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Aroonsiri Sangarlangkarn, MD, MPH, Christina M Wyatt, MD, MS, Jonathan S. Appelbaum, MD, FACP
This case is part of a case-study series on common diseases in aging HIV-infected patients. New cases will be posted monthly on our website. Users should first download the learner portion or read on below, review the suggested reading, and answer the case questions. When you’re ready to check answers, download the answer key to do so. Please contact Ken South at firstname.lastname@example.org if you’d like more information on the series.
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Mr. Creatinine is a 55-year-old African American man who just moved to your town and comes to establish care at your clinic. He was diagnosed with HIV many years ago but did not follow up with his HIV provider due to complicated social issues. Now that he moved to live with his daughter and things are more stable, he looks forward to taking care of his HIV. He has never been on ART. Otherwise, he has a history of hypertension, diabetes and hepatitis C. He is not taking any medications since he has not seen a doctor for a while.
He is afebrile, BP 127/80, pulse 78, oxygen saturation 98% on room air. Physical exam is unremarkable. Labs show CD4 of 55 cells/mm3, viral load 400,000 copies/mL, creatinine 2.85 mg/dL, eGFR 28.3 mL/min with normal electrolytes, hemoglobin A1C 5.9%. Last year his Cr was 1.75 mg/dL, eGFR 49.6 mL/min.
After a 24-hour urine collection, Mr. Creatinine is found to have a protein excretion of 2.5 g/day and albumin excretion of 300 mg/day. Kidney biopsy shows a collapsing form of focal segmental glomerulosclerosis with tubular microcysts and interstitial inflammation. He is diagnosed with HIVAN.
You decide to start Mr. Creatinine on dolutegravir, abacavir and lamivudine. You also start him on lisinopril 5 mg daily, along with statin and aspirin. He will also continue to see the nephrologist who performed his kidney biopsy. You plan to have a discussion regarding goals of care to see whether dialysis would be consistent with his wishes. You wonder about the prognosis for this kidney disease, since this information will help guide your discussion with Mr. Creatinine.