Clinical Case Scenario
A 56-year-old man with a 5-year history of HIV-1, previously managed with elvitegravir, emtricitabine, and tenofovir disoproxil fumarate (TDF) but lost to follow-up, presented to the ICU with acute hypoxic respiratory failure. He reported a week of fever, dry cough, and musculoskeletal pain, treated with NSAIDs. In the emergency department, he was hypertensive (200/111 mmHg), tachypneic (RR 26), and hypoxic, requiring 15 L/min oxygen via non-rebreather mask to maintain SpO2 >94%. Examination revealed bilateral pitting pedal edema to the knees, oliguria, and volume overload. He was stabilized and admitted to the ICU.
Labs: Creatinine 4.7 mg/dL (baseline 2.5 mg/dL), RBC 3-5/HPF, glucosuria (+), proteinuria (3+), spot urine protein/creatinine ratio 5.2 mg/mg (ref <0.10 mg/mgCr), albumin 2 g/dL, total protein 6.5 g/dL, CPK 200, Ultrasound KUB: enlarged kidneys with increased echogenicity, pH 7.29, Na 148, K 3.1, CD4/CD8 ratio 0.11, CD4 cells 86/μL, HIV viral load 119,000 copies/mL.
A renal biopsy, performed due to rapidly declining renal function and nephrotic-range proteinuria, revealed collapsing focal segmental glomerulosclerosis (FSGS), marked interstitial inflammation, dilated cystic tubules, and tubular epithelial inclusion bodies.
Continuous renal replacement therapy (CRRT) was initiated, and NSAIDs were discontinued.
What is the most appropriate next step in the management of this patient?
