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Associate Professor of Medicine, University of Toronto, Ontario, Canada
This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.
This activity is intended for gastroenterologists, primary care physicians, ID/HIV specialists, and nurses.
The goal of this activity is to improve clinicians ability to treat hepatitis C virus (HCV) infection in patients with stage 4/5 chronic kidney disease and human immunodeficiency virus (HIV) infection, and identify appropriate use of elbasvir/grazoprevir.
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As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.
Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.
Associate Professor of Medicine, University of Toronto, Ontario, Canada
This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.
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AMA PRA Category 1 Credit(s)™
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CME / ABIM MOC / CE Released: 2/24/2017
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Daniel is a 57-year-old white man with chronic hepatitis C virus (HCV) infection, who was recently seen by a primary care physician (PCP) for the chief complaints of fatigue that has worsened over the past 3 to 4 months, pain upon swallowing, decreased appetite, and recent weight loss. Upon questioning Daniel, the PCP learned that Daniel was diagnosed with human immunodeficiency virus (HIV) infection 6 years ago, but he has never been in HIV care or treated with antiretroviral therapy (ART). Before Daniel was referred to you, selected laboratory tests (Table 1) and a FibroScan® were done.
Table 1. Daniel's Test Results Sent With Referral
| Test | Result |
|---|---|
| HIV RNA, copies/mL | 65,000 |
| CD4 cell count, cells/mm3 | 190 |
| HCV RNA, IU/mL | 2.3 million |
| HCV genotype | 1a |
| HBV | HBsAg negative, anti-HBs negative |
| HAV | anti-HAV negative |
| FibroScan®, kPa | 15.5 |
anti-HAV = hepatitis A virus antibody; anti-HBs = hepatitis B virus surface antibody; HAV = hepatitis A virus; HBsAg = hepatitis B surface antigen; HBV = hepatitis B virus; HCV = hepatitis C virus; HIV = human immunodeficiency virus; kPa = kilopascal.
You perform an esophagogastroduodenoscopy and order additional laboratory tests (Table 3).
Table 2. Daniel's History and Physical Examination
| History | Findings |
|---|---|
| Medical | Odynophagia, dysphagia, GERD, risk of HIV/HCV was intravenous drug use |
| Social | Divorced with 2 adult children, currently drinks 2-3 beers/week |
| Current medications | 1 multivitamin tablet daily |
| Physical Examination | Findings |
| Vital Signs | BP = 130/87 mm Hg, HR =75 bpm, RR = 15/min, afebrile |
| General impression | Appears tired and uncomfortable |
| BMI | 27 kg/m2 |
| Skin | Clear, no rash |
| Chest and lungs | Clear to auscultation |
| Head and neck | Oral candidiasis |
| Abdomen | Soft, normal bowel sounds |
| Lower extremities | Unremarkable |
BMI = body mass index; BP = blood pressure; bpm = beats per minute; DS = double strength; GERD = gastro-esophageal reflux disease; HR = heart rate; RR = respiratory rate.
Table 3. Daniel's Additional Test Results
| Test | Result |
|---|---|
| Hemoglobin, g/dL WBC count, cells/μL Platelet count, cells/μL Prothrombin time, sec INR |
12.1 5000 125,000 12 1.0 |
| Metabolic panel AST, U/L ALT, U/L Alkaline phosphatase U/L Total bilirubin mg/dL Albumin g/dL |
All WNL 87 63 65 2.0 3.8 |
| Creatinine, mg/dL cGFR, mL/min |
1.0 110 |
| EGD | No evidence of varices, esophageal candidiasis |
| CTP classification | A |
ALT = alanine transaminase; AST = aspartate transaminase; cGFR = calculated glomerular filtration rate; CTP = Child-Turcotte-Pugh; EGD = esophagogastroduodenoscopy; GERD = gastroesophageal reflux disease; INR = international normalized ratio; WBC = white blood cell count; WNL = within normal limits.
You prescribe Daniel fluconazole 100 mg by mouth daily for esophageal candidiasis (Figure 1) and explain that it is a sign of advanced HIV infection or acquired immune deficiency syndrome (AIDS).
Figure 1. Endoscopic Image of Esophageal Candidiasis
You also schedule a return appointment in 1 week to review his test results and to educate him about the benefits of treating his HIV infection and HCV infection, and the serious consequences of not being treated. You point out that both treatment regimens are much simpler and more tolerable than a decade ago, and the HCV treatment regimen is relatively short. Daniel agrees to your treatment recommendations.
