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Case Study

Case Study. Aging Woman with longstanding HIV and multiple comorbidities Dr. Gord Arbess. This activity is supported by an educational grant from:. 62 year old woman From Jamaica HIV + since 1996, heterosexual transmission Nadir CD4 108, VL > 500,000 Intermittent adherence

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Case Study

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  1. Case Study Aging Woman with longstanding HIV and multiple comorbidities Dr. GordArbess This activity is supported by an educational grant from:

  2. 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

  3. Obese Hypertension NIDDM (Gastroparesis-intermittentvomiting) SleepApnea-CPAP Angina? SevereOsteoarthritisKnees Hypothyroid Hyperlipidemia Major Depression Multiple Co-Morbidities

  4. Present HIV Regimen started June 2012 Darunavir 800 mg/d Ritonavir 100 mg/d Raltegravir 400 mg bid Etravirine 400 mg/d HIV Medications

  5. Lisinopril Atorvastatin Ibuprofen Metformin Cipralex Zofran Eltroxin Other Medications

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

  7. What Would You Do?

  8. GFR using CKD-EPI or MDRD < 60 cc/min* < 30 cc/min* * 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 ACRand MAU CaPO4 Renal ultrasound Refer to proteinuria algorithm (next page) Referral to nephrologist or internist

  9. Algorithm

  10. Urinalysis ACR Serum Cr (eGFR) Electrolytes, Bicarb, albumin Urine for Protein, Cr Renal Ultrasound Other? Biopsy? Investigations to assess Renal Function

  11. 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

  12. What Would You Do?

  13. Urinalysis or urine dipstick Glucose > 0 Protein ≥ 1 + or 0.25 g/L Fasting glucose + Rule out diabetes Repeat at next appt. Glycosuria DB + Glycosuria DB – Protein ≥ 1+ or 0.25 g/L Protein < 1+ or 0.25 g/L Repeat 1x ACR and MAU Normal DB follow-up ACR> 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF) ACR ≤ 0.05 g/mmol and MAU < 2.1 mg/mmol Glycosuria DB – • - Renal ultrasound • - Ascertain the risk factors • - Referral to nephrologist or internist, or to urologist for isolated hematuria Normal Referral to nephrologist or internist

  14. Algorithm

  15. What do you think could be accounting forCr elevation?

  16. HIVAN? IgA Nephropathy? Medication-related? Hypertension? NIDDM? Pre-renal component/volume contraction? Other? Etiology

  17. How would you manage this patient?

  18. 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?

  19. 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

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