Abstract
ObjectiveRitonavir-boosted protease inhibitors (bPI) in people living with HIV (PLWH) have been associated with renal impairment. Limited data are available from rural sub-Saharan Africa.MethodsUsing data from the Kilombero and Ulanga Antiretroviral Cohort Study (KIULARCO) in rural Tanzania from 2005-01/2020, we assessed the prevalence of renal impairment (estimated glomerular filtration rate <60 mL/min/1.73m2) at the time of switch from first-line antiretroviral treatment (ART) to bPI-regimen and the incidence of renal impairment on bPI. We assessed risk factors for renal impairment using logistic and Cox regression models.ResultsRenal impairment was present in 52/687 PLWH (7.6%) at the switch to bPI. Among 556 participants with normal kidney function at switch, 41 (7.4%) developed renal impairment after a median time of 3.5 (IQR 1.6–5.1) years (incidence 22/1,000 person-years (95%CI 16.1–29.8)). Factors associated with renal impairment at switch were older age (adjusted odds ratio (aOR) 1.55 per 10 years; 95%CI 1.15–2.11), body mass index (BMI) <18.5 kg/m2 (aOR 2.80 versus ≥18kg/m2; 95%CI 1.28–6.14) and arterial hypertension (aOR 2.33; 95%CI 1.03–5.28). The risk of renal impairment was lower with increased duration of ART use (aOR 0.78 per one-year increase; 95%CI 0.67–0.91). The renal impairment incidence under bPI was associated with older age (adjusted hazard ratio 2.01 per 10 years; 95%CI 1.46–2.78).ConclusionsIn PLWH in rural sub-Saharan Africa, prevalence and incidence of renal impairment among those who were switched from first-line to bPI-regimens were high. We found associations between renal impairment and older age, arterial hypertension, low BMI and time on ART.
Highlights
Factors associated with renal impairment at switch were older age (adjusted odds ratio 1.55 per 10 years; 95%confidence intervals (CI) 1.15–2.11), body mass index (BMI)
The risk of renal impairment was lower with increased duration of antiretroviral treatment (ART) use
The renal impairment incidence under boosted protease inhibitors (bPI) was associated with older age
Summary
Rollout and improvement in HIV care and treatment have led to a shift in the main causes of morbidity and mortality in people living with HIV (PLWH) away from opportunistic infections to chronic non-communicable diseases such as liver, cardiovascular and renal diseases [1]. With a global prevalence of 11–13% [2], chronic kidney disease (CKD) is regarded as an independent risk factor for cardiovascular diseases (CVD) and a leading cause of mortality and morbidity in PLWH [3, 4]. For second-line treatment, the same guidelines recommend the use of TDF in combination with ritonavir-boosted protease inhibitors (bPI)—either atazanavir (ATV/r) or lopinavir (LPV/r). Longer cumulative exposure to the use of TDF [12, 13] and bPIs [14, 15] has been associated with CKD or kidney dysfunction. The risk of kidney dysfunction increases when patients receive TDF in combination with a bPI [15,16,17]. The mechanism of CKD is not well understood, previous studies suggested it might be due to crystalluria, proximal tubular dysfunction, urolithiasis, and interstitial nephritis [18, 19]
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