4.7 Article

Impact of early versus deferred antiretroviral therapy on estimated glomerular filtration rate in HIV-positive individuals in the START trial

Journal

INTERNATIONAL JOURNAL OF ANTIMICROBIAL AGENTS
Volume 50, Issue 3, Pages 453-460

Publisher

ELSEVIER SCIENCE BV
DOI: 10.1016/j.ijantimicag.2017.04.021

Keywords

HIV; Kidney; CKD; HAART; eGFR; START

Funding

  1. National Institutes of Health (NIH), National Institute of Allergy and Infectious Diseases [UM1 AI 068641, UM1-A1120197]
  2. Department of Bioethics at the NIH Clinical Center
  3. National Cancer Institute
  4. National Heart, Lung, and Blood Institute
  5. National Institute of Mental Health
  6. National Institute of Neurological Disorders and Stroke
  7. National Institute of Arthritis and Musculoskeletal Disorders
  8. French Agence Nationale de Recherches sur le SIDA et les Hepatites Virales (ANRS)
  9. Federal Ministry of Education and Research
  10. European AIDS Treatment Network (NEAT)
  11. National Health and Medical Research Council
  12. Medical Research Council
  13. National Institute for Health Research
  14. National Institute of Diabetes and Digestive and Kidney Diseases [R01 DK100272, P01 DK056492, R01 DK112258]
  15. National Institute on Drug Abuse [K24 DA035684, R01 DA026770]
  16. Medical Research Council [MC_UU_12023/23] Funding Source: researchfish

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The impact of early ART initiation (versus deferring) on kidney function has not been studied. START was a randomised comparison of immediate versus deferred ART initiation among HIV-positive persons with CD4(+) (cellsimm(3)) counts >500. Serum creatinine and urine dipstick protein were measured at Months 0, 1, 4, 8 and 12, and annually thereafter. The two arms were compared for changes in eGFR (mL/min/1.73 m(2), calculated by CI94% and >19% of follow-up time, respectively. Overall, 89% started ART using a tenofovir-based regimen. Over 2.1 years median follow-up, mean eGFR was 056 (95% CI 0.003-1.11) higher in the immediate versus deferred arm, which was more prominent after adjustment for current tenofovir or bPI use (1.85, 95% CI 1.21-2.50) and in Black participants (30.1% overall) (3.90, 95% CI 2.84-4.97) versus non-Blacks (1.05, 95% CI 0.33-1.77) (P < 0.001 for interaction). Relative risk for proteinuria in the immediate versus deferred arm was 0.74 (95% CI 0.55-1.00) (P = 0.049). In the short-term, immediate ART initiation was associated with a modestly higher eGFR and lower proteinuria risk versus deferring ART (more pronounced in Black participants). Whether this early benefit translates into a lower risk of CKD requires further follow-up. (C) 2017 Elsevier B.V. and International Society of Chemotherapy. All rights reserved.

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