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VIRTUAL MEDZONE

This presentation discusses the complex case of a 63-year-old man living with HIV since 1985, facing challenges such as a CD4 nadir of 42 and a history of anal squamous cell cancer now in remission. It highlights his antiretroviral treatment regimen over the years, laboratory findings including liver enzyme abnormalities, and the optimization of his lipids. The focus is on the management decisions regarding his antiretroviral therapy in the context of fatty liver disease and renal health, while also examining the implications of his liver scarring progression.

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VIRTUAL MEDZONE

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  1. VIRTUAL MEDZONE Your Resource for HIV Related Innovative Medical Communication

  2. HIV CASE PRESENTATIONS Mike Silverman MD FRCPC David Fletcher MD FRCPC

  3. CASE 1 • 63 yo man • HIV+ 1985 • CD4 nadir 42 • Previous PCP • Anal Squamous Cell Cancer… in remission

  4. CASE 1 2007 • AZT/3TC/Abacavir/RTV/Lopinavir • CD4 650 • Viral load <50

  5. CASE 1

  6. CASE 1 • No family history of liver disease • No alcohol consumption/illicit drug use • No new HIV medications • Vaccinated for Hep A & B

  7. 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

  8. CASE 1

  9. CASE 1 MARCH 2007 • HepAIgG (+) • HepBsAb (+) • HepCAb (-) • Iron studies/secondary liver disease workup negative

  10. CASE 1 MARCH 2007 • HCVRNA and HBVDNA negative • U/S – Enlarged, fatty liver WHAT WOULD YOU DO?

  11. CASE 1 • Lipids optimized • Antiretrovirals switched from AZT/3TC/ ABC/RTV/LPV to ABC/3TC/TDF/ATZ in June/07

  12. CASE 1 ATZ → RTV/LPVr RTV/LPVr → ATZ

  13. CASE 1 2008-2010 • Serial Fibrotest + APRI suggest scarring stability around F 2/4 • No changes on serial U/S

  14. CASE 1 SEPTEMBER 2011 • ABC/3TC/TDF/ATZ • ALT 88 • AST 53 • Fibrotest F3/4 scarring → Progression!!!

  15. CASE 1

  16. CASE 1 WHAT WOULD YOU DO?

  17. CASE 1 PREVIOUS 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

  18. CASE 1 Which antiretroviral regimen would you choose given fatty liver disease and renal abnormalities?

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