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Effect of tenofovir disoproxil fumarate on risk of renal abnormality in HIV-1-infected children on antiretroviral therapy: a nested casecontrol study

Judd, Alia; Boyd, Katherine La; Stöhr, Wolfganga; Dunn, Davida; Butler, Karinab; Lyall, Hermionec; Sharland, Miked; Shingadia, Delanee; Riordan, Andrewf; Gibb, Di Ma

doi: 10.1097/QAD.0b013e3283333680
Clinical Science

Objective: To investigate the association between tenofovir disoproxil fumarate (TDF) use and renal abnormality in a large cohort of HIV-1-infected children on antiretroviral therapy (ART).

Design: Nested case–control study.

Methods: Patients were from the Collaborative HIV Paediatric Study, a cohort of approximately 95% of HIV-1-infected children in the UK/Ireland. Serum (but not urine) biochemistry results for 2002–2008 were obtained for 456 ART-exposed children (2–18 years) seen at seven hospitals. Cases had either confirmed hypophosphataemia DAIDS grade at least 2 or estimated glomerular filtration rate (eGFR) less than 60 ml/min per 1.73 m2; three controls per case were matched by hospital. Conditional logistic regression identified risk factors for renal abnormality.

Results: Twenty of 456 (4.4%) had hypophosphataemia, and one had eGFR less than 60 ml/min per 1.73 m2. Ten of 20 (50%) cases versus 11 of 60 (18%) controls had taken TDF-containing ART for a median [interquartile range (IQR)] of 18 [17–20] months, as part of second-line or salvage therapy. The hypophosphataemia incidence rate was 4.3/100 person-years in the TDF group versus 0.9/100 person-years in those not exposed to TDF. In multivariable analysis, only TDF exposure in the previous 6 months was associated with hypophosphataemia [odds ratio (OR) = 4.81, 95% confidence interval (CI) 1.45–16.0, P = 0.01]. In six of 10 children with hypophosphataemia and at least four subsequent phosphate measurements, phosphate values returned to normal when TDF was stopped; in four with three measures or less, values rose but remained subnormal.

Conclusions: Hypophosphataemia was uncommon (4%), but was associated with prolonged TDF use, and was generally reversible following TDF withdrawal. Findings highlight the importance of continuing to monitor longer-term renal function, in particular tubular function, especially in those taking TDF. Further studies assessing urine biochemistry measures which more accurately indicate renal tubular damage are required.

aMRC Clinical Trials Unit, London, UK

bOur Lady's Children's Hospital, Dublin, Ireland

cImperial College Healthcare NHS Trust, UK

dSt George's Healthcare Trust, UK

eGreat Ormond Street Hospital for Children NHS Trust, London, UK

fRoyal Liverpool Children's NHS Trust, Liverpool, UK.

Received 23 July, 2009

Revised 15 September, 2009

Accepted 18 September, 2009

Correspondence to Dr Ali Judd, MRC Clinical Trials Unit, 222 Euston Road, London NW1 2DA, UK. Tel: +44 20 7670 4830; e-mail:

© 2010 Lippincott Williams & Wilkins, Inc.