Impact of early versus deferred antiretroviral therapy on estimated glomerular filtration rate in HIV-positive individuals in the START trial

Amit C. Achhra, Amanda Mocroft, Michael Ross, Lene Ryom-Nielson, Anchalee Avihingsanon, Elzbieta Bakowska, Waldo Belloso, Amanda Clarke, Hansjakob Furrer, Gregory M. Lucas, Matti Ristola, Mohammed Rassool, Jonathan Ross, Charurut Somboonwit, Shweta Sharma, Christina Wyatt

Research output: Contribution to journalArticlepeer-review

9 Scopus citations


The impact of early ART initiation (versus deferring) on kidney function has not been studied. START was a randomised comparison of immediate versus deferred ART initiation among HIV-positive persons with CD4+ (cells/mm3) counts >500. Serum creatinine and urine dipstick protein were measured at Months 0, 1, 4, 8 and 12, and annually thereafter. The two arms were compared for changes in eGFR (mL/min/1.73 m2, calculated by CKD-EPI equation), over time using longitudinal mixed models. Of 4685 START participants, 4629 (2294 in immediate and 2335 deferred arm) were included. Median baseline CD4+ and eGFR were 651 and 111.5, respectively. ART was initiated in 2271 participants (99.0%) in the immediate and 1127 (48.3%) in the deferred arm, accounting for >94% and >19% of follow-up time, respectively. Overall, 89% started ART using a tenofovir-based regimen. Over 2.1 years median follow-up, mean eGFR was 0.56 (95% CI 0.003–1.11) higher in the immediate versus deferred arm, which was more prominent after adjustment for current tenofovir or bPI use (1.85, 95% CI 1.21–2.50) and in Black participants (30.1% overall) (3.90, 95% CI 2.84–4.97) versus non-Blacks (1.05, 95% CI 0.33–1.77) (P < 0.001 for interaction). Relative risk for proteinuria in the immediate versus deferred arm was 0.74 (95% CI 0.55–1.00) (P = 0.049). In the short-term, immediate ART initiation was associated with a modestly higher eGFR and lower proteinuria risk versus deferring ART (more pronounced in Black participants). Whether this early benefit translates into a lower risk of CKD requires further follow-up.

Original languageEnglish (US)
Pages (from-to)453-460
Number of pages8
JournalInternational Journal of Antimicrobial Agents
Issue number3
StatePublished - Sep 2017

Bibliographical note

Funding Information:
Funding: This work was supported by the National Institutes of Health (NIH), National Institute of Allergy and Infectious Diseases [UM1 AI 068641, UM1-AI120197]; the Department of Bioethics at the NIH Clinical Center; the National Cancer Institute; the National Heart, Lung, and Blood Institute; the National Institute of Mental Health; the National Institute of Neurological Disorders and Stroke; and the National Institute of Arthritis and Musculoskeletal Disorders. Financial support for START was also provided by the French Agence Nationale de Recherches sur le SIDA et les H?patites Virales (ANRS); the Federal Ministry of Education and Research; the European AIDS Treatment Network (NEAT); the National Health and Medical Research Council; and the Medical Research Council and National Institute for Health Research. Six pharmaceutical companies (AbbVie, Inc., Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline/ViiV Healthcare, Janssen Scientific Affairs, LLC, and Merck Sharp and Dohme Corp.) donate antiretroviral drugs to START. The authors were also supported by the National Institute of Diabetes and Digestive and Kidney Diseases [R01 DK100272, P01 DK056492 and R01 DK112258 to CW] and the National Institute on Drug Abuse [K24 DA035684, R01 DA026770 to GML].

Publisher Copyright:
© 2017 Elsevier B.V. and International Society of Chemotherapy


  • CKD
  • HIV
  • Kidney
  • eGFR


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