Department of Infectious Diseases, Ramon y Cajal Hospital, Madrid, Spain.
Nephrol Dial Transplant. 2013 Aug;28(8):2073-81. doi: 10.1093/ndt/gft210. Epub 2013 Jun 5.
To determine the incidence and significance of acute kidney injury (AKI) after initiating highly active antiretroviral therapy (HAART).
A prospective cohort study of 271 consecutively treated HIV-infected patients, initiating first (75) or sequential HAART (196) from January 2008 to June 2011. AKI was diagnosed according to the Risk, Injury, Failure, Loss of kidney function, End-stage renal disease (RIFLE)/Acute Kidney Injury Network (AKIN) criteria, and the risk of progression to chronic kidney disease (CKD) was evaluated.
A greater estimated glomerular filtration rate (eGFR) decrease after 1 year was observed for patients initiating a tenofovir disoproxil fumarate (TDF)-based regimen (-6.45 versus +0.98 mL/min/1.73 m(2) when compared with patients without TDF; P < 0.01), both in the case of the first (-8.5 versus -2.27; P = 0.04) or successive regimens (-5.3 versus + 1.18 mL/min/1.73 m(2); P < 0.01). AKI, as defined, was observed in 10% (28 cases, 6.98 episodes/100 patients-year), mostly stage I (27 cases), in a median time of 6 (3-16.5) months. Four cases (14%), having a worse baseline renal function progressed to CKD, whereas four recovered completely. In the multivariate analysis, AKI was associated with the concomitant use of cotrimoxazole prophylaxis and to low CD4+ count. CKD was diagnosed in 2% (six cases) of patients. Therefore, the overall rate of HAART-associated renal disorders was 11% (30 cases, 7.46 episodes/100 patients-year (95% confidence interval, 6.09-8.83).
The initiation of a tenofovir-based regimen is followed by a significant decline in eGFR, although it could be misinterpreted by the concomitant use of cotrimoxazole. A substantial proportion of patients develop AKI, but only a minority progress to CKD. Patients initiating HAART and developing AKI should be carefully monitored for progression of renal disease.
确定开始高效抗逆转录病毒治疗（HAART）后急性肾损伤（AKI）的发生率和意义。
对 2008 年 1 月至 2011 年 6 月期间连续治疗的 271 例 HIV 感染患者进行前瞻性队列研究，开始首次（75 例）或序贯 HAART（196 例）。根据风险、损伤、衰竭、丧失肾功能、终末期肾病（RIFLE）/急性肾损伤网络（AKIN）标准诊断 AKI，并评估进展为慢性肾脏病（CKD）的风险。
与未使用替诺福韦二吡呋酯（TDF）的患者相比，接受 TDF 为基础方案治疗的患者在 1 年后肾小球滤过率（eGFR）下降幅度更大（-6.45 与+0.98 mL/min/1.73 m2；P < 0.01），首次（-8.5 与-2.27；P = 0.04）或连续方案（-5.3 与+1.18 mL/min/1.73 m2；P < 0.01）中均如此。定义的 AKI 发生率为 10%（28 例，6.98 例/100 患者-年），主要为 1 期（27 例），中位时间为 6（3-16.5）个月。4 例（14%）患者，肾功能基线较差，进展为 CKD，而 4 例患者完全恢复。多变量分析显示，AKI 与同时使用复方新诺明预防和低 CD4+计数有关。2%（6 例）的患者诊断为 CKD。因此，HAART 相关肾损害的总发生率为 11%（30 例，7.46 例/100 患者-年（95%置信区间，6.09-8.83））。
开始使用 TDF 方案后 eGFR 显著下降，但可能因同时使用复方新诺明而被误解。相当一部分患者发生 AKI，但只有少数患者进展为 CKD。开始 HAART 并发生 AKI 的患者应密切监测肾脏疾病的进展。
