Abstract: FR-PO1034
Unveiling the Masquerade: Misdiagnosis of CKD in the Shadow of HIV Treatment
Session Information
- CKD Mechanisms: From Mendel to Mars
November 03, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: CKD (Non-Dialysis)
- 2303 CKD (Non-Dialysis): Mechanisms
Authors
- Rodriguez Ortiz, Yariana Emma, Houston Methodist Hospital, Houston, Texas, United States
- Shafi, Tariq, Houston Methodist Hospital, Houston, Texas, United States
- Edwards, Angelina, Houston Methodist Hospital, Houston, Texas, United States
Introduction
HIV is associated with acute and chronic kidney disease (CKD). The co-existence of CKD with HIV is associated with poor outcomes and limits therapeutic interventions, particularly those that require renal-dose adjustment. Specific antiretroviral therapies (ART) are directly nephrotoxic, leading to low GFR (Glomerular Filtration Rate) and elevated serum creatinine. However, some ART can increase serum creatinine by inhibiting the tubular secretion of creatinine, leading to elevated serum creatinine, erroneous estimation of GFR by eGFR, and a misdiagnosis of CKD. These drugs include non-nucleoside reverse transcriptase inhibitors (NNRTI) such as rilpivirine, HIV integrase inhibitors such as dolutegravir, and pharmacokinetic boosters such as cobicistat. We present a case of mislabeled CKD in the setting of cobicistat use.
Case Description
A 44-year-old man with a history of hypertension, non-insulin-dependent type 2 diabetes, and HIV was referred for evaluation of "CKD," diagnosed due to persistent elevation of serum creatinine. The patient's HIV was well controlled on Genvoya®, ART containing elvitegravir, cobicistat, emtricitabine, and tenofovir. Previous creatinine levels were 1.2, 1.4, and 1.6 mg/dL, in the last 12 months. Recent pre-clinic labs showed a creatinine of 1.48 mg/dL with an eGFR of 59 mL/min/1.73 m2 without albuminuria or hematuria. Renal ultrasound showed preserved renal size and normal anatomy. To obtain an accurate assessment of GFR, we directly measured GFR (mGFR) using plasma clearance of iohexol, a non-radiolabeled contrast agent. The mGFR of 72 mL/min/1.73 m2. Thus, the eGFR calculation was incorrect and mislabeled him as CKD. Cobicistat reduces serum creatinine secretion by reducing proximal tubular creatinine efflux by the SLC47A1 cation transporter.
Discussion
Evolving combination HIV therapies have improved compliance, tolerance, and sustained viral suppression. However, clinicians must be mindful of the impact of ART on the kidney. Our case highlights the false elevation of serum creatinine induced by ART like Genvoya® and the importance of directly measured GFR. Modern methods to measure GFR are simple and easy to implement in outpatient practice. It is essential that nephrologists learn these techniques and use them in clinical practice to prevent misdiagnosis of CKD and avoid further invasive tests, including kidney biopsy.