Glomerular dysfunction and associated risk factors over 4-5 years following antiretroviral therapy initiation in Africa

Background: The aim of this study was to investigate long-term renal function in HIV-infected adults initiating antiretroviral therapy (ART) with a CD4 + T-cell count <200 cells/mm 3 in Africa. Methods: This was an observational analysis within the DART trial randomizing 3,316 adults to routine laboratory and clinical monitoring (LCM) or clinically driven monitoring (CDM). Serum creatinine was measured pre-ART (all ≤360 μmol/l), at weeks 4 and 12, then every 12 weeks for 4-5 years; estimated glomerular filtration rate (eGFR) was determined using the Cockcroft-Gault formula. We analysed eGFR changes, and cumulative incidences of eGFR<30 ml/min/1.73 m 2 and chronic kidney disease (CKD; <60 ml/min/1.73 m 2 or 25% decrease if <60 ml/min/1.73 m 2 pre-ART; confirmed >3 months). Results: At ART initiation, median CD4 + T-cell count was 86 cells/mm 3; 1,492 (45%) participants had mild (60-<90 ml/min/1.73 m 2), 237 (7%) moderate (30-<60 ml/min/1.73 m 2) and 7 (0.2%) severe (15-<30 ml/min/1.73 m 2) decreases in eGFR. First-line ART was zidovudine/lamivudine plus tenofovir (74%), abacavir (9%) or nevirapine (17%). By 4 years, cumulative incidence of eGFR<30 ml/min/1.73 m 2 was 2.8% (n=90) and CKD was 5.0% (n=162). Adjusted eGFR increases to 4 years were 1, 9 and 6 ml/min/1.73 m 2 with tenofovir, abacavir and nevirapine, respectively (P<0.001), and 4 and 2 ml/min/1.73 m 2 for LCM and CDM, respectively (P=0.005; 2 and 3 ml/min/1.73 m 2 to 5 years; P=0.81). Conclusions: On all regimens and monitoring strategies, severe eGFR impairment was infrequent; differences in eGFR changes were small, suggesting that first-line ART, including tenofovir, can be given safely without routine renal function monitoring.