110.    A 45 year old HIV positive patient has been receiving Highly active anti-retroviral therapy. Her medications include Lamivudine, Zidovudine, Indinavir and Ritonavir. His most recent HIV viral load was undetectable and Absolute CD4 count was 400/µl .  Eight weeks after initiation of therapy, the patient comes to the emergency department complaining of  nausea, burning urination, frequency and severe flank pain. One week prior to this visit, the patient visited the ER for burning urination and was treated with Trimethoprim/Sulfamethaxozole. Urine cultures from last visit are negative. Laboratory investigations reveal a serum creatinine of 2.2. A urinalysis is negative for protein, nitrite and leucoesterase with out any bacteriuria. Urine microscopy reveals numerous WBCs and some starburst crystals. A non-contrast abdominal CT scan reveals mild right hydronephrosis without any evidence of stones. Patient is given adequate pain medications. The most likely etiology of this patient’s renal insufficiency :
a)    Acute Pyelonephritis
b)    Acute Bacterial Cystitis
c)    Indinavir Nephropathy
d)    Allergic Interstitial Nephritis
e)    HIV nephropathy

111. Most important next step in managing this patient’s renal failure :

A) IV hydration and Intravenos Ceftriaxone

B) IV hydration and Discontinue Indinavir for three days

C) IV hydration and Enalapril

D) Arrange for Hemodialysis

E) Discontinue Indinavir and refer for Lithotripsy