less information on surgical conditions encountered more so from this part of the subcontinent. Hence, it was decided to report the profile of the conditions encountered.

[Renal colic and lithiasis in HIV(+)-patients treated with protease inhibitors]

INTRODUCTION

Protease inhibitors, mainly Indinavir, are widely used drugs for the treatment of patients infected by the human immunodeficiency virus (HIV) and are related to renal colic and urinary obstruction. These conditions are the result of urine excretion of these drugs which favours the formation of small calculi (crystalluria and lithiasis).

MATERIAL AND METHODS

Five PI treated HIV(+) patients; four males, one female, have recently been seen for renal colic at the Lithiasis Unit, Fundación Jiménez Díaz (FJD). All five patients had renal colic, one bilateral and one renal obstruction and fever. Small lithiasic concretions of null or minor radiological calcium density were identified by urinary X-ray and UIV. The patients had haematuria, crystalluria and urinary pH 5.0-6.0. Treatment was symptomatic, pharmacologic, emergency in situ extracorporeal shock-wave lithotrity (ESWL), or ureteral catheterisation, as appropriate.

RESULTS

Patients had been treated with these antiviral agents for several months. They all required urologic care: pharmacologic, ureteral catheterisation, or ESWL, with good results. No stones were obtained for mineralogic analysis, but crystalluria was identified as being due to Indinavir and calcium oxalate.

CONCLUSIONS

Renal excretion and urinary elimination of PIs (or their metabolites) results in asymptomatic crystalluria in HIV(+) patients treated with this class of drugs. Other cases present genuine calcium oxalate calculi with sings of renal colic and urinary obstruction requiring urologic care.

Detection of indinavir crystals in urine: dependence on method of analysis

OBJECTIVES

To determine the frequency of crystalluria in patients treated with the human immunodeficiency virus protease inhibitor indinavir and to compare methods of detecting crystalluria.

METHODS

A total of 308 freshly voided urine specimens from 168 patients treated with indinavir were evaluated by manual microscopy of sediment and microscopy with an automated workstation and by dipstick analysis.

RESULTS

Crystals were detected in 22%, 31%, or 32% of specimens using, respectively, an automated workstation, manual microscopy, or both methods. Proteinuria or hemoglobinuria occurred significantly more often in specimens with (28%) than without (18%) crystals. Frequency of crystalluria was unrelated to specific gravity, but it increased at higher pH. Crystals were detected in 21% of specimens with pH less than 6 and 42% of specimens with pH of 6 or higher.

CONCLUSIONS

Crystalluria occurs in more than 30% of urine specimens from patients treated with indinavir, but detection rates vary substantially with method of analysis. Manual microscopy detected crystalluria 41% more often than did an automated workstation.