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Relationship between renal dysfunction, nephrotoxicity and death among HIV adults on tenofovir

Brennan, Alanaa,b,c; Evans, Deniseb,e; Maskew, Mhairib,e; Naicker, Saraladevig; Ive, Prudencee; Sanne, Iand,e; Maotoe, Thapelod; Fox, Matthewa,b,c,f

doi: 10.1097/QAD.0b013e32834957da
Basic Science: Concise Communication

Objective: In April 2010, the South African government added tenofovir disoproxil fumarate to its first-line antiretroviral therapy (ART) for HIV patients. We analyzed the relationship between renal dysfunction at tenofovir initiation, nephrotoxicity and mortality.

Design: Cohort analysis of HIV-infected adults who received tenofovir and had a creatinine clearance done at initiation at the Themba Lethu Clinic, Johannesburg, South Africa, between April 2004 and September 2009.

Methods: We estimated the relationship between renal dysfunction, nephrotoxicity [any decline in kidney function from baseline (acute or chronic) that is secondary to a toxin (including drugs)] and mortality for patients initiated onto tenofovir-containing regimens using marginal structural models and inverse probability of treatment weights to correct estimates for lost to follow-up and confounding.

Results: Of 890 patients initiated onto tenofovir, 573 (64.4%) had normal renal function (≥90 ml/min), 271 (30.4%) had mild renal dysfunction (60–89 ml/min) and 46 (5.2%) had moderate renal dysfunction (30–59 ml/min). A total of 2.4% experienced nephrotoxicity, 7.8% died and 9.7% were lost during 48 months of follow-up. Patients with mild [hazard ratio 4.8; 95% confidence interval (CI) 1.5–15.2] or moderate (hazard ratio 15.0; 95% CI 3.4–66.5) renal dysfunction were at greatest risk of nephrotoxicity, whereas those with mild (hazard ratio 1.2; 95% CI 0.7–2.3) or moderate (hazard ratio 3.2; 95% CI 1.3–7.8) renal dysfunction vs. normal renal function were at highest risk of death by 48 months.

Conclusion: Much of the incident renal dysfunction in tenofovir patients is likely related to preexisting renal disorder, which may be exacerbated by tenofovir. With expanded use of tenofovir, screening for renal dysfunction prior to initiation and dose adjustment is necessary to help improve ART outcomes.

aCenter for Global Health and Development, Boston University, Boston, Massachusetts, USA

bHealth Economics and Epidemiology Research Office, Johannesburg

cUniversity of Witwatersrand, Johannesburg

dRight to Care, Johannesburg

eClinical HIV Research Unit, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

fDepartment of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA

gDivision of Nephrology, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa.

Correspondence to Center for Global Health and Development, Boston University, Crosstown Center, 3rd Floor, 801 Massachusetts Ave., Boston, MA 02118, USA. Tel: +1 617 414 1260; e-mail:

Received 3 November, 2010

Revised 6 May, 2011

Accepted 31 May, 2011

© 2011 Lippincott Williams & Wilkins, Inc.