Renal function during tenofovir‑based antiretroviral therapy among people living with HIV in Lilongwe, Malawi: findings from the prospective LighTen cohort study

TL;DR

This study found that tenofovir-based HIV treatment in Malawi did not harm kidney function and may have even improved it over three years.

Contribution

The study provides real-world evidence that TDF-based ART can be safely used without pre-treatment kidney tests in resource-limited settings.

Findings

Tenofovir-based ART was not associated with a decline in estimated glomerular filtration rate (eGFR) over 36 months.

An unexpected trend of improved renal function was observed in people living with HIV.

Baseline eGFR and WHO clinical stage were significant factors influencing changes in kidney function.

Abstract

Most first-line antiretroviral therapy (ART) regimes in Sub-Saharan Africa contain tenofovir disoproxil fumarate (TDF) which has a nephrotoxic potential. Baseline renal function assessment is not feasible in many settings and therefore not required prior to starting ART according to Malawian guidelines. We assessed renal function over 36 months in people living with HIV (PLHIV) starting TDF-based ART at Lighthouse Clinic, Lilongwe, Malawi.

Data on demographics, medical history, laboratory values, WHO stage, and anthropometric measures were collected at study entry and during visits at 1, 3, 6 months, and every 6 months until month 36. The main outcome of the study was renal function, defined by the estimated glomerular filtration rate (eGFR) calculated using the CKD-EPI equation. Descriptive statistics and multivariable linear regression analysis were performed.

A baseline creatinine value was available for 1,430 PLHIV (57% female, mean age ± SD 36.0 ± 9.3 years). Of these, 443 PLHIV (62% female) were observed until month 36. Factors associated with changes in eGFR over time included baseline log-transformed eGFR (coefficient = −0.787; p < 0.001), MAP at baseline, and initial WHO clinical HIV stage. The overall trend in eGFR categories indicated a shift towards lower classes.

In this large cohort of PLHIV, TDF did not result in a decline in eGFR. Indeed, an unexpected trend of improved renal function was observed. Even though findings need to be interpreted with caution due to considerable attrition, our results suggest TDF can be administered safely in resource-limited settings where ART decisions are frequently made without pre-treatment renal assessment.

The online version contains supplementary material available at 10.1186/s12879-026-12675-2.

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