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CASE 2 U/A - ++ WBC + IDV crystals Creatinine – 80 → 115 Indinavir crystal induced interstitial renal disease felt to be responsible
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CASE 2• 54 yo man…HIV+ 1997• PCP• Cryptospordiasis• Chronic HepC • Genotype 1a• Biopsy… 2/4 activity, 3/4scarring
• CD4 40 • No baseline genotype
CASE 21998-2002D4T/3TC/Indinavir initiated
• CD4 30 → 400• Viral load undetectable
CASE 2• U/A - ++ WBC + IDV crystals• Creatinine – 80 → 115
• Indinavir crystal induced interstitial renal disease felt to be responsible
CASE 22002-2008 • D4T/3TC/Nelfinavir
• Mild intermittent diarrhea• Successfully treated for Hepatitis C
with 48 wks of Peg Interferon/RBV• CD4 450-700 VL <50
CASE 22008 • D4T/3TC/Nelfinavir
• Ongoing diarrhea• Increasing recognition of
dorsocervical fat pad• Switched to TDF/FTC/Efavirenz
CASE 2TIME AST ALT OTHER10/08 33 31 Etoh 6 beers/day x yrs11/08 55 86 No increase in Etoh; HepA
IgG (+); HepBsAb (+)12/08 41 59 Workup for secondary liver
disease (-); HCV RNA (-); U/S… fatty liver
04/09 69 143 Repeat HCV RNA (-); Urinary Drug Screen (UDS) (-);
06/09 97 156 UDS (-)
WHAT WOULD YOU DO?
CASE 2June 2009
• TDF/FTC/Efavirenz switched to TDF/FTC/Etravirine to attempt to r/o Efavirenz as cause of hepatitis
CASE 2
TIME AST
ALT OTHER
07/09
64 140 1 month post-switch
08/09
58 117 2 months post switchWHAT WOULD YOU DO?
CASE 2
• TDF/FTC/Etravirine switched to D4T/3TC/Etravirine to attempt to r/o TDF/FTC as rare cause of hepatitis
CASE 2Sept/09 D4T/3TC/Etravirine
TIME AST ALT OTHER08/09 58 117 TDF/FTC/ETV09/09 47 6810/09 49 5511/09 54 91
WHAT WOULD YOU DO?
CASE 2• Switched back to TDF/FTC/Etravirine
as patient concerned about lipodystrophy and unclear whether liver improving at all from Etravirine or TDF/FTC switch
CASE 2TIME AS
TALT OTHER
11/09
54 122 D4T/3TC/Etravirine
03/10
64 143 TDF/FTC/Etravirine… No increase in Etoh
06/10
77 224WHAT IS HAPPENING?WHAT WOULD YOU DO?
CASE 2• Patient self-discontinues meds
TIME AST ALT06/10 77 22407/10 47 69
CASE 2• Restarted TDF/FTC/Efavirenz for
simplicity/convenienceTIME AST ALT OTHER07/10 47 69 No Meds07/10 97 145 2 wks08/10 97 193 4 wks09/10 68 189 8 wks
NOW WHAT?
CASE 2Late September 2010• Switched to D4T/3TC/Raltegravir as
previously had normal liver enzymes for years on D4T/3TC/Nelfinavir and need to get rid of TDF/FTC and NNRTI class.
• Refused PI due to lipohypertrophySTAY TUNED!!!