Presentation on theme: "Case Study This activity is supported by an educational grant from: Aging Woman with longstanding HIV and multiple comorbidities Dr. Gord Arbess."— Presentation transcript:
Case Study This activity is supported by an educational grant from: Aging Woman with longstanding HIV and multiple comorbidities Dr. Gord Arbess
62 year old woman62 year old woman From JamaicaFrom Jamaica HIV + since 1996, heterosexual transmissionHIV + since 1996, heterosexual transmission Nadir CD4 108, VL > 500,000Nadir CD4 108, VL > 500,000 Intermittent adherenceIntermittent adherence Multiple ARV Regimens due to intolerance/resistance (AZT, 3TC, ddI, d4T, Nelfinavir, Amprenavir, LPV, EFV, Indinavir, Tenofovir, RTV)Multiple ARV Regimens due to intolerance/resistance (AZT, 3TC, ddI, d4T, Nelfinavir, Amprenavir, LPV, EFV, Indinavir, Tenofovir, RTV) Hx ABC/3TC HSRHx ABC/3TC HSR Background Information
Present HIV Regimen started June 2012 Darunavir 800 mg/d Ritonavir 100 mg/d Raltegravir 400 mg bid Etravirine 400 mg/d HIV Medications
LisinoprilLisinopril AtorvastatinAtorvastatin IbuprofenIbuprofen MetforminMetformin CipralexCipralex ZofranZofran EltroxinEltroxin 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) 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
Urinalysis ACR Serum Cr (eGFR) Electrolytes, Bicarb, albumin Urine for Protein, Cr Renal Ultrasound Other? Biopsy? Investigations to assess Renal Function
VL < 40 CD Hgb 108 BS 7.3 Hga1c ACR 1.1 Trace Protein, no blood, no glucose, 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 range (eGFR 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 Glycosuri a DB + Glycosuri a DB + Glycosuri a DB – Glycosuri a DB – DB follow-up Fasting glucose + Rule out diabetes Fasting glucose + Rule out diabetes Repeat 1x Glycosuri a DB – Glycosuri a 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 - 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 Normal ACR and MAU ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF) ACR > 0.05 g/mmol or MAU > 2.1 mg/mmol or hematuria (> 2 RBC/HPF)
What do you think could be accounting for Cr elevation?
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 (eGFR range) Follow Up