Book Review

Renal and Urologic Aspects of HIV Infection

N Engl J Med 1996; 334:1750-1751June 27, 1996

Article

Renal and Urologic Aspects of HIV Infection
(Contemporary Issues in Nephrology. Vol. 29.) Edited by Paul L. Kimmel and Jeffrey S. Berns. 427 pp. New York, Churchill Livingstone, 1995. $79.95. ISBN: 0-443-08952-3

The worldwide scourge of HIV infection and AIDS has had a profound and indelible effect on the practice of medicine. With an estimated 18 million people infected already and with a prolonged latency period between initial infection and chronic sequelae, the disorder will be with us for a long time to come even if current efforts to develop effective preventive strategies are successful. Partial control of previously lethal opportunistic infections and better agents for limiting viral replication have extended life, but these advances have been accompanied by an increase in chronic, degenerative, and organ-specific manifestations of HIV infection. This monograph, part of the “Contemporary Issues in Nephrology” series, addresses aspects of HIV infection that result in or are associated with disorders of the kidney and urogenital tract. The editors, themselves recognized experts in the field, have gathered an impressive list of 30 contributing authors, each of whom brings a unique perspective on the disorder and its complications. The breadth of coverage should attract the interest of scientists and clinicians who deal with HIV infection.

Although I consider myself reasonably well informed about the renal and urologic aspects of HIV infection, I learned a great deal from reading this fine collection. The overlap between chapters is at an acceptable level, and the bibliography is extensive and reasonably current. The well-written chapters provide a balanced view of controversial areas. The illustrations, including electron photomicrographs, are of reasonable quality.

The monograph begins with a concise and reasonably up-to-date review of the molecular pathogenesis and natural history of HIV infection (through 1993). The results of clinical trials of protease inhibitors and other antiretroviral drugs recently approved by the Food and Drug Administration are mentioned only briefly. Indeed, only four paragraphs are exclusively devoted to the therapeutic effectiveness of antiretroviral agents. More extensive treatment of this topic would have enhanced the value of the book. Two final chapters on the molecular biology of HIV type 1 and descriptions of animal models of lentivirus infection associated with renal disease round out the basic contributions. Eight chapters deal with renal complications, including extensive discussion of the glomerular lesions observed in patients with HIV infection. The chapters on glomerulosclerosis, immune complex–mediated glomerulonephritis associated with infection, and the renal pathology of the HIV-associated nephropathies are well written and current (through 1994). These chapters provide a thorough and useful analysis of pathogenetic mechanisms, diagnostic approaches, prognosis, and treatment options.

The wide variation in the incidence of HIV-associated glomerulosclerosis among geographic areas and ethnic groups is discussed but remains an enigma. There is appropriate emphasis on distinguishing reversible from irreversible renal lesions in patients with HIV infection and acute renal failure. The chapter on the hemolytic–uremic syndrome and thrombotic thrombocytopenic purpura in HIV infection is particularly interesting, since this unusual, though not rare, complication deserves greater attention from clinicians caring for HIV-infected patients. The two chapters on the urogenital aspects of HIV infection focus largely on neoplasms, urinary infection, and neurologic disorders of the urinary tract (e.g., neurogenic bladder). They also emphasize and analyze the potential role of semen in the transmission of infection and the pathogenesis of azoospermia in HIV-infected patients.

Since many patients with HIV infection receive a broad array of antimicrobial therapies for opportunistic infections and because some of these agents have important adverse effects on renal function, the chapter on the renal aspects of antimicrobial therapy is welcome and highly appropriate. The review of renal complications of antiviral therapy is quite helpful. The chapters on dialysis and transplantation in patients with HIV infection and the effect on medical personnel of providing care for these patients constitute one of the most valuable sections of the monograph. Although the prevalence of HIV infection among patients on dialysis varies widely (from less than 1 percent to 40 percent), all personnel in a dialysis unit must be familiar with the issues that relate to HIV-infected patients. Fortunately, with the widespread application of universal precautions, nosocomial HIV infection among health care workers is quite rare. The section on the medical and legal implications of HIV infection and dialysis therapy provides an extremely useful guide to this complex area.

This monograph has more than met its editors' goal of providing a broad and comprehensive survey of the renal and urologic aspects of HIV infection. It will serve as a good starting point for scientists who seek an overview of the unresolved issues and a reasonably current bibliography. I believe that it will be an extremely useful and practical resource for internists and subspecialists who regularly participate in the care of patients with HIV infection. Mastery of the issues that are raised in this monograph will almost certainly lead to improved care for these patients.

Richard J. Glassock, M.D.
University of Kentucky College of Medicine, Lexington, KY 40536