From the Guidelines
The next step in management for this 50-year-old CKD patient with newly diagnosed HIV who has persistent fever despite negative infectious workup would be to consider drug fever from the antiretroviral therapy (ART), particularly abacavir, and temporarily discontinue the current regimen. Given the patient's recent initiation of abacavir, dolutegravir, and lamivudine, and the development of fever shortly after starting ART, this is highly suspicious for a medication reaction, specifically an abacavir hypersensitivity reaction, which typically presents within the first 2 weeks of therapy with symptoms including fever, rash, gastrointestinal symptoms, and respiratory symptoms 1.
Key Considerations
- Abacavir hypersensitivity reaction is a significant concern in this patient, and the risk can be greatly reduced by screening for the HLA-B*57:01 allele prior to treatment, although this may not be feasible in all cases 1.
- The combination of abacavir/lamivudine plus dolutegravir was superior to tenofovir/emtricitabine plus efavirenz, with no differences by baseline HIV RNA level, but this does not negate the risk of hypersensitivity reaction 1.
- Nucleoside-sparing regimens, which may be considered in patients with CKD, have not been prospectively studied in this population and have been associated with more laboratory abnormalities, higher rates of virologic failure, or higher rates of emergent drug-resistant mutations 1.
Management
- Temporarily discontinue the current ART regimen and consult with an HIV specialist for an alternative regimen, such as tenofovir alafenamide/emtricitabine with dolutegravir, with appropriate dose adjustments for CKD.
- Provide supportive care with antipyretics like acetaminophen while awaiting the HIV specialist consultation.
- Laboratory monitoring should include liver function tests, complete blood count, and renal function tests to assess for other manifestations of drug reaction.
- Once the fever resolves after medication discontinuation, a new ART regimen avoiding abacavir can be initiated.
- It's essential to note that abacavir should never be reintroduced if hypersensitivity is suspected, as rechallenge can be life-threatening.
From the Research
Patient Management
The patient is a 50-year-old with chronic kidney disease (CKD) who has recently been diagnosed with HIV and started on abacavir, dolutegravir, and lamivudine. The patient has been experiencing fever for 7 days, but tests for MP, dengue, and sputum are negative, and the chest X-ray and urine complete examination are within normal limits.
Next Steps
Given the patient's symptoms and test results, the next steps in management could include:
- Monitoring the patient's vital signs and symptoms closely, as the fever could be related to the HIV infection or the start of antiretroviral therapy (ART) 2, 3
- Considering alternative causes of the fever, such as an opportunistic infection, and ordering further tests as needed
- Continuing the current ART regimen, as the combination of abacavir, dolutegravir, and lamivudine has been shown to be effective and well-tolerated in patients with HIV, including those with CKD 4, 5
- Monitoring the patient's kidney function and adjusting the ART regimen as needed to minimize the risk of kidney damage 3, 6
- Providing supportive care, such as antipyretics and hydration, to manage the patient's symptoms and prevent complications
Key Considerations
When managing this patient, it is essential to consider the following:
- The patient's CKD and the potential impact of the ART regimen on kidney function 3, 6
- The risk of opportunistic infections and the need for prompt diagnosis and treatment 2, 4
- The importance of adherence to the ART regimen and the need for ongoing monitoring and support to ensure optimal outcomes 5, 6