Incidence and predictors of tenofovir disoproxil fumarate-induced renal impairment in HIV infected Nigerian patients

Tenofovir-Induced Renal Dysfunction Among HIV-Infected Patients: A Systematic Review

Tenofovir disoproxil fumarate (TDF) is an antiretroviral drug widely used as part of antiretroviral therapy (ART) to treat human immunodeficiency virus (HIV-1) infection. Negative effects of tenofovir include impaired kidney function, especially with long-term use. In studies conducted among HIV-positive individuals, we found evidence of extensive kidney damage associated with TDF use. Despite the therapeutic importance of this consequence, its continued use in ART regimens was not contraindicated. The therapeutic and long-term effects of TDF are a major concern. However, in countries or settings where resources are limited and renal function monitoring cannot be ensured, screening methods to detect ART-related renal failure are still supported by data. Therefore, it is safe to re-evaluate the use of TDF-based ART. However, adherence to guidelines may be hampered by insufficient laboratory testing in low- and middle-income countries. More research is also needed among people under 18 years of age and pregnant and breastfeeding mothers.

Effect of tenofovir containing ART on renal function in patients with moderate/severe reduced creatinine clearance at baseline: A retrospective study at two referral hospitals in Namibia

Prescription of tenofovir disoproxil fumarate (TDF) for patients with baseline creatinine clearances (CrCl) <60 mL/min is said to increase risk of further decline in CrCl. Study objectives were to assess incidence of improvement and predictors thereof; to assess incidence of decline and transition to lower stages of CrCl; and comparison of declines between patients with a baseline CrCl < 60mL/min (group-I) and ≥ 60 mL/min (group-II). The study was retrospective, included patients 16 yrs or older who received TDF-containing ART. Improvement and decline were defined as ≥ 25% increase or decrease in CrCl, respectively. Binary logistic regression was performed to identify predictors of improvement. Groups I and II had 2862 and 7526 patients, respectively. In group-I, improvement in CrCl was observed in 40.1% (n = 1146), and was associated with stage IV of CrCl (adjusted Odds Ratio [aOR]=13.4 [95% CI: 6.7 - 26.9, P < .001]); male gender (aHR = 1.8 [95% CI: 1.5 - 2.2, P < .001]); and a poor HIV-status (aHR = 1.2 [95% CI: 1.0 - 1.4], P = .033). In group-I and group-II, respectively, decline occurred in 2.3% and 13.0%, (P < .001); transition to lower stages occurred in 1.0% and 25.2% (P < .001); and migration to stage IV CrCl occurred in 1.0% and 0.5% (P < .001). Improvement was more likely than decline in group-I patients. Although, group-I patients were more likely to experience new onset severe reduced CrCl than group-II patients, the proportions were extremely low. TDF should not be withheld from HIV-positive patients with a baseline CrCl < 60 mL/min.

Incidence of impaired kidney function among people with HIV: a systematic review and meta-analysis

Background

In the era of combination antiretroviral therapy (ART), the incidence, manifestations and severity of kidney diseases have dramatically changed in people living with HIV (PLWH). Little is known about the incidence of impaired kidney function (IKF) measured by serum creatine-based estimated glomerular filtration rate (eGFR) in PLWH.

Methods

In this systematic review and meta-analysis, we searched PubMed, Ovid, Medline, Embase and Web of Science for studies published before May 7th, 2021, with estimates of incidence of IKF among PLWH. We independently reviewed each study for quality by using the Newcastle-Ottawa scale. The incidence and 95% confidence intervals (CIs) were calculated using random-effects model.

Results

Sixty out of 3797 identifiable studies were eligible for the meta-analysis. A total of 19 definitions of IKF were described and categorized into three types: the threshold of eGFR, an absolute or percent decrease in eGFR, and certain eGFR threshold combined with decrement in eGFR. The eGFR< 60 ml/min/1.73m² was the most widely used definition or criterion for IKF, by which the pooled incidence rate of IKF was 12.50 (95%CI: 9.00–17.36) per 1000 person years (PYs). The second most-studied outcome was a > 25% decrease in eGFR, followed by eGFR< 90 ml/min/1.73m², eGFR< 30 ml/min/1.73m² and a combination of eGFR threshold plus decreased eGFR. The reported incidence rates of IKF differ widely by different definitions of IKF. The highest pooled incidence was observed for those with > 25% decrease in eGFR, while the lowest was observed in those with eGFR < 30 ml/min/1.73m². Substantial heterogeneity was identified across most estimates.

Conclusion

Our study provides a comprehensive summary of eGFR-based definitions and incidence rates of IKF in PLWH, not only promoting our understanding of IKF, but also underscoring needs for a concerted action to unify definitions and outcomes of IKF and their applications in AIDS care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02721-x.

Prognostic model for nephrotoxicity among HIV-positive Zambian adults receiving tenofovir disoproxil fumarate-based antiretroviral therapy

Persons living with HIV (PLWH) receiving tenofovir disoproxil fumarate (TDF)-based antiretroviral therapy (ART) risk suffering TDF-associated nephrotoxicity (TDFAN). TDFAN can result in short- and long-term morbidity, including permanent loss of kidney function, chronic kidney disease (CKD), and end-stage kidney disease (ESKD) requiring dialysis. Currently, there is no model to predict this risk or discern which patients to initiate TDF-based therapy. Consequently, some patients suffer TDFAN within the first few months of initiating therapy before switching to another suitable antiretroviral or a lower dose of TDF. In a prospective observational cohort study of adult Zambian PLWH, we modelled the risk for TDFAN before initiating therapy to identify individuals at high risk for experiencing AKI after initiating TDF-based therapy. We enrolled 205 HIV-positive, ART-naïve adults initiating TDF-based therapy followed for a median of 3.4 months for TDFAN at the Adult Infectious Disease Research Centre (AIDC) in Lusaka, Zambia. We defined TDFAN as meeting any of these acute kidney disease (AKD) criteria: 1) An episode of estimated glomerular filtration rate (eGFR)< 60ml/ min/1.73m² within 3 months, 2) reduced eGFR by> 35% within 3 months or 3) increased serum creatinine by> 50% within 3 months. A total of 45 participants (22%) developed acute kidney disease (AKD) after TDF-based therapy. The development of AKD within the first 3 months of commencing TDF-based therapy was associated with an increase in baseline serum creatinine, age, baseline eGFR and female sex. We concluded that baseline characteristics and baseline renal function biomarkers predicted the risk for AKD within the first 3-months of TDF-based therapy.

Tenofovir Disoproxil Fumarate-Associated Renal Dysfunction Among Adult People Living with HIV at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2019: A Comparative Retrospective Cohort Study

BACKGROUND

The use of tenofovir disoproxil fumarate (TDF) has been reported to be a significant contributor to renal dysfunction. However, patients in Ethiopia may be different than in other parts of the world, and findings from such studies may not apply in this setting.

OBJECTIVE

This study aimed to assess TDF-associated renal dysfunction among adult people living with HIV (PLHIV) at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.

METHODS

This retrospective cohort study included adult PLHIV between January 2015 and June 2019. The Chronic Kidney Disease Epidemiology (CKD-EPI) equation was used to estimate glomerular filtration rate (eGFR). Renal dysfunction was defined as eGFR <60 mL/min/1.73 m2. Data were entered into Epi Info™ 7 and analyzed by using SPSS® software version 20. The Kaplan-Meier method was used to estimate the survival curves. Cox proportional hazards models were used to identify predictors of renal dysfunction using a 95% confidence interval and p-value ≤ 0.05 as a statistical significance.

RESULTS

Out of 400 participants, 200 were TDF-based ART groups, and 200 were non-TDF-based ART groups. The incidence of renal dysfunction of TDF and the non-TDF group was 28.31 per 100 person-years (PYs) and 12.53 per 100 PYs, respectively. Adult PLHIV taking TDF-based regimens were 1.70 (adjusted HR = 1.70; 95% CI = 1.02-2.82) times at higher risk of renal dysfunction than non-TDF-based regimens. Age ≥55, diabetes mellitus, concurrent nephrotoxic drug use, and combined use of ritonavir-boosted protease inhibitors were also associated significantly with renal dysfunction.

CONCLUSION

The incidence rate of renal dysfunction among TDF users is higher than non-TDF users. Exposure to TDF is a significant risk of renal dysfunction in adult PLHIV. Clinicians should regularly monitor the renal function of adult PLHIV who are taking TDF.

Prevalence of kidney injury in patients taking tenofovir based antiretroviral therapy at a primary health care clinic, in East Rand,Gauteng Province

Background: Tenofovir disoproxil fumarate (TDF) is currently one of the key medicines in the management of HIV-1 infection across the globe. Conversely, various studies indicate that TDF is associated with an increased risk of kidney injury. Furthermore, data from different studies indicate that clinically significant TDF-related kidney toxicity is uncommon, with an estimated incidence of reduction in creatinine clearance to below 50 ml/min ranging from 3% to 8%.Objective: This study investigated the prevalence of TDF-induced kidney injury, risk factors associated with the exacerbation of kidney injury, and reversibility of TDF-induced kidney injury in a South African cohort.Methods: A retrospective cross-sectional descriptive study was conducted, where quantitative data were collected through patient file reviews. Files of 600 patients initiated on TDF-based antiretroviral therapy (ART) were reviewed. The degree of kidney function was monitored using the eGFR at baseline, 3, 6, 12, and 36 months of TDF therapy. eGFR after TDF discontinuation was monitored to determine its reversibility. HIV parameters (CD4 count and viral load) were monitored to determine patients' immune response to treatment throughout the study. Comorbidities and other factors that affect kidney function were extracted from the patients' files.Results: Final sample comprised 413 files, 272 (65.9%) were females. Significant variability in the eGFR overtime was observed; 20 (5.9%) experienced mild-moderate kidney injury, four (1.2%) developed moderate-severe kidney injury and three (1%) had severe kidney injury. Significant association with decline in eGFR included high viral load, low CD4 count and long duration of treatment. Six (1.5%) patients were discontinued from TDF treatment and five patients of those fully recovered.Conclusions: TDF-induced kidney injury was uncommon in this setting and where it occurred was associated with full reversibility after discontinuation. Therefore, lack of resources in health-care settings in terms of frequent monitoring of renal function should not prevent prescribing TDF-based therapy.

Lipid profile and renal safety of tenofovir disoproxil fumarate-based anti-retroviral therapy in HIV-infected Chinese patients

BACKGROUND

Tenofovir disoproxil fumarate (TDF) is an important component of antiretroviral therapy (ART) that has been widely used. The aim of this study was to observe the long-term impact of TDF-based ART on lipid metabolism profiles and renal functions in Chinese patients.

METHODS

414 and 124 HIV-infected, ART-naïve patients who initiated TDF-based regimens and non-TDF regimens respectively were retrospectively included. Demographic characteristics and clinical information of each patient was collected. Changes of lipid profiles and renal function, as well as the risk factors of hyperlipidemia and renal dysfunction were analyzed.

RESULTS

After 96 weeks of ART, HIV viral loads were undetectable in 97.34% (403/414) of patients exposed to TDF. The plasma total cholesterol (TCH) increased from 3.97 ± 0.83 mmol/L to 4.53 ± 0.87 mmol/L (P < 0.001), which did not show a significant difference comparing with non-TDF exposed group. By contrast, the plasma triglyceride (TG) levels increased, but were still lower than that in the non-TDF exposed group (0.26 ± 1.24 vs. 0.89 ± 1.78, P < 0.001). The mean estimated glomerular filtration rate (eGFR) decreased from 127.29 ± 24.04ml∙min^-1∙1.73 m^-2 at baseline to 118.84 ± 22.74 ml∙min^-1∙1.73 m^-2(P < 0.001) in the TDF exposed group, while it increased in the non-TDF exposed group. In the TDF group, high body mass index (BMI) (OR = 1.13, P = 0.01), high baseline TG (OR = 2.33, P<0.001) and receiving protease inhibitors (PIs) (OR = 7.58, P < 0.001) were associated with hypertriglyceridemia after ART, while high baseline TCH predicted hypercholesterolemia (OR = 3.58, P < 0.001). MSM (OR = 0.22, P = 0.02) and baseline eGFR (OR = 0.90, P < 0.001) was associated with renal dysfunction after ART.

CONCLUSIONS

TDF-based regimens are of good therapeutic effect among Chinese people. These regimens showed a better plasma lipid profile but mild renal dysfunction as compared to non-TDF based regimens. Patients with high BMI, high baseline TG, high baseline TCH and low baseline eGFR should be closely monitored when using TDF-based ART.