Comorbidities to HIV infection

Question 1

What is the strongest lab predictor for HIV mortality?

Answer 1

Baseline plasma IL-6 was stronger predictor of all cause mortality and many fatal non-AIDS events than D-dimer and hsCRP

Question 2

What cardiovascular finding is associated with HIV?

Answer 2

Elevated LDL cholesterol

Question 3

Certain HIV drugs, specifically ARTs, can also cause hyperlipidemia. What drugs do this a lot and which not so much?

Answer 3

In order from lowest to highest increase in lipids following administration

• Tenofovir
• Raltegravir, Dolutegravir
• Rilpiverine
• Abacavir

The others are really bad about this

• Efavirenz
• Ritonavir, cobicistat, darunavir, elvitegravir

Basically, if you are treating someone with an ART who has really high cholesterol, give them tenofovir, not efavirenz.

Question 4

When treating lipid abnormalities in HIV patients, when do we use statins vs fibrates?

Answer 4

High LDL only - Statin first, then fibrate if needed. Pravastatin or atorvastatin are first line.

High TGs only - Fibrate, then Statin or omega-3 fatty acids if not working - Begin with gemfibrozil or fenofibrate.

High LDL and TG with TG between 200 - 500 - LDL is the main issue so Statin before fibrate, and as before, pravastatin or atorvastatin. Try rosuvastatin or fluvastatin if these don’t work before you try gemfibrozil or fenofibrate.

High LDL and TG (>500) - TGs are the bigger issue. Use fibrate before statins or omega 3’s - As before, begin with gemfibrozil or fenofibrate. Niacin can be used but causes insulin resistance. Add statin if nothing else works

Question 5

Discuss the 5 stages of chronic kidney disease

Answer 5

1 - Normal, GFR >90
2 - Mild reduction - 60-89
3 - Moderate - 30 - 59
4 - Severe - 15-29
5 - Renal Failure -

Question 6

So if my patient has high creatinine, what is my next question and decision-making?

Answer 6

Do they have proteinuria?
If so, we need to worry about their glomeruli.

If not, we need to look for tubular dysfunction.

if they have a specific gravity at 1.010 with casts, consider ATN or allergic interstitial nephritis

If they have a specific gravity that isn’t 1.010, and their microscopic exam is normal, we are looking at a pre-renal or post-renal cause.

Question 7

Discuss what we see with HIVAN (HIV associated nephropathy)

Answer 7

HIV infection of glomerular endothelial and mesangial cells. On biopsy we see collapsing focal glomerulosclerosis with tubulo-interstitial injury.

Question 8

How do we recognize and treat HIVAN

Answer 8

HIVAN means we will have large echogenic kidneys and high Cr and protein levels, but the patient will not have edema or changes in blood pressure.

Treat with ART, ACE inhibitor, or a kidney replacement if needed

Question 9

Discuss HIV associated IgA nephropathy

Answer 9

So this is directly caused by IgA antibodies against HIV antigen creating complexes that get deposited in the basement membranes of the kidneys.

We see proteinuria, hematuria, and sometimes a loss in kidney function.

Look for thickened foot processes on EM

Question 10

What bone diseases are related to HIV?

Answer 10

• osteonecrosis - avascular necrosis
• osteomalacia - Vitamin D deficiency, tenofovir, renal phosphorous wasting
• osteopenia - increased risk of fx, some ARTs drop bone mineral density, especially tenofovir. Can treat this with bisphosphonates