Renal Disease in HIV and Aging

June 8, 2016

Aroonsiri Sangarlangkarn, MD, MPH, Christina M Wyatt, MD, MS, Jonathan S. Appelbaum, MD, FACP

By the end of the session, learners will be able to:

Outline risk factors for chronic kidney disease (CKD) in HIV-infected
Form the differential diagnosis of CKD in HIV-infected
Describe the workup and management of HIV-associated nephropathy (HIVAN).

Reading assignment:

Wyatt C, Klotman P. HIV-associated nephropathy (HIVAN). Available at http://www.uptodate.com/contents/hiv-associated-nephropathy-hivan?source=search_result&search=hivan&selectedTitle=1%7E19. Accessed August 5, 2014.
Wyatt C, Klotman P. Overview of kidney disease in HIV-infected patients. Available at http://www.uptodate.com/contents/overview-of-kidney-disease-in-hiv-infected-patients?source=search_result&search=kidney+disease+hiv&selectedTitle=1%7E150. Accessed August 5, 2014.
Lucas GM, Ross MJ, Stock PG, et al. Clinical practice guideline for the management of chronic kidney disease in patients infected with HIV: 2014 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 9 (2014):e96-e138.

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 ken@aahivm.org if you’d like more information on the series.

You are free to share, copy, or adapt the series for any purpose, even commercially, as long as you give appropriate credit and indicate if changes were made. Please see our license for more information.

CASE ONE

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.

Questions:

What is the definition of chronic kidney disease (CKD)?
How common is CKD in HIV-infected patients?
What are HIV-related risk factors for CKD?
What is the differential diagnosis of CKD in HIV-infected patients? Which one do you think is the cause of Mr. Creatinine’s CKD?
What is the pathogenesis of HIVAN?
What workup would you perform for Mr. Creatinine? How would you establish diagnosis?

CASE ONE CONTINUED

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.

What pharmacologic treatment would you recommend?
How would you monitor treatments?
When would you refer him to a nephrologist?

CASE ONE CONTINUED

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.