1. VIRTUAL MEDZONE Your Resource for HIV Related Innovative Medical Communication

2. CASE PRESENTATIONS Chris Steingart MD FRCPC John MacLeod MD CCFP David Fletcher MD FRCPC

3. CASE 2 45 y.o. man HIV + 1995 CD4…10 asymptomatic

4. CASE 2 1996 Cryptogenic Cirrhosis (biopsy proven) Hepatitis A & B immune/Hepatitis C Ab & HCV RNA (-) Recurrent ascites/UGI bleeds secondary to gastric/esophageal varices

5. CASE 2 1996-97 Varices banded & glued Nadolol instituted for secondary prophylaxis of variceal bleeding

6. CASE 2 2010 No further bleeding or ascites for the past 13 years U/S done q-6 months for hepatoma screening – negative Late 2009 variceal surveillance via OGD reveals very small distal esophageal varices

7. CASE 2 DATEHIV THERAPYCD4VL 1995AZT/ddI10 → 70------ 1996/97AZT/ddI/RTV12064350 1997/00D4T/3TC/IDV1504168

8. CASE 2 Genotype MARCH 2000

9. CASE 2 DATEHIV THERAPYCD4VL 2000/01NONE… PT CHOICE 150 → 504168 → 203,330 2001/05D4T/3TC/LPV/APV/ EFV 50 → 280<50 2005NONE 2 o to NSAID related gastritis 110230,998 2006/07ABC/3TC/LPV/APV/ EFV 510<50 2007/08OD ½ dose ABC/3TC/LPV/APV/ EFV 16097,986

10. CASE 2 Genotype MARCH 2008

11. CASE 2 DATEHIV THERAPYCD4VL 2009/10NO MEDS ON/OFF MEDS 11075809 2010ABC/3TC/RTV/ DRV/ ETR/RGV x 2mos 200<50

12. CASE 2 On another note DATECREATU/AA/C RATIO 2004107(-)X 2005105(-)X 2006119(-)X 2007114(-)25 2008113X141 2009107X160

13. CASE 2 DATECREATU/AA/C RATIO PROT. RAND SERUM ALBUMIN 02/09107X<2<0.15 g/l 36 x 10yrs 06/10125X160XX 09/101463 g/l (-) bld/wbcs 2323.465 g/l X 10/10158X184X36

14. CASE 2 U/S ABDO 10 & 10.9 cm nephrosclerotic kidneys Unchanged in size from 2007 but approximately 1 cm smaller as compared with 2002

15. CASE 2 No NSAIDS No new meds/holistics/herbals No illicit drugs Normotensive…no ankle swelling GFR (C-G) → 35 ml/min!

16. CASE 2 WHAT IS GOING ON ?? HOW WOULD YOU MANAGE THIS PATIENT ??

17. CASE 2 Dosage of ABC/3TC/RTV/ Darunavir/Etravirine/Raltegravir not adjusted Nadolol low dose so kept as is

18. CASE 2 Hepatitis serology inactive ANA,C3,C4,CH50, ANCA negative SIE/UIE negative BS/HBA1C always normal

19. CASE 2 Nephrology consulted regarding renal biopsy

20. CASE PRESENTATIONS Chris Steingart MD FRCPC John Macleod MD CCFP David Fletcher MD FRCPC

21. VIRTUAL MEDZONE Your Resource for HIV Related Innovative Medical Communication