Case Study

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Aging Woman with longstanding HIV and multiple comorbidities

Dr. Gord Arbess

• 62 year old woman

• From Jamaica

• HIV + since 1996, heterosexual transmission

• Nadir CD4 108, VL > 500,000

• Intermittent adherence

• Multiple ARV Regimens due to intolerance/resistance (AZT, 3TC, ddI, d4T, Nelfinavir, Amprenavir, LPV, EFV, Indinavir, Tenofovir, RTV)

• Hx ABC/3TC HSR

Background Information

• Obese

• Hypertension

• NIDDM (Gastroparesis-intermittent vomiting)

• Sleep Apnea-CPAP

• Angina?

• Severe Osteoarthritis Knees

• Hypothyroid

• Hyperlipidemia

• Major Depression

Multiple Co-Morbidities

Present HIV Regimen started June 2012

• Darunavir 800 mg/d

• Ritonavir 100 mg/d

• Raltegravir 400 mg bid

• Etravirine 400 mg/d

HIV Medications

• Lisinopril

• Atorvastatin

• Ibuprofen

• Metformin

• Cipralex

• Zofran

• Eltroxin

Other Medications

You notice Serum Cr is 158 (eGFR 48) on routine BW in August 2012

Routine Bloodwork

What Would You Do?

GFR using CKD-EPI or MDRD

ACR and MAU

Refer to proteinuria algorithm

(next page)

Referral to nephrologist or

internist

< 60 cc/min* < 30 cc/min*

CaPO4 Renal ultrasound

* If GFR < 50 cc/min: consider adjusting the dose of certain ARV and concomitant medications

** Test for tubulopathy if GFR declines > 10 cc/min while on tenofovir

Algorithm

• Urinalysis

• ACR

• Serum Cr (eGFR)

• Electrolytes, Bicarb, albumin

• Urine for Protein, Cr

• Renal Ultrasound

• Other?

• Biopsy?

Investigations to assess Renal Function

• VL < 40 CD 4 843• Hgb 108• BS 7.3• Hga1c 0.061• ACR 1.1• Trace Protein, no blood, no glucose, 10-15 White cells/hpf, occ

red cells/hpf, hyaline casts with some cells• Spot urine 0.1 g/L protein, 7.8 mmol/L Cr• Cr 118-160 range (eGFR 48-54 range) over number of years• Normal electrolytes, normal albumin, normal Bicarb• Normal renal Ultrasound (small-sized kidneys)

Results

What Would You Do?

Urinalysis or urine dipstick

Glucose > 0

Glycosuria

DB +

Glycosuria

DB –

DB follow-up

Fasting glucose+

Rule out diabetes

Repeat 1x

Glycosuria

DB –

Referral to nephrologist or internist

ACR ≤ 0.05 g/mmol and MAU <

2.1 mg/mmol

Normal

- Renal ultrasound- Ascertain the risk

factors- Referral to nephrologist

or internist, or to urologist for isolated

hematuria

Protein ≥ 1 + or 0.25 g/L

Repeat at next appt.

Protein < 1+ or 0.25

g/L

Protein ≥ 1+ or 0.25

g/L

NormalACR and

MAU

ACR > 0.05 g/mmolor

MAU > 2.1 mg/mmolor

hematuria (> 2 RBC/HPF)

Algorithm

What do you think could be accounting forCr elevation?

• HIVAN?

• IgA Nephropathy?

• Medication-related?

• Hypertension?

• NIDDM?

• Pre-renal component/volume contraction?

• Other?

Etiology

How would you manage this patient?

• Do you d/c metformin?

• Do you d/c NSAIDs?

• Do you d/c statin?

• Do you Need to dose Adjust ARVs?

• Should you Change ARVs?

• Do you Hold Ace Inhibitor?

• Do you ensure BP/BS well controlled?

• Do Nothing?

Management Options?

• BP well controlled

• Hga1c 0.062, therefore Metformin stopped

• Asked not to take any NSAIDS

• ARV regimen continued at same doses

• Continued same dose of statin, ACEi

• Cr monitored closely in range of 118-130 (eGFR 55-60 range)

Follow Up