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VIRTUAL MEDZONEYour Resource for HIV Related Innovative Medical Communication
CASE PRESENTATIONSMahin Baqi MD FRCPCKen Logue MDDavid Fletcher MD FRCPC
CASE 1
• 58 y.o. man• HIV + 1989
• CD4 200 on diagnosis
• Previous history of depression and chronic intermittent diarrhea
CASE 1DATE ARV REGIMEN1989 AZT1992 AZT/ddI1994 AZT/ddC/3TC1996 D4T/3TC/Saquinavir… viremia1997 D4T/3TC/Indinavir… viremia1999 D4T/ddI/Nevirapine… viremia
CASE 1
• 2001 stopped meds due to neuropathy, ongoing viremia and chronic diarrhea
• CD4 104 HIV VL 266, 131 c/ml
• No genotype available
CASE 1• Restarted AZT/3TC/Abacavir/Lopinavir/
Amprenavir/Nevirapine
TIME CD4 HIV VIRAL LOAD0 104 2661316 wks 186 140810 wks 230 46118 wks 244 3257
CASE 1
GENOTYPE SEPTEMBER2001
CASE 1TIME CD4 HIV VIRAL LOAD18 wks 244 325724 wks 195 461332 wks 182 491748 wks 250 576672 wks 160 11,46496 wks 230 15,421
CASE 1
• AZT/3TC/Abacavir/Lopinavir/Amprenavir/Nevirapine/Fenofibrate/Fish oil/NiacinTEST VALUETG 5 - >40 mmol/lCholesterol 4 – 7 mmol/lHDL 0.4 mmol/lLDL ? – 1.73 mmol/l
CASE 1
AZT/3TC/Abacavir/Lopinavir/Amprenavir/Nevirapine/Fenofibrate/Fish oil/Niacin
• 104 wks… CD4 150 VL 14,895 c/ml
• Went to Kingston, Ontario in 2003 to live with partner
CASE 1
• Returned to Toronto in 2005 on D4T/Tenofovir/ddI/Fuzeon
• CD4 100 VL 18,295 c/ml
CASE 1
GENOTYPE June 2005
CASE 1
Genotype September 2005
CASE 1
WHAT WOULD YOU DO?
CASE 1
• Tropism Testing…R5
2005-2007
3TC/Maraviroc/Lopinavir/Amprenavir
/T20• CD4 165-250 VL 4,000-10,000
CASE 1
Genotype January 2007
CASE 1
2007
• anal carcinoma in situ
• Lipids terrible…Triglycerides
>40mmole/l develops pancreatitis,
bowel obstruction
• ARVS discontinued
CASE 1
Late 2007
3TC/T20/Ritonavir/Darunavir/Etravirine/
Raltegravir/Maraviroc
• CD4 30 on initiation
CASE 1
TIME CD4 HIV VIRAL LOAD0 30 85,3636 wks 270 98512 wks 246 <50
CASE 1
2008• Develops Diabetes on regimen –
Metformin initiated
• Triglycerides continue out of control despite bezafibrate/fish oil/crestor
• Angina → Severe CAD → CABG
CASE 1
2008
• T20 stopped due to injection site reactions and associated fatigue…viral load remains <50 on 3TC/Ritonavir/Darunavir/ Etravirine/ Raltegravir /Maraviroc
CASE 1
• Lipids remain terrible with TG>40mmole/l
• Bezafibrate/fish oil/Ezetrol/Crestor/ ASA/Coumadin
• Recurrent angina – 4/5 bypassed vessel restenosed via angiography
WHAT WOULD YOU DO?
CASE 1
Late 2008
• Ritonavir/Darunavir discontinued
• Remains on 3TC/Maraviroc/Raltegravir /Etravirine
• CD4 275 VL <50!
• TG 34.70→ 3.78 – 6.07
CASE 1
2009/10 3TC/Maraviroc/Raltegravir/Etravirine
• Angina free, mitral regurgitation, Grade 1 LV
• CD4 250-275 VL <50!
• TG 8.46-6.07• LDL <0.5 • HDL 0.5-0.6
CASE 1
2010
• Furosemide/Perindopril for mitral regurgitation
• Some intermittent orthopnea
• Stable angina
• New onset prostatism
CASE 1TIME CREATININE10/09 10701/10 8004/10 16705/10 196
What would you do ?
CASE 1
• No NSAIDS
• No New Meds/holistics/illicit drugs
• Not dry on clinical examination
• Normotensive
• No CHF clinically
• No swelling of ankles
CASE 1
• U/S – no obstruction
• U/A – normal albumin/creatinine + protein/creatinine ratio
• Urinalysis normal
• Urine sodium-100 mmol/l
CAUSE? MANAGEMENT?
CASE 1
TIME CREATININE05/10 157, 18306/10 14007/10 21308/10 17509/10 153
Perindopril + Furosemide discontinued
EGFR 45-50 ml/min
CASE 1
• Given sudden onset, bland urinalysis
and lack of significant proteinuria,
likely cause is vascular …awaiting MRI
Angiography of kidneys
CASE 1
• Doses of all medications readjusted for
renal dysfunction
• Not required for
3TC/Maraviroc/Raltegravir/ Etravirine