HIV infection is associated with renal dysfunction, including HIV-associated nephropathy (HIVAN), immune complex kidney disease and acute renal failure [1,2], which may be associated with progression to AIDS and death [3,4]. There is increasing evidence that HIV infection of the kidneys is involved with HIVAN , whereas other disorders include nephropathy resulting from coinfection with hepatitis B, hepatitis C or syphilis [6,7]; diabetes or hypertension  and immune complex glomerulonephritis . The incidence and occurrence of renal disease has decreased since the widespread introduction of combination antiretroviral therapy (cART) [10,11], with studies suggesting that cART reduces the incidence of HIVAN , possibly by slowing the decline in renal function [13,14]. Early stages of renal dysfunction are silent and only detectable through laboratory analyses; for example, the glomerular filtration rate (GFR) can be estimated using the Cockcroft–Gault or Modification of Diet in Renal Disease (MDRD) equations [15,16]. GFR correlates with the severity of kidney disease and typically decreases before the onset of symptoms of kidney failure [17–19]. Chronic kidney disease (CKD) is defined by the National Institute of Diabetes and Digestive and Kidney Diseases as an estimated GFR (eGFR) of below 60 ml/min per 1.73 m2 measured over a period of at least 3 months. In HIV-positive persons, there is currently no consensus whether the Cockcroft–Gault or MDRD method for estimating GFR is more accurate compared with the gold standard [20–22].
The role of antiretroviral drugs in the development of CKD remains unclear. Nephrolithiasis was seen in up to 27% of patients treated with indinavir [23,24] and there are numerous studies [25–29] demonstrating that tenofovir is associated with impaired kidney function leading to a ‘Dear Doctor’ letter on the tenofovir package insert in 2006 . There are few studies with long-term follow-up and sufficient statistical power, which have investigated the long-term relationship between specific antiretroviral drugs and the development of CKD using a rigorously defined endpoint. We aimed to describe the incidence of CKD in EuroSIDA, and to determine factors associated with the development of CKD, including the relationship with individual antiretroviral drugs.
EuroSIDA is a prospective study, initiated in 1994, currently including 16 599 HIV-1-infected patients at 103 centres across Europe, Israel and Argentina; further details have been reported elsewhere . Data are collected prospectively at clinical sites and is extracted and sent to the coordinating centre at 6 monthly intervals (see forms at www.cphiv.dk). These data include demographic and clinical information, a complete history of antiretroviral treatment and use of drugs for prophylaxis against opportunistic infections, as well as all CD4 cell counts and plasma HIV-RNA values measured. Data on serum creatinine have routinely been recorded since 1 January 2004. The current analysis includes follow-up to a median date of November 2008.
Patients were selected for inclusion if they had at least three serum creatinine measurements measured after 1 January 2004, and a corresponding body weight measurement. When a patient had repeated creatinine measurements over 28 days, the median value was used and assigned to the mean date of measurement. Baseline for eligible patients was defined as the first eGFR at or after 1 January 2004. eGFR was calculated at each time point using the Cockcroft–Gault formula  standardized for body surface area . CKD was defined as either confirmed (≥3 months apart) eGFR of 60 ml/min per 1.73 m2 or less for patients with baseline eGFR of above 60 ml/min per 1.73 m2 or confirmed 25% decline in eGFR for patients with baseline eGFR of 60 ml/min per 1.73 m2 or less. Patients were followed from baseline to either CKD (as defined above, patients were defined as having CKD at the confirmatory measurement) or the last eGFR measurement. In addition to demographic variables, cardiovascular disease (as evidenced by myocardial infarction, stroke, angioplasty, coronary artery bypass graft or carotic endarterectomy), diabetes (diagnosis of diabetes mellitus, or taking oral antidiabetic agents or insulin at baseline) and hypertension (SBP ≥ 140 mmHg, DBP ≥ 90 mmHg or taking angiotensin-converting enzyme inhibitors/antihypertensive agents) prior to or at baseline were described, as was smoking status and use of nonantiretroviral known nephrotoxic drugs (acyclovir, pentamidine, cidofovir, amphotericin B and foscarnet ).
Kaplan–Meier estimation was used to describe the cumulative probability of developing CKD. Incidence rates of CKD were compared between groups using Poisson regression. Initially, Poisson models were used to determine the factors associated with CKD, using demographic variables, current (time-updated) variables were used for hepatitis C antibody status, age, development of a new AIDS-defining illness or non-AIDS-defining malignancy, use of nephrotoxic drugs, hypertension, diabetes, smoking status, diagnosis of a cardiovascular event, HIV-RNA viral load and CD4 cell count. All demographic factors significant in univariate analyses (P < 0.1) were included in a multivariate model. Use of each antiretroviral was then included into this multivariate model as cumulative exposure time, recalculated on a monthly basis and included as continuous time-updated variables . Those significant (P < 0.1) were included in the final model. Cumulative exposure was also categorized in two alternative ways: never exposed, less than 12, 12–24, 24–36 and more than 36 months exposure and never exposed, exposed and currently on drug and exposed and currently off drug. In addition to including the individual antiretroviral drugs, use of cART was included as a categorical variable as any cART (yes/no) or type of cART (none, nonprotease inhibitor containing cART or protease inhibitor -containing cART; further classified as nonboosted or ritonavir boosted). The primary analyses were repeated using the MDRD  and improved MDRD formula . An additional sensitivity analysis with greater specificity for CKD was used; confirmed decline in eGFR to 60 ml/min per 1.73 m2 or less where baseline eGFR above 80 ml/min per 1.73 m2 (i.e. 25% decline) or confirmed 25% decline in eGFR when baseline eGFR of 60 ml/min per 1.73 m2 or less [International Network for Strategic Initiatives in Global HIV Trials (INSIGHT), M. Ross, personal communication]. We performed additional analyses censoring patients at starting specific antiretroviral drugs such as tenofovir, atazanavir or a boosted-protease inhibitor-containing regimen. For example, censoring patients at initiation of starting a boosted-protease inhibitor-containing regimen allows investigation of the effect of, for example, tenofovir, when it is used without a boosted protease inhibitor.
All statistical analyses were performed using SAS version 9.1 (Statistical Analysis Software, Cary, North Carolina, USA).
Out of 11 752 patients in EuroSIDA with follow-up after 1 January 2004, 2590 were excluded because they had less than three serum creatinine measurements and an additional 2319 patients were excluded because they did not have body weight, height or both measured in order to calculate eGFR using the Cockcroft–Gault formula. Patients excluded from the Cockcroft–Gault analysis because of missing information on weight, height or both were similar to those included in the primary analyses. Patients excluded due to having insufficient serum creatinine measurements were more likely to be men, be of white ethnic origin, infected with HIV through intravenous drug use, be coinfected with hepatitis C virus and be from Eastern Europe. They were also recruited to EuroSIDA later and were younger in age.
Six thousand, eight hundred and forty-three patients were included; the median number of eGFR measurements per patient was nine [interquartile range (IQR) 6–12] with a median time of 3.7 months (IQR 2.8–5.6) between measurements, and a median of 3.0 eGFR measurements per patient year of follow-up (IQR 2.3–3.6). The median date of baseline was July 2004 (IQR May 2004–August 2005). There was very little correlation between time between consecutive eGFR measurements and eGFR values (correlation coefficient 0.040, P < 0.0001), and the correlation was similar at low (≤60 ml/min per 1.73 m2; correlation coefficient 0.043) or high eGFR (>60 ml/min per 1.73 m2; correlation coefficient 0.030). Two hundred and twenty-five patients (3.3%) progressed to CKD during 21 482 person-years of follow-up (PYFU), median follow-up was 3.7 years (IQR 2.8–5.7) giving an overall incidence of 1.05 per 100 PYFU [95% confidence interval (CI) 0.91–1.18]. At baseline, 278 patients (4.1%) had an eGFR of 60 ml/min per 1.73 m2or less and 4132 patients (60.4%) had an eGFR of above 90 ml/min per 1.73 m2. Out of the 225 patients, 203 (90.2%) progressed due to a confirmed decline in eGFR to 60 ml/min per 1.73 m2 or less and 150 (73.9%) progressed from an eGFR above 70 ml/min per 1.73 m2 to 60 ml/min per 1.73 m2 or less. Only 27 patients with a baseline eGFR above 90 ml/min per 1.73 m2 progressed to CKD. Characteristics of the patients are shown in Table 1, together with a description of the patients stratified by whether they had, at baseline, ever been exposed to tenofovir, indinavir, atazanavir or lopinavir/r. There was little variation in the number of eGFR measurements per year of exposure to different antiretroviral drugs. For example, there was a median of 3.1 eGFR measurements per year while patients were treated with tenofovir (IQR 2.4–4.0) compared with 2.5 eGFR measurements per year for indinavir (IQR 2.0–3.3), 3.0 per year for atazanavir (IQR 2.3–4.0) and 2.9 per year for lopinavir/r (IQR 2.2–3.8).
Figure 1 shows the Kaplan–Meier progression to CKD; at 24 months, 1.48% (95% CI 1.18–1.78) were estimated to have developed CKD rising to 2.97% (95% CI 2.51–3.43%) at 36 months after baseline. The crude (unadjusted) incidence of CKD stratified by years of exposure for commonly used antiretroviral drugs are shown in Fig. 2(a and b); a strong increasing incidence of CKD with increasing cumulative exposure to tenofovir, indinavir, atazanavir and lopinavir/r can be seen, which was less evident for efavirenz, abacavir, zidovudine or stavudine, although the test for trend was statistically significant. After adjustment (Table 2), a diagnosis of a new AIDS-defining event was associated with an increased incidence of CKD, as was female sex, older age, developing diabetes, being hypertensive and being hepatitis C antibody positive. In contrast, patients with a higher eGFR at baseline were less likely to develop CKD, as were patients with a higher HIV-RNA viral load. Each additional year of exposure to tenofovir was associated with a 16% increased incidence of CKD, lopinavir/r with an 8% increased incidence, indinavir with an 11% increased incidence and atazanavir with a 22% increased incidence (P < 0.05 for all). When atazanvir and tenofovir were used at the same time, there was a 41% increased incidence of CKD per year of additional exposure [incidence rate ratio (IRR) 1.41, 95% CI 1.24–1.61, P < 0.0001]. No other antiretroviral drugs or type of cART regimen was associated with CKD. For example, after adjustment, each additional year of exposure to abacavir was associated with a 4% increased incidence of CKD (IRR 1.04, 95% CI 0.98–1.09, P = 0.16), with efavirenz was 5% (IRR 1.05, 95% CI 0.98–1.10, P = 0.12), with zidovudine was 0% (IRR 1.00, 95% CI 0.96–1.04, P = 0.97) and with stavudine was 3% (IRR 1.03, 95% CI 0.98–1.08, P = 0.28).
When using the MDRD formula , 9162 patients were included in analyses and 277 developed CKD during 39 250.3 PYFU, an incidence of 0.95 per 100 PYFU (95% CI 0.84–1.06). Using the CKD Epidemiology Collaboration formula , there were 258 patients who developed CKD (incidence of 0.88 per 100 PYFU, 95% CI 0.77–0.99). There were 129 events (incidence of 0.60 per 100 PYFU, 95% CI 0.49–0.70) using the INSIGHT definition (confirmed 25% decline in eGFR to ≤60 ml/min per 1.73 m2 or confirmed 25% decline in eGFR when baseline eGFR ≤60 ml/min per 1.73 m2). In all cases, the results were completely consistent with each other (Fig. 3), as was CKD defined solely as confirmed eGFR of 60 ml/min per 1.73 m2 or less when baseline eGFR above 60 ml/min per 1.73 m2 (203 events).
Antiretroviral drugs are often taken together; therefore, we performed additional analyses censoring patient follow-up, using the Cockcroft–Gault formula (Fig. 3). Censoring patient follow-up at starting, atazanavir reduced the follow-up time by 19%. Figure 3 can then be interpreted as the adjusted IRR per additional year of exposure to tenofovir or lopinavir/r in patients who have not started atazanavir. The adjusted IRR per additional year of exposure to tenofovir and lopinavir/r were very similar, which suggests that the increased incidence of CKD in patients taking lopinavir/r or tenofovir cannot be explained by the fact that the patient was also treated with atazanavir. Similarly, the association with atazanavir and lopinavir/r was unaffected by censoring follow-up at starting tenofovir, although the marked reduction in power (40% of follow-up time was removed) reduced the statistical significance. Finally, the adjusted IRR for tenofovir per additional year of exposure was maintained when the analysis was censored at initiation of a boosted-protease inhibitor-containing regimen (60% of follow-up time was removed).
In addition to assessing the effect of continuous exposure to antiretroviral drugs for their possible association with CKD, other ways of assessing the effect of antiretroviral drugs was explored, as shown in Web Fig. 1(a) (Supplemental Digital Content 1, http://links.lww.com/QAD/A38, stratifying by years of exposure) and Web Fig. 1(b) (Supplemental Digital Content 1, http://links.lww.com/QAD/A39, current and previous use of antiretroviral drugs). Of note, the power of these analyses is reduced compared with our main analysis. After adjustment, there was an increasing trend of CKD associated with increasing exposure to atazanavir or indinavir (Web Fig. 1a, http://links.lww.com/QAD/A38); there was little additional increase in the incidence of CKD after 24 months exposure to tenofovir, whereas the increased incidence of CKD for lopinavir/r was only seen (with marginal significance) in patients with more than 36 months of exposure. Patients who had started atazanavir or lopinavir/r but were not currently taking the drug did not have an increased incidence of CKD compared with those who had never started the drug (Web Fig. 1b, http://links.lww.com/QAD/A39), whereas for indinavir and tenofovir, patients who had stopped the drug continued to have a significantly increased incidence of CKD. This was further investigated for tenofovir. After adjustment, compared with patients who had never started tenofovir, those who had started tenofovir but stopped within the last 12 months had a four-fold increased incidence of CKD (adjusted IRR 4.05, 95% CI 2.51–6.53, P < 0.0001). Patients who had stopped for more than 12 months had a comparable incidence of CKD to those never starting the drug (IRR 1.12, 0.63–1.99, P = 0.69). Patients who were currently taking tenofovir had almost a two-fold increased incidence of CKD (IRR 1.94, 1.43–2.63, P < 0.0001).
There is limited follow-up in this study following CKD; there were 19 deaths during 327.8 PYFU, death rate 5.8 per 100 PYFU (95% CI 3.5–9.1 per 100 PYFU). Only one death was reported to be due to renal failure. Of the 225 patients diagnosed with CKD, 157 patients have at least two subsequent eGFR measurements (69.8%). Among these patients, the median follow-up after CKD was 14 months (IQR 8–21 months) and 56 patients resolved CKD (35.7%), that is, they had two consecutive (≥3 months apart) eGFR above 60 ml/min per 1.73 m2 or two consecutive eGFR reversing the 25% decline. At 12 months after CKD, 23.3% were estimated to have resolved CKD (95% CI 16.1–30.5) using Kaplan–Meier estimation.
This study has demonstrated a relatively low proportion of patients developing CKD and that in addition to the traditional risk factors for renal disease, increasing exposure to tenofovir, indinavir, atazanavir and lopinavir was associated with an increased incidence of CKD. The prevalence and incidence of CKD within EuroSIDA was highly consistent with findings from other studies [35–37]. Well described risk factors such as older age, hypertension and diabetes for CKD in persons without HIV [38–41] were also independently associated with CKD in our study. The development of AIDS and non-AIDS malignancies could be associated with CKD possibly via a general deterioration in health, immune function or exposure to nephrotoxic drugs. Hepatitis C coinfection was also associated with CKD in agreement with a previous study .
Although the incidence and occurrence of renal disease has decreased since the widespread introduction of cART [10,11], we found that cumulative exposure to tenofovir was associated with an increased incidence of CKD. Previous studies have suggested that ART is associated with a decline in kidney function , which may be exacerbated in those taking tenofovir [35,44]. Results from clinical trials, with shorter follow-up and including patients with a lower risk of CKD, have shown no differences in changes in eGFR when comparing tenofovir with nucleoside reverse transcriptase inhibitors  and a mild but nonprogressive decline in eGFR [46–49]. Our study has a median follow-up of almost 4 years, includes approaching 7000 unselected patients, many of whom had preexisting risk factors for CKD, and has considerably more power than previous reports. There was, however, a relatively low proportion of patients with an eGFR at baseline of above 90 ml/min per 1.73 m2 who progressed to CKD, and further follow-up in this patient group is required to more accurately determine long-term risk of CKD with exposure to antiretroviral drugs.
More detailed analyses of our data suggest that those with preexisting excess risk of CKD were more likely to develop tenofovir-associated CKD (Web Table 1, Supplemental Digital Content 1, http://links.lww.com/QAD/A37). Tenofovir may be associated with both glomerular and tubular dysfunction; the latter likely due to re-uptake of the drug via tubular cells . There have been conflicting reports [25,51–53] that the effect of tenofovir on renal function is worse when coadministered with ritonavir-boosted protease inhibitor, and that deteriorating renal function was greater in boosted-protease inhibitor regimens than in nonnucleoside reverse transcriptase inhibitor regimens . We found no effect of boosted protease inhibitors on CKD (data not shown); the association between CKD and atazanavir or lopinavir/r could not be explained by coadministration with tenofovir and the association between CKD and tenofovir could not be explained by concomitant use of boosted protease inhibitors.
Indinavir, previously reported to be associated with a decline in renal function and crystalluria [24,55], was also associated with a higher incidence of CKD in our study, although this is of less clinical relevance, as indinavir is no longer a first-line recommended regimen [24,56]. We also found that cumulative exposure to atazanavir and lopinavir/r was associated with an increased incidence of CKD. There have been case reports of renal problems associated with atazanavir [57–62], possibly exacerbated in patients previously exposed to indinavir . As with indinavir, atazanavir may cause crystalluria, crystal nephropathy and nephrolithiasis, perhaps due to concentrations of atazanavir sulphate increasing with acidity of the urine, which in turn may lead to intratubular crystal formation and renal injury . Of note, 7% of atazanavir is excreted as unchanged drug in urine, substantially higher than, for example, lopinavir/r and saquinavir (<3 and 1%, respectively) [63–65]. As with tenofovir, the most plausible explanation for why this study detects these associations is better power and higher prevalence of CKD risk factors in the population studied. As opposed to the consistent results for atazanavir, those for lopinavir/r using different eGFR estimates were inconsistent and further research is warranted before a possible role in CKD can be determined.
The high risk of CKD in the group of people within 12 months of stopping tenofovir is likely in part due to patients with reduced eGFR stopping tenofovir. The elevated risk of CKD returned to that seen in patients not exposed to the drug 12 months after stopping tenofovir, whereas that associated with atanazavir and lopinavir/r reverted immediately. This observation suggests that the potential nephrotoxicity of these drugs is generally reversible. It is possible that potential tubular and glomerular toxicity due to tenofovir may take longer to revert, whereas continued drug crystallization in the kidneys (atazanavir and indinavir) requires ongoing exposure. When tenofovir exposure was categorized (Web Fig. 1, Supplemental Digital Content 1, http://links.lww.com/QAD/A38, http://links.lww.com/QAD/A39), after adjustment, the incidence of CKD did not continue to significantly increase after the initial 24 months of exposure, which may suggest a threshold with respect to the drug's glomerular toxicity. On the contrary, based on the current data, we cannot rule out that it will continue to increase. The decision to model exposure cumulatively was taken based on the crude incidence rates (Fig. 2) and further follow-up and data are required to establish whether the incidence of CKD continues to increase with time beyond 24 months exposure to tenofovir.
There are a number of limitations to this study. Although EuroSIDA is a well described, observational cohort study with long-term follow-up, patients have not been randomized to treatment and confounding by indication remains a possibility. There may be considerable variation in serum creatinine measurements between different laboratories using different techniques , although this is unlikely to bias the results for one specific antiretroviral drug compared with another. Patients taking different antiretroviral drugs had a similar frequency of eGFR measurements, and duration of follow-up was similar for patients exposed to different antiretroviral drugs (data not shown), both of which reduce potential bias. We have a median follow-up approaching 4 years and are neither able to say whether the risk of CKD will continue to increase with longer exposure nor can we describe the relationship between CKD and antiretroviral drugs more recently introduced such as etravirine, darunavir, raltagravir or maraviroc. EuroSIDA has recently initiated data collection on tenofovir dosage in patients with CKD, wherein dose or dose interval adjustment may be necessary [30,56]; analyses of these data are ongoing. Patients lost to follow-up or who died before the study began collecting serum creatinine data were excluded from analysis and tended to be recruited to EuroSIDA later, were more likely to be coinfected with hepatitis C and were younger, which might suggest a lower incidence of CKD in excluded patients than in those included, whereas patients excluded from the Cockcroft–Gault analysis were very similar to those included in the larger MDRD sensitivity analysis. Patients with a minimal confirmed decrease in eGFR from 61 to 59 ml/min per 1.73 m2 would be classified as having CKD according to our definition, although analyses which required a confirmed 25% drop in eGFR to 60 ml/min per 1.73 m2 or less showed similar results.
To conclude, increasing exposure to tenofovir was associated with a higher incidence of CKD independently of other antiretroviral drugs and traditional CKD risk factors. The increase in risk of CKD was also true for indinavir and atazanavir, whereas the results for lopinavir/r were less clear. There may be some reversibility in CKD after discontinuation of the antiretroviral drugs, but this requires confirmation in larger studies with longer follow-up.
Primary support for EuroSIDA is provided by the European Commission BIOMED 1 (CT94-1637), BIOMED 2 (CT97-2713), the fifth Framework (QLK2-2000-00773) and the sixth Framework (LSHP-CT-2006-018632) programmes. Current support also includes unrestricted grants by Gilead, Pfizer and Merck and Co. The participation of centres from Switzerland was supported by a grant from the Swiss Federal Office for Education and Science.
A.M. has received honoraria, consultancy and/or lecture fees from Boehringer Ingelheim, Pfizer, Bristol Myers Squibb, Gilead and Merck. O.K. has received honoraria, consultancy, lecture fees or all from Abbott, Merck and Tibotec. P.R. has received honoraria for lectures, advisory board membership and consultancy, as well as research grants from Boehringer Ingelheim, Roche, Merck, Tibotec, Gilead, GlaxoSmithKline, Pfizer, Bristol Myers Squibb and Theratechnologies. S.DeW. has received research grants from Pfizer, GlaxoSmithKline, Bristol Myers Squibb and Abbott. D.S. has received honoraria, consultancy, lecture fees or all from Abbott, Merck, Pfizer and GlaxoSmithKline. M.B. has received honoraria, consultancy fees or both from Abbott, Boehringer Ingelheim, Bristol Myers Squibb, Gilead, GlaxoSmithKline, Roche, Pfizer and Tibotec. J.G. has received research grants or honoraria for lectures or advisory boards from Gilead, Abbott, Bristol Myers Squibb, Janssen, Boehringer Ingelheim, Merck and GlaxoSmithKline. A.N.P. has received honoraria, consultancy, grants or all for research from Boehringer Ingelheim, Pfizer, GlaxoSmithKline, Bristol Myers Squibb, Gilead, Roche, Abbott, Merck and Tibotec. B.L. has received travel grants, grants or honoraria from Abbott, Aventis, Bristol-Myers Squibb, Gilead, GlaxoSmithKline, Merck Sharp & Dohme, Roche and Tibotec. J.D.L. has received honoraria, consultancy, lecture fees or all from Boehringer Ingelheim, Pfizer, GlaxoSmithKline, Bristol Myers Squibb, Gilead, Roche, Merck and Tibotec.
A.M. contributed with discussions regarding study design and statistical analysis, performed all statistical analyses and wrote the manuscript. A.M. had full access to the dataset. O.K. contributed with discussions regarding study design, statistical analysis and provided significant input into the manuscript production. P.R., A.N.P. and B.L. provided input into study design, reviewed data and provided significant input into manuscript production. D.S., M.B. and J.G. coordinated national data collection and provided significant input into manuscript production. J.D.L. initiated the study, provided input into study design and statistical analyses, provided significant input into manuscript production and supervised the project.
The EuroSIDA study group (national coordinators) – Argentina: (M. Losso), C Elias, Hospital JM Ramos Mejia, Buenos Aires. Austria: (N. Vetter) Pulmologisches Zentrum der Stadt Wien, Vienna; (R. Zangerle) Medical University Innsbruck, Innsbruck. Belarus: (I. Karpov), A Vassilenko, Belarus State Medical University, Minsk, VM Mitsura, Gomel State Medical University, Gomel; O Suetnov, Regional AIDS Centre, Svetlogorsk. Belgium: (N. Clumeck) S De Wit, B Poll, Saint-Pierre Hospital, Brussels; R Colebunders, Institute of Tropical Medicine, Antwerp; (L. Vandekerckhove) University Ziekenhuis Gent, Gent. Bosnia: (V. Hadziosmanovic) Klinicki Centar Univerziteta Sarajevo, Sarajevo. Bulgaria: (K. Kostov), Infectious Diseases Hospital, Sofia. Croatia: (J. Begovac), University Hospital of Infectious Diseases, Zagreb. Czech Republic: (L. Machala) H Rozsypal, Faculty Hospital Bulovka, Prague; (D. Sedlacek), Charles University Hospital, Plzen. Denmark: (J. Nielsen, G. Kronborg, T. Benfield, M. Larsen), Hvidovre Hospital, Copenhagen; (J. Gerstoft, T. Katzenstein, A-B. E. Hansen, P. Skinhøj), Rigshospitalet, Copenhagen; (C. Pedersen), Odense University Hospital, Odense; (L. Oestergaard), Skejby Hospital, Aarhus. Estonia: (K. Zilmer) West-Tallinn Central Hospital, Tallinn, Jelena Smidt, Nakkusosakond Siseklinik, Kohtla-Järve. Finland: (M. Ristola), Helsinki University Central Hospital, Helsinki. France: (C. Katlama) Hôpital de la Pitié-Salpétière, Paris; (J-P. Viard), Hôpital Necker-Enfants Malades, Paris; (P-M. Girard), Hospital Saint-Antoine, Paris; (J.M. Livrozet), Hôpital Edouard Herriot, Lyon; (P. Vanhems), University Claude Bernard, Lyon; (C. Pradier), Hôpital de l'Archet, Nice; (F. Dabis, D. Neau), Unité INSERM, Bordeaux. Germany: (J. Rockstroh), Universitäts Klinik Bonn; (R. Schmidt), Medizinische Hochschule Hannover; (J. van Lunzen, O. Degen), University Medical Center Hamburg-Eppendorf, Infectious Diseases Unit, Hamburg; (H.J. Stellbrink), IPM Study Center, Hamburg; (S. Staszewski), JW Goethe University Hospital, Frankfurt; (J. Bogner), Medizinische Poliklinik, Munich; (G. Fätkenheuer), Universität Köln, Cologne. Greece: (J. Kosmidis, P. Gargalianos, G. Xylomenos, J. Perdios, Athens General Hospital; (G. Panos, A. Filandras, E. Karabatsaki), 1st IKA Hospital; (H. Sambatakou), Ippokration Genereal Hospital, Athens. Hungary: (D. Banhegyi) Szent Lásló Hospital, Budapest. Ireland: (F. Mulcahy) St. James's Hospital, Dublin. Israel: (I. Yust, D. Turner, M. Burke), Ichilov Hospital, Tel Aviv; (S. Pollack, G. Hassoun), Rambam Medical Center, Haifa; (S. Maayan), Hadassah University Hospital, Jerusalem. Italy: (A. Chiesi) Istituto Superiore di Sanità, Rome; (R. Esposito, I. Mazeu, C. Mussini), Università Modena, Modena; (C. Arici), Ospedale Riuniti, Bergamo; (R. Pristera), Ospedale Generale Regionale, Bolzano; (F. Mazzotta, A. Gabbuti), Ospedale S Maria Annunziata, Firenze; (V. Vullo, M. Lichtner), University di Roma la Sapienza, Rome; (A. Chirianni, E. Montesarchio, M. Gargiulo), Presidio Ospedaliero AD Cotugno, Monaldi Hospital, Napoli; (G. Antonucci, F. Iacomi, P. Narciso, C. Vlassi, M. Zaccarelli), Istituto Nazionale Malattie Infettive Lazzaro Spallanzani, Rome; (A. Lazzarin, R. Finazzi), Ospedale San Raffaele, Milan; (M. Galli, A. Ridolfo), Osp. L. Sacco, Milan; (A. d'Arminio Monforte), Istituto Di Clinica Malattie Infettive e Tropicale, Milan. Latvia: (B. Rozentale) P Aldins, Infectology Centre of Latvia, Riga. Lithuania: (S. Chaplinskas) Lithuanian AIDS Centre, Vilnius. Luxembourg: (R. Hemmer, T. Staub), Centre Hospitalier, Luxembourg. The Netherlands: (P. Reiss) Academisch Medisch Centrum bij de Universiteit van Amsterdam, Amsterdam. Norway: (J. Bruun, A. Maeland, V. Ormaasen), Ullevål Hospital, Oslo. Poland: (B. Knysz, J. Gasiorowski), Medical University, Wroclaw; (A. Horban, E. Bakowska), Centrum Diagnostyki i Terapii AIDS, Warsaw; (D. Prokopowicz, R. Flisiak), Medical University, Bialystok; (A. Boron-Kaczmarska, M. Pynka), Medical Univesity, Szczecin; (M. Beniowski, E. Mularska), Osrodek Diagnostyki i Terapii AIDS, Chorzow; (H. Trocha), Medical University, Gdansk; (E. Jablonowska, E. Malolepsza, K. Wojcik), Wojewodzki Szpital Specjalistyczny, Lodz. Portugal: (F. Antunes, E. Valadas), Hospital Santa Maria, Lisbon; (K. Mansinho), Hospital de Egas Moniz, Lisbon; (F. Maltez), Hospital Curry Cabral, Lisbon. Romania: (D. Duiculescu) Spitalul de Boli Infectioase si Tropicale: Dr Victor Babes, Bucarest. Russia: (A. Rakhmanova), Medical Academy Botkin Hospital, St Petersburg; (E. Vinogradova), St Petersburg AIDS Centre, St Peterburg; (S. Buzunova), Novgorod Centre for AIDS, Novgorod. Serbia: (D. Jevtovic), The Institute for Infectious and Tropical Diseases, Belgrade. Slovakia: (M. Mokráš, D. Staneková), Dérer Hospital, Bratislava. Slovenia: (J. Tomazic) University Clinical Centre Ljubljana, Ljubljana. Spain: (J. González-Lahoz, V. Soriano, L. Martin-Carbonero, P. Labarga), Hospital Carlos III, Madrid; (S. Moreno) Hospital Ramon y Cajal, Madrid; (B. Clotet, A. Jou, R. Paredes, C. Tural, J. Puig, I. Bravo), Hospital Germans Trias i Pujol, Badalona; (J.M. Gatell, J.M. Miró), Hospital Clinic i Provincial, Barcelona; (P. Domingo, M. Gutierrez, G. Mateo, M.A. Sambeat), Hospital Sant Pau, Barcelona. Sweden: (A. Karlsson), Karolinska University Hospital, Stockholm; (P.O. Persson), Karolinska University Hospital, Huddinge; (L. Flamholc), Malmö University Hospital, Malmö. Switzerland: (B. Ledergerber, R. Weber), University Hospital, Zürich; (P. Francioli, M. Cavassini), Centre Hospitalier Universitaire Vaudois, Lausanne; (B. Hirschel, E. Boffi), Hospital Cantonal Universitaire de Geneve, Geneve; (H. Furrer), Inselspital Bern, Bern; (M. Battegay, L. Elzi), University Hospital Basel. Ukraine: (E. Kravchenko, N. Chentsova), Kiev Centre for AIDS, Kiev; (G. Kutsyna) Luhansk AIDS Center, Luhansk; (S. Servitskiy), Odessa Region AIDS Center, Odessa; (S. Antoniak) Kiev; (M. Krasnov) Kharkov State Medical University, Kharkov. United Kingdom: (S. Barton) St Stephen's Clinic, Chelsea and Westminster Hospital, London; (A.M. Johnson, D. Mercey), Royal Free and University College London Medical School, London (University College Campus); (A. Phillips, M.A. Johnson, A. Mocroft), Royal Free and University College Medical School, London (Royal Free Campus); (M. Murphy), Medical College of Saint Bartholomew's Hospital, London; (J. Weber, G. Scullard), Imperial College School of Medicine at St Mary's, London; (M. Fisher), Royal Sussex County Hospital, Brighton; (C. Leen), Western General Hospital, Edinburgh.
Virology group: B. Clotet, R. Paredes (Central Coordinators) along with ad-hoc virologists from participating sites in the EuroSIDA Study.
Steering Committee: F. Antunes, B. Clotet, D. Duiculescu, J. Gatell, B. Gazzard, A. Horban, A. Karlsson, C. Katlama, B. Ledergerber (Chair), A. D'Arminio Montforte, A. Phillips, A. Rakhmanova, P. Reiss (Vice-Chair), J. Rockstroh.
Coordinating Centre Staff: J. Lundgren (project leader), O. Kirk, A. Mocroft, N. Friis-Møller, A. Cozzi-Lepri, W. Bannister, M. Ellefson, A. Borch, D. Podlekareva, J. Kjær, L. Peters, J. Reekie, J. Kowalska.
1. Wyatt CM, Klotman PE. Antiretroviral therapy and the kidney: balancing benefit and risk in patients with HIV infection. Expert Opin Drug Saf 2006; 5:275–287.
2. Gupta SK, Eustace JA, Winston JA, Boydstun II, Ahuja TS, Rodriguez RA, et al
. Guidelines for the management of chronic kidney disease in HIV-infected patients: recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2005; 40:1559–1585.
3. Szczech LA, Hoover DR, Feldman JG, Cohen MH, Gange SJ, Gooze L, et al
. Association between renal disease and outcomes among HIV-infected women receiving or not receiving antiretroviral therapy. Clin Infect Dis 2004; 39:1199–1206.
4. Gardner LI, Holmberg SD, Williamson JM, Szczech LA, Carpenter CC, Rompalo AM, et al
. Development of proteinuria or elevated serum creatinine and mortality in HIV-infected women. J Acquir Immune Defic Syndr 2003; 32:203–209.
5. Marras D, Bruggeman LA, Gao F, Tanji N, Mansukhani MM, Cara A, et al
. Replication and compartmentalization of HIV-1 in kidney epithelium of patients with HIV-associated nephropathy. Nat Med 2002; 8:522–526.
6. Cheng JT, Anderson HL Jr, Markowitz GS, Appel GB, Pogue VA, D'Agati VD. Hepatitis C virus-associated glomerular disease in patients with human immunodeficiency virus coinfection. J Am Soc Nephrol 1999; 10:1566–1574.
7. Szczech LA, Gupta SK, Habash R, Guasch A, Kalayjian R, Appel R, et al
. The clinical epidemiology and course of the spectrum of renal diseases associated with HIV infection. Kidney Int 2004; 66:1145–1152.
8. Szczech LA, Kalayjian R, Rodriguez R, Gupta S, Coladonato J, Winston J. The clinical characteristics and antiretroviral dosing patterns of HIV-infected patients receiving dialysis. Kidney Int 2003; 63:2295–2301.
9. Kimmel PL, Phillips TM, Ferreira-Centeno A, Farkas-Szallasi T, Abraham AA, Garrett CT. Brief report: idiotypic IgA nephropathy in patients with human immunodeficiency virus infection. N Engl J Med 1992; 327:702–706.
10. Ross MJ, Klotman PE. Recent progress in HIV-associated nephropathy. J Am Soc Nephrol 2002; 13:2997–3004.
11. Weiner NJ, Goodman JW, Kimmel PL. The HIV-associated renal diseases: current insight into pathogenesis and treatment. Kidney Int 2003; 63:1618–1631.
12. Wali RK, Drachenberg CI, Papadimitriou JC, Keay S, Ramos E. HIV-1-associated nephropathy and response to highly-active antiretroviral therapy. Lancet 1998; 352:783–784.
13. Szczech LA, Edwards LJ, Sanders LL, van der HC, Bartlett JA, Heald AE, Svetkey LP. Protease inhibitors are associated with a slowed progression of HIV-related renal diseases. Clin Nephrol 2002; 57:336–341.
14. Cosgrove CJ, bu-Alfa AK, Perazella MA. Observations on HIV-associated renal disease in the era of highly active antiretroviral therapy. Am J Med Sci 2002; 323:102–106.
15. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999; 130:461–470.
16. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976; 16:31–41.
17. Levey AS. Measurement of renal function in chronic renal disease. Kidney Int 1990; 38:167–184.
18. Schainuck LI, Striker GE, Cutler RE, Benditt EP. Structural-functional correlations in renal disease. II. The correlations. Hum Pathol 1970; 1:631–641.
19. Striker GE, Schainuck LI, Cutler RE, Benditt EP. Structural–functional correlations in renal disease. I. A method for assaying and classifying histopathologic changes in renal disease. Hum Pathol 1970; 1:615–630.
20. Vrouenraets S, Garcia EF, Wit F, Brinkman K, Hoek F, Krediet R, Reiss P. A comparison between different GFR-estimations and -Iothalamate, the gold standard for GFR-measurements in HIV infected patients on HAART
[abstract #977b]. 15th Conference on Retroviruses and Opportunistic Infections
; February 2008; Boston, Massachusetts, USA.
21. Barraclough K, Er L, Ng F, Harris M, Montaner J, Levin A. A comparison of the predictive performance of different methods of kidney function estimation in a well characterized HIV-infected population. Nephron Clin Pract 2009; 111:c39–c48.
22. Verhave JC, Fesler P, Ribstein J, du CG, Mimran A. Estimation of renal function in subjects with normal serum creatinine levels: influence of age and body mass index. Am J Kidney Dis 2005; 46:233–241.
23. Kohan AD, Armenakas NA, Fracchia JA. Indinavir urolithiasis: an emerging cause of renal colic in patients with human immunodeficiency virus. J Urol 1999; 161:1765–1768.
24. Tashima KT, Horowitz JD, Rosen S. Indinavir nephropathy. N Engl J Med 1997; 336:138–140.
25. Mocroft A, Kirk O, Gatell J, Reiss P, Gargalianos P, Zilmer K, et al
. Chronic renal failure among HIV-1-infected patients. AIDS 2007; 21:1119–1127.
26. Antoniou T, Raboud J, Chirhin S, Yoong D, Govan V, Gough K, et al
. Incidence of and risk factors for tenofovir-induced nephrotoxicity: a retrospective cohort study. HIV Med 2005; 6:284–290.
27. Barrios A, Garcia-Benayas T, Gonzalez-Lahoz J, Soriano V. Tenofovir-related nephrotoxicity in HIV-infected patients. AIDS 2004; 18:960–963.
28. Karras A, Lafaurie M, Furco A, Bourgarit A, Droz D, Sereni D, et al
. Tenofovir-related nephrotoxicity in human immunodeficiency virus-infected patients: three cases of renal failure, Fanconi syndrome, and nephrogenic diabetes insipidus. Clin Infect Dis 2003; 36:1070–1073.
29. Verhelst D, Monge M, Meynard JL, Fouqueray B, Mougenot B, Girard PM, et al
. Fanconi syndrome and renal failure induced by tenofovir: a first case report. Am J Kidney Dis 2002; 40:1331–1333.
30. Olmscheid B. Important renal safety information regarding the use of Viread and Truvada. Dear Dr letter; 2006.
31. Mocroft A, Ledergerber B, Katlama C, Kirk O, Reiss P, d'Arminio MA, et al
. Decline in the AIDS and death rates in the EuroSIDA study: an observational study. Lancet 2003; 362:22–29.
32. Mosteller RD. Simplified calculation of body-surface area. N Engl J Med 1987; 317:1098.
33. Friis-Moller N, Sabin CA, Weber R, d'Arminio MA, El-Sadr WM, Reiss P, et al
. Combination antiretroviral therapy and the risk of myocardial infarction. N Engl J Med 2003; 349:1993–2003.
34. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF III, Feldman HI, et al
. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009; 150:604–612.
35. Campbell LJ, Ibrahim F, Fisher M, Holt SG, Hendry BM, Post FA. Spectrum of chronic kidney disease in HIV-infected patients. HIV Med 2009; 10:329–336.
36. Lucas GM, Lau B, Atta MG, Fine DM, Keruly J, Moore RD. Chronic kidney disease incidence, and progression to end-stage renal disease, in HIV-infected individuals: a tale of two races
. J Infect Dis
37. Fernando SK, Finkelstein FO, Moore BA, Weissman S. Prevalence of chronic kidney disease in an urban HIV infected population. Am J Med Sci 2008; 335:89–94.
38. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis
2002; 39 (2 Suppl 1)
39. Levey AS, Eckardt KU, Tsukamoto Y, Levin A, Coresh J, Rossert J, et al
. Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2005; 67:2089–2100.
40. Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, et al
. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003; 139:137–147.
41. Centers for Disease Control and Prevention. Prevalence of chronic kidney disease and associated risk factors: United States, 1999–2004
. MMWR Morb Mortal Wkly Rep
42. Wyatt CM, Malvestutto C, Coca SG, Klotman PE, Parikh CR. The impact of hepatitis C virus coinfection on HIV-related kidney disease: a systematic review and meta-analysis. AIDS 2008; 22:1799–1807.
43. Choi AI, Shlipak MG, Hunt PW, Martin JN, Deeks SG. HIV-infected persons continue to lose kidney function despite successful antiretroviral therapy. AIDS 2009; 23:2143–2149.
44. Horberg M, Tang B, Towner W, Silverberg M, Bersoff-Matcha S, Hurley L, et al
. Impact of tenofovir on renal function in HIV-infected, antiretroviral-naive patients. J Acquir Immune Defic Syndr 2010; 53:62–69.
45. Gallant JE, Moore RD. Renal function with use of a tenofovir-containing initial antiretroviral regimen. AIDS 2009; 23:1971–1975.
46. Reid A, Stohr W, Walker AS, Williams IG, Kityo C, Hughes P, et al
. Severe renal dysfunction and risk factors associated with renal impairment in HIV-infected adults in Africa initiating antiretroviral therapy. Clin Infect Dis 2008; 46:1271–1281.
47. Daugas E, Rougier JP, Hill G. HAART-related nephropathies in HIV-infected patients. Kidney Int 2005; 67:393–403.
48. Winston A, Amin J, Mallon P, Marriott D, Carr A, Cooper DA, Emery S. Minor changes in calculated creatinine clearance and anion-gap are associated with tenofovir disoproxil fumarate-containing highly active antiretroviral therapy. HIV Med 2006; 7:105–111.
49. Gallant JE, Dejesus E, Arribas JR, Pozniak AL, Gazzard B, Campo RE, et al
. Tenofovir DF, emtricitabine, and efavirenz vs. zidovudine, lamivudine, and efavirenz for HIV. N Engl J Med 2006; 354:251–260.
50. Gitman MD, Hirschwerk D, Baskin CH, Singhal PC. Tenofovir-induced kidney injury. Expert Opin Drug Saf 2007; 6:155–164.
51. Cihlar T, Ray AS, Laflamme G, Vela JE, Tong L, Fuller MD, et al
. Molecular assessment of the potential for renal drug interactions between tenofovir and HIV protease inhibitors. Antivir Ther 2007; 12:267–272.
52. Kiser JJ, Carten ML, Aquilante CL, Anderson PL, Wolfe P, King TM, et al
. The effect of lopinavir/ritonavir on the renal clearance of tenofovir in HIV-infected patients. Clin Pharmacol Ther 2008; 83:265–272.
53. Ray AS, Wright MR, Rhodes GR. Lack of evidence for an effect of lopinavir/ritonavir on tenofovir renal clearance. Clin Pharmacol Ther 2008; 84:660.
54. Goicoechea M, Liu S, Best B, Sun S, Jain S, Kemper C, et al
. Greater tenofovir-associated renal function decline with protease inhibitor-based versus nonnucleoside reverse-transcriptase inhibitor-based therapy. J Infect Dis 2008; 197:102–108.
55. Gagnon RF, Tecimer SN, Watters AK, Tsoukas CM. Prospective study of urinalysis abnormalities in HIV-positive individuals treated with indinavir. Am J Kidney Dis 2000; 36:507–515.
57. Izzedine H, M'rad MB, Bardier A, Daudon M, Salmon D. Atazanavir crystal nephropathy. AIDS 2007; 21:2357–2358.
58. Anderson PL, Lichtenstein KA, Gerig NE, Kiser JJ, Bushman LR. Atazanavir-containing renal calculi in an HIV-infected patient. AIDS 2007; 21:1060–1062.
59. Pacanowski J, Poirier JM, Petit I, Meynard JL, Girard PM. Atazanavir urinary stones in an HIV-infected patient. AIDS 2006; 20:2131.
60. Chan-Tack KM, Truffa MM, Struble KA, Birnkrant DB. Atazanavir-associated nephrolithiasis: cases from the US Food and Drug Administration's Adverse Event Reporting System. AIDS 2007; 21:1215–1218.
61. Chang HR, Pella PM. Atazanavir urolithiasis. N Engl J Med 2006; 355:2158–2159.
62. Brewster UC, Perazella MA. Acute interstitial nephritis associated with atazanavir, a new protease inhibitor. Am J Kidney Dis 2004; 44:e81–e84.
63. Reyataz Product Information. Princeton, New Jersey, USA: Bristol Myers Squibb Co.; 2010.
64. Invirase Product Information. Hoffmann La Roche Ltd.; 2010.
65. Kaletra Product Information. Abbott Pharmaceuticals Ltd.; 2010.
66. Van BW, Vanholder R, Veys N, Verbeke F, Delanghe J, De BD, Lameire N. The importance of standardization of creatinine in the implementation of guidelines and recommendations for CKD: implications for CKD management programmes
. Nephrol Dial Transplant