Case 3: Indinavir Nephrotoxicity

Question | Discussion | References | CME Credit

You answered:

	The patient likely has indinavir-induced nephrolithiasis and should immediately be referred to urology for lithotripsy.

This answer is incorrect. Most cases of indinavir nephrolithiasis can be managed conservatively with analgesia and hydration allowing the passage of the stones. If this fails to relieve the obstruction, ureteral stenting and ureteroscopic removal may be necessary. Lithotripsy is not considered effective because of the gelatinous composition of the stones.

	The patient probably had bacterial cystitis caused by an organism resistant to trimethoprim-sulfamethoxazole, and now the infection has evolved into pyelonephritis and should be treated with ciprofloxacin (Cipro).
	The absence of stones on the abdominal CT scan rules out nephrolithiasis caused by indinavir.
	The patient likely has indinavir-induced nephrolithiasis and antiretroviral therapy should either temporarily be discontinued or the indinavir plus ritonavir should be changed to another protease inhibitor(s), such as lopinavir-ritonavir (Kaletra). The patient should initially be managed conservatively with hydration and pain control.
	The patient likely has HIV-associated nephropathy causing these acute symptoms.

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