In adults with HIV infection, immediate initiation of antiretroviral therapy (ART) does not adversely affect long-term kidney disease outcomes compared with delayed ART, according to a study published in Kidney International.
The Strategic Timing of Antiretroviral Treatment (START) trial enrolled 4684 patients with HIV infection, no previous ART, and a CD4 cell count less than 500 cells/mm3. Patients were randomly assigned to immediate versus deferred ART.
Previous START results showed a small but significantly greater decline in the estimated glomerular filtration rate (eGFR) in the deferred ART group at a median follow-up of 2.1 years. The new analysis included extended follow-up to assess kidney health outcomes: chronic kidney disease (CKD) events, kidney failure, renal death, and changes in the eGFR and the urine albumin/creatinine ratio (UACR).
Over a median follow-up of 9.3 years, kidney failure or renal death occurred in 3 years in the immediate ART group and 5 years in the deferred group. On more comprehensive follow-up for a median of 5 years, the annual rate of decline in the eGFR was 1.19 mL/min/1.73 m2 per year, with little or no difference by the timing of ART initiation.
The eGFR trend remained the same after adjustment for UACR, APOL1 risk genotype, and other CKD-related baseline factors. Rates of confirmed UACR of 30 mg/g or greater were also similar between groups.
People with HIV infection are at elevated risk of CKD, related both to HIV itself and to ART exposure. Earlier initiation of ART reduces serious AIDS and non-AIDS events. However, longer exposure might lead to increased treatment toxicity, including kidney injury.
Extended follow-up from the START trial shows similarly low rates of serious CKD events with immediate versus deferred ART for people with HIV infection and high baseline CD4 cell counts. Both groups show a slightly faster decline in the eGFR for age but no significant difference in annual change in the eGFR over 5 years.
The researchers conclude: “Particularly with a shift towards ART regimens with less potential for kidney injury where resources allow, nephrologists and HIV and primary care providers should focus on modifying traditional CKD risk factors to address the increased risk of CKD and CKD progression in people with HIV” [Pelchen-Matthews A, et al.; INSIGHT START Study Group. Long-term impact of immediate versus deferred antiretroviral therapy on kidney health in people with HIV. Kidney Int, published online April 30, 2024. doi: 10.1016/j.kint.2024.04.010].
