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VIRTUAL MEDZONE. Your Resource for HIV Related Innovative Medical Communication. HIV CASE PRESENTATIONS. Mike S ilverman MD FRCPC David Fletcher MD FRCPC. CASE 1. 63 yo man HIV+ 1985 CD4 nadir 42 Previous PCP Anal Squamous Cell Cancer… in remission. CASE 1. 2007 - PowerPoint PPT PresentationTRANSCRIPT
VIRTUAL MEDZONEYour Resource for HIV Related Innovative Medical Communication
HIV CASE PRESENTATIONSMike Silverman MD FRCPCDavid Fletcher MD FRCPC
CASE 1• 63 yo man• HIV+ 1985
• CD4 nadir 42• Previous PCP• Anal Squamous Cell Cancer…
in remission
CASE 12007• AZT/3TC/Abacavir/RTV/Lopinavir• CD4 650• Viral load <50
CASE 1DATE ALT AST PLTS ALB INR01/05 51 45 ---- ---- ----01/06 73 46 ---- ---- ----10/06 129 73 288 41 1.001/07 153 100 ---- ---- ----03/07 238 130 296 42 1.0
CASE 1• No family history of liver disease• No alcohol consumption/illicit drug
use• No new HIV medications• Vaccinated for Hep A & B
CASE 1• Fenofibrate initiated in late 2006 for
elevated triglycerides…this medication was discontinued in early 2007 with no improvement seen in liver enzymes over the next 2 months
CASE 1DATE ALT AST PLTS ALB INR01/05 51 45 ---- ---- ----01/06 73 46 ---- ---- ----10/06 129 73 288 41 1.001/07 153 100 ---- ---- ----03/07 238 130 296 42 1.0
CASE 1MARCH 2007• HepA IgG (+)• HepB sAb (+)• HepC Ab (-)• Iron studies/secondary liver disease
workup negative
CASE 1MARCH 2007• HCVRNA and HBVDNA negative
• U/S – Enlarged, fatty liver
WHAT WOULD YOU DO?
CASE 1• Lipids optimized
• Antiretrovirals switched from AZT/3TC/ ABC/RTV/LPV to ABC/3TC/TDF/ATZ in June/07
CASE 1DATE ALT AST03/07 238 13007/07 122 6408/07 56 4512/07 334 26702/08 228 17308/08 362 18409/08 84 5409/10 76 5609/11 88 53
ATZ → RTV/LPVr
RTV/LPVr → ATZ
CASE 12008-2010
• Serial Fibrotest + APRI suggest scarring stability around F 2/4
• No changes on serial U/S
CASE 1SEPTEMBER 2011
• ABC/3TC/TDF/ATZ• ALT 88• AST 53• Fibrotest F3/4 scarring → Progression!!!
CASE 1
DATE CREAT EGFR ALB/CREAT URINALYSIS2008 82 77 0.3 (-)2010 123 54 20.2 + protein 0.3 g/l2011 130 47 19.4 + protein 1 g/l
+ GLUCOSE
CASE 1
WHAT WOULD YOU DO?
CASE 1PREVIOUS ANTIRETROVIRAL
HISTORY
• AZT monotherapy• AZT/3TC/SQV with viral load 1500• AZT/3TC/ABC/RTV/LPVr or
ABC/3TC/TDF/ATZ → 3 viral load blips >50 in 8 years
• No genotypes available
CASE 1Which antiretroviral regimen would you choose given fatty liver disease and renal abnormalities?