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Longitudinal real world study on estimated glomerular filtration rate (eGFR) changes in entecavir (ETV) versus tenofovir disoproxil fumarate (TDF)-treated chronic hepatitis B patients: a Real-B Study.
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Worsening Kidney Function With TDF Than Entecavir for HBV in Big Cohort
AASLD The Liver Meeting Digital Experience, November 13-16, 2020
Mark Mascolini
A 10-year matched retrospective comparison of tenofovir disoproxil fumarate (TDF) versus entecavir (ETV) for chronic HBV infection linked TDF to worsening kidney function indicated by falling estimated glomerular filtration rate (eGFR) [1]. In a matched comparison in this 6189-person international study, TDF independently raised the risk of kidney impairment development or progression regardless of whether baseline (initial) eGFR lay above or below 60 mL/min.
Whether long-term kidney toxicity is worse with TDF or ETV in people taking those antivirals for chronic HBV infection remains controversial, according to the international team who led this Real-B Study. Retrospective studies and meta-analyses offer conflicting data on whether TDF carries a higher risk of kidney impairment in people with HBV. A 2000-2016 retrospective 410-person study concluded that TDF does not pose a greater risk of further kidney damage than ETV in people with HBV and a baseline eGFR above 60 mL/min [2].
To get a better fix on kidney function changes in people taking TDF or ETV for chronic hepatitis B infection, the Real-B team retrospectively studied 6189 adults with chronic HBV infection starting treatment for the first time with either TDF (2482 people) or ETV (3707 people).
Study participants in the United States, Hong Kong, Korea, Taiwan, Japan, and China had at least 12 months of follow-up after starting therapy at one of 22 centers. Researchers recorded CKD-EPI-calculated eGFR about every 6 months for all participants. They used propensity score matching [2] to create similar groups of TDF takers and ETV takers, matching the groups by age, gender, diabetes, hypertension, cirrhosis, initial eGFR, and length of follow-up.
Multivariable generalized linear modeling adjusted average eGFR during follow-up for cirrhosis, hypertension, and diabetes. Multivariable Cox regression identified factors independently linked to kidney function falling at least 1 level according to the following grading system: grade 1, eGFR above 90 mL/min; grade 2, eGFR 60-89; grade 3a, eGFR 45-59; grade 3b, eGFR 30-44, grade 4, eGFR 15-29; and grade 5, eGFR below 15.
Propensity score matching gave the researchers 1871 pairs of TDF and ETV takers with an initial eGFR at or above 60 mL/min and 520 pairs with an initial eGFR below 60 mL/min. For the above 60-and below 60-mL/min groups, ages averaged 47.0 with ETV and 47.5 with TDF and 54.1 with ETV and 53.7 with TDF. Respective proportions of men across those four groups were 54.9%, 56.9%, 97.3%, and 97.9%. And respective baseline eGFRs were 86.0, 85.5, 53.7, and 53.2 mL/min. Similar proportions taking ETV or TDF in the two matched groups had diabetes, hypertension, and cirrhosis. In the groups with baseline eGFR above 60, follow-up lasted 46.1 months with ETV and 46.5 months with TDF. In the groups with baseline eGFR below 60, follow-up lasted 49.0 months with ETV and 51.2 months with TDF.
For the total unmatched cohort, adjusted average eGFR through 120 months was significantly higher with ETV than TDF: 83.6 vs 82.5 mL/min (P = 0.002). In unmatched participants 50 or older at baseline, adjusted average eGFR through 120 months also proved significantly higher with ETV than with TDF (80.3 vs 76.4 mL/min, P < 0.0001). But in unmatched people younger than 50 at baseline, adjusted average eGFR was significantly lower with ETV than with TDF (86.4 vs 88.2, P = 0.001).
Average eGFRs adjusted by generalized linear modeling fell significantly more over time with TDF than with ETV in the entire unmatched study group, in the matched group starting with an eGFR above 60 mL/min, and in the matched group starting with an eGFR below 60 mL/min. The authors noted, however, that average eGFR differences between the TDF and ETV group were small, ranging from 1.2 to 3.1 mL/min.
In the propensity score-matched group of 1871 pairs starting the study with an eGFR above 60 mL/min, 5-year cumulative onset of kidney impairment was significantly greater with TDF than with ETV (49.8% vs 45.08%, P = 0.0039). Cox regression analysis determined that taking TDF rather than ETV independently raised chances of worsening kidney function by about 40% (hazard ratio [HR] 1.41). Other factors that independently boosted the risk of worsening kidney function were older age (HR 1.02), male gender (HR 2.16), having diabetes or hypertension (HR 1.4), and a higher FIB-4 fibrosis score (HR 1.02). A higher initial eGFR independently lowered chances of worsening kidney function (HR 0.99).
The investigators believe their findings indicate caution when prescribing TDF for HBV infection, especially in people with other risk factors for kidney impairment.
References
1. Mak LY, Hoang J, Jun DW, et al. Longitudinal real world study on estimated glomerular filtration rate (eGFR) changes in entecavir (ETV) versus tenofovir disoproxil fumarate (TDF)-treated chronic hepatitis B patients: a Real-B Study. AASLD The Liver Meeting Digital Experience, November 13-16, 2020. Abstract 21.
2. Trinh S, Le AK, Chang ET, et al. Changes in renal function in patients with chronic HBV infection treated with tenofovir disoproxil fumarate vs entecavir. Clin Gastroenterol Hepatol. 2019;17:948-956.e1. doi: 10.1016/j.cgh.2018.08.037.
3. Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011;46:399-424. doi: 10.1080/00273171.2011.568786.
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