Aa
Viread and GFR lowering/ Creatinine increased issue?
I've been on Viread since 4/18/15 (almost 6 months). I'm worried but don't know if I need to be. Below are my labs...
6/20/15:
Alt 27 u/l
AST 30 u/l
Creatinine .7 mg/dl
DNA <20 iu detected
7/23/15
Alt 25
AST 26
Creatinine .73
GFR 102
DNA <20 iu detected
10/5/15
Alt 29
AST 30
Creatinine .82
GFR 88
DNA <20 iu detected
My questions are this:
1. GFR and creatinine seem off for me. My GFR has always been 102-110, so 88 is a big difference for me. Also, my creatinine while is in range is usually .6-.7, so this new number seems off for me too. These off labs make me worry it's defiantly the Viread since nothing else has changed.
2. I had Fibroscan in September which was 4.3 kpa. When I went on Viread it was per my doctors recommendation, due to over 40 years old to lower HCC risk. My liver function tests, biopsies, DNA have always been good (DNA never above 2000 iu and I'm HbeAg negative) so I'm now wondering with these latest labs what I was thinking about treatment from the start.
3. If I stop Viread will it be safe? I know Steff has said interferon is needed to safely go off, which will not happen in the US. I will call my doctor tomorrow to go over labs and recommendation but kind of freaking out right now about the 'off' labs and worried about my kidneys now.
6/20/15:
Alt 27 u/l
AST 30 u/l
Creatinine .7 mg/dl
DNA <20 iu detected
7/23/15
Alt 25
AST 26
Creatinine .73
GFR 102
DNA <20 iu detected
10/5/15
Alt 29
AST 30
Creatinine .82
GFR 88
DNA <20 iu detected
My questions are this:
1. GFR and creatinine seem off for me. My GFR has always been 102-110, so 88 is a big difference for me. Also, my creatinine while is in range is usually .6-.7, so this new number seems off for me too. These off labs make me worry it's defiantly the Viread since nothing else has changed.
2. I had Fibroscan in September which was 4.3 kpa. When I went on Viread it was per my doctors recommendation, due to over 40 years old to lower HCC risk. My liver function tests, biopsies, DNA have always been good (DNA never above 2000 iu and I'm HbeAg negative) so I'm now wondering with these latest labs what I was thinking about treatment from the start.
3. If I stop Viread will it be safe? I know Steff has said interferon is needed to safely go off, which will not happen in the US. I will call my doctor tomorrow to go over labs and recommendation but kind of freaking out right now about the 'off' labs and worried about my kidneys now.
Best Answer
I follow your case,allways wander why are you on treatment and if i should be too.I am 57,never had a biopsie,my fibroscans every second year 4.3,3.7,3.7kpa ,genotype A ,HbeAg negative ,DNA bellow 2000iu.I had 2 Hbsag quant., 37000 and 21000iu years ago.My GFR concerns me too,last month was 82,but mine was lately bellow 100,doctors never seem to be concern.My HBV is 25 years old,but i monitor it closely only from 2009,until than never worried,didn't have a US since i was pregnant with my son.
Studyforhope, I was thinking about this. DNA is pricy to test and do not think insurance will allow this monthly. Now in the US we can have some labs done without doctor/insurance. One of these tests is a CMP (that tests liver function) and is very cheap. Do you think it's beneficial to at least have the CMP monthly, even though DNA would be 3 months or do you feel CMP would not be enough to catch anything significant? If you feel it is beneficial, what kind of ALT rise is significant, where I would call my doctor and need to go back on Viread? Thank you!
The drop in platelets is not significant.
Better than wait for an ALT rise is to monitor viral load and block the replication before the liver is struck again.
But for that you would need a much more frequent monitoring of the vl ( like once monthly) than your insurance will be willing to pay for and your doc will not order it.
those are the economic limitations of patient care.
Better than wait for an ALT rise is to monitor viral load and block the replication before the liver is struck again.
But for that you would need a much more frequent monitoring of the vl ( like once monthly) than your insurance will be willing to pay for and your doc will not order it.
those are the economic limitations of patient care.
1 Comments
Thank you very much for your help!
i would agree with your liver doctor , that a rebound flare is not likely anymore. Just monitor the viral load frequent enough that in case it does happen, you can suppress it in time, before it becomes a biochemical flare ( that is defined as a rise in ALT as a result of intensified hepatitis due to immune responses to a higher presence of viral antigens in the liver).
1 Comments
Thank you. I will have labs every 3 months, at least for a little while. Is the platelets dropping to 210 from 271 significant? My doctor also said if ALT does go to 50-60 iu she would recommend meds again.
studyforhope can you please advise. My liver doctor on Friday said she felt I just went back to how I was previously off medication, and does not feel I will see any future surprises. What do you think? Am I still at risk of a possible flare or major uptick of viral load, or do you feel it's looking like I just went back to off treatment parameters for me? Thank you.
UPADATE 2 months off Viread....
I ended Viread October 14. I got labs December 14, so exactly 2 month labs off Viread showed ALT 22, AST 24, and DNA up to 516 iu/ml. My GFR 108 and creatinine .67. The only thing I wasn't sure of is on Viread my platelets were 235 and 271 but this lab they are 210, although I don't know if this is significant? WBC usually low, but now above 5, which is great for me.
I've only been off Viread for 2 months so not sure if things have really stabilized and just go back to "normal" for me, or if I'm still at risk of a flare of viral load/ALT?
I ended Viread October 14. I got labs December 14, so exactly 2 month labs off Viread showed ALT 22, AST 24, and DNA up to 516 iu/ml. My GFR 108 and creatinine .67. The only thing I wasn't sure of is on Viread my platelets were 235 and 271 but this lab they are 210, although I don't know if this is significant? WBC usually low, but now above 5, which is great for me.
I've only been off Viread for 2 months so not sure if things have really stabilized and just go back to "normal" for me, or if I'm still at risk of a flare of viral load/ALT?
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I guess I should mention that off treatment, this 516 iu is within a range of what I'm used to, so this didn't stick out as necessarily good or bad for me.
UPDATE:
I rechecked kidney function tests after being well hydrated and fasting this time. My creatinine was back to a normal .73 for me with a GFR of 102. All normal for me.
My hepatologist said she and Dr. Gish corresponded back and forth a full history of labs, tests, history and he recommended me to go off, saying I shouldn't have been put on it in the first place.
My doctor said neither of them expect my liver to "freak out" (as I put it). I hope I can go back to how I was for many, many years and that I am able to regain immune control. I also hope this is the right decision and was actually surprised with how pro antivirals Dr. Gish is that he gave this recommendation.
Any further help or advise would be greatly appreciated. Thank you.
I rechecked kidney function tests after being well hydrated and fasting this time. My creatinine was back to a normal .73 for me with a GFR of 102. All normal for me.
My hepatologist said she and Dr. Gish corresponded back and forth a full history of labs, tests, history and he recommended me to go off, saying I shouldn't have been put on it in the first place.
My doctor said neither of them expect my liver to "freak out" (as I put it). I hope I can go back to how I was for many, many years and that I am able to regain immune control. I also hope this is the right decision and was actually surprised with how pro antivirals Dr. Gish is that he gave this recommendation.
Any further help or advise would be greatly appreciated. Thank you.
It is a difficult decision and no absolute answer exists.
If you terminate viread you have to tightly monitor the vl and set un upper limit when to restart it, eg one log up , meaning 20000 to 30000 .
Chances are good that you will reach you pretreatment equilibrium again, with a higher phase in between.
Confirming the higher creatinine by yet another test after drinking more water for at least a week is another option, also possibly using the likely kidney protective fibroguard/nutrasooth for this time span might show improvement.
Waiting for TAF is a further option if your rebound self stabilizes. TAF will have no kidney or bone issues.You could also use entecavir in the meantime to contain viral evolution.
If you terminate viread you have to tightly monitor the vl and set un upper limit when to restart it, eg one log up , meaning 20000 to 30000 .
Chances are good that you will reach you pretreatment equilibrium again, with a higher phase in between.
Confirming the higher creatinine by yet another test after drinking more water for at least a week is another option, also possibly using the likely kidney protective fibroguard/nutrasooth for this time span might show improvement.
Waiting for TAF is a further option if your rebound self stabilizes. TAF will have no kidney or bone issues.You could also use entecavir in the meantime to contain viral evolution.
Thank you again for your help. A few more questions, if you do not mind.
Do you think my immune system will regain the control it had prior to treatment, or do you feel if I go off this will be lost and me inevitably have to go back on?
Do you feel it's safer to stay on Viread to reduce mutation, cirrhosis, HCC risk?
We all greatly value your expertise here and especially your vast knowledge over many doctors we see. Do you feel with my history and your extreme knowledge I should just settle in with Viread long term or try going off? I started Viread to have the best possible long term outcome as I age, but with my liver in good shape (4.3 kpa) and my GFR score going down I wonder if the risks of sides outweigh the possible benefits?
Do you think my immune system will regain the control it had prior to treatment, or do you feel if I go off this will be lost and me inevitably have to go back on?
Do you feel it's safer to stay on Viread to reduce mutation, cirrhosis, HCC risk?
We all greatly value your expertise here and especially your vast knowledge over many doctors we see. Do you feel with my history and your extreme knowledge I should just settle in with Viread long term or try going off? I started Viread to have the best possible long term outcome as I age, but with my liver in good shape (4.3 kpa) and my GFR score going down I wonder if the risks of sides outweigh the possible benefits?
The viral load after stopping viread most likely will bounce back up higher than it was before, at least for a while, since immune activity was reduced, but also liver inflammation. I don't think it will get dangerously high.
No new mutation will have been introduced because of this however.
please note that the mutations that they tested you for were only signature mutations, determined with a so called innulipa strip test, not by sequencing portions of the hbv genome. Other mutations might well have been present.
Without viread you might aquire adaptive mutations over time.The hepatitis eventually could become reactivated, once the immune control phase is lost.
To get a feel for the extent of hbv presence in the liver the Quant hbsag would be useful. I know that it is not routinely offered in the us yet, but you might find a way.
No new mutation will have been introduced because of this however.
please note that the mutations that they tested you for were only signature mutations, determined with a so called innulipa strip test, not by sequencing portions of the hbv genome. Other mutations might well have been present.
Without viread you might aquire adaptive mutations over time.The hepatitis eventually could become reactivated, once the immune control phase is lost.
To get a feel for the extent of hbv presence in the liver the Quant hbsag would be useful. I know that it is not routinely offered in the us yet, but you might find a way.
Thank you for your insight. Due you feel if I go off Viread the virus would come back full force with possible mutations and difficultly that I do not have now, or rather should he virus go back to how it was before treatment, since it has been treated a little less than 6 months? Before treatment they tested for the major mutations and they were not detected.
The low vl carrier state that existed before you started viread, has one more important catch, that only few hepatologists are aware of. There is further evolution in the hbv genome towards evading that fairly effective immune pressure which over time leads to increased immune adaptive mutations and a reactivation of hepatitis. Slowing that evolution with the antiviral is possibly a way to stay in a less mutated constellation that avoids future resurgence.
But the side effects of TDF are real, too much pure TFV reaches the kidneys and concentrates in the tubuli. Fortunately the mitochondrial toxicity of TFV DP is rather small, compared with adefovir.
The development of tenofovir alafenamide will literally eliminate the kidney focused toxicity, pure tenofovir burden will be 95% reduced. And that will be available 2017/18.
the extent to which TAF will also reduce mitochondrial toxicity in other organs compared WITH TDF is still not clear, since TAF enters all organs better than TDF, but will be given only at 10% of the TDF dose.
But the side effects of TDF are real, too much pure TFV reaches the kidneys and concentrates in the tubuli. Fortunately the mitochondrial toxicity of TFV DP is rather small, compared with adefovir.
The development of tenofovir alafenamide will literally eliminate the kidney focused toxicity, pure tenofovir burden will be 95% reduced. And that will be available 2017/18.
the extent to which TAF will also reduce mitochondrial toxicity in other organs compared WITH TDF is still not clear, since TAF enters all organs better than TDF, but will be given only at 10% of the TDF dose.
Update:
I got in to see a NP with the office this morning. She said the kidney function is fine and there are a lot of factors (like not enough water that morning) that could have it a little low. She said creatinine is normal. She said since I do not have any other health issues (diabetes, high blood pressure, etc that I guess can cause kidney issues) and a long track record of health care they will monitor.
I asked about going off Viread. Back when I got on it I was at Mayo but insurance changed and moved to another office in which Dr. Gish comes once a month. The NP is going to send Dr. Gish an email and ask about going off, since she said their office never would have put me on it in the first place.
She also said she knows they are working hard on a cure now and we should have at lease a functional cure in 5-10 years. Don't know if that is good or bad, seems like an awful long time. :/
Thanks all for your help!
I got in to see a NP with the office this morning. She said the kidney function is fine and there are a lot of factors (like not enough water that morning) that could have it a little low. She said creatinine is normal. She said since I do not have any other health issues (diabetes, high blood pressure, etc that I guess can cause kidney issues) and a long track record of health care they will monitor.
I asked about going off Viread. Back when I got on it I was at Mayo but insurance changed and moved to another office in which Dr. Gish comes once a month. The NP is going to send Dr. Gish an email and ask about going off, since she said their office never would have put me on it in the first place.
She also said she knows they are working hard on a cure now and we should have at lease a functional cure in 5-10 years. Don't know if that is good or bad, seems like an awful long time. :/
Thanks all for your help!
having kidney problems myself I would suggest 24 hour creatinine clearance. This measures how much creatinine your kidney is filtering. Also check for microalbumin in urine. Usually microalbumin is first sign of kidney disease in urine. tdf is known to cause renal insufficiency but luckily for us telb heals kidney function. if worst case scenario you can always combo with telb. i am on etv becasuse of kidneys instead of tdf. i heard etv also creates kidney issues, but they claim its non nephrotoxic.
i suggest you do creatinine clearance by 24hr urine collection, gfr from creatinine is not always 100% reliable
also be sure you drink at least 1.5l of water per day, low calcium water better
if kidneys problems are confirmed your kidneys were already damaged before therapy so you need to care for kidneys in particular.i also had this when i was on entecavir because my kidneys were surely damaged by cirrhosis.to use both entecavir and tenofovir i started immediately antioxidants and creatinine lowered in about 3 weeks
i used fibroguard, today i also use liposomal resveratrol and curcumim, i drink 1.5-2l of water per day, i drink baking soda 1 tea spoon per day although today not every day because kidneys are alright
also be sure you drink at least 1.5l of water per day, low calcium water better
if kidneys problems are confirmed your kidneys were already damaged before therapy so you need to care for kidneys in particular.i also had this when i was on entecavir because my kidneys were surely damaged by cirrhosis.to use both entecavir and tenofovir i started immediately antioxidants and creatinine lowered in about 3 weeks
i used fibroguard, today i also use liposomal resveratrol and curcumim, i drink 1.5-2l of water per day, i drink baking soda 1 tea spoon per day although today not every day because kidneys are alright
something to take into consideration . Last year my gfr was 95 , this year, before the test i was carefull enough to avoid Dehydration ,i drank more water, and came around 110 .still kind of low having in mind i am only 25 . i know egfr will lower with time around 0,5-1 / year
I went to hit reply and somehow hit the best answer. Haha. Your story interests me since I am genotype A as well and like you, DNA never above 1300 iu. I believe my HBV is almost since birth since I had a transfusion from being very premature.
I don't know why my GFR is off. I've had days of feeling fine with treatment and then other days of wondering why. In January I had a liver lesion scare, so I know that caused me much worry and so when treatment was recommended to lower HCC risk it sounded good. Maybe it still is, I don't know, but I know I do not want to compromise my kidneys to possibly have a slightly lower HCC risk (since women and genotype a are lower HCC risk anway).
I have been very diligent about my labs and scans. I do not know if I go off Viread if my liver will freak out after 6 months only and still showing detected? I will call my doctor ASAP and go from there. Thanks for your post.
I don't know why my GFR is off. I've had days of feeling fine with treatment and then other days of wondering why. In January I had a liver lesion scare, so I know that caused me much worry and so when treatment was recommended to lower HCC risk it sounded good. Maybe it still is, I don't know, but I know I do not want to compromise my kidneys to possibly have a slightly lower HCC risk (since women and genotype a are lower HCC risk anway).
I have been very diligent about my labs and scans. I do not know if I go off Viread if my liver will freak out after 6 months only and still showing detected? I will call my doctor ASAP and go from there. Thanks for your post.
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