The nephrologist as a consultant
As with treatment of any acute or chronic infection, resistance patterns have emerged with HIV-1 in both treatment experienced pa-tients as well as treatment naïve. While frequency of resistance mutations reportedly vary based on risk behavior for acquisition, they have been reportedly as high as 15.2%.34-36
Routine HIV resistance testing prior to initiation of ART, should be done in all patients with HIV RNA levels greater than 1,000 copies/mL. Virologic “blips” refer to intermittent periods of “detectable viremia” with loads greater than 50 copies/mL. Blips do not appear to demonstrate evolution of resistance mutations and do not require intervention unless the increase in load is sustained.37,38
Sustained increases, however, usually indicate the emergence of a resistance mutation and the potential loss in efficacy of certain antiretrovirals or classes of antiretrovirals. The analogy of the finite number of positions for potential arteriovenous access in a dialysis patient and the preservation of the limited therapeutic options is certainly valid.
The recognition that the “therapy” for a potential medication-related toxicity in some circumstances is more complex than simply discontinuing the potential offender is an important one. Stated another way, the need to discontinue a regimen that is currently successful in suppressing viral replication for a potential toxicity brings with it the concurrent and necessary decision to substitute a hopefully equally-as-effective regimen.
Where the toxicity is major or the relationship between the toxicity is clear and indisputable, the decision on simple withdrawal of the most obvious cause (i.e., the antiretroviral) is straightforward. Where toxicity is minor and the relationship is more “possible” than “likely,” the consideration of more definitive diagnostic testing to avoid potentially unneeded changes in successful regimens should be considered.
The arsenal of medications available to prolong survival and enhance quality of life in persons infected with HIV continues to expand. The nephrologist, as a consultant participating in the care of persons with comorbidities or toxicities, needs to find reliable, efficient, and effective resources to understand the complexities of HIV care so that he can provide the best possible advice to patients and infectious disease colleagues.
Dr. Szczech is associate professor of nephrology at the Duke University School of Medicine in Durham, N.C., and a member of the Renal & Urology News editorial advisory board.
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