CASE 1

• 68 yo man• HIV+…1988• HepBsAg(+) HepBeAg (+)• No baseline HBV DNA/Liver Biopsy• Secondary workup for liver disease

negative

CASE 1

• 3TC-based HIV therapy from 1997-2001

• CD4 630/37%• HIV Viral load <50DATE HepBeAg ALT AST PLT INR Alb HBV DNA

2001 (+) 78 60 226 1.0 42 1.10x107 IU/ml

CASE 1

• Tenofovir added to HIV medications (including 3TC) in response to elevated HBV DNA on 3TC monotherapy…no biopsy or assessment of fibrosis done but no obvious cirrhosis/portal hypertension

CASE 1DATE HepB

eAgALT AST INR ALB HBV

DNACREAT

2002 + 41 33 1.0 43 10e3, iu/ml

144

2003 + 35 26 ---- ---- <500 1432004 + 28 39 1.0 45 <500 1462009 (-) 36 28 0.9 43 <12 1492010 (-)

eAb + 31 32 1.0 48 <12 154

Fenofibrate/Ramipril/Tenofovir eod therapy

CASE 1

DATE CREAT U/A PROT/CREAT U/S

08/10 151 +glu, pro 1g/l 0.365 g/l -----

12/10 294 +glu, pro 2g/l 2+ blood

1.17 g/l Normal kidneys

02/11 277 ------ ------ ------

04/11 390 ------ 0.916 g/l ------

Dec 2010 – Apr 2011• Fenofibrate/Ramipril/Tenofovir eod

discontinued in 1/11

WHAT IS GOING ON?WOULD WOULD YOU DO?

CASE 1

• Renal biopsy performed due to blood in urine, increased proteinuria and increasing creatinine

• Interstitial fibrosis/tubular atrophy• 2/9 glomeruli sclerosed• Mild arterial sclerosis• No active diseaseProbably an ischemic insult

CASE 1

DATE CREAT PROT/CREAT ALB/CREAT

05/11 232 0.916 g/l 3007/11 189 ------ -------09/11 179 ------ ------11/11 177 0.562 g/l 20

May 2011– Nov 2011No Tenofovir/Ramipril/Fenofibrate

CASE 1

DATE ALT AST HBV DNA02/11 30 27 (-)06/11 30 27 7.36x102 IU/ml07/11 30 26 3.44x105 IU/ml09/11 216 127 ------11/11 78 49 1.44x108 IU/ml

• HepBeAg (+), 3TC based HIV therapy

• U/S –fatty liver

CASE 1

• Fibrotest 0.74 → F3 scarring• Fibroscan in agreement

HOW WOULD YOU MANAGE HIS HEPATITIS B?