Episode Description:
Chronic kidney disease, or CKD, is becoming a growing concern among people living with HIV, particularly those on tenofovir-based antiretroviral therapy, also known as ART. A recent prospective cohort study published in Kidney Medicine (2025) explored this issue in Tanzania, where researchers followed 495 HIV-positive adults starting tenofovir-based treatment and compared their kidney health to 505 HIV-negative individuals. The study aimed to understand how tenofovir affects kidney function over time and whether those on ART face a higher risk of developing CKD.
The results were striking. HIV-positive individuals on tenofovir experienced a significantly higher rate of CKD than those who did not have HIV. Over the study period, 22.5% of HIV-positive participants developed CKD, compared to just 9.6% of HIV-negative individuals. This means that people with HIV taking tenofovir were 3.4 times more likely to develop CKD than those without the infection. Even among those who did not develop full-blown CKD, kidney function declined much more rapidly in the HIV-positive group. The researchers measured kidney function using a marker called estimated glomerular filtration rate, or eGFR. At the start of the study, people living with HIV already had slightly lower kidney function than those without the virus. But after just one year, HIV-positive participants lost kidney function at more than twice the rate of HIV-negative individuals. By the second year, over one-third of HIV-positive individuals had experienced at least a 20% decline in kidney function, compared to just 12% of those who were HIV-negative.
So, why is this happening? The study identified several risk factors that increased the likelihood of kidney disease among HIV-positive individuals. Older age, pre-existing hypertension or diabetes, and longer use of tenofovir were all linked to faster kidney damage. Additionally, people with low immune system function—measured by CD4 counts below 200—were at greater risk. But one of the most telling warning signs was protein in the urine at the start of the study. Those who already had protein in their urine were nearly four times more likely to develop CKD while on tenofovir.
This research adds to growing evidence that tenofovir, while an essential HIV treatment, has toxic effects on the kidneys. In fact, 32% of those who developed CKD had to stop taking tenofovir entirely because their kidney function worsened too much. Interestingly, the study also found that HIV-positive patients taking tenofovir along with a boosted protease inhibitor, such as lopinavir/ritonavir, had the highest risk of CKD. This suggests that certain HIV drug combinations may intensify the harmful effects of tenofovir on the kidneys.
So, what should be done about this? The study’s authors recommend routine kidney function monitoring for anyone taking tenofovir. Before starting treatment, doctors should check kidney function through eGFR and urine protein tests, especially for those who have other risk factors like high blood pressure or diabetes. Once on treatment, these tests should be repeated every three to six months to catch early signs of kidney damage. In high-risk patients, doctors may need to consider alternative ART regimens that do not contain tenofovir. Abacavir-based or dolutegravir-based treatments could be safer options for those with pre-existing kidney issues. In cases where tenofovir is the best or only option, dose adjustments may be needed if kidney function starts to decline.
Beyond medication changes, lifestyle interventions can also make a difference. Controlling blood pressure, managing diabetes, and avoiding drugs that harm the kidneys—such as nonsteroidal anti-inflammatory drugs, or NSAIDs—can help slow CKD progression. A team-based approach that includes kidney specialists, HIV doctors, and primary care providers will be critical to ensuring the best care for people living with HIV.
Renes Care Radio is a podcast designed for nephrology professionals, offering in-depth scientific explorations of key topics. It equips kidney care providers with the essential knowledge needed for advanced patient care.
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This podcast is for informational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment.