Subclinical Tubular Injury in HIV-Infected Individuals on Antiretroviral

Therapy: A Cross-sectional Analysis

Andrew M. Hall, MD, MRCP,1,2 Simon G. Edwards, MD, FRCP,3 Marta Lapsley, MD, FRCPath,4
John O. Connolly, MD, PhD, FRCP,2 Kreesan Chetty, RGN,3 Stephen O’Farrell, RGN,3
Robert J. Unwin, MD, PhD, FRCP,2 and Ian G. Williams, MD, FRCP3,5

Background: Randomized control studies have not shown an association between treatment with tenofovir
(TDF) and clinically significant kidney toxicity. However, multiple cases of renal tubular toxicity have been
described in patients with HIV treated with TDF. It is unclear whether spot urine protein- or albumin-creatinine ratio
is a sufficiently sensitive screening test to detect subclinical renal tubular toxicity in patients with HIV.
Study Design: Cross-sectional.
Setting & Participants: 99 patients with HIV with serum creatinine levels ⬍ 1.70 mg/dL and
dipstick-negative proteinuria; 19 were antiretroviral treatment (ART) naive, 47 were on a TDF regimen,
and 33 were on ART, but with no history of TDF exposure.
Predictor or Factor: Exposure to TDF.
Outcomes: Spot urine concentrations of retinol-binding protein (RBP; a low-molecular-weight protein nor-
mally reabsorbed by the proximal tubule), N-acetyl-␤-D-glucosaminidase (NAG; a proximal tubule lysosomal
enzyme), albumin (A; a marker of glomerular disease), and protein (P; a standard clinical screening test for kidney
pathological states) expressed as a ratio to creatinine (C; URBP/C, UNAG/C, UA/C, and UP/C, respectively).
Results: There were no significant differences in median UA/C (ART-naive, 7.3 mg/g [range, 0-245.8
mg/g]; TDF, 9.0 mg/g [range, 0.1-184.1 mg/g]; and non-TDF, 10.5 mg/g [range, 2.6-261.6 mg/g]; P ⫽
0.8). URBP/C excretion was significantly higher in the TDF group (median, 214.2 ␮g/g [range, 26.8-
17,454.5 ␮g/g]) than in the ART-naive group (92.5 ␮g/g [range, 21.3-3,969.0 ␮g/g]; P ⫽ 0.03); there was
also a trend toward higher values than in the non-TDF group (111.6 ␮g/g [range, 31.0-6,136.3 ␮g/g];
P ⫽ 0.08). UNAG/C excretion was significantly higher in both the TDF (median, 394.7 ␮mol/h/g [range,
140.5-10,851.3 ␮mol/h/g]; P ⫽ 0.01) and non-TDF (406.8 ␮mol/h/g [range, 12.4-8,485.8 ␮mol/h/g]; P ⫽
0.03) groups compared with the ART-naive group (218.6 ␮mol/h/g [range, 56.5-2,876.1 ␮mol/h/g]). UP/C
was significantly higher in the TDF (median, 123.9 mg/g [range, 53.1-566.4 mg/g]) than the non-TDF
group (97.3 mg/g [range, 0-451.3 mg/g]; P ⫽ 0.03). The proportion of patients with evidence of tubular
dysfunction (increased URBP/C and/or UNAG/C) was considerably higher than the proportion with an
increase in UA/C or UP/C in all groups: for ART-naive, 52.6% vs 31.6% vs 25.0%; for TDF, 80.9% vs
29.8% vs 52.2%; and for non-TDF, 81.8% vs 39.4% vs 30.0%. The level of agreement among the
different urinary test results was low.
Limitations: Causality cannot be established from single measurements of urinary markers in a
cross-sectional study.
Conclusions: Patients with HIV had high rates of subclinical proteinuria, but neither UP/C nor UA/C is
sufficiently sensitive alone to detect many of these cases. Patients using TDF have increased URBP/C
and UP/C; the significance of this will need to be determined from longer-term outcome studies.
Am J Kidney Dis 54:1034-1042. © 2009 by the National Kidney Foundation, Inc.

INDEX WORDS: HIV; renal tubule; antiretroviral therapy; tenofovir; proteinuria.

A s survival in HIV patients improves with the

development of more effective antiretrovi-
ral therapy (ART), the balance of kidney disease
attributed to HIV is changing from direct patho-
logical effects of the virus (HIV-associated ne-
phropathy and immune-complex nephropathy)
to ART-related renal toxicity.1,2 Therefore, it is
becoming increasingly important that the burden

From the 1Department of Cell and Developmental Biol-
ogy and 2Centre for Nephrology, University College Lon-
don; 3The Mortimer Market Centre, Camden Primary
Care Trust, London, 4South West Thames Institute for
Renal Research, Epsom and St. Helier University Hospi-
tals National Health Service Trust, Carshalton, and 5Cen-
tre for Sexual Health and HIV Research, University
College London, London, UK.
Received March 17, 2009. Accepted in revised form July 8,
2009. Originally published online as doi:10.1053/j.ajkd.2009.
07.012 on September 24, 2009.
Address correspondence to Andrew M. Hall, MD, MRCP,
Department of Cell and Developmental Biology, UCL, Gower
St, London WC1E 6BT, UK. E-mail: andrew.hall@ucl.ac.uk
© 2009 by the National Kidney Foundation, Inc.
0272-6386/09/5406-0009$36.00/0
doi:10.1053/j.ajkd.2009.07.012

1034 American Journal of Kidney Diseases, Vol 54, No 6 (December), 2009: pp 1034-1042
Subclinical Renal Tubular Injury in HIV Patients
and nature of ART-related kidney disease are
defined and understood. Tenofovir (TDF) is a
widely used and effective antiretroviral drug.
Although randomized control studies have not
shown an association between treatment with
TDF and clinically significant kidney toxicity,3-5
numerous case reports of renal tubular toxicity in
patients using TDF have begun to emerge in the
literature.6-9 In many cases, patients developed
the renal Fanconi syndrome, which results from
dysfunction of the proximal tubule. Fanconi syn-
drome is characterized by phosphaturia and hy-
pophosphatemia, nondiabetic glycosuria, renal
tubular acidosis, and low-molecular-weight pro-
teinuria,10 and has been linked to toxicity from a
number of drugs, including ART.11
Most of the original TDF studies that screened
for renal dysfunction measured only serum creat-
inine (and estimated glomerular filtration rate
[eGFR]) and urine dipstick proteinuria (mainly
albuminuria), which together are primarily mark-
ers of glomerular disease and will not necessarily
detect tubular disease, especially when mild.
Tubular proteinuria, which consists of low-
molecular-weight proteins such as retinol-bind-
ing protein (RBP) and enzymes such as N-acetyl-
␤-D-glucosaminidase (NAG), is a more sensitive
and reliable marker of early proximal tubule
dysfunction.12 RBP is relatively freely filtered by
the glomerulus and almost completely reab-
sorbed along the proximal tubule; its presence in
urine in increased amounts usually indicates de-
fective proximal tubular uptake and/or trans-
port.13 NAG, which is not delivered, but is de-
rived from proximal tubular cells, is a sensitive
index of proximal tubule damage when levels are
increased in urine.14 Their concentrations can be
compared using a urinary marker of glomerular
disease, such as albumin.12 Urine concentrations
of RBP, NAG, and albumin (A) are normally
expressed as a ratio to creatinine (C; URBP/C,
UNAG/C, and UA/C, respectively) to account for
variations in urine concentrations among indi-
viduals. Urine protein-creatinine ratio (UP/C) is
an established clinical screening tool for nephrop-
athy and correlates well with 24-hour total uri-
nary protein excretion15; however, it is not clear
how sensitive it is in detecting tubular disease.
Recently, The National Institute for Clinical
Excellence (NICE) in the United Kingdom has
advocated use of UA/C as a screening tool for
1035
chronic kidney disease (www.nice.org.uk/
Guidance/CG73), because it is well standardized
among laboratories and is less expensive to per-
form than UP/C. However, this may not detect
subclinical renal tubular disease.
We have screened the urine of patients with
HIV without overt kidney disease to investigate:
(1) the prevalence of subclinical renal tubular
disease, (2) whether patients using TDF are at
increased risk of tubular proteinuria, and (3)
whether UP/C or UA/C is sufficiently sensitive to
detect these cases.
METHODS
Study Groups
Ninety-nine adult patients with serum creatinine lev-
els ⬍ 1.70 mg/dL and dipstick-negative proteinuria were
recruited from an HIV outpatient clinic: 19 were ART
naive and 80 were stable on ART. Of these, 47 were
following a regimen containing TDF and 33 were on an
ART regimen without TDF (non-TDF) and had not re-
ceived TDF in the past. Patients in both treatment groups
were stable on their current ART regimen for ⬎ 6 months
and had an HIV RNA level ⬍ 50 copies/mL for at least 3
months before study entry (although not necessarily ⬍ 50
copies/mL at the time of recruitment). None had viral
hepatitis B or C or diabetes (which tends to cause in-
creases in urinary NAG levels16). Patients with a history
of renal disease were excluded.
Urinary Assays
Random spot urine samples obtained during clinic visits
were frozen within 4 hours of collection and stored at
⫺80°C. URBP/C, UNAG/C, UA/C, and UP/C subsequently were
measured. Urinary RBP was measured using a sandwich
microtiter plate enzyme immunoassay with polyclonal anti-
bodies from Dako Ltd (Glostrup, Denmark); the second
antibody was labeled with horseradish peroxidase. Refer-
ence ranges for the healthy adult population have been
established previously.17 Urinary NAG was measured using
a kit from PPR Diagnostics Ltd (London, UK) with a
microtiter plate format direct assay of enzyme activity and
using 2-methoxy-4-(2-nitrovinyl) phenyl-glucosaminide as
substrate. The reference range used was that given by the
manufacturer. Urinary albumin was measured on a Siemens
Advia 2400 Chemistry System (Siemens Healthcare, Cam-
berley, UK) using an immunoturbidimetric (antibody reac-
tion) method, with reagents from Olympus Ltd (Watford,
UK). Urinary creatinine also was measured on a Siemens
Advia 2400 using a modified Jaffé reaction. Urinary protein
was measured using a Roche Integra 800 analyzer (Roche
Diagnostics UK, Burgess Hill, UK).
Clinical Data
Data for demographics, drug and medical history, and rou-
tine laboratory test results were collected from review of clinic
1036 Hall et al

notes and clinic databases; eGFR was calculated using the
Modification of Diet in Renal Disease (MDRD) Study equation
(4-variable isotope-dilution mass spectrometry traceable).18
Statistical Analysis
One-way analysis of variance (for parametric data) or
Kruskal-Wallis test (for nonparametric data) was used to
investigate statistical differences among study groups. When
differences were found, individual groups were compared
with each other using an unpaired t test (for parametric data)
or unpaired Mann-Whitney test (for nonparametric data)
with Bonferroni correction. The relationship between vari-
ables was explored using Spearman correlation coefficient
(rs). P ⬍ 0.05 was considered significant (all P ⬎ 0.9 are
expressed as 0.9). Agreement between different urinary tests
in defining abnormal proteinuria was measured using ␬ test
(0, no agreement to 1, perfect agreement).
and ethnicity. As expected, patients in the ART-
naive group were slightly younger and had higher
plasma HIV RNA levels compared with the 2
treatment groups. Of patients on ART, 94% (44
of 47 in the TDF group and 31 of 33 in the
non-TDF group) had plasma HIV RNA levels ⬍
50 copies/mL at the time of recruitment; only 1
patient had an HIV RNA level ⬎ 400 copies/mL.
There was no significant difference in CD4 counts
(P ⫽ 0.3) between study groups. The non-TDF
group had received ART for a longer median
time than the TDF group, although both groups
had been treated with a similar median total
number of ART drugs.

Ethical Approval eGFR and Serum Phosphate

The study was approved by the National Hospital for
Neurology and Neurosurgery Regional Ethics Committee.
All patients provided written informed consent.
RESULTS
Patient Characteristics
Table 1 lists baseline demographics, ART his-
tory, and laboratory blood test results, along with
data for prevalence of hypertension and poten-
tially nephrotoxic non-HIV therapy in each study
group. The 3 groups were well matched for sex
Median eGFR was ⬎ 90 mL/min/1.73 m2 in
all 3 study groups, and there were no significant
differences among groups (P ⫽ 0.9). Only 1
patient in the study (in the TDF group) had an
eGFR ⬍ 60 mL/min/1.73 m2. Median serum
phosphate level was lower in the TDF group
(2.91 mg/dL [range, 1.42-4.43 mg/dL]) than in
either the ART-naive (3.07 mg/dL [range, 2.42-3.65
mg/dL]) or non-TDF (3.21 mg/dL [range, 1.80-
4.21 mg/dL]) groups (Fig 1). However, these differ-
ences were not statistically significant (P ⫽ 0.2).

Table 1. Demographics, Drug History, and Routine Laboratory Values

ART-Naive TDF Exposed No TDF Exposure

(n ⫽ 19) (n ⫽ 47) (n ⫽ 33) P

Age (y) 36 (26-47) 43 (27-69) 43 (29-65) ANOVA, ⬍0.05; TDF

vs non-TDF, 0.9
Men 95 (18) 91 (43) 91 (30) 0.2
Ethnicity: white 68 (13) 83 (39) 82 (27) 0.2
Time on ART (mo) — 44 (5-146) 86 (6-137) 0.04
Time on TDF therapy (mo) — 32 (3-68) — —
Proportion on protease inhibitor — 47 (22) 33 (11) 0.2
Total number of ART drugs ever received — 5 (3-10) 4 (3-9) 0.1
Proportion exposed to ⱖ 2 classes of ART — 72 (34) 70 (23) 0.2
Proportion on a nephrotoxic drug 21 (4) 17 (8) 27 (9) 0.2
Proportion on NSAIDs 5 (1) 0 (0) 3 (1) 0.2
Proportion on acyclovir 16 (3) 9 (4) 3 (1) 0.2
Proportion on ACEi/Ang II blocker 0 (0) 4 (2) 6 (2) 0.2
Proportion on statin 0 (0) 9 (4) 15 (5) 0.1
Proportion on valproate 0 (0) 0 (0) 3 (1) 0.2
Hypertension 5 (1) 9 (4) 15 (5) 0.2
CD4 count (⫻ 106/L) 370 (20-860) 420 (120-1,140) 440 (200-1,060) 0.3
Viral load (copies/mL) 14,300 (600-430,000) ⬍50 (⬍50-80) ⬍50 (⬍50-4,600) ANOVA, ⬍0.01; TDF
vs non-TDF, 0.9
eGFR (mL/min/1.73 m2) 100 (64-159) 99 (53-147) 98 (62-131) 0.9

Note: Values given as median (range) or percentage (number).

Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; Ang II, angiotensin II; ANOVA, analysis of variance; ART,
antiretroviral therapy; eGFR, estimated glomerular filtration rate; NSAID, nonsteroidal anti-inflammatory drug; TDF, tenofovir.
Subclinical Renal Tubular Injury in HIV Patients 1037

Figure 1. Serum phosphate levels and hypoposphatemia in the study groups. (A) There were no significant differences
among groups in serum phosphate values. Values given as mean (point), median (solid line), 25th and 75th percentiles (box),
range (crosses), and 5th and 95th percentiles (error bars). The dashed line represents the lower limit of the normal adult
range (⬍ 2.48 mg/dL). (B) The proportion of patients in the group exposed to tenofovir (TDF group) who had a serum
phosphate value less than the normal range was greater than in the antiretroviral treatment (ART)-naive group and those with
no exposure to tenofovir (non-TDF group), but this difference was not statistically significant. Conversion factor for serum
phosphate in mg/dL to mmol/L, ⫻0.3229.

The proportion of patients with phosphate values
less than the normal range (⬍2.48 mg/dL) was
greater in the TDF group (11 of 43 [25.6%]) than
either the ART-naive (1 of 17 [5.9%]) or non-TDF
(3 of 32 [9.4%]) groups; however, these differences
were not statistically significant (P ⬎ 0.2).
Urinary Markers
Values for urinary markers in the 3 study
groups are listed in Table 2. URBP/C was signifi-
cantly different among study groups (P ⫽ 0.01).
It was higher in the TDF group than in the
ART-naive group (P ⫽ 0.03), and there also was
a trend toward it being higher than in the non-
TDF group (P ⫽ 0.08; Fig 2A). Within the TDF
group, there was no significant difference in
URBP/C between patients using a protease inhibi-
tor and those who were not (P ⫽ 0.6). Further-
more, there was no significant correlation be-
tween time on TDF therapy and URBP/C (rs ⫽
0.12; P ⫽ 0.4).
UNAG/C also was significantly different among
groups (P ⫽ 0.01). It was higher in the TDF
group than in the ART-naive group (P ⫽ 0.01),
but not the non-TDF group (P ⫽ 0.9). The
non-TDF group also had significantly higher

Table 2. Urinary Markers in Patients With HIV

ART-Naive (n ⫽ 19) TDF (n ⫽ 47) Non-TDF (n ⫽ 33) P

URBP/C (␮g/g C) 92.5 (21.3-3969.0) 214.2 (26.8-17454.5) 111.6 (31.0-6,136.3) ART-naive vs TDF, 0.03;
ART-naive vs non-TDF,
0.9; TDF vs non-TDF, 0.08
UNAG/C (␮mol/h/g C) 218.6 (56.5-2,876.1) 394.7 (140.5-10,851.3) 406.8 (12.4-8,485.8) ART-naive vs TDF, 0.01;
ART-naive vs non-TDF,
0.03; TDF vs non-TDF, 0.9
UA/C (mg/g C) 7.3 (0-245.8) 9.0 (0.1-184.1) 10.5 (2.6-261.6) ART-naive vs TDF, 0.9;
ART-naive vs non-TDF,
0.9; TDF vs non-TDF, 0.9
UP/C (mg/g C) 92.9 (0-336.3) 123.9 (53.1-566.4) 97.3 (0-451.3) ART-naive vs TDF, 0.06;
ART-naive vs non-TDF,
0.9; TDF vs non-TDF, 0.03
Note: Values given as median (range) and expressed as a ratio to urinary creatinine. Conversion factor for a urinary value
expressed per gram of creatinine to a value per millimoles of creatinine, ⫻0.113.
Abbreviations and definitions: ART, antiretroviral treatment; C, creatinine; non-TDF, no exposure to tenofovir; TDF,
exposed to tenofovir; UA/C, urinary albumin-creatinine ratio; UNAG/C, urinary N-acetyl-␤-D-glucosaminidase– creatinine ratio;
UP/C, urinary protein-creatinine ratio; URBP/C, urinary retinol-binding protein– creatinine ratio.
1038 Hall et al

Figure 2. Urinary markers. (A) Urinary retinol-binding protein (RBP)-creatinine (creat) ratio (normal range, ⬍ 159 ␮g/g]) was
higher in the group exposed to tenofovir (TDF group) than either the antiretroviral treatment (ART)-naive group or those with no
exposure to tenofovir (non-TDF group). (B) Urinary N-acetyl-␤-D-glucosaminidase (NAG)-creat ratio (normal range, ⬍ 248
␮mol/h/g) was higher in both the TDF and non-TDF treatment groups compared with the ART-naive group. (C) Urinary
albumin-creat ratio (normal range, ⬍ 22 mg/g) did not differ significantly among the study groups. (D) Urinary protein-creat ratio
(normal range, ⬍ 115 mg/g) was greater in the TDF group than either the ART-naive or non-TDF group. Values given are mean
(point), median (solid line), 25th and 75th percentiles (box), range (crosses), and 5th and 95th percentiles (error bars). Dashed
lines represent the upper limits of the normal range. Conversion factor for a urinary value expressed per gram of creatinine to a
value per millimoles of creatinine, ⫻0.113.

UNAG/C values than the ART-naive group (P ⫽
0.03; Fig 2B). There was no significant correla-
tion between time on ART therapy and UNAG/C
(rs ⫽ 0.17; P ⫽ 0.1).
There were no significant differences among
study groups in UA/C (P ⫽ 0.8; Fig 2C). How-
ever, UP/C was significantly different among
groups (P ⫽ 0.01), with a trend toward a higher
value in the TDF group than in the ART-naive
group (P ⫽ 0.06). UP/C was significantly higher
in the TDF group than the non-TDF group (P ⫽
0.03; Fig 2D). There was no significant differ-
ence in UP/C between the non-TDF and ART-
naive groups (P ⫽ 0.9). These results indicate
that patients exposed to TDF have increased
proteinuria.
The strongest correlation between urinary
markers was found between URBP/C and UNAG/C,
followed by (in descending order of association)
UNAG/C and UA/C, URBP/C and UA/C, URBP/C and
UP/C, UNAG/C and UP/C, and UA/C and UP/C
(Table 3). Scatter plots comparing UA/C (the

Table 3. Correlation Between Urinary Markers

URBP/C UNAG/C UA/C UP/C

URBP/C — 0.60 (P ⫽ 0.01) 0.53 (P ⫽ 0.01) 0.33 (P ⫽ 0.01)

UNAG/C 0.60 (P ⫽ 0.01) — 0.56 (P ⫽ 0.01) 0.26 (P ⫽ 0.02)
UA/C 0.53 (P ⫽ 0.01) 0.56 (P ⫽ 0.01) — 0.20 (P ⫽ 0.05)
UP/C 0.33 (P ⫽ 0.01) 0.26 (P ⫽ 0.01) 0.20 (P ⫽ 0.05) —
Note: Values given as Spearman coefficients (range, ⫺1 to ⫹1) and relevant P values.
Abbreviations: UA/C, urinary albumin-creatinine ratio; UNAG/C, urinary N-acetyl-␤-D-glucosaminidase– creatinine ratio; UP/C,
urinary protein-creatinine ratio; URBP/C, urinary retinol-binding protein– creatinine ratio.
Subclinical Renal Tubular Injury in HIV Patients
Figure 3. The relationship between urinary albumin-
creatinine (creat) ratio and other urinary markers. Scatter
plots for all 3 study groups (antiretroviral treatment [ART]-
naive [x], group exposed to tenofovir [TDF; filled circle],
and group not exposed to tenofovir [non-TDF; open square])
show the relationship between urinary albumin-creat and
(A) urinary retinol-binding protein (RBP)-creat ratios (rs ⫽
0.53; P ⫽ 0.01); (B) urinary N-acetyl-␤-D-glucosaminidase
(NAG)-creat ratio (rs ⫽ 0.56; P ⫽ 0.01); and (C) urinary
protein-creat ratio (rs ⫽ 0.20; P ⫽ 0.05).
1039
Table 4. Agreement Between Urinary Markers in
Detecting Abnormal Proteinuria
URBP/C UNAG/C UA/C UP/C
URBP/C — 0.33 0.30 0.16
UNAG/C 0.33 — 0.25 0.11
UA/C 0.30 0.25 — 0.19
UP/C 0.16 0.11 0.19 —
Note: Values given as measures of agreement (␬ [range,
0-1]).
Abbreviations: UA/C, urinary albumin-creatinine ratio;
UNAG/C, urinary N-acetyl-␤-D-glucosaminidase– creatinine
ratio; UP/C, urinary protein-creatinine ratio; URBP/C, urinary
retinol binding protein– creatinine ratio.
NICE-recommended screening tool) with URBP/C,
UNAG/c, and UP/C are shown (Fig 3) for each of
the 3 study groups. Although there appeared to
be some degree of correlation among urinary
markers, the level of agreement between each
test in detecting abnormal proteinuria (defined as
greater than the normal range) was low (Table 4).
This suggests that each test measures different
aspects of renal dysfunction in patients with HIV.
To evaluate the sensitivity of either UP/C or
UA/C in detecting subclinical nephropathy, we
compared proportions of patients in each group
with increased values (greater than the normal
upper limit) for UP/C or UA/C with the proportion
with evidence of proximal tubular dysfunction
(defined as increased URBP/C and/or UNAG/C; Fig
4). The proportion of patients in each group with
proximal tubular dysfunction was considerably
higher than proportions with either increased
UA/C or UP/C (ART-naive, 10 of 19 [52.6%] vs 6
of 19 [31.6%] vs 4 of 16 [25.0%]; TDF, 38 of 47
[80.9%] vs 14 of 47 [29.8%] vs 24 of 46 [52.2%];
non-TDF, 27 of 33 [81.8%] vs 13 of 33 [39.4%]
vs 9 of 30 [30.0%]). This implies that either UP/C
or UA/C testing alone cannot reliably detect pa-
tients with ART-associated renal tubular dysfunc-
tion.
DISCUSSION
We have performed a cross-sectional study to
investigate the nature and prevalence of subclini-
cal renal tubular injury in patients with HIV
without overt kidney disease. Our results show
that the prevalence of proximal tubular dysfunc-
tion (increased URBP/C and/or UNAG/C) is high in
both ART-naive patients and those on ART. Rou-
tine testing of either UP/C or UA/C alone is not
1040
Figure 4. Sensitivity of either urinary albumin-creati-
nine ratio or protein-creatinine ratio in detecting renal
tubular dysfunction. The proportion of patients with an
increase (greater than the normal adult range) in either
urinary albumin-creatinine (hatched bar) or protein-creati-
nine (gray bar) ratio was considerably lower than the
proportion with abnormal tubular proteinuria (defined as
increased urinary retinol-binding protein [RBP]-creatinine
and/or N-acetyl-␤-D-glucosaminidase [NAG]-creatinine ra-
tio) (black bar) in all 3 study groups. Abbreviations: ARTN,
antiretroviral therapy naive; non-TDN, group without expo-
sure to tenofovir; TDN, group exposed to tenofovir.
sufficiently sensitive to detect these abnormali-
ties.
Rates of tubular proteinuria were high in pa-
tients with HIV in a previous study19; however,
no significant differences were found among
different treatment groups. Subsequently, cross-
sectional studies have shown an association be-
tween TDF exposure and increased urinary excre-
tion of ␤2-microglobulin in both children20 and
adults.21 Furthermore, a small longitudinal study
reported that excretion of urinary ␤2-microglobu-
lin increased significantly in patients after the
start of TDF therapy.22 Although widely used as
a marker of proximal tubular dysfunction, uri-
nary ␤2-microglobulin has drawbacks as a screen-
ing tool because of its pH-dependence and enzy-
matic breakdown.23 RBP is believed to be a more
reliable low-molecular-weight protein to mea-
sure.24
In our study, patients on ART (regardless of
whether it included TDF) had significantly higher
UNAG/C values compared with ART-naive pa-
tients. However, there were no significant differ-
ences in UA/C (a marker of glomerular disease)
values. This suggests there is a background level
of proximal tubular damage in patients on ART
that is not specific for TDF. However, we have
Hall et al
found that patients using TDF have higher URBP/C
values than other patients with HIV (regardless
of whether they are on ART), which could be
explained by a more specific inhibitory effect of
TDF on proximal tubular uptake and/or transport
of low-molecular-weight proteins. This is consis-
tent with the association of this drug with Fan-
coni syndrome in some case reports.
The level of agreement between the different
urinary test results in our study in detecting
abnormal proteinuria was low, and considerable
numbers of patients with evidence of tubular
dysfunction did not have an increased UA/C or
UP/C. Furthermore, correlation between tubular
markers and UP/C also was weak. Therefore, we
propose that screening for increased urinary ex-
cretion of tubular proteins (such as URBP/C and
UNAG/C) is a more appropriate strategy for moni-
toring patients using TDF than more conven-
tional clinical tests for kidney disease (ie, UP/C or
UA/C). This will need to be assessed in prospec-
tive longitudinal studies to identify patients at
increased risk of TDF-associated renal toxicity.
The finding that URBP/C values in our study were
not normally distributed, and did not correlate
with time on treatment, suggests that TDF toxic-
ity in the kidney may be an “all or none” phenom-
enon (possibly because of underlying pharmacog-
enomic factors25). The significance of tubular
proteinuria in predicting the development of
chronic kidney disease is presently unknown,
although it has been suggested that increased
delivery of low-molecular-weight proteins to dis-
tal parts of the nephron might have pathophysi-
ological consequences.26,27
Renal phosphate wasting is one of the features
of Fanconi syndrome. We did not observe signifi-
cant differences in median serum phosphate lev-
els among our study groups. However, there was
a nonsignificant increase in the proportion of
patients with hypophosphatemia in the TDF
group, and this should be explored further in
larger studies. Renal fractional excretion of phos-
phate was not measured in our study and we are
unable to comment further on the mechanism of
the effect of TDF on serum phosphate level.
We do not believe there have been major
confounding factors in our study, because the
different study groups were well matched and we
excluded patients with diabetes or who were
infected with hepatitis B or C virus. The inci-
Subclinical Renal Tubular Injury in HIV Patients
dence of hypertension and use of potentially
nephrotoxic non-HIV therapy was low in all
groups. Although the non-TDF group had re-
ceived ART for a longer median time than the
TDF group, we do not believe this weakens our
findings. It is possible that even bigger differ-
ences in relative toxicity would have been ob-
served between the 2 treatment groups had they
been matched more closely for duration of
therapy.
Our study was cross-sectional rather than lon-
gitudinal, and as such, we can only show associa-
tions between TDF exposure and renal tubular
dysfunction and cannot establish causality. Fur-
thermore, we cannot answer questions about
progression of chronic kidney disease in patients
using TDF, or recovery after discontinuation.
Prospective randomized controlled trials are re-
quired to address these questions.
In summary, rates of subclinical proteinuria
are high in patients with HIV. Those on ART, and
in particular those using TDF, appear to be at
increased risk. The long-term significance of
these findings needs to be addressed in future
studies, in particular, focusing on progression of
chronic kidney disease and renal outcomes.
ACKNOWLEDGEMENTS
Support: This work was supported by grants awarded to
Dr Hall by The Royal Free & University College London
Medical School and Kidney Research UK.
Financial Disclosure: Dr Hall has previously received a
lectureship fee from Gilead Sciences, which markets TDF.
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