AIDS. 2014 Jun 1;28(9):1289-95.

A chronic kidney disease risk score to determine tenofovir safety in a prospective cohort of HIV-positive male veterans.

Scherzer R1, Gandhi M, Estrella MM, Tien PC, Deeks SG, Grunfeld C, Peralta CA, Shlipak MG.

1 Department of Medicine, University of California, San Francisco bSan Francisco VA Medical Center cPositive Health Program, San Francisco General Hospital, San Francisco, California dSchool of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.

 

Abstract

OBJECTIVE: Tenofovir disoproxil fumarate is a widely used antiretroviral for HIV infection that has been associated with an increased risk of chronic kidney disease (CKD). Our objective was to derive a scoring system to predict 5-year risk of developing CKD in HIV-infected individuals and to estimate difference in risk associated with tenofovir use.

DESIGN: We evaluated time to first occurrence of CKD (estimated glomerular filtration rate <60 ml/min per 1.73 m(2)) in 21 590 HIV-infected men from the Veterans Health Administration initiating antiretroviral therapy from 1997 to 2010.

METHODS: We developed a point-based score using multivariable Cox regression models. Median follow-up was 6.3 years, during which 2059 CKD events occurred.

RESULTS: Dominant contributors to the CKD risk score were traditional kidney risk factors (age, glucose, SBP, hypertension, triglycerides, proteinuria); CD4(+) cell count was also a component, but not HIV RNA. The overall 5-year event rate was 7.7% in tenofovir users and 3.8% in nonusers [overall adjusted hazard ratio 2.0, 95% confidence interval (CI) 1.8-2.2]. There was a progressive increase in 5-year CKD risk, ranging from less than 1% (zero points) to 16% (≥9 points) in nonusers of tenofovir, and from 1.4 to 21.4% among tenofovir users. The estimated number-needed-to-harm (NNH) for tenofovir use ranged from 108 for those with zero points to 20 for persons with at least nine points. Among tenofovir users with at least 1 year exposure, NNH ranged from 68 (zero points) to five (≥9 points).

CONCLUSION: The CKD risk score can be used to predict an HIV-infected individual’s absolute risk of developing CKD over 5 years and may facilitate clinical decision-making around tenofovir use.

PMID: 24922479

 

SUPPLEMENTS:

Use of highly active antiretroviral therapies has dramatically reduced morbidity and mortality in HIV-infected persons, and yet HIV disease remains associated with early onset of kidney disease.  Tenofovir disoproxil fumarate (TDF) is a first-line, widely used treatment of HIV which has been associated with an increased risk of kidney disease.  There is a need for individualized decision making, to weigh the risks and benefits of using TDF.

Our paper used information from the Veterans Health Administration (VHA) Cohort to predict an HIV-infected person’s chance of developing chronic kidney disease (CKD) over 5 years, and to estimate the difference in risk associated with using TDF. We created an online risk assessment calculator, which is available here:  http://hivinsite.ucsf.edu/InSite?page=md-calculator

This tool is designed for HIV-infected adult men who do not have CKD and have not yet started antiretroviral therapy.

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