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Case Study
This activity is supported byan educational grant from:
Aging Woman with longstanding HIV and multiple comorbidities
Dr. Gord Arbess
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• 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
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• Obese
• Hypertension
• NIDDM (Gastroparesis-intermittent vomiting)
• Sleep Apnea-CPAP
• Angina?
• Severe Osteoarthritis Knees
• Hypothyroid
• Hyperlipidemia
• Major Depression
Multiple Co-Morbidities
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Present HIV Regimen started June 2012
• Darunavir 800 mg/d
• Ritonavir 100 mg/d
• Raltegravir 400 mg bid
• Etravirine 400 mg/d
HIV Medications
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• Lisinopril
• Atorvastatin
• Ibuprofen
• Metformin
• Cipralex
• Zofran
• Eltroxin
Other Medications
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You notice Serum Cr is 158 (eGFR 48) on routine BW in August 2012
Routine Bloodwork
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What Would You Do?
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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
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Algorithm
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• Urinalysis
• ACR
• Serum Cr (eGFR)
• Electrolytes, Bicarb, albumin
• Urine for Protein, Cr
• Renal Ultrasound
• Other?
• Biopsy?
Investigations to assess Renal Function
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• 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
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What Would You Do?
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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)
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Algorithm
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What do you think could be accounting forCr elevation?
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• HIVAN?
• IgA Nephropathy?
• Medication-related?
• Hypertension?
• NIDDM?
• Pre-renal component/volume contraction?
• Other?
Etiology
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How would you manage this patient?
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• 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?
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• 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