Ma SP, Wang L, Zhang YL, Wan X, Liu Q, Tang YL, Malhi LR, Ge SF. Effects of tenofovir amibufenamide and entecavir on estimated glomerular filtration rate in treatment-naïve patients with chronic hepatitis B. World J Hepatol 2026; 18(2): 114346 [DOI: 10.4254/wjh.v18.i2.114346]
Corresponding Author of This Article
Shan-Fei Ge, Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Zheng Street, Donghu District, Nanchang 330006, Jiangxi Province, China. geshanfei2010@163.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Cohort Study
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Feb 27, 2026 (publication date) through Feb 12, 2026
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World Journal of Hepatology
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1948-5182
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Ma SP, Wang L, Zhang YL, Wan X, Liu Q, Tang YL, Malhi LR, Ge SF. Effects of tenofovir amibufenamide and entecavir on estimated glomerular filtration rate in treatment-naïve patients with chronic hepatitis B. World J Hepatol 2026; 18(2): 114346 [DOI: 10.4254/wjh.v18.i2.114346]
Author contributions: Ma SP contributed to data organization and research design; Ma SP, Wang L, and Zhang YL contributed to manuscript writing; Ma SP, Wang L, Zhang YL, Wan X, Liu Q, and Tang YL contributed to data collection; Malhi LR contributed to manuscript review; Ge SF contributed to research design guidance, writing guidance, and final manuscript revision. Ma SP and Wang L contributed equally to this manuscript and are co-first authors.
Supported by Chinese Foundation for Hepatitis Prevention and Control Muxin Research Fund of Chronic Hepatitis B, No. MX202418.
Institutional review board statement: This study was approved by the Ethics Committee of the First Affiliated Hospital of Nanchang University [Approval No. (2021) Medical Research Ethics Review (8-016)].
Informed consent statement: As this study was conducted retrospectively, the requirement for written informed consent was waived.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: All data included in this study are available upon request from the corresponding author.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Shan-Fei Ge, Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Zheng Street, Donghu District, Nanchang 330006, Jiangxi Province, China. geshanfei2010@163.com
Received: September 19, 2025 Revised: November 1, 2025 Accepted: December 11, 2025 Published online: February 27, 2026 Processing time: 147 Days and 8.5 Hours
Abstract
BACKGROUND
As a novel antiviral agent, the comparative renal safety of tenofovir amibufenamide (TMF) vs entecavir (ETV) in chronic hepatitis B (CHB) remains unclear.
AIM
To compare changes in the estimated glomerular filtration rate (eGFR) between TMF and ETV in previously untreated patients with CHB over 48 weeks.
METHODS
We retrospectively analyzed clinical records of 187 treatment-naive patients with CHB receiving TMF or ETV for ≥ 48 weeks from June 2021 to January 2025. Patients were allocated to the TMF (n = 48) or ETV (n = 139) group based on their antiviral drug therapy. Propensity score matching (2:1) was used to balance baseline clinical characteristics. eGFR changes at 48 weeks were compared. Patients were then stratified into normal and abnormal eGFR groups, and factors associated with abnormal eGFR were analyzed.
RESULTS
After propensity score matching, 48 patients and 96 patients were stratified into the TMF and ETV group, respectively. At baseline, the two groups had comparable clinical characteristics, with no significant differences (P > 0.05). Baseline eGFR values were 111.83 mL/minute/1.73 m2 for the TMF group and 112.50 mL/minute/1.73 m2 for the ETV group (P = 0.712). At week 48, eGFR declined in both groups, but the ETV group experienced a significantly greater reduction relative to the TMF group (106.10 mL/minute/1.73 m2vs 111.01 mL/minute/1.73 m2; P = 0.019). In univariate analysis, the groups differed significantly in terms of age, serum albumin, triglyceride, and baseline eGFR (all P < 0.05). Multivariate analysis identified baseline eGFR and triglyceride as independent predictors of abnormal eGFR by 48 weeks (P < 0.05).
CONCLUSION
In treatment-naïve patients with CHB, ETV treatment exhibited a strong association with an increased risk of decreased eGFR levels at 48 weeks in comparison with TMF.
Core Tip: This study provides the comparison of renal safety between tenofovir amibufenamide (TMF) and entecavir (ETV) in treatment-naive chronic hepatitis B patients. After propensity score matching, TMF showed significantly less decline in estimated glomerular filtration rate over 48 weeks than ETV. Baseline estimated glomerular filtration rate and triglyceride levels independently predicted abnormal renal function, highlighting TMF’s potential renal safety advantage over ETV and offering clinicians important insights for individualized antiviral therapy.
Citation: Ma SP, Wang L, Zhang YL, Wan X, Liu Q, Tang YL, Malhi LR, Ge SF. Effects of tenofovir amibufenamide and entecavir on estimated glomerular filtration rate in treatment-naïve patients with chronic hepatitis B. World J Hepatol 2026; 18(2): 114346
Hepatitis B virus (HBV) infection is epidemic worldwide and remains a serious public health concern[1]. Early antiviral therapy is important owing to the possible development of chronic HBV infection, which can potentially progress to cirrhosis, liver failure, or hepatocellular carcinoma[2]. Currently, antiviral medications for HBV are primarily limited to interferon and oral nucleotide analogues (NAs). NAs may reduce viral replication, improve the condition of liver tissue, and slow the progression of cirrhosis. Interferon exerts antiviral effects at numerous points of the HBV life cycle via regulation of gene expression and protein translation to achieve an antiviral state in hepatocytes. Nevertheless, many patients who require treatment have adverse reactions to interferon, making it less common in treatment or limiting its use altogether in some cases[3,4].
NAs are considered first-line antiviral agents owing to their high efficacy in inhibiting HBV DNA, a favorable resistance profile, and positive safety record. Widely used NAs include entecavir (ETV), tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide (TAF)[5]. Based on the latest guidelines, tenofovir amibufenamide (TMF) is also considered a first-line oral antiviral agent[6]. TMF is a prodrug of tenofovir[7]. Given its relatively short time on the market, the real-world safety profile of TMF requires further validation in additional studies.
The renal safety of antiviral drugs for chronic hepatitis B (CHB) has long been a research focus. TDF has exhibited a strong association with a definite risk of renal impairment[8-11]. Some studies have also indicated that long-term ETV therapy exhibits a certain increased risk of renal impairment in comparison with TAF[12]. TMF has a chemical structure similar to that of TAF, with an additional methyl group in its structure[13]. However, it remains unclear whether differences exist in terms of renal safety between TMF and ETV. Given that TMF has been on the market for a relatively short time, studies on its real-world renal safety are currently limited. We aimed to conduct a direct comparison between the renal safety of TMF and ETV in a real-world setting to help provide optimized antiviral treatment options in clinical practice.
MATERIALS AND METHODS
Study design and patient selection
According to the diagnostic criteria in the relevant guidelines[6], we collected data for patients with CHB who received treatment at our hospital from June 2021 to January 2025. Data including patient demographics, laboratory results, imaging findings, and use of antiviral drugs were retrospectively collected via the electronic medical record system of our hospital. Inclusion criteria were: (1) Patients that received ≥ 48 weeks of initial treatment with TMF or ETV; (2) Baseline estimated glomerular filtration rate (eGFR) ≥ 90 mL/minute/1.73 m2; and (3) Adults aged 18 years or older. Exclusion criteria were: (1) Coexisting additional types of acute or chronic hepatitis (i.e., hepatitis A, hepatitis C, hepatitis D, hepatitis E, autoimmune hepatitis, alcoholic hepatitis, or drug-induced hepatitis); (2) Diagnosed with concurrent fatty liver or hyperlipidemia; (3) Diagnosed with biliary system diseases or liver dysfunction with unknown cause; (4) Diagnosed with decompensated cirrhosis; (5) Diagnosed with concurrent kidney disease, hypertension, diabetes, other diseases in medications; (6) Pregnant women or patients with a diagnosis of malignancy or human immunodeficiency virus infection; (7) Patients with follow-up time < 48 weeks; and (8) Patients with incomplete data (Figure 1).
Patients were assigned to the TMF (n = 48) or ETV group (n = 139) depending on the antiviral regime received, followed by propensity score matching (PSM) at a 2:1 ratio to balance the baseline clinical data. A total of 144 patients were matched, of whom 48 were assigned to the TMF group and 96 to the ETV group. According to eGFR levels at 48 weeks, patients with CHB were subsequently classified into a normal eGFR group or abnormal eGFR group.
Data collection
We collected patients’ data via the electronic medical record system of our hospital, with general information including sex, age, and presence or absence of cirrhosis. Laboratory parameters included high-sensitivity HBV-DNA, hepatitis B surface antigen (HBsAg), HBV e antigen, complete blood count, liver and kidney function, lipid profile, blood glucose, eGFR (based on the Chronic Kidney Disease Epidemiology Collaboration equation), and a decline in eGFR, all evaluated at baseline and at week 24 and week 48. Imaging parameters included abdominal ultrasonography and liver stiffness measurement. Complete blood counts and biochemical analyses were conducted in the laboratory department of our hospital. High-sensitivity HBV-DNA quantification was conducted using the TaqMan real-time fluorescent quantitative polymerase chain reaction method (Roche 480 real-time fluorescent quantitative polymerase chain reaction system; Roche Diagnostics, Indianapolis, IN, United States), with a detection limit of 20 IU/mL. Serum HBV markers were analyzed using the Abbott ARCHITECT system and reagents (Abbott Laboratories, Abbott Park, IL, United States). For results of repeated tests conducted within a short period, the average values were calculated. For questionable results, re-examinations were performed to confirm the reliability of the results.
Statistical analysis
PSM was carried out on the basis of the nearest neighbor matching method in R Studio (The R Project for Statistical Computing, Vienna, Austria). Statistical analysis was performed using IBM SPSS version 26.0 (IBM Corp., Armonk, NY, United States), and graphic representations were generated with GraphPad Prism version 10 (GraphPad Software Inc., San Diego, CA, United States). Normally distributed continuous data are expressed as mean ± SD and were analyzed using an independent samples t-test. Continuous data that were not normally distributed are presented as median (P25-P75) and analyzed with the Mann-Whitney U test for group comparisons. Categorical data are presented as n (%), with intergroup comparisons conducted using the χ2 or Fisher’s exact test. Multivariate logistic regression analysis was used to investigate factors influencing abnormal renal function, and the receiver operating characteristic (ROC) curve was used to evaluate the performance of each indicator in predicting abnormal renal function. HBV-DNA and HBsAg quantification values were log10-transformed.
Ethical statements
This study was approved by the Ethics Committee of the First Affiliated Hospital of Nanchang University [Approval No. (2021) Medical Research Ethics Review (8-016)]. Because this study was conducted retrospectively, obtaining written informed consent was deemed unnecessary.
RESULTS
Baseline characteristics of the study population
A total of 187 patients with CHB were enrolled in this study, with 144 successfully matched, including 87 men (60.42%) and 57 women (39.58%). Patients were aged 19-66 years. Patients were grouped according to treatment regimen: 48 in the TMF group (32 men, 66.67%) and 96 patients in the ETV group (55 men, 57.29%). The baseline profiles were similar across cohorts before treatment initiation (all P > 0.05; Table 1).
Table 1 Baseline characteristics of the study population before and after propensity score matching, median (interquartile range)/n (%)/mean ± SD.
Baseline eGFR levels in the TMF and ETV groups were 111.83 ± 10.16 mL/minute/1.73 m2 and 112.50 ± 10.28 mL/minute/1.73 m2, respectively (P = 0.712). At 48 weeks, a decreasing trend was observed in eGFR levels for both groups, vs baseline. The TMF group showed a decline of 1.49 ± 6.09 mL/minute/1.73 m2, compared with a reduction of 5.73 ± 9.32 mL/minute/1.73 m2 in the ETV group (P = 0.001). A marked difference in eGFR was observed at week 48, with the ETV group having substantially lower values than the TMF group (106.10 ± 12.27 mL/minute/1.73 m2vs 111.01 ± 10.53 mL/minute/1.73 m2; P = 0.019). In the TMF group, two patients (4.2%) exhibited abnormal eGFR levels; in the ETV group, 11 patients (11.5%) had abnormal eGFR levels (Table 2).
Table 2 Comparison of 48-week clinical data, n (%)/median (interquartile range)/mean ± SD.
The 144 patients with CHB were divided into two groups on the eGFR values assessed at week 48: The normal eGFR group (131 patients, eGFR ≥ 90 mL/minute/1.73 m2) and the abnormal eGFR group (13 patients, eGFR < 90 mL/minute/1.73 m2). Univariate analysis revealed that age, serum albumin (Alb), triglyceride (TG), and baseline eGFR differed significantly between the two groups (all P < 0.05). Multivariate logistic regression revealed that baseline eGFR and TG (all P < 0.05) were independently associated with the occurrence of abnormal eGFR at 48 weeks in patients with CHB (Table 3). According to the results of logistic regression, further ROC curve analysis of baseline eGFR showed that the area under the ROC curve for predicting abnormal eGFR in patients with CHB was 0.788, with a cutoff value of 104.72 mL/minute/1.73 m2, sensitivity of 76.92%, and specificity of 80.15% (Figure 2A). Similarly, the area under the ROC curve for TG was 0.736, with a cutoff of 0.99 mmol/L, sensitivity of 76.92%, and specificity of 64.12% (Figure 2B).
Comparison of baseline and endpoint clinical data in TMF and ETV groups
At 48 weeks of antiviral therapy, significant differences were found in the DNA positivity rate, total bilirubin, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transferase, serum creatinine (SCr), and eGFR values within ETV group vs the baseline (P < 0.05). Nevertheless, the groups did not differ significantly in terms of HBsAg and Hepatitis B e antigen positivity rates, Alb, alkaline phosphatase, TG, total cholesterol, fasting blood glucose, blood urea nitrogen, hemoglobin, platelets, and liver stiffness measurement values (P > 0.05). In the TMF group, SCr and eGFR values remained stable compared with baseline; all other values were consistent with those in the ETV group. Both the ETV and TMF groups showed consistent reductions over time in eGFR, HBsAg, total bilirubin, alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transferase. SCr and blood urea nitrogen were elevated after treatment. In terms of lipid levels in the ETV group, TG values were increased and total cholesterol was decreased whereas both TG and total cholesterol values were elevated in the TMF group (Table 4).
Table 4 Comparison of baseline and endpoint clinical data between tenofovir amibufenamide and entecavir groups in patients with chronic hepatitis B, n (%)/median (interquartile range)/mean ± SD.
Dynamic changes in eGFR and extent of eGFR decline
After PSM, baseline eGFR levels between the TMF and ETV groups were relatively comparable (P > 0.05). After treatment initiation, both groups exhibited a downward trend in eGFR. A comparison of eGFR levels at 24 weeks and 48 weeks revealed that the ETV group demonstrated a lower eGFR compared with the TMF group at 48 weeks (P = 0.019; Figure 3A). When comparing the degree of eGFR decline, both groups showed an increasing decline in eGFR after the start of antiviral treatment. A comparison of the decline in eGFR levels at 24 weeks and 48 weeks revealed a significant difference only at 48 weeks (P = 0.001; Figure 3B).
Figure 3 Dynamic changes and extent of decline in estimated glomerular filtration rate.
A: Dynamic changes over time; B: Extent of decline. eGFR: Estimated glomerular filtration rate; ETV: Entecavir; TMF: Tenofovir amibufenamide.
DISCUSSION
To achieve the World Health Organization goal of eliminating viral hepatitis as a public health threat by 2030, long-term and effective antiviral therapy is crucial for individuals with CHB. Oral antiviral agents, which offer ease of use and a favorable resistance profile, are currently widely used. However, because of the difficulty in achieving a clinical cure with existing antiviral therapies, most patients require long-term medication[14]. Additionally, most NAs are primarily excreted through the kidneys, and HBV itself can lead to HBV-related nephritis[15,16]. Therefore, the renal safety of patients with CHB receiving long-term antiviral therapy should not be overlooked.
TMF is a prodrug of tenofovir, similar to TAF. Tenofovir is an acyclic nucleoside phosphonate analog with excellent antiviral action, but with limited effectiveness in vivo owing to poor oral bioavailability and cellular permeability that can ultimately promote nephrotoxicity and bone health issues. Therefore, tenofovir was developed as several prodrugs to maximize its antiviral effect and minimize side effects. Current tenofovir prodrugs include TDF, TAF, and TMF. TMF uses the innovative phosphoramidate prodrug technology, where a methyl group on TAF is inserted for targeted delivery of tenofovir to liver cells, which improves intracellular concentrations of the active metabolite tenofovir diphosphate decreases plasma exposure to tenofovir, and effectively suppresses HBV replication while minimizing the risk of renal toxicity[17-19].
The most common clinical indicator for effectively evaluating renal function is eGFR, which represents the volume of ultrafiltrate produced by both kidneys per minute[20]. A study by Rong et al[18], which focused on TMF in patients with HBV-related decompensated cirrhosis, found that the glomerular filtration rate remained unchanged following 48 weeks of treatment with TMF. By week 48 of a multicenter, randomized, double-blind clinical study, TMF showed superior bone and renal safety vs TDF among individuals with CHB[13]. Another real-world retrospective study[21] indicated that TMF had favorable safety profiles for both renal function and blood lipids, and its efficacy was superior to that of TAF. Regarding renal safety with ETV, Jung et al[12] found that the risk of renal injury from long-term ETV antiviral treatment was greater than that from TAF in patients with CHB. A consistent result was reported by Peng et al[22], who observed that in patients with HBV-related acute-on-chronic liver failure, the risk of renal injury from long-term ETV antiviral treatment was greater than that from TAF. To compare the renal safety of TMF and ETV, we categorized study participants into the TMF and ETV groups, with no significant difference in eGFR levels found at baseline. Upon completion of 48 weeks of antiviral therapy, the ETV group exhibited a greater decreasing trend in eGFR levels than did the TMF group (5.73 ± 9.32 mL/minute/1.73 m2vs 1.49 ± 6.09 mL/minute/1.73 m2; P < 0.05). Levels of eGFR in the ETV group were significantly lower than those in the TMF group. Further comparison of clinical indicators at baseline and at 48 weeks within each group showed that the ETV group exhibited significant differences in SCr and eGFR levels; these parameters showed no significant changes in the TMF group. These results demonstrate that, among treatment-naïve patients with CHB, long-term ETV antiviral therapy poses a greater risk of renal injury than it does among patients with TMF. Therefore, it is crucial to closely monitor eGFR in patients undergoing antiviral treatment, particularly in those with renal injury risk, and to select a safe and reliable antiviral regimen.
Renal function is influenced by various factors. Previous studies have shown that factors such as age, sex, hypertension, and diabetes are independent risk factors for abnormal eGFR, which is in agreement with this study[23-25]. Our findings indicated that baseline eGFR is a significant factor influencing eGFR abnormalities at 48 weeks in patients with CHB; the calculation of eGFR included factors such as sex and age. We excluded participants who had hypertension and diabetes at enrollment. Additionally, our study indicated that TG is independently associated with eGFR abnormalities, which aligns with the results of several previous studies[20,26-28]. The mechanisms via which TG induces renal injury are as follows: (1) TG is deposited in the kidneys, including in podocytes, mesangial cells, and proximal tubular epithelial cells, resulting in lipid nephrotoxicity; (2) Lipid deposition stimulates podocyte detachment and apoptosis, mesangial cell proliferation, and glomerulosclerosis; (3) Podocyte damage leads to the filtration of free fatty acids bound to Alb into the proximal tubules, where they are reabsorbed. These free fatty acids undergo mitochondrial oxidation, increasing reactive oxygen species, which results in tubular cell damage and apoptosis; and (4) TG-rich lipoproteins may also mediate inflammation via the NOD-, LRR- and pyrin domain-containing protein 3 inflammasome[29,30]. Therefore, in patients with CHB who have low baseline eGFR and high TG levels, it is advisable to choose antiviral agents with minimal nephrotoxicity and to closely monitor changes in eGFR.
According to the above results, patients with CHB under initial treatment showed a greater risk of decreased eGFR at week 48 with ETV antiviral therapy, in comparison with TMF treatment. Baseline eGFR levels and TG were found to be independent factors influencing the occurrence of eGFR abnormalities at 48 weeks in patients with CHB. TMF and ETV have similar efficacy in terms of virologic response and improved liver function.
Our findings provide useful information for decision-making regarding antiviral treatment regimens in patients with CHB. However, this study has some limitations. First, we did not include indicators regarding renal tubules. Additionally, a relatively modest cohort and brief observation time might limit the findings of this retrospective study. Confirmation and further refining of our results are needed in larger, multicenter prospective studies.
CONCLUSION
The present study findings indicated that ETV therapy for treatment-naive patients with CHB exhibited a strong association with the increased risk of eGFR decline at 48 weeks, in comparison with TMF, indicating a potentially greater risk of renal injury with ETV. However, both agents demonstrated comparable efficacy regarding virologic response and improved liver function.
ACKNOWLEDGEMENTS
The authors thank all the participants and all the staff who contributed to this study.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade C
Novelty: Grade C
Creativity or Innovation: Grade C
Scientific Significance: Grade B
P-Reviewer: Wu SZ, MD, Professor, China S-Editor: Zuo Q L-Editor: A P-Editor: Yu HG
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