1. Case Study This activity is supported by an educational grant from: Aging Woman with longstanding HIV and multiple comorbidities Dr. Gord Arbess

2. 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

3. ObeseObese HypertensionHypertension NIDDM (Gastroparesis-intermittent vomiting)NIDDM (Gastroparesis-intermittent vomiting) Sleep Apnea-CPAPSleep Apnea-CPAP Angina?Angina? Severe Osteoarthritis KneesSevere Osteoarthritis Knees HypothyroidHypothyroid HyperlipidemiaHyperlipidemia Major DepressionMajor Depression Multiple Co-Morbidities

4. Present HIV Regimen started June 2012 Darunavir 800 mg/d Ritonavir 100 mg/d Raltegravir 400 mg bid Etravirine 400 mg/d HIV Medications

5. LisinoprilLisinopril AtorvastatinAtorvastatin IbuprofenIbuprofen MetforminMetformin CipralexCipralex ZofranZofran EltroxinEltroxin Other Medications

6. You notice Serum Cr is 158 (eGFR 48) on routine BW in August 2012 Routine Bloodwork

7. What Would You Do?

8. 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

9. Algorithm

10. Urinalysis ACR Serum Cr (eGFR) Electrolytes, Bicarb, albumin Urine for Protein, Cr Renal Ultrasound Other? Biopsy? Investigations to assess Renal Function

11. 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

12. What Would You Do?

13. 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)

14. Algorithm

15. What do you think could be accounting for Cr elevation?

16. HIVAN?HIVAN? IgA Nephropathy?IgA Nephropathy? Medication-related?Medication-related? Hypertension?Hypertension? NIDDM?NIDDM? Pre-renal component/volume contraction?Pre-renal component/volume contraction? Other?Other? Etiology

17. How would you manage this patient?

18. 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?

19. 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