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

Case Presentation JF

History, P/E and relevant labs  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 JF

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 JF

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 JF

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% JF

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 JF

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 JF

Active issues  HIV: stable but low CD4/CD8 c/w persistent immunosuppression and immunosenescence (IRP)  2 clinical periods: -1999-2010 HIV management - > 2010 comorbidities JF

Summary of status  Co-morbidities : arrythmia, dilated cardiomyopathy, post- op, 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 JF

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

Factors affecting this patient’s QOL  Functional decline  Physical dependence  Decreased economic capacity  Change in social activity  Relationship with others JF

Frailty  Heterogenous syndrome common in the elderly  Decreased physiologic reserve, increases vulnerability to negative outcomes including loss of independence, requirement for supervised housing, increased morbidity and mortality  Characterized by low endurance, poor strength, impaired balance, and low physical activity JF

Objective definition of frailty* as proposed by Fried et al Morley JE et al. The Aging Male 2005;8(3/4):135-40 JF

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Spectrum of neurocognitive disorders in HIV infection  Normal  Asymptomatic neurocognitive impairment (ANI)  Mild neurocognitive decline (MND)  HIV-associated dementia (HAD) JF

Proportion of HIV pts with neurocognitive impairment according to HAND criteria Dulioust A et al. CROI ‘09 JF

Risk factors for cognitive decline in HIV patients Specific (HIV-related) Common (increased risk or occurring earlier)  Nadir CD4  Increasing age  Minimal CD4 increase on HAART  (possibly) low education : limited reserve  HIV subtypes (increased risk with D)  Vascular risks: increased risk of  High serum/CSF viral load HPB and increased rates of cigarette smoking  Controversial: HAART with poor CSF penetration  Lipids : increased cholesterol, (possibly) low HDL  (strategic) treatment interruptions  Chronic inflammatory state  Diabetes – HIV infection  Genetic predisposition (Apo-E4 – possible role of GI tract immune homozygous) system as an HIV reservoir  HCV JF

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 JF

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/mm 3 evolution ! Nogueras M et al. BMC Inf Dis 2006;6:159 JF

HIV, Immunosenescence and Clinical Outcomes Serrano-Villar et al. HIV Med 2013 JF

What about long-term effects of TFV in aging HIV patients?  Bone demineralization  Renal toxicity  Role of TAF JF