Tenofovir overdose-induced proximal tubular nephrotoxicity: a case report of incomplete Fanconi syndrome
DOI:
https://doi.org/10.20453/rmh.v37i2.6519Keywords:
Fanconi syndrome, tenofovir, nephrotoxicity, renal tubular acidosisAbstract
A 21-year-old woman was admitted following a suicide attempt by ingesting 28 tablets of tenofovir/lamivudina/dolutegravir, prescribed as post-exposure prophylaxis for HIV after a sexual assault. Initially, she presented with high anion gap metabolic acidosis associated with hyperlactatemia, which later progressed to normal anion gap hyperchloremic metabolic acidosis, accompanied by hypophosphatemia, hypokalemia, and hypomagnesemia, but without glucosuria. Analysis of tubular management, which revealed a decreased tubular reabsorption rate of phosphorus and inappropriate renal potassium wasting, was consistent with proximal tubular dysfunction (type II renal tubular acidosis). In the context of overdose and the observed biochemical pattern, a diagnosis of incomplete Fanconi syndrome was established. Treatment included intensive electrolyte replacement, with a favorable response. This case highlights the importance of suspecting tenofovir-induced tubular toxicity even in unconventional settings such as overdose. Furthermore, it draws attention to partial forms of Fanconi syndrome that may go unnoticed without targeted evaluation.
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Liatsou E, Tatouli I, Mpozikas A, Pavlou MM, Gakiopoulou H, Ntanasis-Stathopoulos I, et al. Tenofovir-induced Fanconi syndrome presenting with life-threatening hypokalemia: review of the literature and recommendations for early detection. J Clin Med. 2023;12(22):7178. doi:10.3390/jcm12227178
Gupta SK, Anderson AM, Ebrahimi R, Fralich T, Graham H, Scharen-Guivel V, et al. Fanconi syndrome accompanied by renal function decline with tenofovir disoproxil fumarate: a prospective, case-control study of predictors and resolution in HIV-infected patients. PLoS One. 2014;9(3):e92717. doi:10.1371/journal.pone.0092717
Zúñiga M, Galindo A, Galaz MI, Vivanco M, Romero P, Balboa P, et al. Síndrome de Fanconi y raquitismo hipofosfatémico asociado al uso de tenofovir en una niña infectada con VIH. Rev Chil Pediatr. 2017;88(1):148-52. doi:10.1016/j.rchipe.2016.08.001
Waheed S, Attia D, Estrella MM, Zafar Y, Atta MG, Lucas GM, et al. Proximal tubular dysfunction and kidney injury associated with tenofovir in HIV patients: a case series. Clin Kidney J. 2015;8(4):420-5. doi:10.1093/ckj/sfv041
Kohler JJ, Hosseini SH, Green E, Abuin A, Ludaway T, Russ R, et al. Tenofovir renal proximal tubular toxicity is regulated by OAT1 and MRP4 transporters. Lab Invest. 2011;91(6):852-8. doi:10.1038/labinvest.2011.48
Pearson A, Haenni D, Bouitbir J, Hunt M, Payne BA, Sachdeva A, et al. Integration of high-throughput imaging and multiparametric metabolic profiling reveals a mitochondrial mechanism of tenofovir toxicity. Function (Oxf). 2022;4(1):zqac065. doi:10.1093/function/zqac065
Medland NA, Chow EP, Walker RG, Chen M, Read TR, Fairley CK. Incidence of renal Fanconi syndrome in patients taking antiretroviral therapy including tenofovir disoproxil fumarate. Int J STD AIDS. 2018;29(3):227-36. doi:10.1177/0956462417722133
Venter WD, Fabian J, Feldman C. An overview of tenofovir and renal disease for the HIV-treating clinician. South Afr J HIV Med. 2018;19(1):a817. doi:10.4102/sajhivmed.v19i1.817
Arellano-Contreras D, Carmona-Guzmán C. Síndrome de Fanconi asociado a toxicidad por tenofovir. Reporte de un caso. Rev Méd MD [Internet]. 2011 [citado el 4 de mayo de 2025];2(2):116-9. Disponible en: https://www.medigraphic.com/pdfs/revmed/md-2011/md112m.pdf
Kohler JJ, Hosseini SH, Hoying-Brandt A, Green E, Johnson DM, Russ R, et al. Tenofovir renal toxicity targets mitochondria of renal proximal tubules. Lab Invest. 2009;89(5):513-9. doi:10.1038/labinvest.2009.14
Joshi M, Clark B, Lee TA. Fanconi syndrome in patients with human immunodeficiency virus treated with tenofovir-based antiretroviral therapy: a systematic literature review. Ann Pharmacother. 2024;58(8):857-69. doi:10.1177/10600280231206703
Escobar L, Mejía N, Gil H, Santos F. La acidosis tubular renal distal: una enfermedad hereditaria en la que no se pueden eliminar los hidrogeniones. Nefrología. 2013;33(3):289-96. doi:10.3265/Nefrologia.pre2012.Oct.11592
Torregrosa JV, Santos F, González E, Espinosa L, Buades JM, Monteagud-Marrahí E, et al. Acidosis tubular renal distal: aspectos epidemiológicos, diagnósticos, de seguimiento clínico y terapéuticos. Nefrología (Engl Ed). 2021;41(1):62-8. doi:10.1016/j.nefro.2020.06.004
Haque SK, Ariceta G, Batlle D. Proximal renal tubular acidosis: a not so rare disorder of multiple etiologies. Nephrol Dial Transplant. 2012;27(12):4273-87. doi:10.1093/ndt/gfs493
Abdel-Razeq SS, Kaplan LJ. Hyperchloremic metabolic acidosis: more than just a simple dilutional effect. En: Vincent JL, editor. Yearbook of intensive care and emergency medicine. Berlin: Springer; 2009. pp. 221-232.
Wesner N, Bihan K, Cez A, Simon L, Biour M, Roos-Weil D, et al. Two cases of reversible Fanconi syndrome induced by lenalidomide. Leuk Lymphoma. 2019;60(4):1092-4. doi:10.1080/10428194.2018.1515941
Tu H, Mou L, Zhu L, Jiang Q, Gao DS, Hu Y. Acquired Fanconi syndrome secondary to light chain deposition disease associated with monoclonal gammopathy of renal significance: a case report. Medicine (Baltimore). 2018;97(36):e12159. doi:10.1097/MD.0000000000012027
Berend K. Review of the diagnostic evaluation of normal anion gap metabolic acidosis. Kidney Dis (Basel). 2017;3(4):149-59. doi:10.1159/000479279
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Copyright (c) 2026 Esteban Ochoa-Robles, Glenda Jiménez-Alulima, Lenin Saltos-Iñiguez, Carlos Ortega-Espinoza, Maribel Carlosama-Mora
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