Date post: | 13-Jun-2015 |
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Health & Medicine |
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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