Transcript Protein ≥ 1 + or 0.25 g/L

Case Study
Aging Woman with longstanding HIV and
multiple comorbidities
Dr. Gord Arbess
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Background Information
• 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
Multiple Co-Morbidities
• Obese
• Hypertension
• NIDDM (Gastroparesis-intermittent vomiting)
• Sleep Apnea-CPAP
• Angina?
• Severe Osteoarthritis Knees
• Hypothyroid
• Hyperlipidemia
• Major Depression
HIV Medications
Present HIV Regimen started June 2012
• Darunavir 800 mg/d
• Ritonavir 100 mg/d
• Raltegravir 400 mg bid
• Etravirine 400 mg/d
Other Medications
• Lisinopril
• Atorvastatin
• Ibuprofen
• Metformin
• Cipralex
• Zofran
• Eltroxin
Routine Bloodwork
You notice Serum Cr is 158 (eGFR 48) on routine BW in
August 2012
What Would You Do?
GFR using CKD-EPI or MDRD
< 60 cc/min*
ACR and MAU
Refer to
proteinuria
algorithm
(next page)
< 30 cc/min*
CaPO4
Renal
ultrasound
Referral to
nephrologist or
internist
* 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
Investigations to assess Renal Function
• Urinalysis
• ACR
• Serum Cr (eGFR)
• Electrolytes, Bicarb, albumin
• Urine for Protein, Cr
• Renal Ultrasound
• Other?
• Biopsy?
Results
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•
•
•
•
•
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•
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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)
What Would You Do?
Urinalysis or urine dipstick
Glucose > 0
Protein ≥ 1 + or 0.25
g/L
Fasting glucose
+
Rule out diabetes
Repeat at next appt.
Glycosuri
a
DB +
Glycosuri
a
DB –
Protein ≥
1+ or 0.25
g/L
Protein <
1+ or 0.25
g/L
DB
follow-up
Repeat 1x
ACR and
MAU
Normal
Glycosuri
a
DB –
Referral to
nephrologist
or internist
ACR > 0.05 g/mmol
or
MAU > 2.1 mg/mmol
or
hematuria (> 2
RBC/HPF)
- Renal ultrasound
- Ascertain the risk
factors
- Referral to nephrologist
or internist, or to urologist
for isolated hematuria
ACR ≤ 0.05 g/mmol
and MAU <
2.1 mg/mmol
Normal
Algorithm
What do you think could be accounting for
Cr elevation?
Etiology
• HIVAN?
• IgA Nephropathy?
• Medication-related?
• Hypertension?
• NIDDM?
• Pre-renal component/volume contraction?
• Other?
How would you manage this patient?
Management Options?
• 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?
Follow Up
• 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)