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Abstract
Nephrolithiasis is a well-known side effect of many HIV protease inhibitors. However, there have not been reports of stones associated with ritonavir use. Here, we report the case of a 33-year-old woman with HIV on antiretroviral therapy who presented with sharp left flank pain and passed a stone that was later found to contain only ritonavir. Of note, the patient’s treatment regimen had not included ritonavir for 2 years prior to this incidence. This case is notable both for the novel finding of a renal calculus composed entirely of ritonavir and the development of nephrolithiasis years after cessation of the aggravating drug. This finding suggests that patients on ritonavir should be more closely monitored and for longer periods of time for potential lithiasis formation.
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2
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Loens C, Amet S, Isnard-Bagnis C, Deray G, Tourret J. [Nephrotoxicity of antiretrovirals other than tenofovir]. Nephrol Ther 2018; 14:55-66. [PMID: 29500080 DOI: 10.1016/j.nephro.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The remarkable improvement of the outcome of HIV infection came with the price of substantial toxicity of some antiretrovirals. The first molecules used to treat HIV included an important nephrotoxicity. Zalcitabine, stavudine and didanosine can induce severe lactic acidosis. Lactate production is enhanced and the renal capacity to regulate pH is overwhelmed. However, this side effect is not due to a direct dysfunction of the kidneys. Zalcitabine was withdrawn from the market because of this risk. Indinavir, a protease inhibitor, is soluble only in very acidic solutions. Consequently, the small fraction that is excreted in the urine precipitates and can be responsible for uro-nephrolithiasis, leukocyturia, cristalluria, obstructive acute kidney failure, and acute or chronic interstitial nephritis. This is the reason why indinavir is almost not prescribed nowadays, even if it is still marketed. In addition to the direct nephrotoxicity of some antiretrovirals, anti-HIV treatment also includes a toxicity which pathophysiology is not completely elucidated. This nephrotoxicity is the consequence of organ accelerated ageing and of an increased vascular risk. Kidney vascularization (from renal arteries to capillaries) is essential to kidney function and all cardiovascular risks are also renal risks. It is now clearly established that combined antiretroviral treatment increases the vascular risk. A better comprehension of the links between HIV infection, its treatment and very long-term kidney risk is needed to improve the complex management of patients who have now cumulated several decades of HIV infection and treatment with various toxicities.
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Affiliation(s)
- Christopher Loens
- Service de néphrologie, groupe hospitalier universitaire Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France; Université Pierre et Marie Curie, 4, place Jussieu, 75005 Paris, France
| | - Sabine Amet
- Service de néphrologie, groupe hospitalier universitaire Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France; ICAR : Information, Conseil, Adaptation Rénale, groupe hospitalier universitaire Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France
| | - Corinne Isnard-Bagnis
- Service de néphrologie, groupe hospitalier universitaire Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France; Université Pierre et Marie Curie, 4, place Jussieu, 75005 Paris, France
| | - Gilbert Deray
- Service de néphrologie, groupe hospitalier universitaire Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France; Université Pierre et Marie Curie, 4, place Jussieu, 75005 Paris, France
| | - Jérôme Tourret
- Service de néphrologie, groupe hospitalier universitaire Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France; Université Pierre et Marie Curie, 4, place Jussieu, 75005 Paris, France.
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McLaughlin MM, Guerrero AJ, Merker A. Renal effects of non-tenofovir antiretroviral therapy in patients living with HIV. Drugs Context 2018; 7:212519. [PMID: 29623097 PMCID: PMC5866095 DOI: 10.7573/dic.212519] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/22/2018] [Accepted: 02/22/2018] [Indexed: 12/19/2022] Open
Abstract
A review of literature published regarding non-tenofovir antiretroviral agents causing renal adverse effects was conducted. The literature involving renal adverse effects and antiretroviral therapy is most robust with protease inhibitors, specifically atazanavir and indinavir, and includes reports of crystalluria, leukocyturia, nephritis, nephrolithiasis, nephropathy and urolithiasis. Several case reports describe potential nephropathy (including Fanconi syndrome) secondary to administration of abacavir, didanosine, lamivudine and stavudine. Case reports documented renal events such as acute renal failure, nephritis, proteinuria and renal stones with efavirenz administration. Regarding rilpivirine, a small increase of serum creatinine levels (SCr) was found in clinical trials; however, the clinical significance and impact on actual renal function is unknown. The integrase strand transfer inhibitors and enfuvirtide have a relatively safe renal profile, although studies have shown dolutegravir and raltegravir cause mild elevations in SCr without an impact on actual renal function. This is similar to the reaction observed with cobicistat, the pharmacokinetic enhancer frequently given with elvitegravir.
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Affiliation(s)
- Milena M McLaughlin
- Chicago College of Pharmacy, Midwestern University, 555 31st Street, Downers Grove, IL 60515, USA.,Northwestern Memorial Hospital, 251 E Huron St, Chicago, IL 60611, USA
| | - Aimee J Guerrero
- Chicago College of Pharmacy, Midwestern University, 555 31st Street, Downers Grove, IL 60515, USA
| | - Andrew Merker
- Chicago College of Pharmacy, Midwestern University, 555 31st Street, Downers Grove, IL 60515, USA.,Mount Sinai Hospital, 1500 S Fairfield Ave, Chicago, IL 60608, USA
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Izzedine H, Lescure FX, Bonnet F. HIV medication-based urolithiasis. Clin Kidney J 2014; 7:121-6. [PMID: 25852859 PMCID: PMC4377784 DOI: 10.1093/ckj/sfu008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Accepted: 01/27/2014] [Indexed: 01/03/2023] Open
Abstract
Drug-induced renal calculi represent 1–2% of all renal calculi. In the last decade, drugs used for the treatment of HIV-infected patients have become the most frequent cause of drug-containing urinary calculi. Among these agents, protease inhibitors (PIs) are well known to induce kidney stones, especially indinavir and atazanavir, and more recently darunavir. Urolithiasis attributable to other PIs has also been reported in clinical cases such as those during non-PI use. Antiretroviral drug-induced calculi deserve consideration because most of them are potentially preventable. This article summarizes the diagnosis, epidemiology, prevention and management of antiretroviral drug-induced urolithiasis.
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Affiliation(s)
- Hassane Izzedine
- Department of Nephrology , Pitie Salpetriere Hospital , Paris , France
| | - François Xavier Lescure
- Department of Infectious and Tropical Diseases , Bichat-Claude Bernard Hospital, APHP Paris , Paris , France ; ATIP/AVENIR U738 INSERM Université Paris Diderot , Paris , France
| | - Fabrice Bonnet
- CHU de Bordeaux, Department of Internal Medicine and Infectious Diseases , and University Bordeaux Segalen University, INSERM U 897 , Bordeaux 33000 , France
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Fracchia JA, Panagopoulos G, Katz RJ, Armenakas N, Sosa RE, DeCorato DR. Adequacy of Low Dose Computed Tomography in Patients Presenting with Acute Urinary Colic. J Endourol 2012; 26:1242-6. [DOI: 10.1089/end.2012.0130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Raheem OA, Mirheydar HS, Palazzi K, Chenoweth M, Lakin C, Sur RL. Prevalence of nephrolithiasis in human immunodeficiency virus infected patients on the highly active antiretroviral therapy. J Endourol 2012; 26:1095-8. [PMID: 22429050 DOI: 10.1089/end.2011.0639] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Protease inhibitors, specifically indinavir, have historically been implicated as a cause of nephrolithiasis in the human immunodeficiency virus (HIV) infected patients. There is a paucity of data, however, on stone disease with nonindinavir etiologies since the introduction of highly active antiretroviral therapy (HAART). We sought to describe the prevalence of nephrolithiasis in the HIV population since the use of HAART. PATIENTS AND METHODS We retrospectively reviewed HIV-positive patients currently receiving HAART treatment in whom image proven kidney and/or ureteral urolithiasis developed, between 1998 and 2010. A detailed analysis of patients' current treatment, surgical intervention, and metabolic studies was performed. RESULTS A total of 436 HIV-positive patients were included and 46 (11%) patients had nephrolithiasis. Each patient included in this study was receiving nonindinavir-based antiretroviral therapy. There were 41 men of whom 36 were Caucasian. Eleven (24%) patients underwent 24-hour urine collections with 11 metabolic abnormalities identified. Stone analysis was available for seven patients (four calcium oxalate monohydrate, one cystine, one uric acid, and one atazanavir). CONCLUSIONS We report the largest series of nephrolithiasis in an HIV population since the introduction of HAART and highlight not only the similar prevalence of nephrolithiasis to the non-HIV population but also the lack of consistent comprehensive metabolic evaluations in HIV patients with recurrent nephrolithiasis.
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Affiliation(s)
- Omer A Raheem
- Division of Urology, Department of Surgery, University of California San Diego Health Care System, San Diego, California 92103, USA.
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Viprakasit DP, Sawyer MD, Herrell SD, Miller NL. Limitations of Ultrasonography in the Evaluation of Urolithiasis: A Correlation With Computed Tomography. J Endourol 2012; 26:209-13. [DOI: 10.1089/end.2011.0177] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Davis P. Viprakasit
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark D. Sawyer
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - S. Duke Herrell
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nicole L. Miller
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Vera T, Stec DE. Moderate hyperbilirubinemia improves renal hemodynamics in ANG II-dependent hypertension. Am J Physiol Regul Integr Comp Physiol 2010; 299:R1044-9. [PMID: 20668235 PMCID: PMC2957382 DOI: 10.1152/ajpregu.00316.2010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Accepted: 07/25/2010] [Indexed: 11/22/2022]
Abstract
We have previously demonstrated that moderate hyperbilirubinemia decreases blood pressure in ANG II-dependent hypertension through mechanisms that decrease oxidative stress and increase nitric oxide levels. Since decreases in renal hemodynamics play an important role in mediating the hypertensive actions of ANG II, the goal of the present study was to examine the effect of moderate hyperbilirubinemia on glomerular filtration rate (GFR) and renal blood flow (RBF) in a mouse model of ANG II hypertension. Mice were made moderately hyperbilirubinemic by two methods: indinavir or specific morpholino antisense oligonucleotides against UGT1A1, which is the enzyme responsible for the conjugation of bilirubin in the liver. GFR and RBF were measured in mice after implantation of an osmotic minipump delivering ANG II at a rate of 1 μg·kg(-1)·min(-1). GFR was measured by continuous infusion of I(125)-labeled iothalamate on days 5 and 6 of ANG II infusion in conscious mice. RBF was measured on day 7 of ANG II infusion in anesthetized mice. Blood levels of unconjugated bilirubin were significantly increased in mice treated with indinavir or anti-UGT1A1 (P = 0.002). ANG II decreased GFR by 33% of control (n = 9, P = 0.004), and this was normalized by moderate hyperbilirubinemia (n = 6). Next, we examined the effect of moderate hyperbilirubinemia on RBF in ANG II-infused mice. ANG II infusion significantly decreased RBF by 22% (P = 0.037) of control, and this decrease was normalized by moderate hyperbilirubinemia (n = 6). These results indicate that improvement of renal hemodynamics may be one mechanism by which moderate hyperbilirubinemia lowers blood pressure in this model.
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Affiliation(s)
- Trinity Vera
- Dept. of Physiology and Biophysics, Center for Excellence in Cardiovascular-Renal Research, University of Mississippi Medical Center, Jackson, 39216-4505, USA
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Kambadakone AR, Eisner BH, Catalano OA, Sahani DV. New and Evolving Concepts in the Imaging and Management of Urolithiasis: Urologists’ Perspective. Radiographics 2010; 30:603-623. [DOI: 10.1148/rg.303095146] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Heyns CF, Groeneveld AE, Sigarroa NB. Urologic complications of HIV and AIDS. ACTA ACUST UNITED AC 2009; 6:32-43. [DOI: 10.1038/ncpuro1273] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Accepted: 11/13/2008] [Indexed: 12/29/2022]
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Yarlagadda SG, Perazella MA. Drug-induced crystal nephropathy: an update. Expert Opin Drug Saf 2008; 7:147-58. [PMID: 18324877 DOI: 10.1517/14740338.7.2.147] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Several medications that are insoluble in human urine are known to precipitate within the renal tubules. Intratubular precipitation of either exogenously administered medications or endogenous crystals (induced by certain drugs) can promote chronic and acute kidney injury, termed crystal nephropathy. Clinical settings that enhance the risk of drug or endogenous crystal precipitation within the kidney tubules include true or effective intravascular volume depletion, underlying kidney disease, and certain metabolic disturbances that promote changes in urinary pH favoring crystal precipitation. OBJECTIVE Identify and review previously described and recently recognized medications that cause crystal nephropathy. METHOD A literature review was performed, using PubMed, Ovid, and Google Scholar, focusing on drugs (sulfadiazine, acyclovir, indinavir, triamterene, methotrexate (MTX), orlistat, oral sodium phosphate preparation, ciprofloxacin) that cause crystal nephropathy. RESULTS/CONCLUSION Sulfadiazine, acyclovir, indinavir, triamterene, and MTX are known to cause crystal nephropathy. Recently, several medications, including orlistat, ciprofloxacin, and oral sodium phosphate solution, along with underlying risk factors have been described as causing crystal nephropathy.
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Affiliation(s)
- Sri G Yarlagadda
- Yale University School of Medicine, Section of Nephrology/Department of Medicine, LMP 2071, 333 Cedar Street, New Haven, CT 06520-8029, USA
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Abstract
The prevalence of HIV continues to grow in the United States and worldwide. HIV-positive patients experience many genitourinary disease processes. With improvements in HIV therapy, patients have questions and concerns pertaining to their quality of life. This article reviews conditions such as HIV-related urinary tract infections, urolithiasis, voiding dysfunction, fertility, sexual dysfunction, HIV-related nephropathy, malignancies, and occupational exposure and prophylaxis. Knowledge of the various HIV manifestations of genitourinary conditions and their treatment options benefits clinicians and improves patient outcomes.
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Affiliation(s)
- Steve Lebovitch
- Department of Urology, Temple University Hospital, Philadelphia, PA 19140, USA
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Obstructive uropathy in a HIV+ infant under indinavir treatment. J Pediatr Urol 2007; 3:512-3. [PMID: 18947806 DOI: 10.1016/j.jpurol.2007.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2007] [Accepted: 05/31/2007] [Indexed: 11/24/2022]
Abstract
The case is presented of a 10-year-old HIV+ male with renoureteral pain, who developed an obstructive uropathy with renal function impairment and required endoscopic placement of a ureteral stent. Certain aspects of the epidemiology, clinical presentation, diagnosis, treatment and prevention are discussed.
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Kalaitzis C, Passadakis P, Giannakopoulos S, Panagoutsos S, Mpantis E, Triantafyllidis A, Touloupidis S, Vargemezis V. Urological management of indinavir-associated acute renal failure in HIV-positive patients. Int Urol Nephrol 2006; 39:743-6. [PMID: 17180736 DOI: 10.1007/s11255-006-9154-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2006] [Accepted: 11/13/2006] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Indinavir, a protease inhibitor that is commonly used to treat HIV infection, may cause crystal formation within the renal tubules when urine pH is above 3.5. Crystallization in the urine may lead to intrarenal crystal deposition and acute renal failure (ARF). AIM To establish the beneficial urological management of acute renal failure caused by indinavir treatment of HIV/AIDS patients. PATIENTS--METHODS Five HIV positive patients (four men, one woman) with a mean age of 32 years (range 28-36 years) were referred to our Department of Urology from an AIDS outpatient Clinic, because of the development of postrenal acute renal failure with continuously elevated creatinine and urea plasma levels after indinavir therapy. Among the initial therapeutic maneuvers, indinavir administration was interrupted for 1 week while bilateral double-J ureteral stents were inserted in all the HIV/AIDS patients, during the first 24-72 h to secure upper-tract drainage. Concurrently urine has been acidified by oral administration of the amino acid L: -methionine and oral fluid intake was increased. RESULTS All the patients responded well to the treatment and their renal function was effortlessly restored to normal within a few days. CONCLUSION HIV-positive patients receiving indinavir therapy might be complicated by acute renal failure, mainly due to intrarenal crystal deposition (tubules) or urolithiasis (postrenal obstruction). This adverse effect may simply manage by the discontinuation of indinavir administration, urine acidification, as well as the possible early insertion of bilateral double-J ureteral stents.
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Affiliation(s)
- C Kalaitzis
- Department of Urology, School of Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
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Kshirsagar SA, Blaschke TF, Sheiner LB, Krygowski M, Acosta EP, Verotta D. Improving data reliability using a non-compliance detection method versus using pharmacokinetic criteria. J Pharmacokinet Pharmacodyn 2006; 34:35-55. [PMID: 17004125 DOI: 10.1007/s10928-006-9032-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2005] [Accepted: 08/18/2006] [Indexed: 12/14/2022]
Abstract
Data from clinical trials present numerous problems for the data analyst. These include non-compliance with the prescribed dosing regimen and inaccurate recollection of dosing history by patients as well as mistakes in recording data. Several methods have been proposed to address these issues. One such technique by Lu et al. (Selecting reliable pharmacokinetic data for explanatory analyses of clinical trials in the presence of possible noncompliance. J. Pharmacokinet. Pharmacodyn. 28:343-362 (2001)) identifies occasions in pharmacokinetic (PK) data where the preceding dosing history is likely to be unreliable. We used this method, implemented in the software program NONMEM (beta) VI, to clean a dataset containing indinavir (IDV) plasma concentrations from HIV-1 infected patients. The data was also cleaned by inspection in Microsoft Excel using clinical PK criteria. A one-compartment model with first order absorption and elimination was fit to both sets of cleaned data. IDV population PK parameters obtained from these analyses were similar to those reported previously. It is established that IDV nephrotoxicity is related to high IDV exposure. However, no relationships were found between any PK parameters and nephrotoxicity in the "compliance cleaned" dataset. In the "PK cleaned" dataset, the oral clearance and apparent volume were lower by 9.1% and 6.6%, respectively in patients with any type of nephrotoxicity and the maximum IDV concentration (C(max)) was 12.1% higher. In patients suffering from nephrolithiasis in particular, C(max) was 15.5% higher. Accordingly, the use of the non-compliance detection method did not improve the reliability of our dataset over the usual method of applying clinical criteria. In fact, analyses on the compliance-cleaned dataset missed some exposure-toxicity relationships. Thus, automated methods must be tested rigorously with 'real life' datasets, used with caution, and always in conjunction with clinical reasoning to avoid overlooking a signal in noisy data.
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Affiliation(s)
- Smita A Kshirsagar
- Department of Medicine, Stanford University Medical Center, Stanford, CA, USA
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16
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Abstract
Indinavir is a new specific and potent drug that inhibits, like other antiretroviral agents, the protease of immune deficiency virus (HIV) or acquired immune deficiency syndrome (AIDS), an enzyme necessary to maduration and replication of the virus. Indinavir has the capacity to bind the active site causing a decrease in plasma of HIV1-RNA and an increase of T-CD4 helper lymphocytes. The aim of this work is to study in HIV and/or AIDS patients treated with indinavir the crystalluria and the formation of renal calculi due to the clearance of this drug. Two out of nine patients studied in this work presented abundant crystalluria and one of them presented spontaneously passed renal stone. Urinary crystals were studied under polarized-light microscopy and renal stone was analyzed by infrared spectroscopy.
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Affiliation(s)
- Ma L Traba Villameytide
- Laboratorio de Bioquímica, Sección de Fisiopatología Osea, Medicina Interna, Fundación Jiménez Díaz, Madrid
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Kalaitzis C, Touloupidis S, Patris E, Lehrich K, Kuntz RM. [Indinavir urolithiasis in HIV-positive patients. Treatment and prophylaxis]. Urologe A 2004; 43:168-71. [PMID: 14991118 DOI: 10.1007/s00120-003-0492-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
TARGET The approximate incidence of indinavir urolithiasis in HIV positive patients receiving the drug is 10%. The exact mechanism of lithogenesis is still unknown. Pure indinavir stones are radiolucent on plane abdominal X-ray or CT scan. Indinavir urolithiasis can be associated with acute unilateral renal colic or severe azotaemia. MATERIAL AND METHODS 20 HIV patients were treated conservatively by increasing oral fluid intake (urine production of 2 l/day and more), discontinuation of indinavir therapy for 1 week and acidification of urine with l-methionin (urine pH 5,3-5,8). Some patients were additionally treated with endoscopic procedures. RESULTS In all patients renal function normalized. Increase of oral fluid intake, especially during the first 2 hours after intake of indinavir and during night prevented recurrence of indinavir urolithiasis. CONCLUSION HIV positive patients with renal colic or renal insufficiency and roentgenological absence of radio-opaque stone formations should make the urologist consider indinavir urolithiasis as a possible diagnosis.
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Affiliation(s)
- C Kalaitzis
- Department of Urology, Democritus University of Thrace, Dragana, 68100 Alexandroupolis, Greece.
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Slaven EM, Lopez F, Weintraub SL, Mena JC, Mallon WK. The AIDS patient with abdominal pain: a new challenge for the emergency physician. Emerg Med Clin North Am 2003; 21:987-1015. [PMID: 14708816 DOI: 10.1016/s0733-8627(03)00070-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
As the prevalence of HIV infection continues to increase, EPs will be called upon to evaluate increasing numbers of AIDS patients who have abdominal pain, some of whom will require emergent surgical intervention. In addition to the myriad causes of abdominal pain in the nonimmunocompromised patient, the differential diagnosis in the AIDS patient includes a wide variety of opportunistic infections and neoplasms (Table 5). Evaluation frequently requires extensive laboratory studies and cultures and advanced imaging (CT, ultrasound, and so forth). A low threshold for surgical and other subspecialty consultation should be in place because of the often subtle presentation of surgical emergencies in AIDS patients.
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Affiliation(s)
- Ellen M Slaven
- Division of Emergency Medicine, Department of Medicine, Charity Hospital, Louisiana State University, 1542 Tulane Avenue, New Orleans, LA 70112, USA
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Kalaitzis C, Dimitriadis G, Tsatidis T, Kuntz R, Touloupidis S, Kelidis G. Treatment of indinavir sulfate induced urolithiasis in HIV-positive patients. Int Urol Nephrol 2003; 34:13-5. [PMID: 12549631 DOI: 10.1023/a:1021340915465] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Indinavir sulfate is a protease inhibitor used of the treatment of primary HIV infection either as monotherapy or as part of antiretroviral treatment schemes. Approximately 10% of all patients develop urolithiasis with radiolucent stones consisting of indinavir. We present our results of the treatment in 11 HIV positive patients (9 men, 2 women), who developed Indinavir lithiasis after 5-8 months of antiretroviral therapy. Following the initial procedures (spasmoanalgetic drugs, ureteroscopy, double J-stent or nephrostomy), the patients were further treated by increasing diuresis and urinary acidification. All the patients responded well to the treatment, the obstruction was releieved and their renal function was restored to normal.
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Affiliation(s)
- Christos Kalaitzis
- Department of Urology, Democritus University of Thrace, Alexandroupolis, Greece
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20
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Sandhu C, Anson KM, Patel U. Urinary tract stones--Part I: role of radiological imaging in diagnosis and treatment planning. Clin Radiol 2003; 58:415-21. [PMID: 12788310 DOI: 10.1016/s0009-9260(03)00103-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The modern management of urolithiasis requires a multi-disciplinary approach. Imaging plays a central role in both diagnosis and planning therapy of renal and ureteric calculi. This article reviews the current status of diagnosis and management of stone disease, and the contribution of radiological imaging in accurately triaging a given case to the most appropriate therapy.
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Affiliation(s)
- C Sandhu
- Department of Radiology, St Georges' Hospital, London, UK.
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Abstract
A physician must be aware of common drug side effects and interactions before prescribing a certain agent. In addition to the drugs that we, as urologists, prescribe, we must also be aware of the urologic side effects of drugs that are commonly prescribed by nonurologists. The mechanisms of the pharmacologic causes for voiding dysfunction, erectile and sexual dysfunction, infertility, and urolithiasis are often mutifactorial and incompletely understood. The recognition and association of a particular drug's potential side effects may save valuable time and money involved in the workup of a patient with a new urologic complaint. It is incumbent on the practicing urologist to be able to recognize the common, and sometimes subtle, urologic complications of medications that are used for nonurologic conditions.
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Affiliation(s)
- Arthur Thomas
- Division of Urology, Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce Street, First Floor, Rhoads Pavilion, Philadelphia, PA 19104, USA
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Abstract
The management of HIV infection has dramatically altered the natural history of the disease. Prevention of opportunistic infections and the development of HAART regimens altered the manifestations and conditions that urologists are being asked to evaluate and manage in this patient population.
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Affiliation(s)
- Grace Hyun
- The New York-Presbyterian Hospital, Columbia University, College of Physicians and Surgeons, 600 West 168 Street, New York, NY 10032, USA
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23
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Barbas C, García A, Saavedra L, Muros M. Urinary analysis of nephrolithiasis markers. J Chromatogr B Analyt Technol Biomed Life Sci 2002; 781:433-55. [PMID: 12450673 DOI: 10.1016/s1570-0232(02)00557-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Renal stone disease is an ancient and common affliction, common in industrialised nations. The causes and incidence of nephrolithiasis are presented. Afterwards, the promoters and inhibitors of renal stone formation analysis in urine are described including enzymatic methods, chromatography, capillary electrophoresis and other techniques. Aspects such as sample collection and storage are also included. The review article includes referenced tables that provide summaries of methodology for the analysis of nephrolithiasis related compounds.
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Affiliation(s)
- C Barbas
- Facultad de CC Experimentales y de la Salud, Universidad San Pablo-CEU, Urbanización Montepríncipe, Ctra. Boadilla del Monte, km 5,3, 28668 Madrid, Spain.
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Kopp JB, Falloon J, Filie A, Abati A, King C, Hortin GL, Mican JM, Vaughan E, Miller KD. Indinavir-associated interstitial nephritis and urothelial inflammation: clinical and cytologic findings. Clin Infect Dis 2002; 34:1122-8. [PMID: 11915002 DOI: 10.1086/339486] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2001] [Revised: 11/16/2001] [Indexed: 11/03/2022] Open
Abstract
The objective of the present study was to characterize the genitourinary syndromes that accompany indinavir-associated pyuria. Of 23 indinavir-treated patients with persistent pyuria, 4 had isolated interstitial nephritis, 10 had both interstitial nephritis and urothelial inflammation, 7 had isolated urothelial inflammation, and 2 had pyuria with nonspecific urinary tract inflammation. A total of 21 patients had multinucleated histiocytes identified by cytologic testing of urine specimens. Urine abnormalities resolved in all 20 patients who stopped receiving indinavir therapy. Pyuria continued in the 3 patients who continued receiving indinavir. Six patients had elevated serum creatinine levels, which returned to baseline levels when indinavir was discontinued. In conclusion, indinavir-associated pyuria was frequently associated with evidence of interstitial nephritis and/or urothelial inflammation, multinucleated histiocytes were commonly present in urine specimens, and cessation of indinavir therapy was associated with prompt resolution of urine abnormalities.
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Affiliation(s)
- Jeffrey B Kopp
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, 20892, USA.
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25
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Lee LK, Dinneen MD, Ahmad S. The urologist and the patient infected with human immunodeficiency virus or with acquired immunodeficiency syndrome. BJU Int 2001; 88:500-10. [PMID: 11678742 DOI: 10.1046/j.1464-410x.2001.02376.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- L K Lee
- Department of Urology, Royal Bolton Hospitals, Lancashire, UK.
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26
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Famularo G, Di Toro S, Moretti S, De Simone C. Symptomatic crystalluria associated with indinavir. Ann Pharmacother 2000; 34:1414-8. [PMID: 11144699 DOI: 10.1345/aph.10092] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To report a case of severe and recurrent crystalluria resulting from the use of indinavir and to review the literature describing this adverse effect. CASE SUMMARY A 26-year-old HIV-positive white woman had recurrent episodes of left-sided flank pain accompanied by dilation of the left renal collecting system while undergoing treatment with a triple-drug regimen including indinavir 1200 mg every 12 hours (full dosage). Typical indinavir crystalluria was observed, with no evidence of stones. Acute episodes were treated with intravenous fluids, diclofenac, and ciprofloxacin. Crystalluria and clinical symptoms eventually resolved with withdrawal of indinavir and substitution with a different protease inhibitor. Renal function remained normal. DISCUSSION A wide spectrum of disorders of the urinary tract can occur in subjects taking indinavir, with potentially severe complications caused by crystalluria and stones. Indinavir is excreted in the urine; the low solubility of those crystals is the critical factor accounting for the risk of stone formation. An elevated pH with a reduced excretion of citric acid contributes to the low urinary solubility of indinavir. Pharmacokinetic interactions with other drugs, leading to elevated plasma concentrations of indinavir, and dehydration could also increase the risk of stone formation. The impact on renal function can be unfavorable over the long-term period. Cornerstones of treatment and prevention are increased fluid intake and possibly urinary acidification. Emergency drainage may be required for patients with severe obstruction. Reducing the dosage of indinavir has been proposed, but this carries the risk of viral mutations with development of resistance. CONCLUSIONS Treatment with indinavir can result in crystalluria with potentially severe obstruction. All patients taking indinavir, not only those with documented crystalluria or renal effects from the drug, should greatly increase their fluid intake and have renal function checked at baseline and then monitored regularly. Urinalysis also should be performed regularly for appropriate monitoring and prevention.
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Affiliation(s)
- G Famularo
- Department of Emergency Medicine, San Camillo Hospital, Rome, Italy.
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27
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Abstract
Indinavir sulfate is a protease inhibitor that has been found to be extremely effective in increasing CD4+ cell counts and in decreasing HIV-RNA titers in patients with HIV and AIDS. However, patients receiving indinavir also have been noted to have a significant risk for developing urolithiasis. Published reports of indinavir urolithiasis estimate its incidence at between 4 and 13%. Indinavir has a high urinary excretion with poor solubility in a physiologic pH solution. Consequently, patients develop urinary stones that are principally composed of indinavir or of a mixture of indinavir and other substances, such as calcium oxalate. Similar to other forms of urolithiasis, acute flank pain and hematuria are the typical symptoms of indinavir urolithiasis. Indinavir urolithiasis is unique in that computed tomography, which was once thought to be efficacious in identifying all urinary calculi, is not useful in imaging stones that are composed of pure indinavir. Indinavir urolithiasis generally responds to a conservative regimen of hydration, pain control, and the temporary discontinuation of the medication. Only a minority of patients need surgical intervention. Approximately 10% of patients ultimately need to discontinue indinavir therapy altogether. Indinavir is an antiviral agent that has a significant role in the treatment of AIDS. Although urolithiasis is a significant side effect of indinavir use, limiting its clinical application is not the answer. Rather, physicians need to know more about indinavir urolithiasis to help their patients cope with its potential complications.
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Affiliation(s)
- D S Wu
- Department of Urology, University of California School of Medicine, San Francisco 94143-0738, USA
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28
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Gagnon RF, Tecimer SN, Watters AK, Tsoukas CM. Prospective study of urinalysis abnormalities in HIV-positive individuals treated with indinavir. Am J Kidney Dis 2000; 36:507-15. [PMID: 10977782 DOI: 10.1053/ajkd.2000.9791] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Indinavir is a potent protease inhibitor widely used in combination with reverse-transcriptase inhibitors to treat human immunodeficiency virus (HIV) disease. Individuals treated with indinavir are prone to develop urinary complications, including renal colic, renal calculi, lower urinary tract symptoms, and indinavir crystalluria. Although renal stones secondary to indinavir have been described and characterized, little is known about the onset, frequency, and significance of the crystalluria. To document the longitudinal characteristics of indinavir crystalluria and associated urine abnormalities, 54 asymptomatic indinavir-naive HIV-positive individuals had urinalysis testing initially weekly and then monthly during the first year of indinavir treatment. Six hundred eight urinalyses were performed (11 +/- 2 urinalysis/subject), including 579 microscopy examinations performed by a nephrologist (10 +/- 2 examinations/subject). Baseline urinalysis results were essentially normal. After the start of treatment, indinavir crystalluria was frequently observed (67% of subjects). After the first 2 weeks, indinavir crystalluria remained constant at a frequency of approximately 25% of urine sediments examined at each test point. Other urine abnormalities, principally leukocytes (>/=10/high-power field) and casts, were observed in 39% of subjects. These abnormalities were more severe in five subjects, with concomitant increasing serum creatinine levels in three of them. Additional urine findings include the predominance of low pH (</=5. 5 in 72% of urinalyses) and high specific gravity (>/=1.025 in 66% of urinalyses). In conclusion, abnormal urinalysis results were noted frequently during the first year of treatment with indinavir. The main findings were the high proportion of subjects with crystalluria and the relatively high frequency of crystalluria observed consistently throughout. These findings may occasionally be associated with other urine abnormalities, presumably secondary to indinavir crystalluria.
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Affiliation(s)
- R F Gagnon
- Departments of Medicine and Pathology, The Montreal General Hospital, Montreal, Quebec, Canada.
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Abstract
Introduction of several classes of antiviral agents for the treatment of immunodeficiency virus has led to increased survival and improved quality of life for patients with HIV infection. Protease inhibitors have become the mainstays of current therapy in patient with AIDS. Renal intolerance of indinavir is a rare but important complication in HIV positive patients. The renal function of patients receiving indinavir should be closely monitored. Benign and asymptomatic crystalluria occurs in 4-13% of HIV positive patients. Several cases of acute renal failure, renal atrophy and interstitial nephritis have also been reported. A hydration protocol consisting of one to two liters of fluid should be initiated three hours after each indinavir dose. If significant renal insufficiency persists, temporary indinavir withdrawal or switching to another protease inhibitor should be considered.
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Affiliation(s)
- A J Olyaei
- Division of Nephrology, Hypertension and Clinical Pharmacology, Oregon Health Sciences University, Portland 97201, USA.
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30
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Affiliation(s)
- R C Smith
- Department of Radiology, Cornell University Medical College, New York, NY, USA
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31
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Drach GW. Secondary and miscellaneous urolithiasis. Medications, urinary diversions, and foreign bodies. Urol Clin North Am 2000; 27:269-73. [PMID: 10778469 DOI: 10.1016/s0094-0143(05)70256-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Secondary stones, those with no "classic" cause, provide unusual diagnostic and treatment challenges to the urologist. Stones related to medications, to urinary diversions or augmentation, or to presence of foreign bodies within the urinary tract occur rarely. Nevertheless, they represent situations that may be corrected fully by appropriate conservative or procedural therapy, and therefore they must be included in the differential diagnosis of many patients who present with symptoms of urolithiasis.
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Affiliation(s)
- G W Drach
- Division of Urology, University of Pennsylvania, Philadelphia, USA
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32
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González Enguita C, Jiménez Jiménez I, Pérez Pérez J, Montero Rubio R, Cancho Gil MJ, Vela Navarrete R. [Renal colic and lithiasis in HIV(+)-patients treated with protease inhibitors]. Actas Urol Esp 2000; 24:212-8. [PMID: 10870227 DOI: 10.1016/s0210-4806(00)72434-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- C González Enguita
- Cátedra y Servicio de Urología, Fundación Jiménez Díaz, Universidad Autónoma, Madrid
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33
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Chen MY, Scharling ES, Zagoria RJ, Bechtold RE, Dixon RL, Dyer RB. CT diagnosis of acute flank pain from urolithiasis. Semin Ultrasound CT MR 2000; 21:2-19. [PMID: 10688064 DOI: 10.1016/s0887-2171(00)90010-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The use of noncontrast helical CT (NHCT) to assess patients with acute flank pain and hematuria for potential urinary tract stone disease was first reported in 1995. After several years of experience with the technique, sensitivity and specificity of NHCT has proven to be better than intravenous urography for evaluating ureteral stones. NHCT imaging findings for urinary calculi and the differential diagnosis are discussed in this article. Various extraurinary diseases found while using NHCT in searching for stone disease are addressed and illustrated. As experience with the use of NHCT has increased, clinicians have broadened the indications for this technique, which has a lower charge than standard CT, beyond the specific evaluation of urinary colic. This indication creep has increased the number of NHCT examinations ordered. It has also reduced the rate of stone positivity and increased the diagnostic yield for extraurinary disease.
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Affiliation(s)
- M Y Chen
- Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1088, USA
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34
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Hortin GL, King C, Miller KD, Kopp JB. Detection of indinavir crystals in urine: dependence on method of analysis. Arch Pathol Lab Med 2000; 124:246-50. [PMID: 10656734 DOI: 10.5858/2000-124-0246-doiciu] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- G L Hortin
- Clinical Pathology Department, Warren Grant Magnusson Clinical Center, National Institute of Diabetes and Digestive Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
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35
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Abstract
Indinavir is a protease inhibitor used in the treatment of patients with HIV infection. Combination antiretroviral therapy with indinavir plus 2 nucleoside reverse transcriptase inhibitors (NRTIs) is associated with greater reductions in viral load, greater increases in CD4+ cell counts, and reduced morbidity and mortality when compared with 2 NRTIs alone. In the landmark clinical trial ACTG 320, the rate of progression to AIDS or death (primary end-point) among zidovudine-experienced patients treated with indinavir, zidovudine and lamivudine was approximately half that of patients who received only zidovudine plus lamivudine (6 vs 11%; p < 0.001). The durability of an indinavir-containing regimen was demonstrated in Merck protocol 035, an ongoing trial in which a significant proportion of patients had sustained viral suppression for up to 3 years. Merck protocol 039, also an ongoing trial, showed a greater effect on surrogate markers of HIV disease progression with indinavir-based triple therapy than with zidovudine plus lamivudine or indinavir monotherapy in patients with advanced disease (median baseline CD4+ count 15 cells/microL). Numerous additional clinical trials have established the beneficial antiviral and immunological effects of indinavir in both antiretroviral-naive and -experienced patients with HIV infection. Indinavir is associated with various drug class-related adverse events, including gastrointestinal disturbances (e.g. nausea, diarrhoea), headache and asthenia/fatigue. A lipodystrophy syndrome has been commonly reported with indinavir and other protease inhibitors combined with NRTIs, but it has also been reported in many protease inhibitor-naive patients, and a definitive causal link has not been established between the syndrome and protease inhibitors. Nephrolithiasis may develop in about 9% of patients receiving indinavir but does not appear to be associated with other protease inhibitors; <0.5% of patients receiving indinavir discontinue the drug because of nephrolithiasis, which may be the extreme end of a continuum of crystal-related renal syndromes. Additional renal problems (e.g. nephropathy) have been reported in small numbers of patients receiving indinavir. In summary, indinavir is a protease inhibitor with well documented efficacy when used as part of combined therapy in patients with HIV infection. Both US and UK treatment guidelines continue to recommend protease inhibitor-based regimens including indinavir as a first-line option. Indinavir is being studied as a twice daily and once daily regimen with a low dosage of ritonavir as a way to alleviate tolerability, drug interaction and patient compliance/adherence issues. Indinavir-containing triple therapy has demonstrated positive effects not only on surrogate markers of disease progression, but also on clinical end-points of mortality and morbidity in patients with HIV disease. Protease inhibitors are a significant advance in the care of patients with HIV infection, and, in an era of evidence-based medicine, indinavir represents an important component of antiretroviral treatment strategies.
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Affiliation(s)
- G L Plosker
- Adis International Limited, Mairangi Bay, Auckland, New Zealand.
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36
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Roca B, Gómez CJ, Arnedo A. Stavudine, lamivudine and indinavir in drug abusing and non-drug abusing HIV-infected patients: adherence, side effects and efficacy. J Infect 1999; 39:141-5. [PMID: 10609532 DOI: 10.1016/s0163-4453(99)90006-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To compare adherence and clinical outcome with highly active antiretroviral therapy (HAART) in intravenous drug users (IDUs) and subjects with other HIV risk behaviours (non-IDUs). METHODS A total of 133 non-naive HIV-infected patients, 95 (71%) IDUs and 38 (29%) non-IDUs received triple drug therapy with stavudine, lamivudine, and indinavir. Adherence, side effects, and immunological and virological efficacy of treatment were assessed every 3 months. RESULTS During a median follow-up of 12 months, 43 patients (32% of the total) showed adequate adherence in all clinical appointments. Adherence was superior in non-IDUs than in IDUs in every visit, but a significant difference was found only at 6 months, when 22 (58%) non-IDUs versus 37 (39%) IDUs were adherent (P = 0.047). Mildly increased bilirubin was observed in 69 (52%) patients, and renal colic in 34 (26%). No difference in side effects was found between IDUs and non-IDUs. After 6 months of treatment, 35 (43%) participants presented a CD4 cell count increase >100x10(6)/l, and 47 (58%) achieved undetectable HIV RNA (lower limit of detection: 200 copies/ml). CD4 cell count and HIV RNA responses were similar in both groups. CONCLUSIONS Adherence to the employed HAART regimen was poor. Non-IDUs were more adherent than IDUs, but the difference between both groups was small. Side effects and efficacy were similar in IDUs and non-IDUs.
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Affiliation(s)
- B Roca
- Division of Infectious Diseases, Hospital General, Castellón, Spain
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37
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Smith RC, Levine J, Rosenfeld AT. Helical CT of urinary tract stones. Epidemiology, origin, pathophysiology, diagnosis, and management. Radiol Clin North Am 1999; 37:911-52, v. [PMID: 10494278 DOI: 10.1016/s0033-8389(05)70138-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Urolithiasis is a common medical problem. The diagnosis of this entity in the setting of acute flank pain presents an interesting challenge to the radiologist. Unenhanced helical CT has recently entered the fray and has quickly become the imaging study of choice when evaluating patients with acute flank pain and suspected ureterolithiasis. The nature and origin of ureteral stones and the pathophysiology of ureteral obstruction provide a basis for understanding the imaging findings in these patients.
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Affiliation(s)
- R C Smith
- Department of Diagnostic Imaging, Yale University School of Medicine, New Haven, Connecticut, USA.
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38
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Pickens CL, Milliron AR, Fussner AL, Dversdall BC, Langenstroer P, Ferguson S, Fu X, Schmitz FJ, Poole EC. Abuse of guaifenesin-containing medications generates an excess of a carboxylate salt of beta-(2-methoxyphenoxy)-lactic acid, a guaifenesin metabolite, and results in urolithiasis. Urology 1999; 54:23-7. [PMID: 10414721 DOI: 10.1016/s0090-4295(99)00031-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Several urinary calculi were submitted to our institution for compositional analysis. The typical techniques of analysis, polarized light microscopy, electron microprobe analysis, and infrared spectroscopy proved inadequate for a definitive identification. As a result, a more detailed organic analysis was conducted to determine the exact chemical structure of the material. METHODS Infrared spectroscopy and mass spectrometric analysis were carried out on the solid material, providing information concerning the functional groups and the molecular mass of the organic constituent and its components. The stone was solubilized in deuterated solvents and analyzed by nuclear magnetic resonance spectroscopy, which resulted in a definitive chemical structure. RESULTS The spectroscopic analysis indicated that the stones were composed of a calcium salt of beta-(2-methoxyphenoxy)-lactic acid, a metabolite of the pharmaceutical guaifenesin, which is used as an expectorant. CONCLUSIONS Guaifenesin, an expectorant common in over-the-counter cold and allergy remedies, can cause urolithiasis if taken in excess. Discussions with physicians and their patients confirmed that most patients admitted to taking large doses of guaifenesin-containing medications.
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Affiliation(s)
- C L Pickens
- UroSciences Group, UroCor, Inc., Oklahoma City, Oklahoma 73104, USA
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39
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INDINAVIR UROLITHIASIS. J Urol 1999. [DOI: 10.1097/00005392-199906000-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Kohan AD, Armenakas NA, Fracchia JA. Indinavir urolithiasis: an emerging cause of renal colic in patients with human immunodeficiency virus. J Urol 1999; 161:1765-8. [PMID: 10332431 DOI: 10.1016/s0022-5347(05)68795-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE We evaluate the clinical, diagnostic and radiographic findings in patients on indinavir therapy who presented with renal colic, and propose appropriate treatment options for indinavir urolithiasis. MATERIALS AND METHODS A total of 16 patients positive for human immunodeficiency virus on indinavir were evaluated for 18 episodes of severe renal colic requiring hospitalization. Laboratory evaluation was performed in all patients followed by an imaging study. Conservative treatment included intravenous hydration, narcotic analgesics and temporary cessation of indinavir. Intervention was elected only in patients with persistent fever or intractable pain. A month after hospital discharge an excretory urogram and metabolic stone evaluation were performed. Mean followup was 9.3 months and 2 patients had recurrent symptoms. RESULTS All patients presented with nausea or vomiting and hematuria. Imaging studies confirmed obstruction in all patients with 13 radiolucent (indinavir) and 3 radiopaque (calcium oxalate) stones. Patients with radiolucent and radiopaque stones demonstrated significant differences in urinary pH (p = 0.002) and serum creatinine (p = 0.03). Conservative therapy was successful in 11 patients (68.8%) within 48 hours and 4 patients (25%) with radiolucent calculi required endoscopic stenting for persistent fever. Metabolic stone evaluation demonstrated significant hypocitruria (less than 50 mg./24 hours) in all patients with radiolucent calculi. CONCLUSIONS The urologist should be familiar with this growing cause of renal colic in patients on indinavir therapy. Pure indinavir stones are radiolucent and have a soft, gelatinous endoscopic appearance. Conservative treatment is successful in most patients and if intervention is deemed medically necessary, endoscopic stent placement should be the procedure of choice.
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Affiliation(s)
- A D Kohan
- Section of Urology, Lenox Hill Hospital, New York, New York 10021, USA
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41
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Abstract
The management of HIV disease has evolved into a complicated and sophisticated subspecialty in recent years. Fourteen drugs, in various combinations, are being used in increasingly complex treatment regimens. The side effects of some of these drugs, as well as certain drug-drug interactions may mimic signs and symptoms of HIV disease itself. Therefore it is imperative for the emergency physician to be knowledgeable about the new medications as well as about selected adverse effect and drug interaction profiles in order to be able to take care of the increasing numbers of HIV-positive patients presenting to emergency departments. This article aims to provide a focused review of these topics. In addition, health care workers with significant exposures to HIV-infected body fluids may present to the emergency department for initial evaluation. This presents a situation whereby emergency physicians may have to prescribe appropriate combinations of antiretroviral agents themselves. Thus familiarity with the basic principles of post-exposure prophylaxis is desirable and current Centers for Disease Control and Prevention guidelines are briefly reviewed.
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Affiliation(s)
- H C Hovanessian
- Department of Emergency Medicine, University of California-San Francisco University Medical Center, Fresno, CA, USA.
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42
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Abstract
OBJECTIVE We evaluated the radiographic characteristics as well as the clinical management of urolithiasis induced by systemic therapy with indinavir sulfate, a protease inhibitor utilized in the treatment of HIV infection. PATIENTS AND METHODS Fifteen consecutive HIV-positive male patients (average age 41.3 years) who presented with urolithiasis while being treated with indinavir sulfate (average time 11.1 months) were studied. RESULTS All patients presented with flank pain, and eight had gross hematuria. All but one patient had microscopic hematuria. The location of the stones was the kidney in three, the proximal ureter in four, and the distal ureter in nine. One patient had both a renal and a proximal ureteral stone. The stones were radiolucent on CT imaging in five patients and could not be seen in five. In the five cases in which a stone was not definitely identified, a diagnosis of urolithiasis was established on the basis of ureteral obstruction and periureteral/renal streaking noted on CT. Treatment included observation with hydration in eight patients, ureteral stent placement in two patients, ureteroscopy in three patients, and extracorporeal shockwave lithotripsy in two patients. Stones were analyzed in five patients and proved to be 100% indinavir in three and a mixture of indinavir, calcium oxalate monohydrate, and calcium oxalate dihydrate in two. CONCLUSIONS Urolithiasis is a recognized complication of treatment with indinavir sulfate. Pure indinavir stones cannot be seen on CT unless intravenous contrast medium is utilized. Mixed calcium and indinavir stones can occur and may be radiopaque. The majority of HIV-positive patients with symptomatic urolithiasis can be treated conservatively with hydration. Metabolic evaluation of these patients with identification and correction of factors predisposing to stone formation may minimize future recurrences. Administration of this effective medication thus can continue uninterrupted.
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Affiliation(s)
- C P Sundaram
- Division of Urology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Smith RC, Levine J, Dalrymple NC, Barish M, Rosenfield AT. Acute flank pain: a modern approach to diagnosis and management. Semin Ultrasound CT MR 1999; 20:108-35. [PMID: 10222519 DOI: 10.1016/s0887-2171(99)90042-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Acute flank pain is a common and complex clinical problem. In addition to flank pain caused by ureterolithiasis, other urinary and extraurinary abnormalities can result in a similar clinical picture. Unenhanced CT can rapidly, accurately, and safely determine the presence or absence of ureteral obstruction. When obstruction is caused by ureterolithiasis, CT allows precise determination of stone size and location. These are the two most important factors used for patient management. In addition to direct stone visualization, there are many secondary CT signs of ureteral obstruction that are direct manifestations of the underlying pathophysiology. On the other hand, when obstruction is absent, CT can diagnose or exclude most other abnormalities that result in flank pain. As a result of its many advantages, unenhanced helical CT should become the dominant imaging modality for evaluation of all patients with acute flank pain in whom a clinical diagnosis is uncertain.
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Affiliation(s)
- R C Smith
- Yale University School of Medicine, New Haven, CT 06520, USA
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FREQUENCY OF UROLITHIASIS IN INDIVIDUALS SEROPOSITIVE FOR HUMAN IMMUNODEFICIENCY VIRUS TREATED WITH INDINAVIR IS HIGHER THAN PREVIOUSLY ASSUMED. J Urol 1999. [DOI: 10.1097/00005392-199904000-00007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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REITER WERNERJ, SCHON-PERNERSTORFER HEIDEMARIE, DORFINGER KARL, HOFBAUER JOHANN, MARBERGER MICHAEL. FREQUENCY OF UROLITHIASIS IN INDIVIDUALS SEROPOSITIVE FOR HUMAN IMMUNODEFICIENCY VIRUS TREATED WITH INDINAVIR IS HIGHER THAN PREVIOUSLY ASSUMED. J Urol 1999. [DOI: 10.1016/s0022-5347(01)61595-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- WERNER J. REITER
- From the Departments of Urology and Dermatology, University of Vienna, Vienna, Austria
| | | | - KARL DORFINGER
- From the Departments of Urology and Dermatology, University of Vienna, Vienna, Austria
| | - JOHANN HOFBAUER
- From the Departments of Urology and Dermatology, University of Vienna, Vienna, Austria
| | - MICHAEL MARBERGER
- From the Departments of Urology and Dermatology, University of Vienna, Vienna, Austria
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Jean-Pastor M. Les lithiases urinaires médicamenteuses: Le point de vue de la pharmacovigilance. ACTA ACUST UNITED AC 1999. [DOI: 10.1016/s1164-6756(00)88315-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Dieleman JP, Gyssens IC, van der Ende ME, de Marie S, Burger DM. Urological complaints in relation to indinavir plasma concentrations in HIV-infected patients. AIDS 1999; 13:473-8. [PMID: 10197375 DOI: 10.1097/00002030-199903110-00005] [Citation(s) in RCA: 145] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the relationship between indinavir-associated urological complaints and indinavir plasma concentrations. DESIGN Case series, comparing indinavir plasma concentrations in cases with average concentrations in a control group. METHODS Patients taking 800 mg indinavir three times a day (tid), who presented with overt urological complaints (renal colic, flank pain or haematuria) were selected for the study. Plasma indinavir concentrations were measured by means of a standardized high performance liquid chromatography (HPLC) method. Plasma samples taken at 1.5-8 h after the last indinavir ingestion were included for evaluation. Results were compared with the full pharmacokinetic curves of indinavir plasma concentrations from a control group of 14 patients taking 800 mg indinavir tid without urological complaints, and were expressed as concentration ratios. A ratio of 1 indicated a plasma concentration equalling the average concentration in the control population at the same point in time after the ingestion of indinavir. RESULTS Seventeen patients (five women) were enrolled and the indinavir concentrations of 15 patients could be evaluated. Fourteen (93%) patients had a concentration above the mean of the controls, 12 (80%) patients had a concentration above the upper 95% confidence limit, and one (7%) patient had a concentration below the lower 95% confidence limit. The mean indinavir concentration in patients with urological complaints (ratio range 0.55-11.49) was significantly higher than the average concentration and the upper 95% confidence limit of the control group (P < 0.05). The results could not be explained by differences in weight, sex or drug interactions. Two patients had chronic active hepatitis B infection. In six patients with indinavir concentrations above the upper 95% limit, indinavir was reduced to 600 mg tid. Upon repeat measurement after the dose adjustment, their indinavir plasma concentrations fell within the 95% confidence interval around the mean of the control population. All six patients remained asymptomatic and had viral loads of less than 500 copies per ml after a follow-up of 5-16 months. CONCLUSIONS Urological complications occurring during indinavir treatment were associated with elevated indinavir plasma concentrations in 80% of patients in this study. Indinavir plasma concentrations should be monitored upon presentation of urological complaints, on the basis of which dose reductions may be applied if brief interruption and increased hydration are ineffective.
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Affiliation(s)
- J P Dieleman
- Department of Internal Medicine, Erasmus University Medical School, Rotterdam, The Netherlands
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48
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Sarcletti M, Zangerle R. Persistent flank pain, low-grade fever, and malaise in a woman treated with indinavir. AIDS Patient Care STDS 1999; 13:81-7. [PMID: 11362124 DOI: 10.1089/apc.1999.13.81] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This case report describes a 32-year-old woman treated with indinavir who developed mild to moderate flank pain, malaise, and low-grade fever. Sterile pyuria preceded increased serum creatinine levels. Workup revealed persistent pyuria, normal-sized kidneys, a normal intravenous pyelography, and negative urinary cultures. Renal biopsy showed interstitial nephritis and chronic inflammation. Collecting ducts contained crystals. Two months after treatment with indinavir was discontinued, serum creatinine levels returned to normal and pyuria disappeared. Sterile pyuria in patients taking indinavir may help to identify patients at risk for renal dysfunction and interstitial nephritis. Markedly increasing the fluid intake above the recommended dosage may ameliorate or even reverse the process of tubulointerstitial disease.
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Affiliation(s)
- M Sarcletti
- Department of Dermatology and Venereology, University of Innsbruck, Austria
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Brodie SB, Keller MJ, Ewenstein BM, Sax PE. Variation in incidence of indinavir-associated nephrolithiasis among HIV-positive patients. AIDS 1998; 12:2433-7. [PMID: 9875581 DOI: 10.1097/00002030-199818000-00012] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nephrolithiasis may be an important consequence of indinavir therapy; however little has been published on the variation in incidence between different populations of patients or the possible mechanisms of calculus formation. OBJECTIVE To examine variation in the incidence of indinavir-associated nephrolithiasis (IAN) in HIV-positive patients in relation to hemophilia and hepatitis C virus (HCV) infection. METHODS Clinical data were abstracted retrospectively from the medical records of all adult patients treated with indinavir from September 1995 to September 1997. Occurrence of first IAN, defined as flank pain and hematuria after initiation of therapy, was analyzed in relation to hemophilia status and HCV infection. RESULTS There were 17 episodes of IAN (22%) among 79 patients treated with indinavir. Of 10 patients with hemophilia, 50% developed IAN as compared with 17% of patients without hemophilia (P = 0.03). Median days to first IAN was 22 (range 7-110 days) for hemophiliacs and 156 (range 5-611 days) for those without hemophilia. Data for HCV status were available for 74 out of 79 patients: 10 out of 27 (37%) patients with HCV developed IAN compared with six out of 42 (14%) without HCV (P = 0.02). CONCLUSION Overall incidence of IAN was higher than that previously reported and was significantly greater in hemophiliacs than in non-hemophiliacs. HCV may be a contributing factor.
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Affiliation(s)
- S B Brodie
- Division of Infectious Disease, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Hsu A, Granneman GR, Cao G, Carothers L, Japour A, El-Shourbagy T, Dennis S, Berg J, Erdman K, Leonard JM, Sun E. Pharmacokinetic interaction between ritonavir and indinavir in healthy volunteers. Antimicrob Agents Chemother 1998; 42:2784-91. [PMID: 9797204 PMCID: PMC105944 DOI: 10.1128/aac.42.11.2784] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The pharmacokinetic interaction between indinavir and ritonavir was evaluated in five groups of healthy adult volunteers to explore the potential for twice-daily (b.i.d.) dosing of this combination. All subjects received 800 mg of indinavir every 8 h (q8h) on day 2. In addition, subjects in group I received one dose of 800 mg of indinavir on day 1 and 800 mg of indinavir q8h on day 17. Subjects in Groups II and IV each received one dose of 600 mg of indinavir on days 1 and 17, and subjects in groups III and V each received one dose of 400 mg of indinavir on days 1 and 17. During days 3 to 17, ritonavir placebo or ritonavir at 200, 300, 300, or 400 mg q12h was given to groups I, II, III, IV, and V, respectively. Ritonavir at steady state probably inhibited the cytochrome P-450 3A metabolism of indinavir and substantially increased plasma indinavir concentrations, with the area under the plasma concentration-time curve (AUC) increasing up to 475% and the peak concentration in serum (Cmax) increasing up to 110%. The Cmax/trough concentration ratio decreased from 50 in standard q8h regimens to less than 14 when indinavir was administered with ritonavir. For a constant indinavir dose, an increase in the ritonavir dose yielded similar indinavir AUCs, Cmaxs, and concentrations at 12 h (C12s). For a constant ritonavir dose, an increase in the indinavir dose resulted in approximately proportional increases in the indinavir AUC, less than proportional increases in Cmax, and slightly more than proportional increases in C12. Ritonavir reduced between-subject variability in the indinavir AUC and trough concentrations and did not affect indinavir renal clearance. With the altered pharmacokinetic profile, indinavir likely could be given as a b.i.d. combination regimen with ritonavir. This could potentially improve patient compliance and thereby reduce treatment failures.
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Affiliation(s)
- A Hsu
- Abbott Laboratories, Abbott Park, Illinois 60064-3500, USA.
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