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Núñez MJ, Martín-Carbonero L, Moreno V, Valencia E, Garcia-Samaniego J, Castillo JGD, Barreiro P, González-Lahoz J, Soriano V. Impact of antiretroviral treatment-related toxicities on hospital admissions in HIV-infected patients. AIDS Res Hum Retroviruses 2006; 22:825-9. [PMID: 16989605 DOI: 10.1089/aid.2006.22.825] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
While classical opportunistic infections have decreased as the main cause of hospital admission of HIV-infected patients, other conditions including drug-related toxicities seem to have increased. We assessed the proportion of patients with hospital admission due to antiretroviral (ARV)-related toxicities over the last 7 years at a single HIV/AIDS reference institution located in Madrid. A total of 1981 consecutive hospital admissions in 1581 different HIV-infected patients were analyzed. Nearly half of them (45%) were on ARV therapy. Overall, ARV-related toxicities were the main or secondary reason for hospital admission in 141 patients (7%). Liver toxicity was the most frequent complication (n = 42; 30%), of which one-third were associated with NVP use and 80% occurred in subjects with underlying chronic hepatitis C virus (HCV) infection. Other main ARV-related toxicities were bone marrow toxicity due to zidovudine (17%), pancreatitis (13%), and indinavirassociated nephrolithiasis (6%). Eight patients presented with symptomatic hyperlactatemia, two of them with lactic acidosis. All subjects with ARV-related toxicities had a favorable outcome, except one with prior HCVrelated end-stage liver disease, who died after experiencing hepatic decompensation following initiation of a protease inhibitor-based regimen.
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Affiliation(s)
- María José Núñez
- Service of Infectious Diseases, Hospital Carlos III, Madrid, Spain
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52
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Kjaer A, Lebech AM, Gerstoft J, Hesse B, Petersen CL. Right ventricular volume and mass determined by cine magnetic resonance imaging in HIV patients with possible right ventricular dysfunction. Angiology 2006; 57:341-6. [PMID: 16703194 DOI: 10.1177/000331970605700310] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Impaired right ventricular (RV) function has been reported to occur in patients with HIV when studied by echocardiography. However, for accurate evaluation of RV function and morphology, first-pass radionuclide ventriculography (RNV) and cine magnetic resonance imaging (cine-MRI) are methods of choice. Studies of RV involvement in patients with HIV are of interest since pulmonary hypertension is a known serious complication of HIV recognized with increasing frequency. The aim of the present study was to characterize cardiac function and geometry in patients with HIV and reduced right ventricular ejection fraction (RVEF). To do so, we screened patients with RNV and performed an additional cine-MRI in those with reduced RVEF determined by RNV. Ninety patients with HIV were included. To evaluate the MRI measures exactly we included 18 age- and gender-matched healthy volunteers to establish reference values. RNV showed in 13 of the 90 patients a reduced RVEF with a standard cutoff value for RVEF of 0.50. Six of these agreed to have an additional MRI investigation performed. These 6 patients with HIV had an RVEF measured by RNV between 0.41-0.49. Measured by MRI the range of RVEF was 0.47-0.55 with 3 below the lower 95% reference limit according to the control group (lower reference limit: 0.49). None of the 6 patients with HIV had dilated right ventricle and only 1 had a marginally increased right ventricular mass index of 43 g/m(2) (reference: <41 g/m(2)). With use of MRI, a few patients with HIV may have a marginally reduced RVEF but normal RV dimensions and mass. Thus, RV dysfunction does not seem to constitute a major clinical problem in this antivirally treated HIV population.
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Affiliation(s)
- Andreas Kjaer
- Department of Clinical Physiology, Nuclear Medicine, and PET, Rigshospitalet, Copenhagen, Denmark.
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53
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McGovern BH, Ditelberg JS, Taylor LE, Gandhi RT, Christopoulos KA, Chapman S, Schwartzapfel B, Rindler E, Fiorino AM, Zaman MT, Sax PE, Graeme-Cook F, Hibberd PL. Hepatic steatosis is associated with fibrosis, nucleoside analogue use, and hepatitis C virus genotype 3 infection in HIV-seropositive patients. Clin Infect Dis 2006; 43:365-72. [PMID: 16804853 DOI: 10.1086/505495] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2006] [Accepted: 03/13/2006] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We conducted a study to determine the prevalence and factors associated with hepatic steatosis in human immunodeficiency virus (HIV)-seropositive patients with hepatitis C and to investigate whether steatosis is associated with liver fibrosis. METHODS Retrospective chart reviews were conducted in 4 hospitals that serve community-based and incarcerated HIV-infected patients who had undergone a liver biopsy for evaluation of hepatitis C virus (HCV) infection during the period of 2000-2003. Demographic characteristics and medication and laboratory data were collected from the time of the biopsy. A pathologist blinded to all clinical data evaluated the specimens. The primary outcome was presence or absence of steatosis. RESULTS Of 260 HIV-HCV-coinfected patients, 183 met inclusion criteria and had a biopsy specimen adequate for review. Steatosis was present in 69% of patients (graded as minimal in 31%, mild in 27%, moderate in 18%, and severe in 1%). Factors associated with steatosis included use of dideoxynucleoside analogues, such as didanosine and stavudine (odds ratio [OR], 4.63; 95% confidence interval [CI], 1.55-13.82). There was a trend toward presence of steatosis and use of other nucleoside analogues or infection with HCV genotype 3 (OR, 2.65 [95% CI, 0.95-7.41] and 3.38 [95% CI, 0.86-13.28], respectively). The presence of steatosis was associated with fibrosis (OR, 1.37; 95% CI, 1.03-1.81). CONCLUSIONS In this multiracial population of HIV-HCV-coinfected patients, steatosis was prevalent and was associated with severity of liver fibrosis. Use of nucleoside analogues (particularly didanosine and stavudine) and HCV genotype 3 infection were associated with hepatic steatosis. The development of steatosis is multifactorial in nature and may play a contributory role in the progression of liver disease in HIV-infected patients.
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Affiliation(s)
- Barbara H McGovern
- HIV/HCV Co-infection Clinic, Lemuel Shattuck Hospital, Jamaica Plain, Jamaica Plain, MA 02494, USA.
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54
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Abstract
HIV-infected individuals have myriad causes of hepatotoxicity that range from mild hepatitis to significant liver failure with its associated morbidity and mortality, especially in the setting of chronic viral hepatitis (HCV and HBV). Immune restoration by HAART therapy can contribute liver-related toxicity in HIV-coinfected patients. Clinicians need to be aware of this problem and individualize management in this challenging clinical scenario. Avoidance of potentially hepatotoxic agents or close monitoring during treatment of HIV may prevent liver failure in patients who have HIV. Furthermore, vaccination against hepatitis A virus and HBV in nonimmune HIV individuals may prevent acquisition of hepatitis A virus and HBV infections in patients who have HIV. Finally, treatment of HIV, and, if appropriate, treatment of those who are coinfected with HCV and HBV with close monitoring, may improve the outcome of patients who have HIV and are at risk fo r significant hepatotoxicity during treatment from immune restoration or hypersensitivity reactions.
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Affiliation(s)
- Homayon Sidiq
- St. Luke's Episcopal Hospital Center for Liver Disease, 6620 Main St. 15051, Houston, TX 77301, USA
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55
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Abstract
Numerous drugs and toxins may induce the development of a metabolic acidosis. The treating physician should be cognizant of the many compounds that can produce metabolic acidosis following an overdose or an accidental exposure, or with therapeutic use. Knowledge and comprehension of the substances associated with metabolic acidosis will facilitate the diagnosis and treatment of poisoned patients.
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Affiliation(s)
- Bryan S Judge
- DeVos Children's Hospital Regional Poison Center, Grand Rapids, MI 49503, USA.
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56
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Abstract
PURPOSE OF REVIEW The treatment of HIV infection has been transformed by the introduction of highly active antiretroviral therapy. For patients who respond and can tolerate lifelong therapy, HIV infection may become a chronic disease requiring long-term ambulatory care follow-up. The current management of antiretrovirals is increasingly complex because of the large number of agents, wide spectrum of toxicities, adherence issues, and drug interactions. This review summarizes the currently available agents, recommended and alternative combinations, commonly encountered adverse events, and viral resistance issues. RECENT FINDINGS Twenty antiretroviral medications are commercially available in the United States. Six new agents have been introduced since 2000, including one drug in a novel class of HIV fusion inhibitors. The adverse effects of antiretrovirals are well characterized and include lactic acidosis related to nucleoside reverse transcription inhibitors; metabolic and body habitus changes, primarily attributed to protease inhibitors; and concern about the long-term vascular consequences of elevated lipids and insulin resistance associated with treatment. The recommended antiretroviral therapy by an expert panel as of October 2004 is summarized. SUMMARY The benefits of antiretroviral therapy are clear: reduced morbidity and mortality related to advanced HIV infection. Managing antiretroviral therapy, along with their adverse effects and drug interactions, is complex. Modern treatment mandates a thorough understanding of the agents. Consultation with an HIV-experienced clinician should be considered in most circumstances.
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Affiliation(s)
- Gary Kalkut
- Division of Infectious Diseases and Department of Clinical Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA.
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57
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Madeddu G, Spanu A, Chessa F, Calia GM, Lovigu C, Solinas P, Mannazzu M, Falchi A, Mura MS, Madeddu G. Thyroid function in human immunodeficiency virus patients treated with highly active antiretroviral therapy (HAART): a longitudinal study. Clin Endocrinol (Oxf) 2006; 64:375-83. [PMID: 16584508 DOI: 10.1111/j.1365-2265.2006.02472.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Given that few and controversial data have been reported on thyroid function in human immunodeficiency virus (HIV) patients on highly active antiretroviral therapy (HAART), we further investigated whether HAART affects thyroid hormones. DESIGN AND PATIENTS Two hundred two consecutive adult HIV patients in stable clinical condition were enrolled, 182 on HAART and 20 naïve; 128 were rechecked during follow-up. Body mass index (BMI), CD4 cell count, HIV RNA, hepatitis C and B virus status and infection duration were determined in all HIV patients and HAART duration in treated patients. In all patients and in 60 controls, the following were measured: FT4 and FT3 by radioimmunoassay; TSH, antithyroid peroxidase (TPO) and antithyroglobulin (TG) antibodies by immunoradiometric assay. RESULTS Abnormalities in thyroid function tests were found in 23/182 (12.6%) HAART patients, but not in naïve patients. Most abnormalities were subclinical hypothyroidism, with mean FT4 and TSH levels lower and higher, respectively, in HAART patients compared to naïve patients and controls, FT4 levels being significantly lower than controls. TSH negatively correlated with CD4 count nadir and positively with HAART duration. During follow-up, FT4 and FT3 significantly decreased and TSH increased in patients continuing HAART, whereas CD4 counts were unmodified; subclinical hypothyroid conditions persisted and further cases occurred, whereas the only hypothyroid patient who interrupted HAART shows a normalization of thyroid tests. Patients on stavudine, included in most hypothyroid patient protocols, had significantly lower FT4 levels with prolonged treatment. CONCLUSIONS HAART, particularly stavudine, is associated with a high prevalence of subclinical hypothyroidism. Hypotheses are made regarding responsible mechanisms and risk factors. Thyroid function should be tested and sequentially rechecked in HAART patients.
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Affiliation(s)
- Giordano Madeddu
- Department of Infectious Diseases, Referral HIV Care Center, University of Sassari, Sassari, Italy
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58
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Abstract
As survival continues to improve in the era of highly active antiretroviral therapy, kidney, liver, and cardiac disease have become increasingly important sources of mortality and morbidity in patients with HIV. The incidence of end-stage renal disease in patients with HIV is projected to increase, and the incidence of earlier chronic kidney disease, acute renal failure, and electrolyte abnormalities is likely to be much higher than appreciated. Both acute and chronic kidney disease are more common in the setting of advanced HIV, hepatitis coinfection or liver disease, and medication toxicity. Close collaboration between nephrologists and infectious disease specialists is important to facilitate the identification, diagnosis, and management of acute and chronic kidney disease in patients with HIV. Recently published guidelines highlight the increased awareness of kidney disease in the infectious disease community and provide guidelines for the detection and management of chronic kidney disease in patients with HIV.
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Affiliation(s)
- Christina M Wyatt
- Division of Nephrology, Box 1243, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA.
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59
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Gérard Y, Melliez H, Mouton Y, Yazdanpanah Y. [Mitochondrial cytopathies associated with HIV infection]. Rev Neurol (Paris) 2006; 162:62-70. [PMID: 16446624 DOI: 10.1016/s0035-3787(06)74983-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The tremendous progress achieved during the last few years with the use of highly active antiretroviral therapy in suppressing HIV replication together with improvements in immunity have been tempered by a growing number of new adverse effects. Mitochondrial toxicity is one aspect of these long-term toxicities of antiretroviral drugs, with the role of nucleoside analogs particularly underlined. Some cases of impaired mitochondrial function have been clearly identified, such as pancreatitis due to didanosine, neuropathy due to zalcitabine, myopathy due to zidovudine, and lactic acidosis due to stavudine. These mitochondrial toxicities can affect several organs, presenting different patterns of symptoms: from asymptomatic to states with few symptoms despite huge metabolic abnormalities whose prognosis is immediately life-threatening. Beyond the inhibition of DNA polymerase gamma using nucleoside analogs, responsible for decreasing mitochondrial DNA in certain targeted organs, it appears that several physiopathologic mechanisms interact to explain this observed toxicity, HIV itself plays a role, and the underlying genetic pool needs to be better identified. Such cases mean that, it is imperative to avoid cumulated toxicities caused by associated treatments. With serious cases, or persistent symptoms despite discontinuing the nucleoside analogs responsible for such toxicity, one must propose vitamins, mitochondrial co-factors, or anti-oxidants. However, the future lies in the use of potent, less toxic nucleoside analogs, and in developing compounds belonging to other classes of antiretrovirals.
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Affiliation(s)
- Y Gérard
- Service de Maladies Infectieuses, Hôpital Dron, Tourcoing.
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60
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Cherry CL, Lala L, Wesselingh SL. Mitochondrial toxicity of nucleoside analogues: mechanism, monitoring and management. Sex Health 2006; 2:1-11. [PMID: 16334706 DOI: 10.1071/sh04016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Nucleoside analogues (NRTIs) are potent antiretroviral medications and are central to effective highly active antiretroviral therapy (HAART). Their intended action is to inhibit HIV reverse transcriptase. Nucleoside analogues also inhibit replication of mitochondrial DNA, and the pathogenesis of many of the toxicities associated with HAART is thought to be NRTI-induced mitochondrial dysfunction. Individuals with HIV infection may be particularly susceptible to clinically significant mitochondrial toxicity due to possible effects of HIV itself on mitochondria. At present there is no reliable method of detecting subclinical mitochondrial toxicity in patients exposed to NRTIs. Clinical awareness of this problem is therefore important to ensure the early detection of significant side effects and to allow timely consideration of changing therapy in those affected. There is no proven, effective therapy for NRTI-associated mitochondrial toxicity other than ceasing the implicated agent, and even with this strategy, resolution of symptoms may be incomplete. Similarly, there are no established methods for preventing mitochondrial toxicity in those on therapy including NRTIs. Micronutrients may have a role, but further study is needed to clarify optimal prevention as well as monitoring strategies.
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Affiliation(s)
- Catherine L Cherry
- Burnet Institute for Medical Research and Public Health, GPO Box 2284, Melbourne, Vic. 3001, Australia.
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61
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Abstract
Lactic acidosis is frequently encountered in the intensive care unit. It occurs when there is an imbalance between production and clearance of lactate. Although lactic acidosis is often associated with a high anion gap and is generally defined as a lactate level >5 mmol/L and a serum pH <7.35, the presence of hypoalbuminemia may mask the anion gap and concomitant alkalosis may raise the pH. The causes of lactic acidosis are traditionally divided into impaired tissue oxygenation (Type A) and disorders in which tissue oxygenation is maintained (Type B). Lactate level is often used as a prognostic indicator and may be predictive of a favorable outcome if it normalizes within 48 hours. The routine measurement of serum lactate, however, should not determine therapeutic interventions. Unfortunately, treatment options remain limited and should be aimed at discontinuation of any offending drugs, treatment of the underlying pathology, and maintenance of organ perfusion. The mainstay of therapy of lactic acidosis remains prevention.
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Affiliation(s)
- Pamela J Fall
- Section of Nephrology, Hypertension and Transplantation, Department of Medicine, Medical College of Georgia, Augusta 30912, USA
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62
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. CF, . JH, . FS, . ETF, . JB, . LL, . CG. An Overview of Mitochondrial Toxicity of Nucleoside Reverse Transcriptase Inhibitors Associated with HIV Therapy. INT J PHARMACOL 2005. [DOI: 10.3923/ijp.2006.152.162] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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63
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Cengiz C, Park JS, Saraf N, Dieterich DT. HIV and liver diseases: recent clinical advances. Clin Liver Dis 2005; 9:647-66, vii. [PMID: 16207569 DOI: 10.1016/j.cld.2005.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Because the life expectancy of patients infected with HIV has been prolonged, liver diseases have assumed far greater importance as a cause of morbidity and mortality in these patients. Given the shared risks of transmission, patients who have HIV often are coinfected with hepatotrophic viruses such as hepatitis C and hepatitis B. Further, antiretroviral therapy (ART) used by patients who have HIV is often hepatotoxic, contributing to liver damage. With increasing immunosuppression caused by AIDS, patients who have HIV have to deal with these issues and the increased risk of infection with opportunistic viral, fungal, bacterial, and protozoal pathogens. In addition, steatosis and lipodystrophy now are recognized more commonly in patients who have HIV, particularly in the setting of ART. Thus, understanding of liver diseases in the setting of HIV infection becomes an important focus in caring these individuals. There have been numerous advances in the treatment of liver disease in patients who have HIV, particularly in treating viral hepatitis C and B. This article reviews various liver manifestations in patients who have HIV and the recent advances in diagnostic and therapeutic options.
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Affiliation(s)
- Cem Cengiz
- Division of Liver Diseases, Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029, USA
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64
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Abstract
Metabolic acidosis may arise from several drugs and toxins through a variety of mechanisms. Differentiating the causes of metabolic acidosis in the poisoned patient is an indispensable skill in clinical practice. Comprehension of toxin-induced metabolic acidosis, combined with a thorough history, physical examination, appropriate use of laboratory tests, and a stepwise approach, should aid the clinician in determining the cause of metabolic acidosis in the poisoned patient. When confronted with such a patient, it is imperative that one administer appropriate antidotal therapy, when necessary, and provide the patient with exceptional supportive care.
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Affiliation(s)
- Bryan S Judge
- DeVos Children's Hospital Regional Poison Center, Grand Rapids, MI 49503, USA.
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65
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Lo JC, Kazemi MR, Hsue PY, Martin JN, Deeks SG, Schambelan M, Mulligan K. The Relationship between Nucleoside Analogue Treatment Duration, Insulin Resistance, and Fasting Arterialized Lactate Level in Patients with HIV Infection. Clin Infect Dis 2005; 41:1335-40. [PMID: 16206112 DOI: 10.1086/496981] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2005] [Accepted: 06/14/2005] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Treatment with nucleoside reverse-transcriptase inhibitors (NRTIs) is associated with hyperlactatemia, presumably as a result of NRTI-induced mitochondrial toxicity. We examined the association of NRTI treatment duration and lactate level in human immunodeficiency virus (HIV)-infected patients and assessed the relationship of treatment duration and lactate level with insulin resistance. METHODS Fasting arterialized venous lactate levels, routine blood chemistry findings, insulin resistance (determined by homeostasis model assessment [HOMA-IR]), percentage of body fat (determined by dual-energy radiographic absorptiometry), and detailed histories of antiretroviral therapy were obtained for 95 HIV-infected individuals. The independent association of NRTI treatment duration and lactate level was examined using multivariable linear regression. RESULTS Among 95 subjects with a mean age (+/- standard deviation [SD]) of 44 +/- 8 years), 95% had NRTI exposure, with current NRTI use in 83%. The mean (+/- SD) lactate level was 1.24 +/- 0.46 mmol/L (6% had a lactate level > 2 mmol/L). Longer duration of NRTI use was positively associated with lactate level (beta = 0.047; P < .01), as were age, duration of protease inhibitor treatment, and HOMA-IR. Female sex and percentage of body fat were negatively associated with lactate level. After adjustment for age, sex, diabetes, percentage of body fat, and duration of protease inhibitor therapy, an increased duration of NRTI therapy remained significantly associated with lactate level (beta = 0.035; P = .04). However, the addition of HOMA-IR to the adjusted model attenuated the relation between duration of NRTI therapy and lactate level (beta = 0.024; P = .14), whereas HOMA-IR was significantly associated with lactate level (beta = 0.206; P < .01). Furthermore, HOMA-IR was also associated with NRTI treatment duration in adjusted analyses. CONCLUSION NRTI treatment duration was independently associated with higher lactate level, but this relationship was attenuated after adjusting for HOMA-IR. These data raise the possibility that insulin resistance may be an additional mechanism through which NRTI therapy is related to lactate level.
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Affiliation(s)
- Joan C Lo
- Department of Medicine, University of California San Francisco, CA, USA.
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66
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Lien LF, Feinglos MN. Protease inhibitor-induced diabetic complications : incidence, management and prevention. Drug Saf 2005; 28:209-26. [PMID: 15733026 DOI: 10.2165/00002018-200528030-00003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Protease inhibitors (PIs) have become a crucial element in the treatment of patients infected with HIV. However, the widespread use of PI therapy has also been associated with a number of metabolic adverse effects, including fat redistribution and hyperglycaemia. The objective of this review is a discussion of the incidence, pathophysiology, management and prevention of PI-associated hyperglycaemia. Initial case reports have been followed by large cross-sectional and cohort studies, which demonstrate that the incidence of PI-induced impaired glucose tolerance, as well as frank diabetes mellitus, is significant and demands attention. Investigations into the pathophysiology behind PI-associated hyperglycaemia have identified an underlying problem of insulin resistance that is presumably caused by both direct PI-induced mechanisms and lipotoxicity. Given this, clinical trials have explored the use of various classes of oral hypoglycaemic agents in the management of PI-induced diabetic complications, and the use of insulin therapy must be considered as well. Newer PI agents are also under development, with the hope of reducing metabolic adverse effects. In the meantime, prevention, in the form of dietary modification, regular physical activity and periodic screening for impaired glucose tolerance, must receive heightened attention in the care plan of patients receiving long-term PI therapy.
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Affiliation(s)
- Lillian F Lien
- Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA.
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67
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Tien PC. Management and treatment of hepatitis C virus infection in HIV-infected adults: recommendations from the Veterans Affairs Hepatitis C Resource Center Program and National Hepatitis C Program Office. Am J Gastroenterol 2005; 100:2338-54. [PMID: 16181388 DOI: 10.1111/j.1572-0241.2005.00222.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nearly 40% of human immunodeficiency virus- (HIV-) infected veterans on highly active antiretroviral therapy (HAART) in the United States are coinfected with hepatitis C virus (HCV). With the increased survival due to declining opportunistic infections as a result of HAART, HCV-associated liver disease has become a leading cause of death in HIV-infected individuals. HCV infection has been shown to lead to rapid progression of HCV-related liver disease in HIV infection. Results from recent clinical trials in HIV/HCV-coinfected patients show improved response rates using pegylated formulations of interferon plus ribavirin when compared to standard interferon plus ribavirin. However, the treatment of HCV in HIV/HCV-coinfected patients can be complicated by the hepatotoxic and myelosuppressive effects of HIV therapy and HIV infection itself. Prior to initiating HCV therapy, HIV therapy should be optimized by improving immune suppression and avoiding specific antiretroviral drugs that may cause hepatotoxicity and myelosuppression. In the event of treatment-related neutropenia or anemia during HCV therapy, the use of growth factors should be considered to maximize sustained virologic response to HCV therapy. In HIV/HCV-coinfected patients with end-stage liver disease, liver transplantation is being investigated and shows promise as a potential therapeutic option. With the recent advances in the treatment of HCV in HIV/HCV-coinfected individuals, all HIV/HCV-coinfected patients eligible for HCV treatment should be evaluated for HCV combination therapy with careful consideration of their HIV disease.
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Affiliation(s)
- Pyllis C Tien
- VAMC Infectious Disease Section, San Francisco, CA 94121, USA
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68
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Imhof A, Ledergerber B, Günthard HF, Haupts S, Weber R. Risk Factors for and Outcome of Hyperlactatemia in HIV-Infected Persons: Is There a Need for Routine Lactate Monitoring? Clin Infect Dis 2005; 41:721-8. [PMID: 16080096 DOI: 10.1086/432471] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2004] [Accepted: 04/12/2005] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Lactic acidosis is a rare but life-threatening complication of combination antiretroviral therapy (CART). Asymptomatic or mildly symptomatic episodes of hyperlactatemia are more frequent, but their clinical relevance is unknown. METHODS The incidences of, risk factors for, and courses of hyperlactatemia and lactic acidosis were prospectively assessed in the following 3 groups at the Zurich center of the Swiss HIV Cohort Study: persons already receiving CART at baseline, treatment-naive persons who initiated CART during the observation period, and persons who received no CART before or during the observation period. RESULTS During 4788 person-years of follow-up, a total of 22,678 lactate assessments were performed for 1566 persons; 662 (42.3%) had at least 1 lactate level measurement of > 2.4 mmol/L, and 49 (3.1%) had severe hyperlactatemia (lactate level of > 5.0 mmol/L). The incidence of hyperlactatemia was 227 cases (95% confidence interval [CI], 210-245) and 59 cases (95% CI, 38-93) per 1000 person-years of follow-up among persons with and persons without CART, respectively. During the observation period, the incidence decreased from 459 cases (95% CI, 415-508) to 85 cases (95% CI, 76-107) per 1000 person-years of follow-up, respectively, because of changing CART prescription patterns. Severe hyperlactatemia occurred in treated persons only. In multivariable Cox proportional hazards models, significant risk factors for severe hyperlactatemia were regimens containing stavudine and didanosine (hazard ratio [HR], 6.65; 95% CI, 2.70-16.3) and regimens containing efavirenz (HR, 2.85; 95% CI, 1.31-6.21). Lactic acidosis was diagnosed in 4 of 1566 persons, all of whom were receiving stavudine and didanosine. CONCLUSIONS Hyperlactatemia was frequently observed in all 3 groups, but severe hyperlactatemia and lactic acidosis were rarely observed among persons who received CART. Lactate monitoring appears to be indicated primarily for persons receiving stavudine and didanosine and for persons who are symptomatic. Long-term follow-up is needed to investigate the risk of novel treatment regimens for hyperlactatemia.
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Affiliation(s)
- Alexander Imhof
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zürich, Switzerland
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69
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Gazzard B. British HIV Association (BHIVA) guidelines for the treatment of HIV-infected adults with antiretroviral therapy (2005). HIV Med 2005; 6 Suppl 2:1-61. [PMID: 16011536 DOI: 10.1111/j.1468-1293.2005.0311b.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- B Gazzard
- Chelsea and Westimnster Hospital, London, UK.
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70
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Abstract
There is increasing concern that patients with chronic HIV infection may be at increased risk of nonalcoholic fatty liver disease (NAFLD), which can evolve into nonalcoholic steatohepatitis (NASH) and cirrhosis. Multiple factors have been hypothesized to be necessary for the development and progression of this condition. Potential risk factors, which tend to accumulate in the HIV-positive population, include metabolic derangements, chronic inflammation, hepatitis coinfection, and treatment with certain nucleoside reverse transcriptase inhibitors (NRTIs). HIV-associated conditions such as hyperlactatemia and lipodystrophy frequently overlap with fatty liver disease. The cornerstone of management of HIV-associated fatty liver disease is currently to treat the predominant underlying condition. There is a need for more epidemiologic data to better define the role of comorbidities and drugs in the development of NAFLD. Further work is also needed to elucidate the pathogenesis and to evaluate the therapeutic effect of treating comorbidities and avoiding certain antiretroviral drugs.
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Affiliation(s)
- Maria Ristig
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
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71
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Ghosn J, Guiguet M, Jardel C, Benyaou R, Zeller V, Simon A, Valantin MA, Amellal B, Assoumo L, Hogrel JY, Costagliola D, Katlama C, Lombès A. Muscle and Liver Lactate Metabolism in Haart-Treated and Naive HIV-Infected Patients: The Mitovir Study. Antivir Ther 2005. [DOI: 10.1177/135965350501000412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To assess the impact of nucleoside analogue reverse transcriptase inhibitor (NRTI) combination therapy on muscle and liver lactate metabolism in HIV-infected patients. Methods This cross-sectional study involved HIV-infected patients who were either antiretroviral-naive (Group 1) or were receiving either a stable triple-drug combination including at least one d-drug (zidovudine, zalcitabine, stavudine, didanosine; Group 2) or a backbone of abacavir and lamivudine (Group 3). Lactataemia was measured at rest. Muscle lactate metabolism was assessed during a standardized exercise test and liver lactate metabolism during intravenous lactate infusion. Mitochondrial DNA was quantified in peripheral blood mononuclear cells. Results A total of 65 patients were enrolled (16, 31 and 18 patients in Group 1, Group 2 and Group 3, respectively). None of the patients had symptoms of hyperlactataemia. Patients in Group 3 had received d-drugs for a median of seven years before switching to abacavir and lamivudine. Median baseline lactataemia, although within the normal range, was significantly higher in both treatment groups than in the naive patients (Group 2: 1.4, Group 3: 1.5, and Group 1: 1.0 mmol/l, P=0.005). Muscle lactate clearance was significantly lower in both treatment groups than in naive patients (Group 2: 1.6, Group 3: 1.8, and Group 1: 2.1, P=0.01). Lactate liver metabolism and mitochondrial DNA levels did not differ among the three groups. Conclusions In HIV-infected patients without symptomatic hyperlactataemia, all NRTI-containing HAART regimens appear to cause muscle mitochondrial damage but to spare the liver. Absence of difference between Group 2 and Group 3 raises questions about the potential reversibility of muscle mitochondrial dysfunction, and/or the ability of abacavir and lamivudine to induce such mitochondrial damage.
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Affiliation(s)
- Jade Ghosn
- Département des Maladies Infectieuses, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
- INSERM U720, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Marguerite Guiguet
- INSERM U720, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Claude Jardel
- Laboratoire de Biochimie, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
- Institut de Myologie, INSERM 582, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Rabah Benyaou
- Institut de Myologie, INSERM 582, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Valérie Zeller
- Département des Maladies Infectieuses, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Anne Simon
- Service de Médecine Interne, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Marc-Antoine Valantin
- Département des Maladies Infectieuses, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
- INSERM U720, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Bahia Amellal
- Laboratoire de Virologie, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Lambert Assoumo
- INSERM U720, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Jean-Yves Hogrel
- Institut de Myologie, INSERM 582, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Dominique Costagliola
- INSERM U720, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Christine Katlama
- Département des Maladies Infectieuses, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
- INSERM U720, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
| | - Anne Lombès
- Institut de Myologie, INSERM 582, CHU Pitié-Salpétrière, AP-HP, Université Pierre et Marie Curie, Paris, France
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Rosso R, Ferrazin A, Di Biagio A, Bassetti M, Bassetti D. Consecutive blood lactate assessment in HIV-infected children: correlation with therapy and clinical characteristics. Int J Infect Dis 2005; 9:173-5. [PMID: 15840459 DOI: 10.1016/j.ijid.2004.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2003] [Revised: 07/20/2004] [Accepted: 07/26/2004] [Indexed: 10/25/2022] Open
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Temesgen Z, Cainelli F, Warnke D, Koirala J. Initial antiretroviral therapy in chronically-infected HIV-positive adults. Expert Opin Pharmacother 2005; 5:595-612. [PMID: 15013928 DOI: 10.1517/14656566.5.3.595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Currently, there are 20 individual antiretroviral drugs and two co-formulation products that are approved by the FDA for the treatment of HIV-infected individuals. It is widely accepted that the selection of an appropriate first-line regimen is critical in assuring durable treatment response. This article reviews the factors that should be considered in the selection of an initial antiretroviral regimen and present the currently available evidence regarding the status of individual antiretroviral agents and treatment strategies relative to these factors.
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Affiliation(s)
- Zelalem Temesgen
- Mayo Clinic and Foundation, Division of Infectious Diseases, Rochester, MN 55905, USA.
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74
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Viganò A, Giacomet V. Nucleoside Analogues Toxicities Related to Mitochondrial Dysfunction: Focus on HIV-Infected Children. Antivir Ther 2005. [DOI: 10.1177/135965350501002s06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Vania Giacomet
- Paediatrics, L Sacco Hospital, University of Milan, Italy
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75
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Calza L, Manfredi R, Chiodo F. Hyperlactataemia and lactic acidosis in HIV-infected patients receiving antiretroviral therapy. Clin Nutr 2005; 24:5-15. [PMID: 15681097 DOI: 10.1016/j.clnu.2004.03.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2004] [Accepted: 03/31/2004] [Indexed: 11/30/2022]
Abstract
Nucleoside reverse-transcriptase inhibitors (NRTIs) have been associated with functional and structural mitochondrial abnormalities, leading to several adverse events, such as increased serum lactic acid levels and lactic acidosis. Mild-to-moderate, asymptomatic hyperlactataemia has been frequently reported in human immunodeficiency virus (HIV)-infected patients treated with NRTIs, with an estimated prevalence between 15% and 35%. On the contrary, symptomatic, severe hyperlactataemia and lactic acidosis are less common, with an incidence ranging from 1.7 to 25.2 cases per 1000 person-years of antiretroviral treatment, and are associated with a remarkable mortality rate, which varies from 30% to 60% in different studies. The clinical presentation of lactic acid syndrome is non-specific and includes asthenia, malaise, nausea, vomiting, abdominal pain, weight loss, tachypnoea, dyspnoea, liver steatosis and increased transaminase levels, and risk factors include previous or concurrent therapy with stavudine or didanosine. Management of symptomatic lactic acid alterations involves NRTI-therapy interruption and supportive care, while natural history of hyperlactataemia is still unknown, and it is uncertain whether asymptomatic patients with increased lactate concentrations are at increased risk of developing lactic acidosis.
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Affiliation(s)
- Leonardo Calza
- Section of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Bologna "Alma Mater Studiorum", S. Orsola Hospital, via G. Massarenti 11, 40138, Bologna, Italy.
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76
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Moyle G. Mechanisms of HIV and Nucleoside Reverse Transcriptase Inhibitor Injury to Mitochondria. Antivir Ther 2005. [DOI: 10.1177/135965350501002s05] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Graeme Moyle
- St Stephens HIV Research, Chelsea and Westminster Hospital, London, UK
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77
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Côté HCF. Possible Ways Nucleoside Analogues Can Affect Mitochondrial Dna Content and Gene Expression during HIV Therapy. Antivir Ther 2005. [DOI: 10.1177/135965350501002s02] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In recent years, research into nucleoside reverse transcriptase inhibitor (NRTI)-related mitochondrial (mt) toxicity in HIV therapy has led to conflicting results and many unanswered questions regarding the molecular mechanisms that lead to such toxicity. From the early hypothesis that inhibition of the human mt polymerase γ by NRTIs was responsible for the drugs’ mt toxicity, an increasingly complex picture is emerging that probably involves multiple mt pathways. Results have been presented suggesting that NRTIs affect not only mtDNA but also mtRNA, nucleotide phosphorylation and the mt respiratory chain. Based on the current level of knowledge, this overview addresses some of the potential mechanisms through which NRTIs could affect mitochondria and ultimately cause the toxicity symptoms observed in HIV patients receiving NRTI-containing antiretroviral therapy.
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Affiliation(s)
- Hélène CF Côté
- British Columbia Centre for Excellence in HIV/AIDS, Department of Pathology & Laboratory Medicine/University of British Columbia, Vancouver, BC, Canada
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78
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Milazzo L, Piazza M, Sangaletti O, Gatti N, Cappelletti A, Adorni F, Antinori S, Galli M, Moroni M, Riva A. [13C]Methionine breath test: a novel method to detect antiretroviral drug-related mitochondrial toxicity. J Antimicrob Chemother 2005; 55:84-9. [PMID: 15590719 DOI: 10.1093/jac/dkh497] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES A major side effect of antiretroviral drugs is nucleoside reverse transcriptase inhibitor (NRTI)-related mitochondrial toxicity, the in vivo diagnosis of which is difficult and not yet standardized. We used the [(13)C]methionine breath test to investigate hepatic mitochondrial oxidation in HIV-1-infected patients receiving antiretroviral therapy. PATIENTS AND METHODS The [(13)C]methionine breath test was performed in healthy subjects (n=10), HIV-infected patients on antiretroviral therapy with (n=6) and without (n=15) hyperlactataemia and naive HIV-infected patients (n=11). After oral administration of [(13)C]methionine (2 mg/kg body weight), hepatic methionine metabolism was measured by breath (13)CO(2) enrichment, expressed as delta over baseline (DOB) every 15 min for 120 min by mass spectrometry. RESULTS The four study groups showed a significant difference in (13)CO(2) exhalation (P=0.001). HIV-infected patients on antiretroviral therapy with normal serum lactate had reduced exhalation of (13)CO(2) compared with healthy subjects (DOB mean peak: 8.82+/-0.62 versus 11+/-0.9, P<0.05). HIV patients with hyperlactataemia had even lower values when compared with patients with normal lactataemia (DOB mean peak: 4.98+/-0.68 versus 8.82+/-0.62, P<0.05). CONCLUSIONS The [(13)C]methionine breath test possibly showed mitochondrial impairment in antiretroviral-treated HIV-positive patients, particularly with hyperlactataemia. This non-invasive test can be used to monitor drug-related mitochondrial toxicity in vivo and to discover early and asymptomatic damage of the respiratory chain.
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Affiliation(s)
- Laura Milazzo
- Institute of Infectious and Tropical Diseases, University of Milan, L. Sacco Hospital, Via GB Grassi 74, 20157 Milan, Italy.
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Haugaard SB, Andersen O, Pedersen SB, Dela F, Richelsen B, Nielsen JO, Madsbad S, Iversen J. Depleted skeletal muscle mitochondrial DNA, hyperlactatemia, and decreased oxidative capacity in HIV-infected patients on highly active antiretroviral therapy. J Med Virol 2005; 77:29-38. [PMID: 16032748 DOI: 10.1002/jmv.20410] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The nucleoside reverse transcriptase inhibitors (NRTIs), especially stavudine, may deplete mitochondrial (mt) DNA in human tissues by inhibiting the mitochondrial polymerase gamma, a setting, which is associated with hyperlactatemia. The aim of the present study was to examine whether hyperlactatemia is associated with depletion of skeletal muscle (sm)-mtDNA and decreased oxidative capacity in HIV-infected patients on NRTI based highly active antiretroviral therapy (HAART) and whether HIV infection itself is associated with sm-mtDNA depletion. Sm-mtDNA was determined in 42 HIV-infected patients (35 patients on HAART including at least one NRTI (HIV-NRTI) and 7 patients never treated with antiretroviral drugs (NAIVE)) and 14 healthy controls. Whole body oxidative capacity (DeltaGOX) was estimated in HIV-infected patients by indirect calorimetry. Hyperlactatemia (>or=2.0 mM) was detected in six HIV-NRTI, who all used Stavudine (P < 0.01), displayed depleted sm-mtDNA (P < 0.02) and decreased DeltaGOX (P < 0.01) compared with normolactatemic HIV-NRTI (n = 29). NAIVE displayed decreased sm-mtDNA (P < 0.05), increased HIV-RNA (P < 0.01) and increased plasma TNF-alpha (P < 0.05) compared to all HIV-NRTI (n = 35), in turn displaying decreased sm-mtDNA (P < 0.01) compared to healthy controls. Thus, hyperlactatemia in HIV-NRTI may be associated with pronounced depletion of sm-mtDNA, decreased oxidative capacity and current stavudine therapy. Further, HIV may deplete sm-mtDNA of NAIVE, which in part could be mediated through an enhanced pro-inflammatory response.
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Affiliation(s)
- Steen B Haugaard
- Department of Infectious Diseases, Hvidovre University Hospital, Copenhagen, Denmark.
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Dubé MP, Kitch DW, Parker RA, Alston-Smith BL, Mulligan K. The effect of long-term storage on measured plasma lactate concentrations and prospective lactate results from a multicenter trial of antiretroviral therapy. Clin Chem Lab Med 2005; 43:947-52. [PMID: 16176175 DOI: 10.1515/cclm.2005.162] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractPlasma lactate measurements are typically performed in real time, limiting their usefulness in multicenter or longitudinal studies. To determine the stability of lactate specimens, blood was drawn in sodium fluoride/potassium oxalate tubes from 13 volunteers before and after 5min of handgrip exercise to intentionally increase lactate concentrations. Plasma was stored at −70°C. Aliquots were assayed in real time and after 1, 3, 6, 9, 12, 18, and 24months. Real-time lactate concentrations measured at baseline ranged from 0.52 to 2.23mmol/L before and from 2.91 to 11.04mmol/L after handgrip exercise. Using a linear mixed model, the estimated change from baseline at month 24 was 1.67% (95% confidence interval, −0.70% to 4.03%) for pre-exercise samples and 0.39% (95% CI, −1.13% to 1.91%) for post-exercise samples. Stored serial specimens from 232 HIV-infected subjects in a multicenter trial of antiretroviral therapy were also assayed centrally. Among those, median plasma lactate increased from baseline to 64weeks by 0.4mmol/L with zidovudine+lamivudine treatment and by 0.6mmol/L with didanosine+stavudine (each p<0.001 from baseline; p=0.04 for difference between groups over time). When performed as in this study, frozen storage with central batch lactate analysis is appropriate for prospectively collected samples in multicenter trials.
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Affiliation(s)
- Michael P Dubé
- Department of Medicine and Division of Infectious Diseases, Indiana University School of Medicine, Wishard Memorial Hospital, 1001 W. 10th Street, Suite OPW-430, Indianapolis, IN 46202, USA.
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81
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Abstract
Much of the success attributed to HIV therapy in the last few years has resulted from improved ways of using existing drugs in combination therapy regimens. The availability of new, more potent drugs such as protease inhibitors and more accurate viral load tests to aid decisions to start or change treatment has also contributed to the success. Published recommendations for pediatric HIV therapy, generated by a panel of experts and specialists, are readily available and regularly updated. Preferred regimens of 'potent' therapy (referred to as highly active antiretroviral therapy, or HAART) currently consist of two nucleoside reverse transcriptase inhibitors (NRTIs) combined with either a non-nucleoside reverse transcriptase inhibitor (NNRTI) or a protease inhibitor. More intense four-drug regimens using an NNRTI or a second protease inhibitor as a fourth drug are being evaluated. Problems with HAART include: unpalatable drug formulations and adverse effects, coupled with lack of data on the pharmacokinetics, efficacy, and safety of various drug combinations. Adherence is a major factor influencing the efficacy and outcome of antiretroviral therapy. Many children cannot adhere to complex multidrug regimens, which cause virologic failure, despite excellent CD4+ cell count responses. This means a rapid progression through the limited number of treatment regimens available. Simpler regimens such as those containing three NRTIs have been proposed as a method of treatment that will allow suppression of the virus, yet circumvent many of the problems previously mentioned. An additional benefit would be the preservation of antiretroviral drugs from other classes for future treatment options if required. The major advantages of triple NRTI regimens are the simplicity of the regimen, good tolerability, few drug-drug interactions, and infrequent adverse effects coupled with a low pill burden. However, abacavir hypersensitivity remains a major problem. Up to 3% of patients may develop an early idiosyncratic hypersensitivity reaction - fever, malaise, and mucositis with or without rash, which can progress to more advanced stages of shock and death. A major concern is the apparently inferior virologic control of triple NRTI therapy as demonstrated in the AIDS Clinical Trials Group A5095 study with zidovudine/lamivudine/abacavir (Trizivir) combination in adults. Such a combination should only be considered in special situations. Examples cited include informed patient choice based on anticipated poor adherence on other treatment regimens, or if concomitant drugs such as tuberculosis medication are prescribed. The low pill burden of triple NRTI regimens (especially if combined in a single pill such as Trizivir), offers hope that regimen simplification may still be possible in the future.
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Affiliation(s)
- Jennifer Handforth
- Paediatric Infectious Diseases Unit, St George's Hospital, Tooting, London, UK
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82
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Noguera A, Fortuny C, Muñoz-Almagro C, Sanchez E, Vilaseca MA, Artuch R, Pou J, Jimenez R. Hyperlactatemia in human immunodeficiency virus-uninfected infants who are exposed to antiretrovirals. Pediatrics 2004; 114:e598-603. [PMID: 15492359 DOI: 10.1542/peds.2004-0955] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Exposure to nucleoside analogues in fetal or early life has been associated with rare clinically significant mitochondrial toxic effects, mainly neurologic symptoms. Lactate (LA) measurements have been used to monitor nucleoside-related mitochondrial toxicity. Our aim was to determine the prevalence, clinical evolution, and risk factors for hyperlactatemia in our cohort of human immunodeficiency virus (HIV)-uninfected children who were exposed to antiretrovirals. METHODS We conducted a prospective observational study of 127 HIV-uninfected infants who were born to HIV-infected women. Clinical symptoms suggesting mitochondrial dysfunction were analyzed in routine follow-up, and LA and alanine plasma levels were obtained at 6 weeks, 3 months, 6 months, and 12 months in all patients. Elevated alanine levels, together with hyperlactatemia, suggest chronic mitochondrial injury. RESULTS Most (85%) women received highly active antiretroviral therapy (HAART) during pregnancy (mean duration: 31 weeks) and zidovudine during labor (93%). Most (96%) children received zidovudine alone. Hyperlactatemia with hyperalaninemia was detected in 63 children in at least 1 of the measurements. Mean LA levels were significantly higher in children who were exposed to nucleoside analogue reverse transcriptase inhibitors than in control subjects (2.88 vs 1.61 at 6 weeks, 2.78 vs 1.49 at 3 months, 1.89 vs 1.39 at 6 months, and 1.71 vs 1.24 at 12 months; peak levels: 8.06, 10.1, 7.28, and 4.48 mmol/L, respectively). In 44 patients, LA levels progressed spontaneously to normality within the first year of life. Three girls presented a slight and self-limited delay in psychomotor development, with LA peak levels of 7.3, 4.0, and 4.6 mmol/L. Only the gestational use of didanosine was associated with a higher risk of hyperlactatemia. CONCLUSIONS In our series, almost half of the children (63 of 127) who were exposed to nucleoside analogues developed benign and self-limited hyperlactatemia. When symptomatic, nucleoside analogue-induced toxicity affected neurologic development.
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Affiliation(s)
- Antoni Noguera
- Infectious Diseases Unit, Pediatrics Department, Integrated Unit Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
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Bauer AM, Sternfeld T, Horster S, Schunk M, Goebel FD, Bogner JR. Kinetics of lactate metabolism after submaximal ergometric exercise in HIV-infected patients. HIV Med 2004; 5:371-6. [PMID: 15369513 DOI: 10.1111/j.1468-1293.2004.00237.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES It is unknown whether high levels of lactate result from enhanced production or decreased degradation. We therefore investigated differences in the kinetics of plasma lactic acid in HIV-infected patients receiving or not receiving highly active antiretroviral therapy (HAART) and in uninfected controls after submaximal ergometric exercise. METHODS Ten healthy controls, 11 HIV-infected therapy-naïve patients, 15 HIV-infected patients on HAART with normal baseline lactate levels, and nine HIV-infected patients on HAART with elevated baseline lactate levels >2 mmol/L performed 10 min of ergometric exercise, with a heart rate of 200 beats/min minus age. Lactate levels were measured at baseline, at the end of exercise and 15, 30, 45, 60 and 120 min thereafter. RESULTS Mean baseline lactate levels were 1.4, 1.5, 1.5 and 2.8 mmol/L in the controls, the therapy-naïve patients, the patients on HAART with normal lactate levels and the patients on HAART with elevated lactate levels, respectively. Maximum lactate levels after exercise were similar in all groups (9.7, 9.4, 9.0 and 10.1 mmol/L, respectively). Significant differences were found in the slope of lactate decline between controls and untreated individuals (P=0.038) and between patients on HAART with normal baseline lactate and patients on HAART with elevated baseline lactate (P=0.028). CONCLUSIONS Differences in lactate metabolism do exist between healthy controls and HIV-infected therapy-naïve individuals. Thus, HIV infection in itself may influence lactate levels. Elevated baseline lactate levels are associated with a delayed decline of lactate after exercise. These results could be explained by impaired lactate clearance. Lactate production upon exercise does not seem to be affected by baseline lactate levels.
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Affiliation(s)
- A-M Bauer
- Department of Infectious Diseases, Medizinische Poliklinik, University Hospital of Munich, Pettenkoferstrasse 8a, 80336 Munich, Germany
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85
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Nolan D, Mallal S. Complications Associated with Nrti Therapy: Update on Clinical Features and Possible Pathogenic Mechanisms. Antivir Ther 2004. [DOI: 10.1177/135965350400900609] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The availability of durable, effective antiretroviral therapy for HIV-infected patients has fundamentally altered the prognosis of this disease and has also increased awareness that long-term drug toxicities have the potential to cause significant morbidity and even mortality in this patient population. The long-term use of nucleoside analogue reverse transcriptase inhibitor (NRTI) drugs has been associated with a number of clinically relevant toxicities including hyperlactataemia and lactic acidosis, neuropathy, pancreatitis and, more recently, a syndrome of pathological loss of subcutaneous fat tissue (lipoatrophy). Importantly, the toxicity profile of each NRTI drug within this class is unique in terms of the overall risk of long-term complications, as well as the tissue specificity of its toxic effects. In this review, the clinical manifestations, risk factors and pathological basis for NRTI-associated toxicity syndromes are explored, with an emphasis on clinical assessment and management.
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Affiliation(s)
- David Nolan
- Centre for Clinical Immunology and Biomedical Statistics, Royal Perth Hospital and Murdoch University, Western Australia, Australia
| | - Simon Mallal
- Centre for Clinical Immunology and Biomedical Statistics, Royal Perth Hospital and Murdoch University, Western Australia, Australia
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86
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Ballesteros ÀL, Miró Ò, López S, Fuster D, Videla S, Martínez E, Garrabou G, Salas A, Côté H, Tor J, Rey-Joly C, Planas R, Clotet B, Tural C. Mitochondrial Effects of a 24-Week Course of Pegylated-Interferon plus Ribavirin in Asymptomatic HCV/HIV Co-Infected Patients on Long-Term Treatment with Didanosine, Stavudine or Both. Antivir Ther 2004. [DOI: 10.1177/135965350400900613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background It has been suggested that the addition of ribavirin (RBV) as a part of the treatment for chronic hepatitis C virus (HCV) in HIV co-infected patients on didanosine (ddI) or stavudine (d4T) might increase the nucleoside-induced impairment of mitochondrial function. Design: Comparative study to investigate the impact on mitochondrial function of adding RBV to a long-term treatment with ddI, d4T or both in HCV/HIV non-cirrhotic, asymptomatic patients. We included 26 patients: 16 continued with their current antiretroviral therapy (control group) and 10 patients received a concomitant 24-week course of RBV plus pegylated interferon (PEG-IFN) α-2b therapy (HCV-treated group). Methods We assessed peripheral blood mononuclear cells mitochondrial DNA (mtDNA) content and mitochondrial respiratory chain (MRC) function at baseline and at 24 weeks of follow-up. In the HCV-treated group we performed additional determinations at 12 weeks during anti-HCV therapy and 24 weeks after finishing anti-HCV therapy. Results Times on ddI or d4T exposure were 194 ±54.9 and 131 ±66.5 weeks in the HCV-treated and control groups, respectively. There were no differences either in mtDNA content, the enzyme activity of MRC complexes or clinical parameters at baseline. Throughout the study, mitochondrial measurements remained stable within groups and without differences when we compared HCV-treated and control groups. Conclusions In our study, the addition of RBV and PEG-IFN during a 24-week period in HCV/HIV non-cirrhotic, asymptomatic patients on long-term ddI, d4T or both had no impact on mitochondrial function. These findings could suggest that additional triggers are required to achieve a critical threshold in the degree of mitochondrial damage needed for symptoms to develop.
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Affiliation(s)
| | - Òscar Miró
- Mitochondrial Research Laboratory, Fundació Clínic-IDIBAPS, Barcelona, Spain
| | - Sònia López
- Mitochondrial Research Laboratory, Fundació Clínic-IDIBAPS, Barcelona, Spain
| | | | | | | | - Glòria Garrabou
- Mitochondrial Research Laboratory, Fundació Clínic-IDIBAPS, Barcelona, Spain
| | | | - Hélène Côté
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Jordi Tor
- Internal Medicine Department, Barcelona, Spain
| | | | - Ramon Planas
- Hepatology and Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autónoma de Barcelona (UAB), Barcelona, Spain
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87
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Lonergan JT, McComsey GA, Fisher RL, Shalit P, File TM, Ward DJ, Williams VC, Hessenthaler SM, Lindsey L, Hernandez JE. Lack of Recurrence of Hyperlactatemia in HIV-Infected Patients Switched From Stavudine to Abacavir or Zidovudine. J Acquir Immune Defic Syndr 2004; 36:935-42. [PMID: 15220700 DOI: 10.1097/00126334-200408010-00007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Stavudine (d4T) has been observed in clinical trials and cohort studies to be more often implicated in cases of hyperlactatemia than other nucleoside reverse transcriptase inhibitors, possibly because of its relatively greater propensity to induce mitochondrial toxicity. The ESS40010 study was a 48-week, open-label, switch study that assessed changes in serum lactate levels and signs/symptoms of hyperlactatemia after substitution of abacavir (n = 86) or zidovudine (n = 32) for d4T in 118 virologically suppressed HIV-infected patients (HIV-1 RNA <400 copies/mL) who had developed serum lactate concentrations > or =2.2 mmol/L (n = 16) or had remained normolactatemic (n = 102) after receiving > or =6 months of d4T-based treatment. Median serum lactate decreased significantly below baseline at week 24 (-0.15 mmol/L, P = 0.0002) and week 48 (-0.15 mmol/L, P = 0.0015). In 10 hyperlactatemic patients in whom d4T was discontinued, serum HIV-1 RNA levels rebounded over the ensuing 31 days, but virologic suppression (HIV-1 RNA <400 copies/mL) was regained when treatment using abacavir or zidovudine was subsequently instituted. In the group with elevated lactate at baseline, symptoms of hyperlactatemia improved in 8% to 23% of patients, did not change in 69%, and worsened in 8%. Serum transaminases, which had been elevated while patients received d4T, normalized after d4T discontinuation and remained in the normal range after the switch to abacavir or zidovudine. Overall, in patients with d4T-associated hyperlactatemia, stopping d4T results in normalization of lactate and a rebound in viral load; restarting treatment using abacavir or zidovudine subsequently maintains normal lactate levels and rapidly leads to a return of virologic suppression.
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Affiliation(s)
- J Tyler Lonergan
- Department of Medicine, Owen Clinic/University of California at San Diego Medical Center, 92103, USA.
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88
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Note R, Maisonneuve C, Lettéron P, Peytavin G, Djouadi F, Igoudjil A, Guimont MC, Biour M, Pessayre D, Fromenty B. Mitochondrial and metabolic effects of nucleoside reverse transcriptase inhibitors (NRTIs) in mice receiving one of five single- and three dual-NRTI treatments. Antimicrob Agents Chemother 2004; 47:3384-92. [PMID: 14576092 PMCID: PMC253807 DOI: 10.1128/aac.47.11.3384-3392.2003] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although treatments with nucleoside reverse transcriptase inhibitors (NRTIs) can modify fat metabolism and fat distribution in humans, the mechanisms of these modifications and the roles of diverse NRTIs are unknown. We studied the mitochondrial and metabolic effects of stavudine (d4T), zidovudine (AZT), didanosine (ddI), lamivudine (3TC), zalcitabine (ddC), and three combinations (AZT-3TC, d4T-3TC, and d4T-ddI) in mice treated for 2 weeks with daily doses equivalent to the human dose per body area. Concentrations of AZT and d4T in plasma were lower when these drugs were administered with 3TC or ddI. Whatever the treatment, mitochondrial DNA was not significantly decreased in muscle, heart, brain, or white adipose tissue but was moderately decreased in liver tissue after the administration of AZT, 3TC, or d4T alone. Blood lactate was unchanged, even when NRTIs were administered at supratherapeutic doses. In contrast, the level of plasma ketone bodies increased with the administration of AZT or high doses of d4T but not with ddC, 3TC, or ddI, suggesting that the thymine moiety could be involved. Indeed, the levels of plasma ketone bodies increased in mice treated with beta-aminoisobutyric acid, a thymine catabolite. Treatment with AZT, d4T, or beta-aminoisobutyric acid increased hepatic carnitine palmitoyltransferase I (CPT-I) mRNA expression and the mitochondrial generation of ketone bodies from palmitate. In conclusion, therapeutic doses of NRTIs have no or moderate effects on mitochondrial DNA and no effects on plasma lactate in mice. However, AZT and high doses of d4T increase the levels of hepatic CPT-I, mitochondrial fatty acid beta-oxidation, and ketone bodies, and these catabolic effects are reproduced by beta-aminoisobutyric acid, a thymine metabolite.
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Affiliation(s)
- Reine Note
- INSERM Unité 481 and Centre Claude Bernard de Recherches sur les Hépatites Virales, Clichy, France
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89
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Abstract
OBJECTIVE To investigate progressive, severe neuromuscular weakness associated with lactic acidosis in some HIV-infected patients after exposure to nucleoside reverse transcriptase inhibitors (NRTI). METHODS HIV-associated neuromuscular weakness syndrome (HANWS) was retrospectively identified and classified based on the level of diagnostic certainty: possible (progressive weakness owing to neuromuscular disease), probable (progressive neuromuscular weakness with documented exclusion of confounding causes), or definite (progressive weakness and electrophysiological or pathological evidence of neuromuscular pathology). RESULTS Of 69 patients identified with HANWS, 27 had definite HANWS, 19 probable, and 23 possible. In 44 patients with documented follow-up, 16 required intubation and nine died. There was a marginal association between death and hyperlactatemia (P = 0.061). At onset of neurological symptoms, 68 were receiving antiretroviral therapy, including stavudine for 61 (89.7%). Serum lactate level was elevated (> 2.2 mmol/l) in 30/37 (81%), with a trend towards an association between hyperlactatemia and stavudine usage (P = 0.087). In 25, neurological symptoms occurred after antiretroviral therapy discontinuation (median, 14 days). Electrophysiological studies (n = 24) indicated sensorimotor neuropathy in 20 patients and myopathy in three. Nerve biopsy (n = 9) revealed axonal degeneration and inflammation in three, mixed axonal and demyelinating lesions in three, and primary axonal neuropathy in three. Of 15 muscle biopsies, three revealed inflammation and four mitochondrial abnormalities. CONCLUSIONS A severe neuromuscular weakness syndrome may occur in HIV-infected individuals. The association with hyperlactatemia and NRTI exposure supports mitochondrial toxicity as a pathogenesis. In some, the onset of neurological symptoms lagged significantly after discontinuation of antiretroviral therapy, suggesting that different etiological mechanisms may underlie these cases.
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90
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Tripuraneni NS, Smith PR, Weedon J, Rosa U, Sepkowitz D. Prognostic factors in lactic acidosis syndrome caused by nucleoside reverse transcriptase inhibitors: report of eight cases and review of the literature. AIDS Patient Care STDS 2004; 18:379-84. [PMID: 15307926 DOI: 10.1089/1087291041518229] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We conducted a retrospective study to identify prognostic factors in the lactic acidosis syndrome (LAS) caused by nucleoside reverse transcriptase inhibitors (NRTIs) in patients with HIV/AIDS. Fifty-eight cases of LAS were included in our analysis, 8 from our hospital spanning the years 1992-2002, and 50 reported in the English language literature from 1986 through 2002. Peak venous lactate level was the best predictor of mortality. Zidovudine was associated with higher lactate levels and higher mortality than stavudine and lamuvidine. Mortality declined progressively after 1986 when the first cases of NRTI-related LAS were described. Increased mortality with zidovudine in this study appears due in part to its greater use prior to 1990 when LAS was not widely recognized as a potential complication of NRTI therapy.
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Affiliation(s)
- Naga S Tripuraneni
- Division of Pulmonary Medicine Long Island College Hospital, Brooklyn, New York 11201, USA
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91
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Chiappini F, Teicher E, Saffroy R, Pham P, Falissard B, Barrier A, Chevalier S, Debuire B, Vittecoq D, Lemoine A. Prospective evaluation of blood concentration of mitochondrial DNA as a marker of toxicity in 157 consecutively recruited untreated or HAART-treated HIV-positive patients. J Transl Med 2004; 84:908-14. [PMID: 15122308 DOI: 10.1038/labinvest.3700113] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Highly active antiretroviral therapy (HAART) can cause mitochondrial toxicity. The concentration of mitochondrial DNA (mtDNA) in peripheral blood cells has been reported to be a marker of this toxicity. However, these observations are controversial and were drawn from small series. Thus, we analysed the value of blood mtDNA as a marker of mitochondrial toxicity in a large cohort of human immunodeficiency virus (HIV)-infected out-patients during routine clinical evaluations. Real-time quantitative PCR was used to determine the mtDNA to nuclear DNA (nDNA) ratio in peripheral blood mononuclear cells from 157 consecutive HIV-1-infected patients (13 naive, 144 receiving HAART) and 30 HIV-1-uninfected patients. The mtDNA to nDNA ratio was significantly lower in both groups of HIV-infected patients than in the control group. No significant difference was observed between treated and naive HIV-infected patients. Lactataemia was significantly lower in controls than in the group of HIV-treated patients. None of the treated patients had lactataemia >5 mmol/l or bicarbonates <20 mmol/l. Triglyceride levels were significantly higher in the HAART-treated patients than in the nontreated patients. Clinical symptoms of lipodystrophy were observed in 62 HAART-treated patients. These symptoms were not associated with an abnormal mtDNA to nDNA ratio or plasma triglyceride concentration. The mtDNA to nDNA ratio was lower in DDI/D4T-treated patients than in AZT/3TC-treated patients. In conclusion, there are no obvious links between the mtDNA to nDNA ratio in peripheral mononuclear cells and any clinical symptoms or lactate level. Thus, the mtDNA to nDNA ratio in leukocytes does not seem to be an accurate marker of mild and/or long-term mitochondrial toxicity.
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Affiliation(s)
- Franck Chiappini
- Service de Biochimie et de Biologie Moléculaire-INSERM 602, Hôpital Paul Brousse, 12 avenue Paul Vaillant-Couturier, 94800 Villejuif, France
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92
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Montaner JSG, Côté HCF, Harris M, Hogg RS, Yip B, Harrigan PR, O'Shaughnessy MV. Nucleoside-related mitochondrial toxicity among HIV-infected patients receiving antiretroviral therapy: insights from the evaluation of venous lactic acid and peripheral blood mitochondrial DNA. Clin Infect Dis 2004; 38 Suppl 2:S73-9. [PMID: 14986278 DOI: 10.1086/381449] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Nucleoside analogues inhibit human DNA polymerase gamma. As a result, they can produce mitochondrial toxicity. We evaluated the possible role of random venous lactic-acid determinations as a screening tool for mitochondrial toxicity among patients receiving nucleoside therapy. More recently, we have developed an assay that can detect changes in mitochondrial DNA (mtDNA) levels in peripheral blood cells. Using this assay, we have characterized changes in mtDNA relative to nuclear DNA (nDNA) in peripheral blood cells from patients with symptomatic nucleoside-induced hyperlactatemia. Our results demonstrated that symptomatic hyperlactatemia was associated with markedly low mtDNA : nDNA ratios. A statistically significant increase in the mtDNA : nDNA ratio was observed after the discontinuation of antiretroviral therapy. Full validation of monitoring the mtDNA : nDNA ratio is currently under way.
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Affiliation(s)
- Julio S G Montaner
- BC Centre for Excellence in HIV/AIDS and the Canadian HIV Trials Network, St. Paul's Hospital, Providence Health Care, University of British Columbia, Vancouver, Canada.
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93
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Palacio H, Li X, Wilson TE, Sacks H, Cohen MH, Richardson J, Young M, Muñoz A. Healthcare use by varied highly active antiretroviral therapy (HAART) strata: HAART use, discontinuation, and naivety. AIDS 2004; 18:621-30. [PMID: 15090767 DOI: 10.1097/00002030-200403050-00006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Prior reports have found a temporal association between the introduction of highly active antiretroviral therapy (HAART) and population rates of health service use among persons living with HIV. Our objective was to explore further the effect of HAART by comparing healthcare use among persons who use HAART and persons who discontinue HAART to that among HAART-naive and HIV-negative persons. METHODS Longitudinal analyses of 1485 women with and at-risk for HIV who contributed data to the Women's Interagency HIV Study between April 1997 and March 2000. RESULTS Compared with HAART-naive women, those using HAART had a higher probability of more than three primary care visits per 6 months [odds ratio (OR), 1.38; 95% confidence interval (CI), 1.16-1.65), a lower probability of more than one emergency room visit per 6 months (OR, 0.75; CI, 0.59-0.95), and a lower probability of more than one hospitalization per 6 months (OR, 0.67; CI, 0.51-0.88). Compared with HAART-naive women, women who had discontinued HAART had a higher frequency of primary care visits (OR, 1.57; CI, 1.26-1.97) but did not demonstrate a significant change in emergency room or hospital use. Modeling of a standardized population HIV-positive women without AIDS indicated hospitalization and emergency room use among HAART users was equivalent to that among HIV-negative women. CONCLUSIONS HIV-positive HAART users (without AIDS) exhibited emergency room and hospitalization use patterns equivalent to those of HIV-negative women. Furthermore, the discontinuation of HAART was associated with a loss of the reduction in hospital use that was achieved with HAART.
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Affiliation(s)
- Herminia Palacio
- Harris County Public Health and Environmental Services, 2223 West Loop South, Houston, TX 77027, USA
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94
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Carter RW, Singh J, Archambault C, Arrieta A. Severe lactic acidosis in association with reverse transcriptase inhibitors with potential response to L-carnitine in a pediatric HIV-positive patient. AIDS Patient Care STDS 2004; 18:131-4. [PMID: 15104873 DOI: 10.1089/108729104322994810] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We report a case of life-threatening lactic acidosis in a 10-year-old male with HIV stage B2 infection, presumed to be vertically acquired. This occurred after several months of therapy with d4t, ddl, and nevirapine. His most recent CD4 count was 347 cells per microliter and viral load 16,000 copies per milliliter 3 weeks prior to admission. The peak lactic acid level was 12.4 mmol/L. Although multiple therapeutic interventions took place, the patient showed rapid improvement and resolution temporally associated with the administration of levocarnitine.
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Affiliation(s)
- Robert W Carter
- Department of Pediatrics, Naval Medical Center, San Diego, California, USA
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95
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Wohl DA, Pilcher CD, Evans S, Revuelta M, McComsey G, Yang Y, Zackin R, Alston B, Welch S, Basar M, Kashuba A, Kondo P, Martinez A, Giardini J, Quinn J, Littles M, Wingfield H, Koletar SL. Absence of Sustained Hyperlactatemia in HIV-Infected Patients With Risk Factors for Mitochondrial Toxicity. J Acquir Immune Defic Syndr 2004; 35:274-8. [PMID: 15076242 DOI: 10.1097/00126334-200403010-00008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The prevalence of asymptomatic hyperlactatemia among HIV-infected individuals has been reported to be 4% to 36%. This variability may reflect differences in the definition of and risk factors for hyperlactatemia and/or techniques for venous lactate collection. METHODS We examined the prevalence of elevated venous lactate collected in accordance with Adult AIDS Clinical Trials Group (AACTG) guidelines among HIV-infected and nucleoside analogue-treated subjects with risk factors associated with hyperlactatemia. Sustained hyperlactatemia was defined as 2 consecutive levels >or=1.5 but <or=4 times the upper limit of normal (ULN) within 30 days. RESULTS Eighty-three subjects were enrolled. Two thirds had >or=2 risk factors, with 11% having >4 risk factors. The median entry venous lactate level was 1.2 mmol/L (range: 0.7-5.1 mmol/L). Two subjects had a lactate level >1.5 times the ULN: 1 with a value of 2.1 times the ULN at entry and a week 2 level of 1.2 times the ULN and a second subject with a week 2 value of 1.9 times the ULN but an entry level of 1.4 times the ULN. The latter subject developed symptomatic lactic acidosis 3 weeks following study discontinuation. CONCLUSIONS Sustained asymptomatic hyperlactatemia among subjects with risk factors associated with hyperlactatemia was not observed when venous lactate was measured in a standardized fashion. One case of hyperlactatemia that evolved into symptomatic lactic acidosis was diagnosed soon after the completion of the study, however. Our findings indicate that asymptomatic hyperlactatemia is either very rare or an artifact of collection technique.
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Affiliation(s)
- David A Wohl
- Department of Medicine, University of North Carolina, Chapel Hill, USA.
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96
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Cho BC, Han SH, Choi SH, Choi JY, Chang KH, Song YG, Kim JM. A case of lactic acidosis caused by stavudine in an AIDS patient. Korean J Intern Med 2004; 19:66-9. [PMID: 15053048 PMCID: PMC4531542 DOI: 10.3904/kjim.2004.19.1.66] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Nucleoside reverse transcriptase inhibitors (NRTIs), which are used for the treatment of human immunodeficiency virus (HIV) infection have been associated with a wide spectrum of clinical manifestations, including hepatic steatosis, lipodystrophy, myopathy, and lactic acidosis. Such adverse effects are postulated to result from the inhibition of mitochondrial DNA gamma polymerase, which causes the depletion of mitochondrial DNA and eventual the disruption of oxidative phosphorylation. Although cases of severe decompensated lactic acidosis are rare, this syndrome is associated with a high mortality rate. We report upon the first Korean case, of severe lactic acidosis in an acquired immunodeficiency syndrome (AIDS) patient receiving stavudine, an anti-HIV drug.
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Affiliation(s)
- Byoung Chul Cho
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hoon Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Suk Hoon Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Yong Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Hee Chang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young Goo Song
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - June Myung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Correspondence to: June Myung Kim, M.D., Department of Internal Medicine, Yonsei University College of Medicine, 134, Shinchon-dong, Seodaemun-gu, Seoul 120-752, Korea Tel: 82-2-361-5431, Fax: 82-2-393-6884, E-mail:
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97
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Walker UA, Bäuerle J, Laguno M, Murillas J, Mauss S, Schmutz G, Setzer B, Miquel R, Gatell JM, Mallolas J. Depletion of mitochondrial DNA in liver under antiretroviral therapy with didanosine, stavudine, or zalcitabine. Hepatology 2004; 39:311-7. [PMID: 14767983 DOI: 10.1002/hep.20074] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
The "D drug" HIV reverse-transcriptase inhibitors zalcitabine, didanosine, and stavudine are relatively strong inhibitors of polymerase-gamma compared with the "non-D drugs" zidovudine, lamivudine, and abacavir. D drugs deplete mitochondrial DNA (mtDNA) in cultured hepatocytes. This mtDNA depletion is associated with an increased in vitro production of lactate. To investigate the origin of hyperlactatemia in HIV-infected patients and the effects of antiretroviral therapy on liver mtDNA, we biopsied liver tissue from 94 individuals with chronic hepatitis C virus (HCV) infection. Eighty subjects were coinfected with HIV. Serum lactate was measured at the time of biopsy. Hepatic mtDNA and liver histology were centrally assessed. Liver mtDNA content of HIV-infected patients receiving D drugs at the time of biopsy (n = 34) was decreased by 47% (P<.0001) compared with those without D drugs (n = 35). Aside from a possible association between HCV genotype I status and mtDNA depletion in multivariate analysis, there were no other virologic, immunologic, histologic, demographic or treatment-related variables that could explain the mtDNA depletion. Lactate was above the upper limit of normal in only three patients, all of whom were treated with D drugs. The mtDNA in each of them was lower than in any non-D drug patient and significantly (P =.017) depleted compared with D drug patients with normal lactate. In conclusion, D drug treatment is associated with decreased hepatic mtDNA in HIV-infected patients with chronic HCV infection. Moderate mtDNA depletion in liver does not necessarily lead to hyperlactatemia, but more pronounced decreases in hepatic mtDNA may be an important contributor to lactate elevation.
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Affiliation(s)
- Ulrich A Walker
- Medizinische Universitätsklinik, Department of Clinical Immunology, Freiburg, Germany.
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98
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McComsey GA, Yau L. Asymptomatic Hyperlactataemia: Predictive Value, Natural History and Correlates. Antivir Ther 2004. [DOI: 10.1177/135965350400900210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The significance of asymptomatic hyperlactataemia is unknown. Methods We measured serial lactate levels in a group of HIV-infected subjects. Objectives were to identify covariates associated with hyperlactataemia, and to explore the natural history of hyperlactataemia. Results Overall, 1487 lactate measurements were performed on 396 subjects; 299 subjects had serial lactate testing, with a median of four performed per patient (range: 2–16). At study entry, lactate was >2.4 mmol/l in 6% of subjects and >3.6 mmol/l in 1%. A multiple logistic regression analysis revealed that cholesterol and current stavudine were the only predictors of hyperlactataemia. Lactate levels were highly reproducible both for short-term (within 3 months) and long-term (>1 year) follow-up. During the study period, 16 subjects were identified with sustained hyperlactataemia; 12/16 remained asymptomatic after a median of 210 days (30–585), and four developed symptoms suggestive of lactic acidosis syndrome. In three of the four, asymptomatic hyperlactataemia had preceded the onset of symptoms by 18–122 days. A longitudinal model showed a rapid rise of lactate levels from 0 to 12 months on nucleoside reverse transcriptase inhibitor (NRTI) and then stabilization. Lactate levels did not correlate with baseline or on-study development of lipoatrophy. Conclusions Even when optimal methods of collection are used, asymptomatic hyperlactataemia does exist and could be sustained in a subset of NRTI-treated subjects for as long as 585 days. A subset of these subjects became symptomatic, after as long as 122 days of asymptomatic hyperlactataemia. Asymptomatic hyperlactataemia is not predictive of lipoatrophy. This work was partly presented at the 9th Conference on Retroviruses & Opportunistic Infections. Seattle, Wash., USA, February 2002.
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Affiliation(s)
- Grace A McComsey
- Rainbow Babies and Children's Hospital, Center for AIDS Research of Case Western Reserve University and the University Hospitals of Cleveland, Cleveland, Oh., USA
- GlaxoSmithKline, Research Triangle Park, NC, USA
| | - Linda Yau
- GlaxoSmithKline, Research Triangle Park, NC, USA
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100
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