I’ll Take Electrolyte Abnormalities for $100…

Our 52 year old M with history of CAD s/p LAD stent,  HIV/AIDS (most recent CD4 291,  VL 199K),  St III CKD, HTN, DM, cocaine use presented with 2 days of lightheadedness secondary to hypoglycemic episodes.  He initially endorsed decreased PO intake with skipping meals as well as feeling more fatigued and confused.  Furthermore, he reports a number of changes to his med regimen: specifically restarting his three drug HAART regimen of etravirine, tenofovir, and raltegravir two weeks prior to admission after a couple of months hiatus, taking standing doses of Ibuprofen for the past week, and ceasing to self-administer insulin over the past few days.

Further evaluation revealed that the patient had a number of electrolyte abnormalities including hypokalemia, hyperchloremia, CO2 of 14, Cr at 5.2 (with his baseline at 2) in addition to a non-anion gap acidosis. Additionally, urinalysis was only significant for pH 5.5, +2 blood and +3 protein.  Residents delved into interpreting these findings, where  highlights of the discussion included the following:

*Risk factors leading to an acute inciting event to worsen his chronic renal insufficiency (i.e. nephrotoxic agents, cocaine use)

*The significance of non-anion gap acidosis and etiologies to consider

*Tenofovir creating a side effect similar to renal tubular acidosis

*Introduction of HIV associated nephropathy, the risk factors and its association  as the collapsing form of focal segmental glomerulosclerosis

*Guidelines to follow with HIV patients and CKD: screening for proteinuria and management to protect renal function

References including case reports and guidelines used in the discussion can be found here and here. Enjoy!