Adherence to renal function monitoring guidelines in HIV-infected patients starting tenofovir disoproxil fumarate-based antiretroviral therapy in rural Rwanda

Abstract

Tenofovir disoproxil fumarate (TDF) is a component of several first-line HIV antiretroviral regimens. However, TDF  causes 
nephrotoxicity and guidelines for creatinine monitoring are in place. This study evaluated creatinine testing  practices in a 
retrospective cohort of antiretroviral-naive adult HIV patients initiated on a TDF-containing regimen between January 1, 
2012 and December 31, 2012, in 23 outpatient health centers in rural Rwanda. Electronic medical records (EMR) were used 
to identify eligible subjects. Demographic data and creatinine testing orders and results at baseline, 1, 3, and 6 months, 
were collected from paper charts. 496 patients were included. At baseline, 252 (51%) patients had a creatinine test ordered 
and 239 (48%) received a test result. At the 1-, 3-, and 6-month visits, 2.3%-9.3% of the patients had their creatinine 
monitored. Documentation of creatinine clearance (CrCl) was reported in only 3 patients. 210 patients had sufficient data to 
calculate CrCl by the Cockcroft-Gault equation, with 24 (11%) patients started on TDF despite a CrCl < 50 mL/min. 
Adherence to TDF-specific laboratory testing guidelines proved challenging. Automated EMR-generated testing reminders, 
studies to understand reasons for non-adherence, local adaptation of guidelines, and advocacy for safer medications more 
easily administered in a resource-limited setting are recommended.