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Aging Woman with longstanding HIV and multiple comorbidities

Dr. Gord Arbess

Background Information

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

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

Normal ACR and

MAU

ACR > 0.05 g/mmol or

MAU > 2.1 mg/mmol or

hematuria (> 2 RBC/HPF)

Algorithm

What do you think could be accounting for Cr elevation?

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