101
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Abstract
Stavudine is a potent nucleoside analogue and a well-recognized component of highly active antiretroviral therapy. Clinical trials have shown stavudine to have a superior or at least comparable virological efficacy and immune reconstitution when compared with other nucleoside analogues. Studies have shown that the prevalence of phenotypic resistance to stavudine is low compared with that of zidovudine, lamivudine and abacavir, and any loss of sensitivity to stavudine is slow to develop and of low intensity. Stavudine has a low incidence of clinically significant adverse events, and those experienced are generally long-term, manageable class effects.
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Affiliation(s)
- E Martínez
- Infectious Diseases Unit, Hospital Clinic-IDIBAPS, Barcelona, Spain.
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102
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Miró O, López S, Martínez E, Rodríguez-Santiago B, Blanco JL, Milinkovic A, Miró JM, Nunes V, Casademont J, Gatell JM, Cardellach F. Short communication: reversible mitochondrial respiratory chain impairment during symptomatic hyperlactatemia associated with antiretroviral therapy. AIDS Res Hum Retroviruses 2003; 19:1027-32. [PMID: 14678610 DOI: 10.1089/088922203322588387] [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: 12/26/2022] Open
Abstract
Direct evidence confirming the hypothesis that a dysfunction of the mitochondrial respiratory chain (MRC) underlies the pathogenesis of hyperlactatemia associated with highly active antiretroviral therapy (HAART) is scarce. We studied mitochondrial DNA (mtDNA) content and MRC function in the skeletal muscle of an HIV-infected patient during an episode of symptomatic hyperlactatemia. Skeletal muscle biopsy was performed during the episode when the patient was symptomatic and 3 months later when the patient was clinically recovered. Assessment of mitochondria was performed using histological, polarographic, spectrophotometrical, and Southern blot and real time PCR DNA quantification methods. The histological study disclosed extensive mitochondrial impairment in the form of ragged-red fibers or equivalents on oxidative reactions. These findings were associated with an increase in mitochondrial content and a decrease in both mitochondrial respiratory capacity and MRC enzyme activities. Mitochondrial DNA content declined to 53% of control values. Mitochondrial abnormalities had almost disappeared later when the patient became asymptomatic. Our findings support the hypothesis that MRC dysfunction stands at the basis of HAART-related hyperlactatemia.
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Affiliation(s)
- Oscar Miró
- Mitochondrial Research Laboratory, Department of Internal Medicine, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), School of Medicine, University of Barcelona, Barcelona, Catalonia, Spain.
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103
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Abstract
OBJECTIVE To describe the first pediatric case of fatal lactic acidosis in an antiretroviral-treated child with human immunodeficiency virus (HIV) infection. DESIGN Case report. SETTING Pediatric intensive care unit. PATIENTS A patient with fatal antiretroviral therapy-associated type B lactic acidosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We report the case of a 5-yr-old girl with HIV infection, receiving ritonavir, stavudine, and didanosine, who presented with a 10-day history of nausea and vomiting. Severe lactic acidosis was found. Her clinical condition worsened, with progressive increase in serum lactate, despite aggressive supportive therapy, including intravenous alkali and continuous arteriovenous hemodiafiltration. CONCLUSIONS Fatal lactic acidosis is a complication of antiretroviral therapy in pediatric HIV patients, which has not been previously reported in children. Early recognition of mitochondrial dysfunction in these patients could prevent the development of fatal lactic acidosis.
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Affiliation(s)
- Corsino Rey
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario Central de Asturias, University of Oviedo, Oviedo, Spain.
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104
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Manfredi R, Motta R, Patrono D, Calza L, Chiodo F, Boni P. Frequency, risk factors and features of hyperlactatemia in a large number of patients undergoing antiretroviral therapy. AIDS 2003; 17:2131-3. [PMID: 14502021 DOI: 10.1097/00002030-200309260-00019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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105
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Phillips AN, Lepri AC, Lampe F, Johnson M, Sabin CA. When should antiretroviral therapy be started for HIV infection? Interpreting the evidence from observational studies. AIDS 2003; 17:1863-9. [PMID: 12960818 DOI: 10.1097/00002030-200309050-00004] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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106
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Abstract
Although non-specific gastrointestinal and hepatic symptoms are commonly found in most mitochondrial disorders, they are among the cardinal manifestations of several primary mitochondrial diseases, such as: mitochondrial neurogastrointestinal encephalomyopathy; mitochondrial DNA depletion syndrome; Alpers syndrome; and Pearson syndrome. Management of these heterogeneous disorders includes the empiric supplementation with various "mitochondrial cocktails," supportive therapies, and avoidance of drugs and conditions known to have a detrimental effect on the respiratory chain. There is a great need for improved methods of treatment and controlled clinical trials of existing therapies. Liver transplantation is successful in acquired cases; however neuromuscular involvement in primary mitochondrial disorders should be a contraindication for liver transplantation.
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Affiliation(s)
- Lynette A Gillis
- Division of Gastroenterology and Nutrition, Department of Pediatrics, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, 34th St. and Civic Center, Blvd., Philadelphia, PA 19104, USA
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107
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Noguera A, Fortuny C, Sanchez E, Artuch R, Vilaseca MA, Muñoz-Almagro C, Pou J, Jiménez R. Hyperlactatemia in human immunodeficiency virus-infected children receiving antiretroviral treatment. Pediatr Infect Dis J 2003; 22:778-82. [PMID: 14506367 DOI: 10.1097/01.inf.0000083826.11124.b1] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hyperlactatemia and lactic acidosis occur in HIV-infected adults receiving antiretroviral treatment. Our objective was to determine the incidence, course and risk factors for hyperlactatemia in our HIV-infected pediatric patients. DESIGN A prospective observational study of venous lactate concentrations during a 28-month period in 80 HIV-infected children, most of whom were receiving antiretrovirals. METHODS Venous blood lactate concentrations were measured every 6 months under optimal sample-obtaining conditions. Alanine values from the same blood sample were performed when lactate concentrations were elevated. Hyperalaninemia is observed only when mitochondrial oxidative phosphorylation is chronically disturbed. RESULTS Twenty-three patients (29%) were identified with hyperlactatemia, in 9 of the cases with normal alaninemia, probably caused by difficult venous punctures. The other 14 children (17%) had pathologic alanine concentrations with a mean lactate peak of 2.67 mmol/l (range, 2.05 to 4.9 mmol/l); none of them showed metabolic acidosis, and they were all symptom-free. Treatment was continued in all cases, and lactate has progressed spontaneously to normal values in 5 patients. CONCLUSIONS Symptom-free hyperlactatemia was observed in HIV-infected children receiving nucleoside analog reverse transcriptase inhibitors. In our study, only a younger age at the beginning of antiretroviral treatment was a statistically significant risk factor for hyperlactatemia. Random measurements of blood lactate concentrations should be included in the clinical follow-up of those HIV-infected children <3 years of age who are treated with nucleoside analog reverse transcriptase inhibitors, symptomatic or not.
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Affiliation(s)
- Antoni Noguera
- Infectious Diseases unit, Pediatric Department, Hospital Sant Joan de Déu-Hospital Clinic, University of Barcelona, 08950 Esplugues, Barcelona, Spain
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108
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Pau AK. Antiretroviral Therapy-associated Serious and Life-threatening Toxicities. Curr Infect Dis Rep 2003; 5:429-438. [PMID: 13678573 DOI: 10.1007/s11908-003-0023-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
In the late 1980s and early 1990s, when HIV/AIDS had become the leading cause of death in 25- to 44-year-old persons in the United States, it was acceptable to prescribe newer antiretroviral therapy such as zidovudine, which has significant bone marrow toxicities but can potentially improve patient survival. Although current antiretroviral therapy is not likely to eradicate HIV-1 infection, the advances in the use of combination antiretroviral therapy (including protease inhibitors and non-nucleoside reverse transcriptase inhibitors) have dramatically improved the overall survival, immune status, and productivity of HIV-infected individuals in developed countries. Instead of prevention and treatment of HIV-associated complications, many of the patients" clinic visits are focused on finding strategies to manage and prevent antiretroviral therapy-associated complications. Because only a few HIV-infected persons fulfilling stringent inclusion criteria were included in premarketing clinical trials and because the US Food and Drug Administration"s (FDA) accelerated approval process for antiretroviral therapy requires only 24-week safety and efficacy data, newly emerging and previously unrecognized adverse effects of antiretroviral therapy continue to surface when these drugs are administered to a larger patient population for a longer duration. Unfortunately, some of these adverse effects can be unpredictable and serious, and, if not recognized early and managed aggressively, can lead to fatality. This article reviews four of the most serious, life-threatening toxicities associated with antiretroviral therapy.
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Affiliation(s)
- Alice K. Pau
- Clinical Center Pharmacy Department, National Institutes of Health, Department of Health and Human Services, Building 10, Room 1N257, Bethesda, MD 20892, USA.
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109
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Falcó V, Crespo M, Ribera E. Lactic acidosis related to nucleoside therapy in HIV-infected patients. Expert Opin Pharmacother 2003; 4:1321-9. [PMID: 12877640 DOI: 10.1517/14656566.4.8.1321] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The incidence of nucleoside analogue-related lactic acidosis has been estimated in 0.57 - 8.5 cases/1000 person years of antiretroviral therapy. The onset of lactic acidosis is usually insidious and patients complain of nausea, vomiting, abdominal pain, fatigue and weight loss. When lactate levels are high enough, a catastropic clinical situation develops, resulting in multiorgan failure. The mortality rate of patients with lactic acidosis related to nucleoside therapy is very high, 33 - 60%. Although all nucleoside analogues have been implicated in lactic acidosis, most cases are associated with stavudine. At present, there are no controlled trials to evaluate the treatment of nucleoside-induced lactic acidosis. Therapy is based on supportive measures and discontinuation of all antiretroviral drugs. Administration of essential vitamin coenzymes, electron acceptors and L-carnitine may be useful in some cases.
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Affiliation(s)
- Vicenç Falcó
- Infectious Diseases Division, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, P masculine Vall d'Hebron 119-129 08035, Barcelona, Spain.
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110
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Sipsas NV, Kosmas N, Kontos A, Eftychiadis C, Agapitos E, Kordossis T. Fatal nucleoside-associated lactic acidosis in an obese woman with human immunodeficiency virus type 1 infection on a very low-calorie diet. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 2003; 35:291-3. [PMID: 12839166 DOI: 10.1080/00365540310004054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This study reports the case of an obese woman with human immunodeficiency virus type 1 (HIV-1) infection who developed fatal nucleoside-associated lactic acidosis 10 d after she started a weight-loss dietary regimen containing 600 kcal/d. This case suggests that very low-calorie diets may be life threatening for HIV-infected patients receiving nucleoside analogues.
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Affiliation(s)
- Nikolaos V Sipsas
- Academic Department of Pathophysiology (AIDS Unit), Laikon General Hospital and Medical School, National and Kapodistrian University of Athens, Athens, Greece
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111
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Worth L, Elliott J, Anderson J, Sasadeusz J, Street A, Lewin S. A cautionary tale: fatal lactic acidosis complicating nucleoside analogue and metformin therapy. Clin Infect Dis 2003; 37:315-6. [PMID: 12856228 DOI: 10.1086/375850] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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112
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Abstract
A total of 251 venous lactate levels were obtained from 127 children with HIV/AIDS; 104 on highly active antiretroviral therapy, and 23 not on therapy. Asymptomatic hyperlactatemia (> 2 mmol/l) was found in 41 children; no hepatic dysfunction or life-threatening lactic acidosis occurred. Asymptomatic hyperlactatemia is associated with treatment with nucleoside reverse transcriptase inhibitors or protease inhibitors and with undetectable viral loads regardless of treatment regimen, suggesting that elevated lactate levels are useful in evaluating adherence.
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Affiliation(s)
- Ninad Desai
- Children's Hospital, SUNY Downstate Medical Center, Brooklyn Pediatric AIDS Network, Brooklyn, NY, USA
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113
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Ogedegbe AEO, Thomas DL, Diehl AM. Hyperlactataemia syndromes associated with HIV therapy. THE LANCET. INFECTIOUS DISEASES 2003; 3:329-37. [PMID: 12781504 DOI: 10.1016/s1473-3099(03)00654-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hyperlactataemia is seen in 8-18.3% of HIV-infected patients taking nucleoside-analogue reverse transcriptase inhibitors (NRTIs). Recent epidemiological studies suggest that most episodes are transient and subclinical. However, symptomatic and occasionally life-threatening cases accompanied by metabolic acidosis and hepatic steatosis (ie, lactic acidosis syndrome) have also been described. Though yet to be fully elucidated, the proposed mechanism is NRTI-induced inhibition of mitochondrial DNA polymerase culminating in derangements in oxidative phosphorylation and lactate homeostasis. Signs and symptoms range from mild hyperlactataemia accompanied by nausea, abdominal discomfort, and weight loss to severe, intractable lactic acidosis complicated by coma and multi-organ failure. Significant progress has recently been made with regard to the natural history of NRTI-related hyperlactataemia. However, other important aspects of the disorder, such as its pathogenesis, predisposing conditions, and management, remain poorly understood. This article reviews the current published work on these issues, identifies areas of controversy, and addresses directions for future research.
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114
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Delobel P, Khatibi S, Alvarez M, Obadia M, Bonnet E, Massip P, Marchou B. Reversible nucleoside analogue-associated lactic acidosis despite a prolonged course. Intensive Care Med 2003; 29:1028-1029. [PMID: 12684748 DOI: 10.1007/s00134-003-1750-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2003] [Accepted: 03/14/2003] [Indexed: 10/22/2022]
Affiliation(s)
- P Delobel
- Department of Infectious and Tropical Diseases, Purpan University Hospital, Place Baylac, 31059, Toulouse cedex, France.
| | - S Khatibi
- Department of Infectious and Tropical Diseases, Purpan University Hospital, Place Baylac, 31059, Toulouse cedex, France
| | - M Alvarez
- Department of Infectious and Tropical Diseases, Purpan University Hospital, Place Baylac, 31059, Toulouse cedex, France
| | - M Obadia
- Department of Infectious and Tropical Diseases, Purpan University Hospital, Place Baylac, 31059, Toulouse cedex, France
| | - E Bonnet
- Department of Infectious and Tropical Diseases, Purpan University Hospital, Place Baylac, 31059, Toulouse cedex, France
| | - P Massip
- Department of Infectious and Tropical Diseases, Purpan University Hospital, Place Baylac, 31059, Toulouse cedex, France
| | - B Marchou
- Department of Infectious and Tropical Diseases, Purpan University Hospital, Place Baylac, 31059, Toulouse cedex, France
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115
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Bonnet F, Bonarek M, Morlat P, Mercié P, Dupon M, Gemain MC, Malvy D, Bernard N, Pellegrin JL, Beylot J. Risk factors for lactic acidosis in HIV-infected patients treated with nucleoside reverse-transcriptase inhibitors: a case-control study. Clin Infect Dis 2003; 36:1324-8. [PMID: 12746780 DOI: 10.1086/374601] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2002] [Accepted: 01/10/2003] [Indexed: 11/03/2022] Open
Abstract
A case-control study was undertaken to determine risk factors for lactic acidosis in human immunodeficiency virus-infected patients treated with nucleoside reverse-transcriptase inhibitors (NRTIs). From May 1996 to June 2000, 9 patients with lactic acidosis (defined as a plasma lactic acid level of >5 mM and plasma pH of <7.38) were identified. Control patients were randomly selected from among a large cohort of patients who initiated a dual NRTI regimen in 1996 or after. Two factors were associated with an increased risk of lactic acidosis: first, a creatinine clearance of <70 mL/min before lactic acidosis (OR, 15.8 [range, 3.0-86.5], P<10(-4)), and, second, a low nadir CD4+ T lymphocyte count before the inception of NRTI therapy (OR, 8.4 [range, 1.2-infinity], P=.03). The total cumulative exposure to NRTIs was not associated with an increased risk of lactic acidosis, nor was the cumulative exposure to any of the 4 NRTIs studied. According to these results, monitoring of creatinine clearance, especially in patients with a low nadir CD4+ T lymphocyte count, could lead to modifications in antiretroviral therapy in order to diminish the risk of occurrence of lactic acidosis.
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Affiliation(s)
- F Bonnet
- Fédération de Médecine Interne, Maladies Infectieuses et Pathologies Tropicales, Hôpital Saint-André, Bordeaux, France.
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116
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Abstract
ART-related hepatotoxicity can manifest in a variety of ways. Although benign, asymptomatic LEEs predominate, liver injury occurring in the context of either hypersensitivity or hyperlactatemia, represents a medical emergency and mandates immediate cessation of ART. Underpinning this broad spectrum of presentations are several, as yet poorly understood, mechanisms of liver damage that reflect contributions by constituents of HAART and host factors. Thus far, the most significant predisposing condition to emerge from clinical studies is chronic viral hepatitis. A more precise understanding, however, of the processes and factors that underlie ART-related hepatotoxicity is critical not only to the management of liver injury from current antiretroviral drugs but also to the design of safer drugs in the future.
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Affiliation(s)
- Anthony O Ogedegbe
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, 1830 East Monument Street, Room 448, Baltimore, MD 21287, USA
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117
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Gérard Y, Viget N, Yazdanpanah Y, Ajana F, de La Tribonnière X, Bocket L, Deuffic-Burban S, Dos Santos A, Ballester L, Mouton Y. Hyperlactataemia during antiretroviral therapy: incidences, clinical data and treatment. Therapie 2003; 58:153-8. [PMID: 12942856 DOI: 10.2515/therapie:2003022] [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: 11/20/2022]
Abstract
Lactic acidosis is a serious complication of antiretroviral therapy. Symptomatic hyperlactataemia is a milder form of this syndrome, but its incidence is unclear. In this prospective ongoing observational study of a large cohort of HIV-infected adults, hyperlactataemia was diagnosed in 64 patients. Incidences were 18.3/1000 person-years with antiretroviral therapy, and 35.8/1000 person-years for stavudine (d4T) regimens. Ten of the 64 patients developed lactic acidosis during the first 13 months of treatment (incidence 2.9/1000 treated person-years). In four of ten patients, symptoms were absent or mild. More patients on d4T first-line therapy developed lactic acidosis than patients previously treated with other drugs (p = 0.008). Despite the occurrence of one death, the subsequent outcome for the remaining patients was favourable after antiretroviral therapy was stopped and supportive treatment with vitamins and antioxidants initiated. The early diagnosis of cases was the result of great vigilance and, combined with routine measurements of the anion gap, might be the most crucial factor explaining the low mortality rate observed here.
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Affiliation(s)
- Yann Gérard
- Service Régional Universitaire des Maladies Infectieuses et du Voyageur, Hôpital Dron, Tourcoing, France.
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118
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Blanco F, García-Benayas T, José de la Cruz J, González-Lahoz J, Soriano V. First-line therapy and mitochondrial damage: different nucleosides, different findings. HIV CLINICAL TRIALS 2003; 4:11-9. [PMID: 12577192 DOI: 10.1310/hf1j-3p6k-1k9h-agpy] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Antiretroviral therapy has been associated with the development of morphologic body-shape changes and metabolic abnormalities, including dislipemia, insulin resistance, and hyperlactatemia. Mitochondrial damage secondary to the use of nucleoside analogue reverse transcriptase inhibitors (NRTIs) has been related to some of these complications, although the role of different NRTIs in their development is not well established. OBJECTIVES To assess the incidence of hyperlactatemia and lipodystrophy body-shape changes in drug-naïve HIV-infected patients who began highly active antiretroviral therapy (HAART) based on a backbone of two different NRTI combinations. METHOD Prospective, longitudinal, observational study of all consecutive drug-naïve HIV-infected individuals who started HAART with zidovudine (AZT) plus lamivudine (3TC) or didanosine (ddI) plus stavudine (d4T) between June 2000 and June 2001 at one single institution. Serum lactate levels and lipodystrophy body-shape changes were monitored periodically during 12 months. RESULTS At 1 year, mean lactate values remained <2 mmol/L in all 26 patients who received AZT+3TC, but they significantly increased (mean, 2.6 mmol/L) in 50 patients treated with ddI+d4T. The percentage of patients with hyperlactatemia (lactate >or=2 mmol/L) steadily increased in those on ddI+d4T (from 30% at 3 months to 71% at 12 months), whereas it remained below 10% in patients treated with AZT+3TC. Two patients on ddI+d4T developed lactic acidosis. Mean serum lactate dehydrogenase (LDH), gamma-glutamyltransferase (GGT), and amylase significantly increased in patients treated with ddI+d4T, whereas they remained unaltered in patients under AZT+3TC. Significant correlations were found between lactate and LDH, alkaline phosphatase (AP), and GGT. In the multivariate analysis, treatment with ddI+d4T, LDH, and AP was significantly associated with lactate levels. At 12 months, subcutaneous lipoatrophy was significantly more frequent in patients treated with ddI+d4T than in those on AZT+3TC (35% vs. 8%; p =.01). CONCLUSION In drug-naïve HIV-infected patients who start antiretroviral therapy, ddI+d4T-based combinations produce a greater increase in serum lactate and lipoatrophy than therapies based on AZT+3TC within the first year of therapy. An increase in LDH, amylase, GGT, and AP levels may signal an increase in lactate, which may be harmful.
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Affiliation(s)
- Francisco Blanco
- Service of Infectious Diseases, Instituto de Salud Carlos III, Madrid, Spain
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119
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Cornejo-Juárez P, Sierra-Madero J, Volkow-Fernández P. Metabolic acidosis and hepatic steatosis in two HIV-infected patients on stavudine (d4T) treatment. Arch Med Res 2003; 34:64-9. [PMID: 12604378 DOI: 10.1016/s0188-4409(02)00454-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Nucleoside analog reverse transcriptase inhibitors (NRTI) have been used to treat HIV-infected patients for >10 years. Some severe adverse events have been attributed to mitochondrial dysfunction. Since 1991, cases of severe lactic acidosis have been reported in association with nucleoside therapy. Our objective was to report two cases of metabolic acidosis and hepatic steatosis in patients receiving stavudine (d4T) and to review the literature. A male and a female, 47 and 45 years of age, respectively, presented with abdominal pain, nausea, vomiting, and weakness after 9 and 6 months, respectively, of treatment with stavudine. At presentation, both patients had severe metabolic acidosis and liver failure. Ultrasonography showed hepatic steatosis (confirmed by biopsy in one case). All antiretroviral drugs were withdrawn and patients were treated with bicarbonate. Both patients developed fulminant liver dysfunction and multiple organ failure. We reviewed the literature and found 75 cases of lactic acidosis and hepatic steatosis associated with use of NRTI; 57 of these patients received d4T (76%). Of all cases reported in association with nucleoside therapy, 63% were females and mortality was 47%. General weakness, hepatic enzyme elevation, and liver steatosis are data that should alert physicians to this serious adverse event and to respond with prompt interruption of antiretroviral drugs and measurement of lactic acid in plasma. It is important to report serious adverse events in commercially released drugs to know prevalence in an exposed population. Physicians should be aware of risk and early signs of this serious adverse event.
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Affiliation(s)
- Patricia Cornejo-Juárez
- Departamento de Enfermedades Infecciosas, Instituto Nacional de Cancerología, Mexico City, Mexico.
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120
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Bonnet F, Bonarek M, Abridj A, Mercié P, Dupon M, Gemain MC, Malvy D, Bernard N, Pellegrin JL, Morlat P, Beylot J. [Severe lactic acidosis in HIV-infected patients treated with nucleosidic reverse transcriptase analogs: a report of 9 cases]. Rev Med Interne 2003; 24:11-6. [PMID: 12614853 DOI: 10.1016/s0248-8663(02)00702-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Symptomatic lactic acidosis requiring intensive care is a rare and severe adverse event related to the mitochondrial toxicity of the nucleoside analog reverse transcriptase inhibitors (NRTIs). METHOD We retrospectively investigated the clinical and biological features of HIV-infected patients who developed severe lactic acidosis syndrome at the University teaching hospital of Bordeaux and the regional community hospital, during 1996-2000. RESULTS Nine patients were identified (incidence: 0,9/1000 NRTI treated patient-years), 4 men and 5 women with a median age of 36 years. They had a moderate immunodeficiency (median CD4+ T lymphocyte counts: 197/mm(3)) and only one of them presented a virological failure. The causes of hospital admission were abdominal pain (n = 6), dyspnea (n = 6), asthenia (n = 5), jaundice (n = 4), and vomiting (n = 2). Hepatomegaly was present in 6 patients. Lactic acidosis was found in all cases: median pH: 7.28, bicarbonate: 12 mmol/l, anion gap: 27 mEq/l, plasma lactic acid: 13 mmol/l. Cytolysis (n = 8), cholestasis (n = 6), hepatic failure (n = 4), rhabdomyolysis (n = 4) and pancreatitis (n = 2), were also present. Despite medical intensive care, seven patients died. The only two post-mortem examinations revealed severe hepatic steatosis. Median duration of NRTI therapy was 4 years. At presentation, five patients were receiving lamivudine, five didanosine, four stavudine and three zidovudine. Six patients were coinfected by HCV and/or HBV, four had chronic renal failure and five an immediately preceding infectious disease. CONCLUSION The prognosis of lactic acidosis is severe. Nucleosid-analog therapy needs clinical and biological monitoring, specially in patients with comorbidities.
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Affiliation(s)
- F Bonnet
- Fédération de médecine interne, maladies infectieuses et pathologies tropicales, hôpital Saint-André, Bordeaux, France
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121
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Hocqueloux L, Alberti C, Feugeas JP, Lafaurie M, Lukasiewicz E, Bagnard G, Carel O, Erlich D, Molina JM. Prevalence, risk factors and outcome of hyperlactataemia in HIV-infected patients. HIV Med 2003; 4:18-23. [PMID: 12534955 DOI: 10.1046/j.1468-1293.2003.00132.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We describe the prevalence, risk factors and outcome of hyperlactataemia (HL) in a cohort of 140 HIV-infected patients. PATIENTS AND METHODS Patients were enrolled consecutively within a 3-month period (July to September 1999) and followed until 31 October 2000. One hundred and forty HIV-infected patients had venous plasma lactate levels measured. HL was defined at baseline by two consecutive lactate levels > 2.1 mmol/L (upper limit of normal). We compared baseline demographic characteristics, immuno-virological parameters, antiretroviral therapy and outcome between patients with HL (cases) or without HL (controls). We described the clinical features of patients with HL. RESULTS Among 129 patients included in the analysis, HL was found in 11 patients (8.5%), all of whom were receiving nucleoside reverse transcriptase inhibitors (NRTIs). Cases were more likely than controls to receive didanosine or stavudine (82% vs. 19%, P= 2.7 x 10(-6) and 82% vs. 48%, P= 0.03, respectively). Only 4/11 cases (36%) had symptoms consistent with HL. After a median follow-up of 15 months, lactate level returned to normal in all three patients who discontinued NRTIs, but in only 2/8 patients who did not (P = 0.06). Only one case experienced lactic acidosis and died during follow-up. Mortality rate was similar in cases and controls. CONCLUSION HL is associated with NRTI use, in particular didanosine and stavudine, and discontinuation of NRTIs seems to be associated with rapid resolution of HL. Lactic acidosis remains rare and the long-term outcome of patients with HL does not seem to be poorer than controls.
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Affiliation(s)
- L Hocqueloux
- Clinique des Maladies Infectieuses, Département de Biostatistique et Informatique Médicale, Laboratoire de Biochimie B, Hôpital Saint-Louis, Paris, France
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Montes Ramírez ML, Rodríguez Zapata M. [Report of three cases of hyperlactacidemiae/lactic acidosis after treatment of hepatitis C with pegylated interferon and ribavirin in HIV coinfected patients]. Rev Clin Esp 2002; 202:543-5. [PMID: 12361553 DOI: 10.1016/s0014-2565(02)71139-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The hepatitis C infection is highly prevalent among HIV-infected patients. As a direct consequence of the increased survival of these patients in the HAART era, liver disease and its long-term complications have became a genuine health problem in these patients. The treatment of chronic HCV hepatitis is associated with several secondary effects, hiperlactacidemiae/lactic acidosis is one of the most dangerous. It appears to be related with the association of ribavirin and ddI, d4T or AZT. These are three cases of hiperlactacidemiae/lactic acidosis collected during the first twelve months of treatment with pegylated interferon and ribavirin in University Hospital of Guadalajara.
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Affiliation(s)
- M L Montes Ramírez
- Servicio de Medicina Interna. Hospital Universitario de Guadalajara. Departamento de Medicina. Universidad de Alcalá de Henares. Madrid. Spain
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O'Neil KM. The changing landscape of HIV-related lung disease in the era of highly active antiretroviral therapy. Chest 2002; 122:768-71. [PMID: 12226010 DOI: 10.1378/chest.122.3.768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Rubio R, Berenguer J, Miró JM, Antela A, Iribarren JA, González J, Guerra L, Moreno S, Arrizabalaga J, Clotet B, Gatell JM, Laguna F, Martínez E, Parras F, Santamaría JM, Tuset M, Viciana P. [Recommendations of the Spanish AIDS Study Group (GESIDA) and the National Aids Plan (PNS) for antiretroviral treatment in adult patients with human immunodeficiency virus infection in 2002]. Enferm Infecc Microbiol Clin 2002; 20:244-303. [PMID: 12084354 DOI: 10.1016/s0213-005x(02)72804-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To provide an update of recommendation on antiretroviral treatment (ART) in HIV-infected adults.Methods. These recommendations have been agreed by consensus by a committee of the spanish AIDS Study Group (GESIDA) and the National AIDS Plan. To do so, advances in the physiopathology of AIDS and the results on efficacy and safety in clinical trials, cohort and pharmacokinetics studies published in biomedical journals or presented at congresses in the last few years have been reviewed. Three levels of evidence have been defined according to the data source: randomized studies (level A), case-control or cohort studies (level B) and expert opinion (level C). Whether to recommend, consider, or not to recommend ART has been established for each situation. RESULTS Currently, ART with combinations of at least three drugs constitutes the treatment of choice in chronic HIV infection. In patients with symptomatic HIV infection, initiation of ART is recommended. In asymptomatic patients initiation of ART should be based on the CD41/mL lymphocyte count and on the plasma viral load (PVL): a) in patients with CD41 lymphocytes < 200 cells/mL, initiation of ART is recommended; b) in patients with CD41 lymphocytes between 200 and 300 cells/mL, initiation of ART should, in most cases, be recommended; however, it could be delayed when the CD41 lymphocyte count remains close to 350 cells/mL and the PVL is low, and c) in patients with CD41 lymphocytes > 350 cells/mL, initiation of ART can be delayed. The aim of ART is to achieve an undetectable PVL. Adherence to ART plays a role in the durability of the antiviral response. Because of the development of cross-resistance, the therapeutic options in treatment failure are limited. In these cases, genotypic analysis is useful. Toxicity limits ART. The criteria for ART in acute infection, pregnancy and postexposure prophylaxis and in the management of coinfection with HIV and hepatitis C and B virus are controversial. CONCLUSIONS The current approach to initiating ART is more conservative than in previous recommendations. In asymptomatic patients, the CD41 lymphocyte count is the most important reference factor for initiating ART. Because of the considerable number of drugs available, more sensitive monitoring methods (PVL) and the possibility of determining resistance, therapeutic strategies have become much more individualized.
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