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Stamerra CA, Di Giosia P, Giorgini P, Ferri C, Sukhorukov VN, Sahebkar A. Mitochondrial Dysfunction and Cardiovascular Disease: Pathophysiology and Emerging Therapies. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:9530007. [PMID: 35958017 PMCID: PMC9363184 DOI: 10.1155/2022/9530007] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/15/2022] [Indexed: 11/24/2022]
Abstract
Mitochondria ensure the supply of cellular energy through the production of ATP via oxidative phosphorylation. The alteration of this process, called mitochondrial dysfunction, leads to a reduction in ATP and an increase in the production of reactive oxygen species (ROS). Mitochondrial dysfunction can be caused by mitochondrial/nuclear DNA mutations, or it can be secondary to pathological conditions such as cardiovascular disease, aging, and environmental stress. The use of therapies aimed at the prevention/correction of mitochondrial dysfunction, in the context of the specific treatment of cardiovascular diseases, is a topic of growing interest. In this context, the data are conflicting since preclinical studies are numerous, but there are no large randomized studies.
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Affiliation(s)
- Cosimo Andrea Stamerra
- University of L'Aquila, Department of Life, Health and Environmental Sciences, Building Delta 6, San Salvatore Hospital, Via Vetoio, Coppito 67100 L'Aquila, Italy
- Department of Internal Medicine, Mazzoni Hospital, Ascoli Piceno, Italy
| | - Paolo Di Giosia
- University of L'Aquila, Department of Life, Health and Environmental Sciences, Building Delta 6, San Salvatore Hospital, Via Vetoio, Coppito 67100 L'Aquila, Italy
- Department of Internal Medicine, Mazzoni Hospital, Ascoli Piceno, Italy
| | - Paolo Giorgini
- University of L'Aquila, Department of Life, Health and Environmental Sciences, Building Delta 6, San Salvatore Hospital, Via Vetoio, Coppito 67100 L'Aquila, Italy
| | - Claudio Ferri
- University of L'Aquila, Department of Life, Health and Environmental Sciences, Building Delta 6, San Salvatore Hospital, Via Vetoio, Coppito 67100 L'Aquila, Italy
| | - Vasily N. Sukhorukov
- Institute for Atherosclerosis Research, Osennyaya Street 4-1-207, Moscow 121609, Russia
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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2
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Sood V, Jermy S, Saad H, Samuels P, Moosa S, Ntusi N. Review of cardiovascular magnetic resonance in human immunodeficiency virus-associated cardiovascular disease. SA J Radiol 2017; 21:1248. [PMID: 31754483 PMCID: PMC6837809 DOI: 10.4102/sajr.v21i2.1248] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 08/28/2017] [Indexed: 11/01/2022] Open
Abstract
Despite ongoing advances in the treatment of patients with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), they remain a major global public health concern conferring an increased risk of morbidity and mortality in affected individuals. This is, in part, because of the widespread dysfunction imposed by HIV and its treatment on the cardiovascular system, including the myocardium, valvular apparatus, pericardium and coronary, pulmonary and peripheral vasculature. In recent times, cardiovascular magnetic resonance (CMR) imaging has emerged as the gold standard tool for assessment of a variety of indications, allowing comprehensive characterisation of functional, morphological, metabolic and haemodynamic sequelae of several cardiovascular pathologies. Furthermore, continued advancement in imaging techniques has yielded novel insights into the underlying pathophysiology and guides future therapeutic strategies. In this article, we review the various clinical phenotypes of HIV-associated cardiovascular disease and highlight the utility of CMR in their assessment.
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Affiliation(s)
- Vishesh Sood
- Division of Radiology, Department of Radiation Medicine, University of Cape Town.,Groote Schuur Hospital, Cape Town, South Africa
| | - Stephen Jermy
- Cape Universities Body Imaging Centre, University of Cape Town, South Africa.,Department of Medicine, University of Cape Town, South Africa
| | - Hadil Saad
- Cape Universities Body Imaging Centre, University of Cape Town, South Africa.,Department of Medicine, University of Cape Town, South Africa
| | - Petronella Samuels
- Cape Universities Body Imaging Centre, University of Cape Town, South Africa.,Department of Medicine, University of Cape Town, South Africa
| | - Sulaiman Moosa
- Division of Radiology, Department of Radiation Medicine, University of Cape Town
| | - Ntobeko Ntusi
- Cape Universities Body Imaging Centre, University of Cape Town, South Africa.,Department of Medicine, University of Cape Town, South Africa.,Hatter Institute of Cardiovascular Research in Africa, Department of Medicine, University of Cape Town, South Africa
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3
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Ntusi NAB, Ntsekhe M. Human immunodeficiency virus-associated heart failure in sub-Saharan Africa: evolution in the epidemiology, pathophysiology, and clinical manifestations in the antiretroviral era. ESC Heart Fail 2016; 3:158-167. [PMID: 28834662 PMCID: PMC5657330 DOI: 10.1002/ehf2.12087] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 01/24/2016] [Accepted: 01/26/2016] [Indexed: 01/12/2023] Open
Abstract
The survival of patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) who have access to highly active antiretroviral therapy (ART) has dramatically increased in recent times. This review focuses on HIV‐associated heart failure in sub‐Saharan Africa (SSA). In HIV infected persons, heart failure may be related to pathology of the pericardium, the myocardium, the valves, the conduction system, or the coronary and pulmonary vasculature. HIV‐associated heart failure can be because of direct consequences of HIV infection, autoimmune reactions, pro‐inflammatory cytokines, opportunistic infections (OIs) or neoplasms, use of ART or therapy for OIs and presence of traditional cardiovascular risk factors. Myocardial involvement includes diastolic dysfunction, asymptomatic left ventricular dysfunction, cardiomyopathy, myocarditis, fibrosis, and steatosis. Pericardial diseases include pericarditis, pericardial effusions (rarely causing tamponade), pericardial constriction, and effusive‐constrictive syndromes. Coronary artery disease is commonly reported in industrial nations, although its prevalence is thought to be low in HIV‐infected persons from SSA.
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Affiliation(s)
- Ntobeko A B Ntusi
- Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Mpiko Ntsekhe
- Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
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4
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Kooman JP, Kotanko P, Schols AMWJ, Shiels PG, Stenvinkel P. Chronic kidney disease and premature ageing. Nat Rev Nephrol 2014; 10:732-42. [PMID: 25287433 DOI: 10.1038/nrneph.2014.185] [Citation(s) in RCA: 267] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Chronic kidney disease (CKD) shares many phenotypic similarities with other chronic diseases, including heart failure, chronic obstructive pulmonary disease, HIV infection and rheumatoid arthritis. The most apparent similarity is premature ageing, involving accelerated vascular disease and muscle wasting. We propose that in addition to a sedentary lifestyle and psychosocial and socioeconomic determinants, four major disease-induced mechanisms underlie premature ageing in CKD: an increase in allostatic load, activation of the 'stress resistance response', activation of age-promoting mechanisms and impairment of anti-ageing pathways. The most effective current interventions to modulate premature ageing-treatment of the underlying disease, optimal nutrition, correction of the internal environment and exercise training-reduce systemic inflammation and oxidative stress and induce muscle anabolism. Deeper mechanistic insight into the phenomena of premature ageing as well as early diagnosis of CKD might improve the application and efficacy of these interventions and provide novel leads to combat muscle wasting and vascular impairment in chronic diseases.
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Affiliation(s)
- Jeroen P Kooman
- Department of Internal Medicine, Division of Nephrology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastrich, Netherlands
| | - Peter Kotanko
- Renal Research Institute, 315 East 62nd Street, 4th floor, NY 10065, New York, USA
| | - Annemie M W J Schols
- Department of Respiratory Medicine, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastrich, Netherlands
| | - Paul G Shiels
- Institute of Cancer Sciences, Wolfson Wohl Translational Research Centre, University of Glasgow, Garscube Estate, Switchback Road, Bearsden, Glasgow G61 1QH, UK
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska University Hospital, Huddinge, Karolinska Institutet, SE-14157 Stockholm, Sweden
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5
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Bernard MA, Han X, Inderbitzin S, Agbim I, Zhao H, Koziel H, Tachado SD. HIV-derived ssRNA binds to TLR8 to induce inflammation-driven macrophage foam cell formation. PLoS One 2014; 9:e104039. [PMID: 25090652 PMCID: PMC4121254 DOI: 10.1371/journal.pone.0104039] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 07/04/2014] [Indexed: 01/12/2023] Open
Abstract
Even though combined anti-retroviral therapy (cART) dramatically improves patient survival, they remain at a higher risk of being afflicted with non-infectious complications such as cardiovascular disease (CVD). This increased risk is linked to persistent inflammation and chronic immune activation. In this study, we assessed whether this complication is related to HIV-derived ssRNAs inducing in macrophages increases in TNFα release through TLR8 activation leading to foam cell formation. HIV ssRNAs induced foam cell formation in monocyte-derived macrophages (MDMs) in a dose-dependent manner. This response was reduced when either endocytosis or endosomal acidification was inhibited by dynasore or chloroquine, respectively. Using a flow cytometry FRET assay, we demonstrated that ssRNAs bind to TLR8 in HEK cells. In MDMs, ssRNAs triggered a TLR8-mediated inflammatory response that ultimately lead to foam cell formation. Targeted silencing of the TLR8 and MYD88 genes reduced foam cell formation. Furthermore, foam cell formation induced by these ssRNAs was blocked by an anti-TNFα neutralizing antibody. Taken together in MDMs, HIV ssRNAs are internalized; bind TLR8 in the endosome followed by endosomal acidification. TLR8 signaling then triggers TNFα release and ultimately leads to foam cell formation. As this response was inhibited by a blocking anti-TNFα antibody, drug targeting HIV ssRNA-driven TLR8 activation may serve as a potential therapeutic target to reduce chronic immune activation and inflammation leading to CVD in HIV+ patients.
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Affiliation(s)
- Mark A. Bernard
- Division of Pulmonary, Critical Care, and Sleep Medicine; Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Xinbing Han
- Division of Pulmonary, Critical Care, and Sleep Medicine; Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Sonya Inderbitzin
- Division of Pulmonary, Critical Care, and Sleep Medicine; Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ifunanya Agbim
- Division of Pulmonary, Critical Care, and Sleep Medicine; Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Hui Zhao
- Division of Pulmonary, Critical Care, and Sleep Medicine; Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
- From Department of Respiratory Medicine, The Second Hospital of Shanxi Medical University, Taiyuan, PR China
| | - Henry Koziel
- Division of Pulmonary, Critical Care, and Sleep Medicine; Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Souvenir D. Tachado
- Division of Pulmonary, Critical Care, and Sleep Medicine; Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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6
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Freitas P, Carvalho D, Santos AC, Madureira AJ, Martinez E, Pereira J, Sarmento A, Medina JL. Carotid intima media thickness is associated with body fat abnormalities in HIV-infected patients. BMC Infect Dis 2014; 14:348. [PMID: 24958511 PMCID: PMC4087129 DOI: 10.1186/1471-2334-14-348] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 06/13/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND HIV-infected patients may be at increased risk of cardiovascular (CV) events, and lipodystrophy is generally associated with proatherogenic metabolic disturbances. Carotid intima-media thickness (cIMT) has been used as a surrogate marker for atherosclerosis and it has been shown to be an independent risk factor for CV disease. Our objective was to evaluate cIMT in HIV-infected patients on combined anti-retroviral therapy (cART) with and without lipodystrophy defined by fat mass ratio (L-FMR), and to determine the association of lipodystrophy and visceral obesity [(visceral (VAT), subcutaneous adipose tissue (SAT) volume and VAT/SAT ratio, objectively evaluated by CT scan] with cIMT. METHODS Cross-sectional study of 199 HIV-infected patients. Body composition by DXA and abdominal CT, lipids, blood pressure, inflammatory markers, and cIMT by ultrasonography were performed. L-FMR was defined as the ratio of the percentage of trunk fat mass to the percentage of lower limb fat mass by DXA. Categorical variables were compared using the chi-square or Fisher's exact test. Spearman correlation coefficients were estimated to study the association between cIMT and clinical and metabolic characteristics. Means of cIMT, adjusted for age, were calculated, using generalized linear models. RESULTS L-FMR was present in 41.2% of patients and cIMT was higher in these patients [0.81 (0.24) vs. 0.76 (0.25); p=0.037)]. Lipodystrophic patients had higher VAT and VAT/SAT ratio and lower SAT. cIMT was associated with lipodystrophy evaluated by FMR, trunk fat, total abdominal fat, VAT and VAT/SAT ratio. No association was observed between cIMT and leg fat mass. Using generalized linear models, cIMT means were adjusted for age and no significant differences remained after this adjustment. The adjusted mean of cIMT was 0.787 (95%CI: 0.751-0.823) in patients without lipodystrophy, and 0.775 (95%CI: 0.732-0.817) in those with lipodystrophy (p=0.671). CONCLUSIONS HIV-infected patients on cART with lipodystrophy defined by FMR, had a significantly higher cIMT. Carotid IMT was also associated with classical cardiovascular risk factors. In these patients, visceral adipose tissue had a significant impact on cIMT, although age was the strongest associated factor.
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Affiliation(s)
- Paula Freitas
- Endocrinology Department, Hospital de São João and University of Porto Medical School, Alameda Hernâni Monteiro, Porto 4200, Portugal
| | - Davide Carvalho
- Endocrinology Department, Hospital de São João and University of Porto Medical School, Alameda Hernâni Monteiro, Porto 4200, Portugal
| | - Ana Cristina Santos
- Hygiene and Epidemiology Department, University of Porto Medical School, Porto, Portugal
- University of Porto Institute of Public Health, Porto, Portugal
| | - António José Madureira
- Radiology Department, Hospital de São João and University of Porto Medical School, Porto, Portugal
| | - Esteban Martinez
- Department of Infectious Diseases, Hospital Clinic, University of Barcelona Medical School, Barcelona, Spain
| | - Jorge Pereira
- Nuclear Medicine Department, Hospital de São João l, Porto, Portugal
| | - António Sarmento
- Infectious Disease Department, Hospital de São João and University of Porto Medical School, Porto, Portugal
| | - José Luís Medina
- Endocrinology Department, Hospital de São João and University of Porto Medical School, Alameda Hernâni Monteiro, Porto 4200, Portugal
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7
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Lytwyn M, Fallah-Rad N, Walker J, Bohonis S, Hussain F, Barac I, Jassal DS. The Utility of Dobutamine Stress Echocardiography for the Diagnosis of Coronary Artery Disease in the HIV Population. Echocardiography 2010; 27:1228-32. [DOI: 10.1111/j.1540-8175.2010.01218.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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8
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Abstract
The advent of highly active antiretroviral therapy has led to a significant decline in the incidence of mortality and progression to AIDS in HIV-infection. With increased life expectancy, HIV-infected individuals are being affected by cardiovascular disease. Research studies have identified an increased prevalence of traditional coronary risk factors in HIV-infected patients. Additional investigations suggest that the virus itself may independently result in atherosclerosis. Further studies have linked the use of highly active antiretroviral therapy to the atherosclerotic processes. These findings suggest the need to reconsider HIV as one of the traditionally accepted risk factors for coronary artery disease, with treatment aimed at prevention of myocardial infarction.
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9
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Lekakis J, Ikonomidis I, Palios J, Tsiodras S, Karatzis E, Poulakou G, Rallidis L, Antoniadou A, Panagopoulos P, Papadopoulos A, Triantafyllidi H, Giamarellou H, Kremastinos DT. Association of highly active antiretroviral therapy with increased arterial stiffness in patients infected with human immunodeficiency virus. Am J Hypertens 2009; 22:828-34. [PMID: 19556973 DOI: 10.1038/ajh.2009.90] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Metabolic disorders associated with atherosclerosis and cardiovascular disease have been described in "HIV-infected" individuals. We investigated (i) whether normotensive "HIV-infected" individuals and hypertensive patients have similarities regarding their arterial elastic properties and (ii) the effect of highly active antiretroviral therapy (HAART) and metabolic factors on arterial stiffness. METHODS In a case-control study, we compared measurements of pulse wave velocity (PWV), arterial blood pressure, and markers of metabolic profile in 56 normotensive, "HIV-infected" patients (mean age 40 +/- 13 years) to 28 age- and sex-matched newly diagnosed untreated patients with hypertension and 28 healthy individuals. RESULTS "HIV-infected" patients had higher PWV than healthy controls but lower PWV than hypertensives (8.1 +/- 1.4 m/s vs. 6.7 +/- 1.1 m/s vs. 9.0 +/- 1.0 m/s, P = 0.003 and 0.01, respectively). However, patients on HAART had similar PWV with hypertensives (8.4 +/- 1.4 vs. 9.0 +/- 1.0 m/s P = 0.25). Patients on HAART had higher PWV than patients without (8.4 +/- 1.4 m/s vs. 7.5 +/- 1.3 m/s, P = 0.03). Patients on HAART had higher total cholesterol, triglycerides, and diastolic blood pressure than patients naive to HAART (P < 0.05). In multivariate analysis, the independent determinants of increased PWV were HAART duration (unstandardized coefficient b v = 0.007, P = 0.04), serum cholesterol (b = 0.007, P = 0.04), mean or diastolic blood pressure (b = 0.049 and b = 0.060, P < 0.01). CONCLUSIONS "HIV-infected" individuals have increased arterial stiffness compared to healthy controls. Patients on antiretroviral therapy have similarities regarding their arterial elastic properties with patients with untreated hypertension. There is an independent association between duration of antiretroviral therapy, cholesterol levels, and blood pressure with increased arterial stiffness in "HIV-infected" patients.
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10
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HIV-positive patients treated with protease inhibitors have vascular changes resembling those observed in atherosclerotic cardiovascular disease. Clin Sci (Lond) 2008; 115:189-96. [PMID: 18251713 DOI: 10.1042/cs20070353] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A metabolic syndrome associated with atherosclerosis and cardiovascular disease has been described in HIV-positive individuals. In the present study we investigated whether HIV-positive individuals and CAD (coronary artery disease) patients have similarities in their vascular function and structure. In a case-control study, we compared measurements of carotid artery IMT (intima-media thickness) and brachial artery FMD (flow-mediated vasodilation) in HIV-positive individuals with age- and sex-matched controls with similar risk factors and patients with established CAD. Seventy-one HIV patients, age 42+/-13.9 years (91% male), were compared with 29 CAD patients and 25 controls. HIV patients had higher IMT than controls and similar IMT to CAD patients (0.64+/-0.2 compared with 0.55+/-0.05 and 0.66+/-0.08 mm respectively; F=4.2, P=0.01). Patients taking protease inhibitors had higher IMT (0.69+/-0.2 compared with 0.57+/-0.15 mm; P=0.01), blood pressure, cholesterol and triacylglycerols than those not taking protease inhibtors (P<0.05). In multiple regression analyses, increasing blood pressure (beta: 0.37, P=0.001), glucose (beta: 0.26, P=0.016), cholesterol (beta: 0.24, P=0.033), duration of HIV disease (beta: 0.33, P=0.008) and use of protease inhibitors (beta: 0.27, P=0.04) were the most important determinants of IMT respectively. FMD was associated only with triacylglycerol measurements. Patients with HIV present arterial changes resembling those found in patients with atherosclerotic cardiovascular disease. These vascular changes are closely related to protease-inhibitor-induced changes of metabolic parameters. Thus intensive treatment of these metabolic parameters might retard atherosclerosis in HIV patients.
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Khunnawat C, Mukerji S, Havlichek D, Touma R, Abela GS. Cardiovascular manifestations in human immunodeficiency virus-infected patients. Am J Cardiol 2008; 102:635-42. [PMID: 18721528 DOI: 10.1016/j.amjcard.2008.04.035] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Revised: 04/17/2008] [Accepted: 04/17/2008] [Indexed: 10/21/2022]
Abstract
Human immunodeficiency virus (HIV) is now a pandemic. It afflicts multiple organs, including the cardiovascular system. This occurs by direct invasion as well as opportunistic infections complicating acquired immunodeficiency syndrome. The presence of newer highly active antiretroviral therapy has led to longer survival of patients infected with HIV, but the cardiac abnormalities related to HIV have remained less well characterized. It is now evident that cardiac involvement in patients with acquired immunodeficiency syndrome is relatively common. This includes coronary artery disease, dilated cardiomyopathy, pericardial effusion, pulmonary hypertension, and ill effects of highly active antiretroviral therapy in the form of lipodystrophy, lipoatrophy, and dyslipidemia. In fact, HIV can now be viewed as a potential risk factor for coronary artery disease, and the dilemma facing clinicians is how to quantify this risk. Awareness of accelerated coronary artery disease and dilated cardiomyopathy is critical to implement preventive measures early in the course of HIV. However, better guidelines are still needed on the basis of prospective randomized controlled studies involving large populations. In conclusion, this review describes cardiac abnormalities associated with HIV, including possible molecular mechanisms. The co-morbid sequelae, their presentation, and pharmacologic management are also discussed.
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12
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Wierzbicki AS, Purdon SD, Hardman TC, Kulasegaram R, Peters BS. HIV lipodystrophy and its metabolic consequences: implications for clinical practice. Curr Med Res Opin 2008; 24:609-24. [PMID: 18208641 DOI: 10.1185/030079908x272742] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The introduction of highly active antiretroviral therapy (HAART) around 1996 markedly reduced mortality and morbidity from human immunodeficiency virus (HIV) infection. As life expectancy has improved, the chronic complications of HIV and HAART have become increasingly relevant. SCOPE This article provides an overview of the HIV-associated lipodystrophy, its pathogenesis and its clinical consequences (based on a search strategy in PubMed including literature published to November 2007). FINDINGS Lipodystrophy syndrome is characterized by abnormal fat distribution syndrome associated with metabolic disturbances and includes insulin resistance, deranged glucose and lipid metabolism. It is associated with increased risks of progression to type 2 diabetes and cardiovascular disease. Robust diagnostic criteria are required for lipodystrophy, and subsequent prospective cohort studies and randomized controlled trials are then required to determine the etiology and prognosis of lipodystrophy, and to evaluate therapeutic interventions for this consequence of HAART. Therapies to improve insulin resistance have been tried but they are frequently ineffective, and are limited by potential toxicity in this population. Hence, current management options for HIV associated lipodystrophy are limited and are mostly based on avoidance of risk factors and switching of antiretroviral drugs. CONCLUSION As the '3 by 5 strategy' of providing HIV drugs to the developing world is implemented worldwide, the numbers of patients adhering to antiretroviral medicines is dramatically increasing. One must be aware that in reducing the burden of acute retroviral disease, the treatments proposed might lead to significant rates of metabolic complications and further exacerbation of the epidemic of diabetes and cardiovascular disease.
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13
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Miller TL, Grant YT, Almeida DN, Sharma T, Lipshultz SE. Cardiometabolic Disease in Human Immunodeficiency Virus-Infected Children. ACTA ACUST UNITED AC 2008; 3:98-105. [DOI: 10.1111/j.1559-4572.2008.07651.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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Schillaci G, De Socio GVL, Pirro M, Savarese G, Mannarino MR, Baldelli F, Stagni G, Mannarino E. Impact of Treatment With Protease Inhibitors on Aortic Stiffness in Adult Patients With Human Immunodeficiency Virus Infection. Arterioscler Thromb Vasc Biol 2005; 25:2381-5. [PMID: 16123321 DOI: 10.1161/01.atv.0000183744.38509.de] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background—
The role of antiretroviral therapy in acceleration of atherosclerosis in patients with human immunodeficiency virus (HIV) infection is controversial. We hypothesized that aortic stiffness, an early marker of arteriosclerosis, may be increased in HIV patients treated with protease inhibitors.
Methods and Results—
In 32 HIV-infected patients treated with protease inhibitors and 32 age-, sex-, and blood pressure–matched HIV-uninfected control subjects, we obtained aortic pulse wave velocity and central aortic pressure waveform, from which aortic augmentation was calculated. HIV patients had a higher aortic pulse wave velocity (7.6±1.1 versus 6.8±1.2 m×s
−1
,
P
=0.015) and aortic augmentation (6.8±5 versus 4.6±4 mm Hg,
P
=0.037) than control subjects. Age and HIV infection (both
P
<0.05) independently predicted aortic pulse wave velocity when a consistent number of cardiovascular risk factors was simultaneously controlled for. The cumulative duration of treatment was a predictor of aortic pulse wave velocity, each 5 years of treatment duration being independently related to a 1.35 m×s
−1
increase in pulse wave velocity.
Conclusions—
Aortic stiffness is increased in HIV-positive individuals receiving antiretroviral therapy including a protease inhibitor. Pulse wave velocity increases with longer exposure to protease inhibitors. We hypothesize that arteriosclerosis is a side effect of antiretroviral treatment including a protease inhibitor.
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Affiliation(s)
- Giuseppe Schillaci
- Unit of Internal Medicine, Angiology, and Arteriosclerosis, University of Perugia, Italy.
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15
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Calza L, Manfredi R, Colangeli V, Tampellini L, Sebastiani T, Pocaterra D, Chiodo F. Substitution of nevirapine or efavirenz for protease inhibitor versus lipid-lowering therapy for the management of dyslipidaemia. AIDS 2005; 19:1051-8. [PMID: 15958836 DOI: 10.1097/01.aids.0000174451.78497.8f] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To evaluate simplified protease inhibitor (PI)-sparing antiretroviral treatment versus lipid-lowering therapy for the management of highly active antiretroviral therapy (HAART)-induced hyperlipidaemia. DESIGN Randomized, open-label clinical trial assessing the efficacy on hyperlipidaemia of a switching therapy from PI to non-nucleoside reverse transcriptase inhibitor (NNRTI) nevirapine or efavirenz versus a hypolipidaemic treatment (with pravastatin or bezafibrate) added to current, unchanged antiretroviral combination. METHODS All HIV-infected patients on their first HAART regimen, with stable immuno-virological features, naive to all NNRTIs, and with mixed hyperlipidaemia, were randomized to replace PI with nevirapine (arm A) or efavirenz (arm B), or to receive pravastatin (arm C) or bezafibrate (arm D) with unchanged HAART regimen, and were followed-up for 12 months. RESULTS One hundred and thirty patients were evaluated: 29 patients were randomized to arm A, 34 to arm B, 36 to arm C, and 31 to arm D. At the end of the 12-month follow-up, a reduction of 25.2, 9.4, 41.2 and 46.6% in mean triglyceridaemia versus respective baseline values was reported in groups A, B, C and D, respectively, with statistically significant difference between arms A-B and C-D (P < 0.01). Similar results were reported for total and low-density lipoprotein cholesterol levels. Viro-immunological efficacy and tolerability profile were comparable in all considered arms. CONCLUSION Pravastatin and bezafibrate proved significantly more effective in the management of HAART-related hyperlipidaemia than the switching therapy from PI to nevirapine or efavirenz.
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Affiliation(s)
- Leonardo Calza
- Department of Clinical and Experimental Medicine, Division of Infectious Diseases, "Alma Mater Studiorum" University of Bologna, S. Orsola Hospital, Bologna, Italy.
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16
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Charakida M, Donald AE, Green H, Storry C, Clapson M, Caslake M, Dunn DT, Halcox JP, Gibb DM, Klein NJ, Deanfield JE. Early structural and functional changes of the vasculature in HIV-infected children: impact of disease and antiretroviral therapy. Circulation 2005; 112:103-9. [PMID: 15983247 DOI: 10.1161/circulationaha.104.517144] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Premature cardiovascular disease is increasingly recognized in HIV-infected patients, but the mechanisms involved are unclear. The purpose of this study was to determine the impact of HIV infection and antiretroviral therapy (ART) on markers of early vascular disease in children. METHODS AND RESULTS We studied 83 HIV-infected children (56 had taken ART, of whom 31 received a regimen containing protease inhibitors [PIs]; 27 were never treated) and a control group of 59 healthy children. Carotid intima-media thickness (IMT) and brachial artery flow-mediated dilatation (FMD) were measured. IMT was significantly greater in HIV-infected children compared with the control subjects (P<0.001). Among the HIV-infected children, age and treatment were significantly associated with increased IMT. Children exposed to PIs had greater IMT compared with both non-PI-treated children and untreated children (P=0.02). FMD was also significantly reduced in the HIV-infected children compared with control subjects (P=0.02). Pairwise comparisons of different treatment exposure groups revealed that FMD was impaired by a mean of 3.6% (95% CI, 1.8 to 5.3; P<0.001) for children exposed to PIs compared with untreated children and by a mean of 1.8% (95% CI, 0.01 to 3.5; P=0.05) compared with non-PI-treated children. HIV-infected children had lipid abnormalities, but they did not account for the observed differences in either FMD or IMT. CONCLUSIONS HIV infection in childhood is associated with adverse structural and functional vascular changes that are most pronounced in children exposed to PI therapy. Longitudinal studies are required to differentiate the relative impact of HIV disease and ART and to assess the potential for prevention.
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17
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Baliga RS, Chaves AA, Jing L, Ayers LW, Bauer JA. AIDS-related vasculopathy: evidence for oxidative and inflammatory pathways in murine and human AIDS. Am J Physiol Heart Circ Physiol 2005; 289:H1373-80. [PMID: 15923317 DOI: 10.1152/ajpheart.00304.2005] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Increased life expectancy of human immunodeficiency virus (HIV)-positive patients has led to evidence of complications apparently not directly related to immunodeficiency or opportunistic infection, including increased cardiovascular risk. We tested the hypothesis that vascular dysfunction occurs in the murine acquired immune deficiency syndrome (AIDS) model and evaluated potential mechanisms in murine AIDS tissues and relevant human HIV/AIDS vascular tissues. We also investigated endothelial activation and/or endothelial protein nitration and their association with time-dependent vascular dysfunction. At 1 and 5 wk of murine AIDS, statistically significant decreases in KCl contractility and time-dependent contractile deficits in response to phenylephrine were observed. The maximal response (E(max)) was reduced by approximately 40% at 10 wk, and EC(50) values were significantly changed: 102 +/- 7.3 ng for control vs. 190 +/- 37 and 130 +/- 22 ng at 5 and 10 wk, respectively (P < 0.05). Endothelium-dependent relaxation to ACh was decreased (EC(50) = 120 +/- 27 and 343 +/- 94 nM for control and at 10 wk, respectively), whereas the response to an exogenous nitric oxide donor, sodium nitroprusside, remained unchanged, suggesting a specific endothelial dysfunction. Histochemical investigations of the same vascular tissues as well as corresponding coronary endothelium showed an increase in protein 3-nitrotyrosine, intercellular adhesion molecule, and nitric oxide synthase isoforms 2 and 3. These findings were corroborated in concurrent experiments in a cohort of well-cataloged human cardiac microvascular tissues. We have demonstrated, for the first time, a specific functional vasculopathy with endothelial involvement in a murine model of AIDS that was also associated with and correlated to increased oxidative stress and specific endothelial activation. This finding was echoed in a relevant population of human HIV/AIDS patients. Research into sources and intracellular targets of oxidants in this disease could provide important mechanistic insights and may reveal new therapeutic opportunities for this increasingly important cardiovascular disease state.
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Affiliation(s)
- Reshma S Baliga
- Center of Cardiovascular Medicine, 700 Children's Drive, Columbus, OH 43205, USA
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18
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Ballinger SW. Mitochondrial dysfunction in cardiovascular disease. Free Radic Biol Med 2005; 38:1278-95. [PMID: 15855047 DOI: 10.1016/j.freeradbiomed.2005.02.014] [Citation(s) in RCA: 271] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2004] [Revised: 02/15/2005] [Accepted: 02/15/2005] [Indexed: 12/11/2022]
Abstract
Whereas the pathogenesis of atherosclerosis has been intensively studied and described, the underlying events that initiate cardiovascular disease are not yet fully understood. A substantial number of studies suggest that altered levels of oxidative and nitrosoxidative stress within the cardiovascular environment are essential in the development of cardiovascular disease; however, the impact of such changes on the subcellular or organellar components and their functions that are relevant to cardiovascular disease inception are less understood. In this regard, studies are beginning to show that mitochondria not only appear susceptible to damage mediated by increased oxidative and nitrosoxidative stress, but also play significant roles in the regulation of cardiovascular cell function. In addition, accumulating evidence suggests that a common theme among cardiovascular disease development and cardiovascular disease risk factors is increased mitochondrial damage and dysfunction. This review discusses aspects relating mitochondrial damage and function to cardiovascular disease risk factors and disease development.
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Affiliation(s)
- Scott W Ballinger
- Division of Molecular and Cellular Pathology, VH G019F, 1530 3rd Avenue South, Birmingham, AL 35294-0019, USA.
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19
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Liu K, Chi DS, Li C, Hall HK, Milhorn DM, Krishnaswamy G. HIV-1 Tat protein-induced VCAM-1 expression in human pulmonary artery endothelial cells and its signaling. Am J Physiol Lung Cell Mol Physiol 2005; 289:L252-60. [PMID: 15805138 DOI: 10.1152/ajplung.00200.2004] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Expression of cell adhesion molecule in endothelial cells upon activation by human immunodeficiency virus (HIV) infection is associated with the development of atherosclerotic vasculopathy. We postulated that induction of vascular cell adhesion molecule-1 (VCAM-1) by HIV-1 Tat protein in endothelial cells might represent an early event that could culminate in inflammatory cell recruitment and vascular injury. We determined the role of HIV-1 Tat protein in VCAM-1 expression in human pulmonary artery endothelial cells (HPAEC). HIV-1 Tat protein treatment significantly increased cell-surface expression of VCAM-1 in HPAEC. Consistently, mRNA expression of VCAM-1 was also increased by HIV-1 Tat protein as measured by RT-PCR. HIV-1 Tat protein-induced VCAM-1 expression was abolished by the NF-kappaB inhibitor pyrrolidine dithiocarbamate (PDTC) and the p38 MAPK inhibitor SB-203580. Furthermore, HIV-1 Tat protein enhanced DNA binding activity of NF-kappaB, facilitated nuclear translocation of NF-kappaB subunit p65, and increased production of reactive oxygen species (ROS). Similarly to VCAM-1 expression, HIV-1 Tat protein-induced NF-kappaB activation and ROS generation were abrogated by PDTC and SB-203580. These data indicate that HIV-1 Tat protein is able to induce VCAM-1 expression in HPAEC, which may represent a pivotal early molecular event in HIV-induced vascular/pulmonary injury. These data also suggest that the molecular mechanism underlying the HIV-1 Tat protein-induced VCAM-1 expression may involve ROS generation, p38 MAPK activation, and NF-kappaB translocation, which are the characteristics of pulmonary endothelial cell activation.
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Affiliation(s)
- Kai Liu
- Department of Medicine, Tulane Univ. School of Medicine, New Orleans, LA 70112-2699, USA.
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20
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Abstract
In patients with haemophilia, a close correlation is usually observed between the clinical expression of the disease and plasmatic factor VIII/factor IX clotting activity. However, some patients experience milder bleeding phenotypes than others, although they exhibit a similar biological profile. The high prevalence of some inherited thrombophilia risk factors offers the possibility of a co-inheritance in haemophilic patients which could influence the phenotypic expression of the disease. Rare thrombotic complications occurring in haemophiliacs could also be facilitated by the co-inheritance of modifier genes. The majority of thrombotic events occurring in haemophiliacs are in relation to clotting factor infusions or central venous catheters. Concerning surgical situations, in the absence of therapeutic recommendations, postoperative thromboprophylaxis is not systematically performed in haemophiliacs. However, substitutive treatment more or less completely corrects the coagulation defect and makes the venous thrombosis risk closer to the control population. It should be emphasized that haemophilia does not fully protect against venous thromboembolic disease. Patients with haemophilia very infrequently experience thrombotic events. Thus, the management of thrombotic complications occurring in haemophilic patients should be discussed in each case according to the precipitating risk factors, the clinical context and the thrombo-haemorrhagic balance of the patient with respect to a particular clinical situation.
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Affiliation(s)
- Y Dargaud
- Centre Regional de Traitement des Hemophiles, Hopital Edouard Herriot, Lyon, France
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21
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Florindo AA, Latorre MDRDDO, Santos ECMD, Borelli A, Rocha MDS, Segurado AAC. Validação de métodos de estimativa da gordura corporal em portadores do HIV/Aids. Rev Saude Publica 2004; 38:643-9. [PMID: 15499434 DOI: 10.1590/s0034-89102004000500005] [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: 11/22/2022] Open
Abstract
OBJETIVO: Validar métodos de estimativas da gordura corporal (somatória de espessura de dobras cutâneas, circunferência da cintura (CC) e razão cintura-quadril (RCQ)) em portadores do HIV/Aids, tendo como padrão ouro a absortometria por dupla emissão de raios-X (Dexa) e a tomografia computadorizada de abdômen (TCA). MÉTODOS: Foram estudados 15 portadores do HIV/Aids tratados em uma unidade de saúde coligada a um hospital público universitário, São Paulo. Foram medidas a gordura subcutânea total (GST) mediante a somatória da espessura de sete dobras (bíceps, tríceps, subescapular, axilar média, supra-ilíaca, abdominal e panturrilha medial), a gordura subcutânea central (GSC) (somatória da espessura de quatro dobras) e a gordura subcutânea de membros (GSM) (somatória da espessura de três dobras). A GST, GSC e GSM foram comparadas com as medidas de gordura obtidas pela Dexa. A CC, a RCQ e a GSC foram comparadas com as medidas de gordura obtidas pela TCA. Na análise estatística, utilizou-se o coeficiente de correlação de Pearson (r) e foi utilizado o teste de Mann-Whitney. RESULTADOS: A gordura medida pela Dexa foi correlacionada com GST, a GSC e GSM, mesmo após o ajuste pela idade (r>0,80 para todos). A gordura total de abdômen medida pela TCA foi correlacionada com a CC, RCQ e a GSC após o ajuste pela idade (r>0,80 para todos). CONCLUSÕES: Os métodos de estimativa da gordura corporal devem ser escolhidos de acordo com o tipo de gordura a ser avaliada e podem ser utilizados em pesquisas e nos serviços de saúde como alternativa à Dexa e TCA para portadores do HIV/Aids.
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Affiliation(s)
- Alex Antonio Florindo
- Departamento de Epidemiologia, Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, SP, Brazil.
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22
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Stoll M, Schmidt RE. Immune restoration inflammatory syndromes: Apparently paradoxical clinical events after the initiation of HAART. Curr HIV/AIDS Rep 2004; 1:122-7. [PMID: 16091232 DOI: 10.1007/s11904-004-0018-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Immune reconstitution occurs after initiation of highly active antiretroviral therapy in immunodeficient HIV-positive individuals. Unexpected deterioration of inflammatory disease and atypical clinical features resembling symptoms of autoimmune disease may arise. These atypical inflammatory disorders, synonymously summarized as immune reconstitution syndrome, immune restoration disease, and immune restoration inflammatory syndrome (IRIS), are caused by augmentation of inflammation during immune reconstitution in an immunocompromised host. These disorders have to be distinguished from intercurrent infection and rheumatic disease, respectively. Treatment of IRIS consists of elements for both potential differential diagnoses (ie, anti-inflammatory and immunosuppressive drugs, such as in autoimmune disorders and antimicrobial chemotherapy, to decrease the burden of pathogen, such as in infectious disease). Therefore, awareness for IRIS is of increasing importance from a clinical point of view. However, diagnostic criteria and standards of treatment are still preliminary.
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Affiliation(s)
- Matthias Stoll
- Department Clinical Immunology, Medical School Hannover, Carl Neuberg Street 1, D-30625 Hannover, Germany.
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23
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Taylor P, Worrell C, Steinberg SM, Hazra R, Jankelevich S, Wood LV, Zwerski S, Yarchoan R, Zeichner S. Natural history of lipid abnormalities and fat redistribution among human immunodeficiency virus-infected children receiving long-term, protease inhibitor-containing, highly active antiretroviral therapy regimens. Pediatrics 2004; 114:e235-42. [PMID: 15286262 DOI: 10.1542/peds.114.2.e235] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To characterize the type and frequency of biochemical lipid abnormalities and physical changes in body composition associated with the use of protease inhibitor (PI)-containing antiretroviral therapy among human immunodeficiency virus-infected children treated for up to 6 years. METHODS A retrospective study of human immunodeficiency virus-infected pediatric patients enrolled in research protocols between August 1995 and December 2001 was performed. All patients who had received a PI for > or =2 years as part of their investigational antiretroviral treatment regimens during the study period were eligible. Of the 110 patients identified as having received PI therapy, 94 met the study criteria. RESULTS Of the 94 patients evaluated, 9 patients (10%) developed fat redistribution as well as dyslipidemia, 49 patients (52%) developed dyslipidemia without associated physical changes, and 36 patients (38%) exhibited no elevation of lipid levels or physical signs of fat redistribution. For all 9 patients with fat redistribution, the onset of the physical changes was closely associated with changes during pubertal development. Fat redistribution was also associated with lower viral loads and higher, more sustained levels of dyslipidemia. The onset of dyslipidemia and fat redistribution peaked between 10 and 15 years of age. CONCLUSION Among pediatric patients receiving PI therapy, there seems to be an age range in which children are at greater risk of developing hypercholesterolemia and subsequent fat redistribution, suggesting that unidentified physiologic changes associated with puberty may predispose pediatric patients treated with PI therapy to developing lipodystrophy.
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Affiliation(s)
- Perdita Taylor
- Pediatric HIV Working Group, HIV and AIDS Malignancy Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
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24
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Stoll M, Schmidt RE. Adverse events of desirable gain in immunocompetence: the Immune Restoration Inflammatory Syndromes. Autoimmun Rev 2004; 3:243-9. [PMID: 15246019 DOI: 10.1016/j.autrev.2003.09.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2003] [Accepted: 09/28/2003] [Indexed: 11/20/2022]
Abstract
Augmentation of inflammation may occur during immune reconstitution in a immunocompromised host. This phenomenon is able to cause atypical inflammatory disorders, synonymously summarized as 'Immune Reconstitution Syndrome', 'Immune Restoration Disease' and 'Immune Restoration Inflammatory Syndrome' (IRIS). Immune reconstitution occurs, if temporarily use of immunosuppressive agents was terminated or if highly active antiretroviral therapy in human immunodeficiency virus positive individuals with secondary immunodeficiency was initiated. Unexpected deterioration of inflammatory disease and atypical clinical features, resembling symptoms of autoimmune disease may arise. They have to be distinguished from intercurrent infection and rheumatic disease, respectively. Treatment of IRIS would consist of both potential differential diagnoses: use of anti-inflammatory and immunosuppressive drugs like in autoimmune disorders as well as antimicrobial chemotherapy to decrease the burden of pathogen like in infectious disease. Therefore, awareness for IRIS is of increasing importance from a clinical point of view. However, diagnostic criteria and standards of treatment still have to be defined.
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Affiliation(s)
- Matthias Stoll
- Department of Clinical Immunology, Medical School Hannover, Carl Neuberg Str. 1, D-30625 Hannover, Federal Republic of Germany.
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25
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Abstract
Dyslipidemia, characterized by elevated serum levels of triglycerides and reduced levels of total cholesterol, low-density lipoprotein-cholesterol (LDL-C) and high-density lipoprotein-cholesterol, has been recognized in patients with human immunodeficiency virus (HIV) infection. It is thought that elevated levels of circulating cytokines, such as tumor necrosis factor-alpha and interferon-alpha, may alter lipid metabolism in patients with HIV infection. Protease inhibitors, such as saquinavir, indinavir and ritonavir, have been found to decrease mortality and improve quality of life in patients with HIV infection. However, these drugs have been associated with a syndrome of fat redistribution, insulin resistance, and hyperlipidemia. Elevations in serum total cholesterol and triglyceride levels, along with dyslipidemia that typically occurs in patients with HIV infection, may predispose patients to complications such as premature atherosclerosis and pancreatitis. It has been estimated that hypercholesterolemia and hypertriglyceridemia occur in greater than 50% of protease inhibitor recipients after 2 years of therapy, and that the risk of developing hyperlipidemia increases with the duration of treatment with protease inhibitors. In general, treatment of hyperlipidemia should follow National Cholesterol Education Program guidelines; efforts should be made to modify/control coronary heart disease risk factors (i.e. smoking; hypertension; diabetes mellitus) and maximize lifestyle modifications, primarily dietary intervention and exercise, in these patients. Where indicated, treatment usually consists of either pravastatin or atorvastatin for patients with elevated serum levels of LDL-C and/or total cholesterol. Atorvastatin is more potent in lowering serum total cholesterol and triglycerides compared with other hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, but it is also associated with more drug interactions compared with pravastatin. Simvastatin and lovastatin are significantly metabolized by cytochrome P450 enzymes (CYP3A4) and are therefore not recommended for coadministration with protease inhibitors. A fibric acid derivative (gemfibrozil or fenofibrate) should be used in patients with primary hypertriglyceridemia. However, it must be kept in mind that protease inhibitors, such as nelfinavir and ritonavir, induce enzymes involved in the metabolism of the fibric acid derivatives and may, therefore, reduce the lipid-lowering activity of coadministered gemfibrozil or fenofibrate. In certain patients HMG-CoA reductase inhibitors may be used in combination with fibric acid derivatives but patients should be carefully monitored for liver and skeletal muscle toxicity. Select patients may experience improvements in serum lipid levels when their offending protease inhibitor(s) is/are exchanged for efavirenz, nevirapine, or abacavir; however each patient's virologic and immunologic status must be taken closely into consideration.
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Affiliation(s)
- Scott R Penzak
- Clinical Pharmacokinetics Laboratory, Clinical Center Pharmacy Department, National Institutes of Health, Bethesda, Maryland 20892, USA.
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26
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Gavrila A, Tsiodras S, Doweiko J, Nagy GS, Brodovicz K, Hsu W, Karchmer AW, Mantzoros CS. Exercise and vitamin E intake are independently associated with metabolic abnormalities in human immunodeficiency virus-positive subjects: a cross-sectional study. Clin Infect Dis 2003; 36:1593-601. [PMID: 12802761 DOI: 10.1086/375225] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2002] [Accepted: 03/05/2003] [Indexed: 11/03/2022] Open
Abstract
We investigated the relationship among habitual exercise, diet, and the presence of metabolic abnormalities (body fat redistribution, dyslipidemia, and insulin resistance) in a cross-sectional study of 120 human immunodeficiency virus (HIV)-infected subjects with use of bivariate and multivariate regression-analysis models. Total and aerobic exercise were significantly and negatively associated with fasting plasma triglyceride levels in the entire sample and in the fat redistribution group. Inverse associations between total or aerobic exercise and insulin resistance were suggestive but did not achieve statistical significance. Diastolic blood pressure was significantly and inversely associated with supplemental or total but not habitual dietary intake of vitamin E. In conclusion, exercise and vitamin E intake were independently and negatively associated with several phenotypic manifestations of HIV-associated metabolic syndrome, whereas other macro- or micronutrients did not have comparable significance.
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Affiliation(s)
- Alina Gavrila
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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27
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Stoll M, Schmidt RE. Immune Restoration Inflammatory Syndromes: The Dark Side of Successful Antiretroviral Treatment. Curr Infect Dis Rep 2003; 5:266-276. [PMID: 12760825 DOI: 10.1007/s11908-003-0083-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The prevalence of cellular immunodeficiency has increased due to rising use of immunosuppressive therapies and the pandemic spread of HIV infection. More recently, the introduction of highly active antiretroviral therapy (HAART) in HIV has led to significant immune reconstitution, even in patients with previously long-lasting secondary immunodeficiency. HAART reduces morbidity and mortality in HIV infection and also changes the clinical course of prevalent subclinical opportunistic infections or autoimmune diseases. Atypical inflammatory disorders develop after initiation of HAART and have been summarized as "immune reconstitution syndrome," "immune restoration disease," and "immune restoration inflammatory syndrome." However, diagnostic criteria and standards of therapy are yet to be defined. The awareness for these diseases is of increasing importance from a clinical point of view. This review summarizes the variety of immunoreconstitution disorders and describes possible diagnostic pitfalls. We also propose possible therapeutic options.
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Affiliation(s)
- Matthias Stoll
- Department Clinical Immunology, Medical School Hannover, Carl Neuberg Str. 1, D-30625 Hannover, Germany.
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28
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Schecter AD, Berman AB, Taubman MB. Chemokine receptors in vascular smooth muscle. Microcirculation 2003; 10:265-72. [PMID: 12851644 DOI: 10.1038/sj.mn.7800192] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2002] [Accepted: 02/01/2003] [Indexed: 01/22/2023]
Abstract
Atherosclerosis is considered to be an inflammatory disease. Chemokines are low-molecular-weight proteins that exert their effects, in part, through mediating leukocytic infiltration into the vessel wall. Recently, studies have determined that chemokines and their receptors are present, and function on other cellular components comprising the arterial wall, such as the endothelium and vascular smooth muscle. Smooth muscle cells (SMC) constitute the major cellular element of the arterial wall and are located predominantly in the arterial media. Recent studies have demonstrated that SMC possess a number of functional chemokine receptors, including CCR5, CXCR4, and a receptor for monocyte chemoattractant protein-1 (MCP-1). It is likely that SMC are increasingly recognized as potential targets for chemokines, and that these effects may influence a variety of normal and pathological processes involving SMC such as atherosclerosis and arterial injury.
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Affiliation(s)
- Alison D Schecter
- The Zena and Michael A. Wiener Cardiovascular Institute, New York, NY 14642, USA.
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29
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Dargaud Y, Cruchaudet BB, Lienhart A, Coppéré B, Ninet J, Négrier C. Spontaneous proximal deep vein thrombosis in a patient with severe haemophilia A. Blood Coagul Fibrinolysis 2003; 14:407-9. [PMID: 12945884 DOI: 10.1097/00001721-200306000-00013] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Venous thrombosis is a very rare occurrence in patients with haemophilia A. The majority of these cases occurred during or after the administration of clotting factor concentrates. We report the case of a patient with severe haemophilia A, who spontaneously developed a deep venous thrombosis (DVT). The thrombosis occurred in the superficial femoral vein with an extension in the profunda femoris vein. Neither any local anatomic compression nor any predisposing thrombophilic risk factors were identified. Treatment with recombinant factor VIII at prophylactic doses associated with unfractionated heparin led to a successful resolution. This case illustrates the possibility for severe haemophilia patients to develop authentic spontaneous DVT without anti-haemophilic treatment and predisposing risk factors.
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Affiliation(s)
- Yesim Dargaud
- Centre Regional de Traitement de l'Hémophilie, Pavilion E, Hôpital Edouard Herriot, Lyon, France
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30
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Tanwani LK, Mokshagundam SL. Lipodystrophy, insulin resistance, diabetes mellitus, dyslipidemia, and cardiovascular disease in human immunodeficiency virus infection. South Med J 2003; 96:180-8; quiz 189. [PMID: 12630645 DOI: 10.1097/01.smj.0000051731.69719.2e] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The introduction of highly active antiretroviral therapy has significantly reduced morbidity and mortality in patients infected with the human immunodeficiency virus. Treatment with antiretroviral agents--protease inhibitors in particular--has uncovered a syndrome of abnormal fat redistribution, dyslipidemia, and impaired glucose metabolism, collectively termed lipodystrophy syndrome. The cause of the syndrome seems to be multifactorial; however, its exact mechanisms have yet to be elucidated. Accelerated risk for cardiovascular disease is likely to be a major concern in these patients in the future. At this time, no clinical guidelines are available for the prevention and/or the treatment of lipodystrophy syndrome. The available treatment options range from switching the different antiretroviral drugs and lifestyle modifications to the use of pharmacologic agents to treat patients with dyslipidemia, impaired glucose tolerance and/or diabetes, and changes in body composition. This review emphasizes the clinical features, potential molecular mechanisms, and treatment options for patients infected with human immunodeficiency virus who have lipodystrophy syndrome.
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Affiliation(s)
- Lal K Tanwani
- University of Louisville and Veterans Affairs Medical Center, Louisville, KY, USA.
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31
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Pieper GM, Olds CL, Bub JD, Lindholm PF. Transfection of human endothelial cells with HIV-1 tat gene activates NF-kappa B and enhances monocyte adhesion. Am J Physiol Heart Circ Physiol 2002; 283:H2315-21. [PMID: 12427593 DOI: 10.1152/ajpheart.00469.2002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Human immunodeficiency virus (HIV)-1 Tat released from HIV-1-infected monocytes is believed to enter other cells via an integrin-facilitated pathway, resulting in altered gene expression. Indeed, exogenous Tat protein can increase cell adhesion molecule gene expression in human endothelial cells. Signaling pathways initiated by Tat in endothelial cells are not known. We evaluated the ability of endogenous tat to stimulate monocyte adhesion via activation of nuclear factor-kappaB (NF-kappaB) within human umbilical vein endothelial cells. Transfection with pcTat, but not control vector DNA, increased NF-kappaB binding activity, NF-kappaB luciferase reporter activity, and monocyte adhesion. pcTat also increased kappaB-dependent HIV-1-LTR-CAT reporter activity 28-fold compared with a 3-fold increase produced by transfection with an equivalent amount of pcTax (from human leukemia virus). The pcTat-induced increase in pNF-kappaB-Luc activity and monocyte adhesion to endothelial cells was blocked by cotransfection with dominant-negative mutant IkappaBalpha and by incubation with 10 mM aspirin. We conclude that monocyte adhesion to human endothelial cells stimulated by pcTat is mediated via an NF-kappaB-dependent mechanism. Furthermore, inhibition studies using aspirin suggest that pcTat-stimulated NF-kappaB activation and monocyte adhesion occur via a redox-sensitive mechanism.
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Affiliation(s)
- Galen M Pieper
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee 53226, USA.
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Abstract
Atherosclerosis is an inflammatory disease. Its lesions are filled with immune cells that can orchestrate and effect inflammatory responses. In fact, the first lesions of atherosclerosis consist of macrophages and T cells. Unstable plaques are particularly rich in activated immune cells, suggesting that they may initiate plaque activation. We have seen a rapid increase in the understanding of the mechanisms that govern the recruitment, differentiation, and activation of immune cells in atherosclerosis. Experimental research has identified several candidate antigens, and there are encouraging data suggesting that immune modulation as well as immunization can reduce the progression of the disease. This review provides an overview of our current understanding of the role of immune mechanisms in atherosclerosis.
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Affiliation(s)
- G K Hansson
- Center for Molecular Medicine and the Department of Medicine at Karolinska Hospital, Karolinska Institute, Stockholm, Sweden.
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