What is the most appropriate management for a 49-year-old woman with chronic kidney disease (CKD), hypertension, and Human Immunodeficiency Virus (HIV) infection, taking dolutegravir (Tivicay)-abacavir (Ziagen)-lamivudine (Epivir) and lisinopril (Zestril)-hydrochlorothiazide (HCTZ), with a recent increase in serum creatinine level to 1.6 mg/dL, indicating impaired renal function?

From the Guidelines

The most appropriate management for this patient is to return to the prior antiretroviral regimen (option C). The patient's serum creatinine increased from a baseline of 1.2 mg/dL to 1.6 mg/dL after changing her antiretroviral regimen 6 weeks ago, suggesting that the new regimen is causing kidney dysfunction. Dolutegravir can inhibit the renal tubular secretion of creatinine, leading to increases in serum creatinine without actual kidney injury. However, given the patient's history of chronic kidney disease, this significant increase warrants caution. The timing of the creatinine elevation correlating with the medication change strongly suggests a causal relationship. The patient's urinalysis is normal and the urine albumin-creatinine ratio is unchanged from baseline, indicating that there is no new proteinuria or hematuria that would suggest another cause of kidney injury. Discontinuing lisinopril-hydrochlorothiazide is not appropriate as the patient has been stable on these medications for 6 years, and they are beneficial for hypertension management in a patient with chronic kidney disease. A 24-hour urine creatinine clearance would not add significant diagnostic value in this case where the cause of the creatinine elevation is likely medication-related. Returning to the previous antiretroviral regimen that did not affect her kidney function is the safest approach, as supported by guidelines for the management of chronic kidney disease in HIV-infected patients 1.

Some key points to consider in the management of this patient include:

• The importance of monitoring renal function in patients with HIV infection and chronic kidney disease, as recommended by the HIV Medicine Association of the Infectious Diseases Society of America 1.
• The potential for certain antiretroviral medications to cause kidney dysfunction, and the need to adjust or change these medications if kidney injury occurs 1.
• The benefits of antiretroviral therapy in reducing the incidence and progression of kidney disease in HIV-infected patients, as demonstrated by several studies 1.

Overall, the patient's history, physical examination, and laboratory results suggest that the new antiretroviral regimen is causing kidney dysfunction, and returning to the previous regimen is the most appropriate management strategy.

From the FDA Drug Label

Use with diuretics in adults If blood pressure is not controlled with lisinopril tablets alone, a low dose of a diuretic may be added (e.g., hydrochlorothiazide, 12. 5 mg). 2. 4 Dose in Patients with Renal Impairment No dose adjustment of lisinopril tablets is required in patients with creatinine clearance > 30 mL/min.

The patient's serum creatinine level has increased from 1.2 mg/dL to 1.6 mg/dL, but there is no direct information in the drug label that supports discontinuing lisinopril-hydrochlorothiazide or changing the antiretroviral regimen based on this increase.

• The patient's creatinine clearance is not explicitly stated, but based on the provided serum creatinine level, it is likely above 30 mL/min.
• No dose adjustment of lisinopril tablets is required in patients with creatinine clearance > 30 mL/min. The most appropriate management is D No further management is indicated, as there is no clear evidence of renal impairment that would require a dose adjustment of lisinopril tablets 2.

From the Research

Patient Management

The patient's serum creatinine level has increased from 1.2 mg/dL to 1.6 mg/dL, indicating a potential decline in renal function. However, the urine albumin-creatinine ratio remains unchanged from baseline at 100 mg/g, suggesting that the patient's kidney function is still relatively stable.

Considerations for Antihypertensive Medication

• The patient is currently taking lisinopril-hydrochlorothiazide, an angiotensin-converting enzyme (ACE) inhibitor combined with a diuretic 3.
• ACE inhibitors are known to be beneficial for patients with hypertension and kidney disease, as they help to reduce proteinuria and slow the progression of kidney disease.
• However, the patient's increased serum creatinine level may indicate a need to monitor kidney function more closely.

Considerations for Antiretroviral Regimen

• The patient recently changed to a new antiretroviral regimen, dolutegravir-abacavir-lamivudine, which is a once-daily dosing regimen 4.
• There is no indication that the new antiretroviral regimen is causing the patient's increased serum creatinine level.

Appropriate Management

Given the patient's stable urine albumin-creatinine ratio and the lack of evidence suggesting that the new antiretroviral regimen is causing kidney damage, the most appropriate management would be to continue monitoring the patient's kidney function and adjust the antihypertensive medication as needed.

• Discontinuing lisinopril-hydrochlorothiazide (Option A) may not be necessary, as the patient's kidney function is still relatively stable.
• Measuring 24-hour urine creatinine clearance (Option B) may be useful in assessing the patient's kidney function, but it is not the most immediate concern.
• Returning to the prior antiretroviral regimen (Option C) is not indicated, as there is no evidence suggesting that the new regimen is causing harm.
• No further management is indicated (Option D) may be the most appropriate choice, as the patient's condition is being monitored and the current treatment regimen is still effective 3, 4, 5.