Case Presentation JF History, P/E and relevant labs Male 85 yo, - - PowerPoint PPT Presentation

JF

Case Presentation

JF

• Male 85 yo, HIV Dx 1996 (CD4-550, HIV-RNA 5000)

referred for care 1999

• PHx: syphilis, 50 pack-yr cigarettes Meds: none
• MSM, single, unemployed, previous multiple partners
• P/E tall & robust, BMI 25.6
• HIV-RNA – 100,000 copies; CD4- 420 (15%), CD8- 76%,

CD4/8 - 0.20 (N>1.0)

• Fasting lipids: TC – 4.9 mmol/L, TG – 2.19, HDL - 0.8,

LDL – 3.15, TC/HDL – 6.1

• HBV - immune, HCV - negative, VDRL - neg

History, P/E and relevant labs

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Summary of initial status

• Clinically well
• Moderate immunosuppresion
• High nadir CD4 but increased HIV-RNA

and low CD4/CD8 ratio

• Mild hypertriglyceridemia, low HDL c/w

inflammatory dyslipidemia

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Course

• 1999 Nelfinavir plus Combivir
• 2001 CMB plus Kaletra: VL < 50, CD4-550
• 2002 ED, low free testosterone, Rx w andriol & viagra

DXA-normal LS & FN BMD, Fat Mass Ratio 1.8 (N)

• 2004 EMG-mild peripheral neuropathy
• 2006 syphilis; CMB plus ATV/r, jaundice, change to

SQV/r plus CMB; DLP (Rx w atorvastatin 10 mg) FRS- 20% (high), WC-103 cm ( = high risk for CVD)

• 2008 (Dx elsewhere, delay in notification) extrasystoles

Echo- EF 40%, mild LV dysfunction- no Rx

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Course

• 2010 abdominal pain, CT – infrarenal AAA (5x4 cm)

Cardiac - echo 25% EF Cath- 20-30% obstruction c/w non-ischemic cardiomyopathy ( HIV, AZT) Multiple diuretics + beta-blockers,  low BP, AF (CHADS 3) coumadin, ICD inserted

• LGI bleed, C & G scope negative
• KLT monotherapy (high CPE), CD4-700
• 2011 f/u echo- EF 40%

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Course

• 2013 increased TGs, RAL/KVX
• 2014 uncomplicated AAA repair
• Meds (non-HIV): tamsulosin, finasteride,

furosemide, atorvastatin, apixaban, vitamin D, pantoprazole

• Concern from friend about driving (lives off-

island) and poor self-care ( occ incontinent)

• MOCA-25/30, home visit from community clinic

x1 then no f/u

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Course

• 2015 CD4-800, Weight 97 kg, BMI 31

waist circumference 105 cm GFR > 60, postural hypotension (no falls), back pain (lumbar DDD), slow gait, using cane & wheelchair (convenient) still driving

• 2016 No c/o, says ok for ADL/IADL

concern re short-term memory decline, MOCA-16 new iron def anemia, several months to arrange C-scope (negative), G-scope- ??, transfusion

• Sept 2016- formal driving assessment arranged

bathroom aids installed, friend supervising meals, limited community support

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Active issues

• HIV: stable but low CD4/CD8 c/w persistent

immunosuppression and immunosenescence (IRP)

• 2 clinical periods:
• 1999-2010 HIV management
• > 2010 comorbidities

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Summary of status

• Co-morbidities: arrythmia, dilated cardiomyopathy, post-
• p, anemia nyd, metabolic syndrome (abdominal obesity

[WC> 102] + incr TG + low HDL), spine DDD, cognitive decline

• Multimorbidity (> 2 co-morbidities)
• Geriatric syndromes: frailty (Fried criteria ≥ 3 of

slowness, weakness, low activity, exhaution, wt loss); increased risk of falls (NB use of NOAC); polypharmacy (2 ARVs, 6 others and 1 vitamin); social isolation; impaired functional status; cognitive decline

• Cognitive decline risks: age; abdominal obesity; low

cardiac output; vascular (AF); ART; HAND

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Question: What issues typical of older HIV patients does this person exhibit?

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Factors affecting this patient’s QOL

• Functional decline
• Physical dependence
• Decreased economic capacity
• Change in social activity
• Relationship with others

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Frailty

• Heterogenous syndrome common in the elderly
• Decreased physiologic reserve, increases

vulnerability to negative outcomes including loss

• f independence, requirement for supervised

housing, increased morbidity and mortality

• Characterized by low endurance, poor strength,

impaired balance, and low physical activity

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Objective definition of frailty* as proposed by Fried et al

Morley JE et al. The Aging Male 2005;8(3/4):135-40

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Spectrum of neurocognitive disorders in HIV infection

• Normal
• Asymptomatic neurocognitive impairment

(ANI)

• Mild neurocognitive decline (MND)
• HIV-associated dementia (HAD)

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Proportion of HIV pts with neurocognitive impairment according to HAND criteria

Dulioust A et al. CROI ‘09

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Risk factors for cognitive decline in HIV patients

Specific (HIV-related) Common (increased risk or

• ccurring earlier)
• Nadir CD4
• Minimal CD4 increase on HAART
• HIV subtypes (increased risk with D)
• High serum/CSF viral load
• Controversial: HAART with poor

CSF penetration

• (strategic) treatment interruptions
• Chronic inflammatory state

– HIV infection – possible role of GI tract immune system as an HIV reservoir

• Increasing age
• (possibly) low education: limited

reserve

• Vascular risks: increased risk of

HPB and increased rates of cigarette smoking

• Lipids: increased cholesterol,

(possibly) low HDL

• Diabetes
• Genetic predisposition (Apo-E4

homozygous)

• HCV

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Alternative classification of dementia: Alzheimer disease (AD) and vascular dementia (VaD) fall on a continuous spectrum of disease

Viswanathan A et al. Neurol 2009;72:368-74

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Treatment outcomes: older pts often have lower pre-HAART and plateau CD4’s but similar HIV-RNA post-HAART (suggesting

delayed Dx and better adherance)

Median log 10 (HIV- RNA) evolution Median CD4 + T cell count/mm3evolution

Nogueras M et al. BMC Inf Dis 2006;6:159

!

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HIV, Immunosenescence and Clinical Outcomes

Serrano-Villar et al. HIV Med 2013

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What about long-term effects of TFV in aging HIV patients?

• Bone demineralization
• Renal toxicity
• Role of TAF