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Grand Rounds |

Metabolic and Skeletal Complications of HIV Infection The Price of Success

Caryn G. Morse, MD, MPH; Joseph A. Kovacs, MD
JAMA. 2006;296(7):844-854. doi:10.1001/jama.296.7.844.
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Over the past 10 years, in conjunction with the broad availability of potent antiretroviral regimens, the care of human immunodeficiency virus (HIV)–infected patients has shifted from prevention and treatment of opportunistic infections and malignancies to management of the metabolic and related complications associated with HIV infection and its treatment. Metabolic disorders, including lipodystrophy, dyslipidemia, and insulin resistance, occur at a high rate in HIV-infected individuals receiving highly active antiretroviral therapy (HAART). These disorders are associated with increased risk of cardiovascular disease and have become an important cause of morbidity and mortality in HIV-infected patients. Herein, we present the case of a patient with HIV infection who responded well to HAART but developed multiple complications potentially related to this therapy. This article reviews the clinical characteristics of the metabolic and skeletal disturbances observed in HIV infection and discusses strategies for their management.

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Figure 1. Time Line for the Course of HIV Disease and Metabolic and Skeletal Complications for the Patient in the Case Presentation
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Dates in this time line are approximate. Table shows selected laboratory data; blank cells indicate no data. Selected medications, including antiretroviral drugs, and clinical events are indicated graphically. Lengths of bars are scaled according to dates of laboratory measurements and do not accurately reflect duration. ABC indicates abacavir; D4T, stavudine; DDI, didanosine; HIV, human immunodeficiency virus; IDV, indinavir; LPV, lopinavir; NFV, nelfinavir; NRTI, nucleoside reverse transcriptase inhibitor; RTV, ritonavir; TDF, tenofovir; and 3TC, lamivudine.

Figure 3. Percentage of Patients With Abnormal Serum Lipid Levels as a Function of Antiretroviral Therapy Regimens
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The percentage of patients with elevated total cholesterol, triglycerides, or decreased high-density lipoprotein (HDL) cholesterol is shown by the class of antiretroviral drugs (ARVs) they were receiving: no ARVs, nucleoside reverse transcriptase inhibitor (NRTI) therapy without a nonnucleoside reverse transcriptase inhibitor (NNRTI) or protease inhibitor (PI), NNRTI-based therapy, or PI-based therapy. Data are from the Data Collection of Adverse Events of Anti-HIV Drugs (DAD) Study Group.44 HAART indicates highly active antiretroviral therapy. Error bars indicate 95% confidence intervals.

Figure 2. Body Composition Changes in HIV-Infected Patients
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Figure 4. Magnetic Resonance Imaging Scans of a Patient With Multiple Lesions of Osteonecrosis
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T1-weighted images show osteonecrosis of the right hip (A) and left shoulder (B). Areas of osteonecrosis are highlighted in yellow in the insets. The cystic lesion in the left lateral humerus is an incidental finding.



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