| Objective: To identify the risk factors for kidney damage in HIV infection/AIDS patients(abbreviated as HIV/AIDS patients)after antiviral therapy(ART).To assess whether there were differences in estimated glomerular filtration rate(e GFR)between the regiment contained AZT and the regiment contained TDF at 3th,6th,9th,12 th,15th,18 th,21th,24 th,27th,30 th,33th,36 th,39th,42 th,45th,48 th,51th,54 th,57th,and 60 th months of follow-up at different time points.To determine the efficacy of different intervention strategies after kidney damage in patients with initial antiviral regimen contain TDF.Methods: A total of 2043 patients who were treated in the Care Clinic of Liuzhou City People’s Hospital from January 1,2004 to June 30,2022 were retrospectively analyzed.Five patients aged <14 years old,21 patients without initial antiviral regimen,120 patients with non-first-line antiviral regimen and 133 patients without baseline e GFR were excluded.There were 934 patients with no e GFR follow-up record or too many missing follow-up records,24 patients with baseline e GFR<60 ml/min/1.73m2 were excluded,and 806 patients with HIV/AIDS were finally included.The gender,age,body mass index,route of transmission,marital status,baseline CD4+T lymphocyte count,baseline viral load,baseline hemoglobin,baseline e GFR,baseline alanine aminotransferase,baseline aspartate aminotransferase,hepatitis B surface antigen,hepatitis C antibody,etc.,as well as e GFR at the 3rd,6th,9th to 60 th months after ART were collected for patients in each group.The measurement data conforming to normal distribution are expressed by mean ± standard deviation((?)±s),and the measurement data conforming to non-normal distribution were expressed by median and quartile [M(Q1,Q3)].The ROC curve was used to obtain the best diagnostic value of the log baseline viral load value.The comparison of baseline measurement data was performed by group t-test,and the comparison of enumeration data was performed by 2-test.The risk factors of renal impairment in HIV/AIDS patients during antiviral therapy were analyzed by binary logistic regression,and the predictive model of renal impairment was developed according to the B value of multivariate analysis.Generalized estimating equations were used to assess whether differences in e GFR between regimens and at each time point were statistically significant.The time to renal impairment was calculated for the AZT-containing regimen and the TDF-containing regimen,and the generalized estimating equation was used to assess whether there was statistical differences between the regimens after the renal impairment occurred in the TDF-containing regimen.The above statistical analysis was performed using SPSS 25.0,and the difference was statistical differences with P<0.05.Results:(1)The e GFR<60ml/min/1.73m2 was defined as the criterion for changing antiviral regimen in case of renal impairment.In this study,86 patients(10.7%)had renal impairment and 720 patients(89.3%)had no renal impairment.There were 563 patients(69.9%)baseline age <50 years and 243 patients(30.1%)baseline age ≥50 years.There were 239(48.4%)patients with baseline Lg VL<4.32 and 255(51.6%)patients with baseline Lg VL≥4.32.There were 576(71.9%)patients baseline HB≥110g/L,and 225(28.1%)patients baseline HB<110g/L.There were 674(84.6%)patients baseline AST≤40U/L and 123(15.4%)patients baseline AST>40U/L.There were 670(83.1%)patients baseline e GFR ≥90ml/min/1.73m2 and 136(16.9%)patients baseline e GFR 60-89ml/min/1.73m2.There were 375(46.5%)patients who received TDF regimen and 431(53.5%)patients who received AZT regimen.(2)Univariate analysis showed significant differences in baseline age(P<0.01),baseline Lg VL(P=0.016),baseline HB(P=0.001),baseline AST(P=0.033),baseline e GFR(P<0.01),and antiviral regimen(P<0.01)among HIV/AIDS patients.(3)Binary logistic regression analysis suggested that baseline age(P<0.01,OR:6.069,95%CI:3.020-12.196),antiviral regimen(P=0.018,OR:2.240,95%CI : 1.147-4.373),baseline e GFR(P<0.01,OR:7.373,95%CI : 3.820-14.233)were independent risk factor for renal function in HIV/AIDS patients after antiviral therapy.(4)Those univariate analysis meaningful factors and baseline CD4+T lymphocyte counts were included in multivariate analysis,and corresponding scores were assigned according to the B value of multivariate table to establish the prediction model of kidney damage: Baseline age(>50 years old is 1,≤50 years old is 0)*5+ initial antiviral regimens(antiviral regiments contained TDF is 1,antiviral regiments contained AZT is 0)*2+ baseline e GFR(60-89 ml/min/1.73m2 is 1,≥90 ml/min/1.73 m2 is 0)*4+ baseline CD4+T lymphocyte counts(<200μL-1 is 1,≥200μL-1 is 0)*1.According to the ROC curve,the best diagnostic value was 4.5,the area under the curve was 0.834,P<0.01,the sensitivity was 0.826,and the specificity was 0.714.(5)Generalized estimation equation analysis showed that with the extension of antiviral time,e GFR in both the TDF containing antiviral regiments and AZT containing antiviral regiments groups showed a similar downward trend,and e GFR of the two antiviral regiments(Wald 2=40.786,P<0.01)and different follow-up times(Wald 2=262.838,P<0.01)were statistically significant.(6)In this study,a total of 86 patients developed kidney damage during the follow-up period,and the median time of kidney damage was 28.5th(11.25 th,45th)months.There were 27 cases of kidney damage in patients with AZT antiviral regiments,and the median time of kidney damage was 36th(18th,54th)months.There were 59 patients with TDF antiviral regiments,and the median time of renal injury was 27th(9th,42th)months.(7)After kidney damage occurred in patients with TDF included in the initial antiviral therapy regimen,there were three dressing changes,among which 41 cases were treated with reduced dosage regimen,9 cases were treated with simplified regimen,and 9 cases were treated with AZT.There were significant differences in the e GFR of the three replacement regimens(Wald 2=17.231,P<0.01)and follow-up time(Wald 2=46.188,P<0.01).There was no statistically significant difference between the reduction scheme and the scheme containing AZT(Wald 2=0.156,P=0.693),but there was statistically significant difference between the simplified scheme and the scheme containing AZT(Wald 2=10.996,P=0.001).Conclusion:(1)Patients with baseline age > 50 years,low baseline e GFR,and initial antiviral regimen contained TDF are more likely to develop renal impairment after antiviral therapy.For older patients with low baseline e GFR,the TDF regimen should be avoided.Patients who choose the TDF regimen should be closely monitored for changes in renal function during follow-up.(2)Prediction model of kidney damage(PMKD): Baseline age(>50 years old is 1,≤50 years old is 0)*5+ initial antiviral regimens(antiviral regiments contained TDF is 1,antiviral regiments contained AZT is 0)*2+ baseline e GFR(60-89 ml/min/1.73m2 is 1,≥90 ml/min/1.73 m2 is 0)*4+ baseline CD4+T lymphocyte counts(<200μL-1 is 1,≥200μL-1 is 0)*1.Patient with PMKD ≥4.5 has a higher risk of kidney damage.(3)Patients with initial antiviral regimen contained TDF developed kidney damage earlier after antiviral therapy than patients whose antiviral regimen contained AZT.(4)Regardless of the ART option,there is a risk of kidney damage.Choosing a simplified regimen after renal impairment in patients with TDF on the initial antiviral regimen is optimal for renal function recovery. |
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