Renal outcomes with dolutegravir plus lamivudine versus bictegravir/emtricitabine/tenofovir alafenamide in ART-naive adults with HIV

OBJECTIVE: Dolutegravir plus lamivudine (DTG + 3TC) and bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) are guideline-recommended first-line regimens for people with HIV (PWH), but their comparative renal safety remains unclear. We aimed to compare kidney outcomes between these regimens in antiretroviral therapy (ART)-naive PWH, stratified by baseline renal function. METHODS: We conducted a multicenter, prospective cohort study in China (2018-2025) enrolling 2,655 ART-naive PWH initiating DTG + 3TC (n = 788) or BIC/FTC/TAF (n = 1,867). Participants were stratified by baseline estimated glomerular filtration rate (eGFR; <90 vs ≥90 mL/min/1.73 m2). Stabilized inverse probability of treatment weighting was applied to evaluate incident chronic kidney disease (CKD) and longitudinal eGFR changes over 24 months. RESULTS: Among participants with baseline creatinine-based eGFR (eGFRcreat) <90 mL/min/1.73 m2, DTG + 3TC was associated with greater declines in eGFRcreat compared with BIC/FTC/TAF at 12 and 24 months. In contrast, no significant differences were observed when kidney function was assessed using the cystatin C-based or creatinine-cystatin C-based equation. In the eGFRcreat ≥90 mL/min/1.73 m2 stratum, trajectories were comparable. CKD incidence was comparable between regimens in both strata (eGFRcreat <90 mL/min/1.73 m2: 29.9% vs 16.8%; ≥90 mL/min/1.73 m2: 5.1% vs 4.7%; both P > 0.05), and adjusted Cox models showed no significant difference in CKD risk. CONCLUSION: DTG + 3TC and BIC/FTC/TAF showed comparable renal safety over 24 months among ART-naive PWH. However, when a decline in eGFRcreat is observed during DTG treatment, cystatin C-based assessment may help clarify true kidney function.