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Lv YB, Liu S, Yin ZX, Gao X, Kraus VB, Mao C, Yuan JQ, Zhang J, Luo JS, Chen HS, Zeng Y, Shi XM. Associations of Body Mass Index and Waist Circumference with 3-Year All-Cause Mortality Among the Oldest Old: Evidence from a Chinese Community-Based Prospective Cohort Study. J Am Med Dir Assoc 2018; 19:672-678.e4. [PMID: 29807748 PMCID: PMC6934415 DOI: 10.1016/j.jamda.2018.03.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/27/2018] [Accepted: 03/30/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Current international and national guidelines for body mass index (BMI) and waist circumference (WC) have been recommended to all adults. However, whether recommendations applied to the oldest old (aged 80+) is poorly known. The study objective was to investigate the relation of BMI and WC with 3-year all-cause mortality among the oldest old. DESIGN, SETTING, AND PARTICIPANTS A total of 4361 Chinese oldest old (mean age 91.8) participated in this community-based prospective cohort study. MEASUREMENTS BMI and WC were measured at baseline in 2011 and were used as continuous variables and as categorized variables by recommendations or by tertiles. Adjusted, sex-stratified Cox models with penalized splines and Cox models were constructed to explore the association. RESULTS Greater BMI and WC were linearly associated with lower mortality risk in both genders. The mortality risk was the lowest in overweight or obese participants (BMI ≥ 24.0) and was lower in participants with abdominal obesity. Compared to the upper tertile, those in the middle and lower tertile of BMI had a higher risk of mortality for men [hazard ratio (HR): 1.23 (1.02-1.48) and 1.53 (1.28-1.82)] and for women [HR: 1.21 (1.03-1.41) and 1.35 (1.15-1.58)]; it was also found in participants in the middle and lower tertile of WC for men [HR: 1.21 (1.01-1.46) and 1.41 (1.18-1.69)] and for women [HR: 1.35 (1.15-1.58) and 1.55 (1.32-1.81)] (all the P values for trend <.001). These findings were robust in further sensitivity analyses or when using propensity score matching, in subgroup analyses, or in octogenarians, nonagenarians, and centenarians. CONCLUSIONS In Chinese oldest old, both higher BMI and higher WC predict better survival in both genders. The finding suggests optimal BMI and WC may be sensitive to age, thus, the current recommendations for the oldest old may need to be revisited.
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Affiliation(s)
- Yue-Bin Lv
- National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Simin Liu
- Department of Epidemiology, Brown University, Providence, RI
| | - Zhao-Xue Yin
- Division of Non-Communicable Disease Control and Community Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Xiang Gao
- Department of Nutritional Sciences, Pennsylvania State University, Philadelphia, PA
| | - Virginia Byers Kraus
- Duke Molecular Physiology Institute and Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Chen Mao
- Division of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, China
| | - Jin-Qiu Yuan
- Division of Epidemiology, JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Juan Zhang
- School of Public Health, Peking Union Medical College/ Chinese Academy of Medical Sciences, Beijing, China
| | - Jie-Si Luo
- Division of Non-Communicable Disease Control and Community Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Hua-Shuai Chen
- Center for the study of Aging and Human Development and the Geriatric Division of School of Medicine, Duke University, Durham, NC
| | - Yi Zeng
- Center for the study of Aging and Human Development and the Geriatric Division of School of Medicine, Duke University, Durham, NC; Center for Study of Healthy Aging and Development Studies, Raissun Institute for Advanced Studies, Peking University, Beijing, China
| | - Xiao-Ming Shi
- National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China.
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de Aquino Favarato GKN, da Silva ACS, Oliveira LF, da Fonseca Ferraz ML, de Paula Antunes Teixeira V, Cavellani CL. Skin aging in patients with acquired immunodeficiency syndrome. Ann Diagn Pathol 2016; 24:35-9. [PMID: 27649952 DOI: 10.1016/j.anndiagpath.2016.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 07/11/2016] [Accepted: 07/27/2016] [Indexed: 11/18/2022]
Abstract
To evaluate the histomorphometric skin changes over aging patients with autopsied acquired immunodeficiency syndrome (AIDS). In 29 skin fragments of autopsied elderly (older than 50 years) and nonelderly patients with AIDS, epidermal thickness, the number of layers, the diameter of cells, the percentage of collagen and elastic fibers in the dermis, and the number and morphology of Langerhans cells were assessed. Statistical analysis was performed by SigmaStat 2.03 program. The thickness of the epidermis (92.55 × 158.94 μm), the number of layers (7 × 9 layers), and the diameter of the cells (13.27 × 17.6 μm) were statistically lower among the elderly. The quantity of collagen fibers (9.68 × 14.11%) and elastic fibers (11.89 × 15.31%) was also significantly lower in the elderly. There was a decrease in total (10.61 × 12.38 cel/mm(2)) and an increase in immature Langerhans cells (6.31 × 4.98 cel/mm(2)) in elderly patients with AIDS. The aging of the skin of patients with AIDS is amended in different histomorphometric aspects, the epidermis constituents suffer less pronounced changes in normal aging, and the dermis has more intense changes in elastic fibers and collagen.
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Affiliation(s)
| | - Aline Cristina Souza da Silva
- Biological and Natural Science Institute, General Pathology Discipline, Triângulo Mineiro Federal University (UFTM), Uberaba, MG, Brazil
| | - Lívia Ferreira Oliveira
- Biological and Natural Science Institute, General Pathology Discipline, Triângulo Mineiro Federal University (UFTM), Uberaba, MG, Brazil
| | - Mara Lúcia da Fonseca Ferraz
- Biological and Natural Science Institute, General Pathology Discipline, Triângulo Mineiro Federal University (UFTM), Uberaba, MG, Brazil
| | - Vicente de Paula Antunes Teixeira
- Biological and Natural Science Institute, General Pathology Discipline, Triângulo Mineiro Federal University (UFTM), Uberaba, MG, Brazil
| | - Camila Lourencini Cavellani
- Biological and Natural Science Institute, General Pathology Discipline, Triângulo Mineiro Federal University (UFTM), Uberaba, MG, Brazil.
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Affiliation(s)
| | - S K Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
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Luetkemeyer AF, Rosenkranz SL, Lu D, Marzan F, Ive P, Hogg E, Swindells S, Benson CA, Grinsztejn B, Sanne IM, Havlir DV, Aweeka F. Relationship between weight, efavirenz exposure, and virologic suppression in HIV-infected patients on rifampin-based tuberculosis treatment in the AIDS Clinical Trials Group A5221 STRIDE Study. Clin Infect Dis 2013; 57:586-93. [PMID: 23592830 DOI: 10.1093/cid/cit246] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Rifampin (RIF) upregulates CYP 450 isoenzymes, potentially lowering efavirenz (EFV) exposure. The US EFV package insert recommends an EFV dose increase for patients on RIF weighing ≥50 kg. We conducted a pharmacokinetic study to evaluate EFV trough concentrations (Cmin) and human immunodeficiency virus (HIV) virologic suppression in patients on EFV (600 mg) and RIF-based tuberculosis treatment in the multicenter randomized trial (ACTG A5221). METHODS EFV Cmin was measured 20-28 hours post-EFV dose at weeks 4, 8, 16, 24 on-RIF and weeks 4, 8 off-RIF. Results were evaluated with 2-sided Wilcoxon rank-sum, χ(2), Fisher exact tests and logistic regression (5% type I error rate). RESULTS Seven hundred eighty patients received EFV; 543 provided ≥1 EFV Cmin. Median weight was 52.8 kg (interquartile range [IQR], 48.0-59.5), body mass index 19.4 kg/m(2) (IQR, 17.5-21.6), and age 34 years (IQR, 29-41); 63% were male, 74% black. Median Cmin was 1.96 µg/mL on-RIF versus 1.80 off-RIF (P = .067). Cmin were significantly higher on-RIF versus off-RIF in blacks (2.08 vs 1.75, P = .005). Weight ≥60 kg on-RIF, compared to <60 kg, was associated with lower EFV Cmin (1.68 vs 2.02, P = .021). However, weight ≥60 kg was associated with more frequent HIV RNA < 400 copies/mL at week 48, compared to weight <60 kg (81.9% vs 73.8%, P = .023). CONCLUSIONS EFV and RIF-based tuberculosis therapy coadministration was associated with a trend toward higher, not lower, EFV Cmin compared to EFV alone. Patients weighing ≥60 kg had lower median EFV Cmin versus those <60 kg, but there was no association of higher weight with reduced virologic suppression. These data do not support weight-based dosing of EFV with RIF.
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Affiliation(s)
- Anne F Luetkemeyer
- HIV/AIDS Division, San Francisco General Hospital, University of California, San Francisco, CA 94110, USA.
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LeCapitaine NJ, Wang ZQ, Dufour JP, Potter BJ, Bagby GJ, Nelson S, Cefalu WT, Molina PE. Disrupted anabolic and catabolic processes may contribute to alcohol-accentuated SAIDS-associated wasting. J Infect Dis 2011; 204:1246-55. [PMID: 21917898 DOI: 10.1093/infdis/jir508] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Alcohol abuse is a comorbid factor in many human immunodeficiency virus (HIV)-infected patients. Previously, we demonstrated that chronic binge alcohol accentuates loss of body mass at terminal stage of simian immunodeficiency virus (SIV) infection. The purpose of this study was to investigate changes in pathways that may contribute to muscle wasting in chronic binge alcohol-fed SIV-infected macaques. METHODS The impact of chronic binge alcohol during SIV infection on insulin signaling and the ubiquitin (Ub)-proteasome system-regulators of protein synthesis and degradation-was examined in SIV-infected macaques. RESULTS SIV infection induced an inflammatory and pro-oxidative milieu in skeletal muscle, which was associated with decreased insulin-stimulated phosphatidylinositol 3-kinase (PI-3k) activity and upregulated gene expression of mTOR and atrogin-1, and protein expression of Ub-proteasome system 19S base. Chronic binge alcohol accentuated the skeletal muscle pro-oxidative milieu and 19S base expression. Additionally, chronic binge alcohol increased skeletal muscle protein expression of protein-tyrosine phosphatase 1B (a negative regulator of insulin signaling) and 19S proteasome regulator non-ATPase (Rpn) 6 subunit and Rpn12, and suppressed PI-3K activity. Animals that were alcohol-fed and SIV-infected for >15 months had increased Ub-proteasome system activity. CONCLUSIONS These data suggest negative modulation of insulin signaling coupled with enhanced Ub-proteasome system activity may be central mechanisms underlying chronic binge alcohol-induced accentuation of SIV-associated muscle wasting.
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Affiliation(s)
- Nicole J LeCapitaine
- Department of Physiology, Louisiana State University, Health Sciences Center, New Orleans, LA 70112, USA
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Koyanagi A, Humphrey JH, Moulton LH, Ntozini R, Mutasa K, Iliff P, Ruff, and the ZVITAMBO Study Group AJ. Predictive value of weight loss on mortality of HIV-positive mothers in a prolonged breastfeeding setting. AIDS Res Hum Retroviruses 2011; 27:1141-8. [PMID: 21226627 DOI: 10.1089/aid.2010.0293] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
HIV-positive lactating women may be at high risk of weight loss due to increased caloric requirements and postpartum physiological weight loss. Ten percent weight loss is associated with a higher risk of mortality in HIV-positive patients and this alone is a criterion for highly active antiretroviral therapy (HAART) initiation where CD4 counts are not available. However, no study has investigated this association in lactating postpartum women. We investigated whether 10% weight loss predicts death in postpartum HIV-positive women. A total of 9207 HIV-negative and 4495 HIV-positive mothers were recruited at delivery. Women were weighed at 6 weeks, 3 months, and every 3 months thereafter for up to 24 months postpartum and data on mortality up to 2 years were collected. The median duration of breastfeeding was longer than 18 months. Among HIV-positive women, the independent predictors of ≥10% weight loss were CD4 cell count, body mass index, and household income. Mortality was up to 7.12 (95% CI 3.47-14.61) times higher in HIV-positive women with ≥10% weight loss than those without weight loss. Ten percent weight loss in postpartum lactating HIV-positive women was significantly predictive of death. Our findings suggest that 10% weight loss is an appropriate criterion for HAART initiation among postpartum breastfeeding women.
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Affiliation(s)
- Ai Koyanagi
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland
| | - Jean H. Humphrey
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland
- ZVITAMBO Study Team, Harare, Zimbabwe
| | - Lawrence H. Moulton
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland
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Abstract
Human immunodeficiency virus (HIV) endocrinopathy encompasses a broad spectrum of disorders. Almost all the endocrine organs are virtually affected by HIV infection. HIV can directly alter glandular function. More commonly secondary endocrine dysfunction occurs due to opportunistic infections and neoplasms in immunocompromised state. The complex interaction between HIV infection and endocrine system may be manifested as subtle biochemical and hormonal perturbation to overt glandular failure. Antiretroviral therapy as well as other essential medications often result in adverse endocrinal consequences. Apart from adrenal insufficiency, hypogonadism, diabetes and bone loss, AIDS wasting syndrome and HIV lipodystrophy need special reference. Endocrinal evaluation should proceed as in other patients with suspected endocrine dysfunction. Available treatment options have been shown to improve quality of life and long-term mortality in AIDS patients.
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Affiliation(s)
- Uma Sinha
- Department of Medicine, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Nilanjan Sengupta
- Department of Endocrinology, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Prasanta Mukhopadhyay
- Department of Medicine, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Keshab Sinha Roy
- Department of Medicine, Nilratan Sircar Medical College and Hospital, Kolkata, India
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Dorner TE, Rieder A. Obesity paradox in elderly patients with cardiovascular diseases. Int J Cardiol 2011; 155:56-65. [PMID: 21345498 DOI: 10.1016/j.ijcard.2011.01.076] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 01/01/2011] [Indexed: 12/21/2022]
Abstract
Many elderly people are affected by cardiovascular diseases (CVD) and the majority of CVD patients are elderly people. For both patient populations, studies have shown that a high body mass index (BMI) is associated with lower mortality when compared to normal weight subjects, a fact commonly known as the "obesity paradox". Whether the correlation between obesity and better survival is based on methodological influences and other non-causal factors alone, or whether there is a causal link between obesity and a better survival in these subjects remains widely unexplored. The interrelation between aging, obesity, CVD, frailty and inflammation is a current issue of intensive research. For the elderly, parameters which include measures of body composition, fat and fat-free mass are of greater importance than BMI. Weight management in elderly people with cardiovascular diseases should aim at improvement and maintenance of physical function and quality of life rather than prevention of medical problems associated with obesity in younger and middle aged patients. Although many studies have shown that weight loss in elderly patients is associated with a poor prognosis, recent data demonstrate that intentional weight reduction in obese elderly people ameliorates the cardiovascular risk profile, reduces chronic inflammation and is correlated with an improved quality of life. An individual approach to weight management that includes the participation of the patient, co-morbidity, functional status, and social support should be aspired.
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Affiliation(s)
- Thomas E Dorner
- Institute of Social Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria.
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Koethe JR, Heimburger DC. Nutritional aspects of HIV-associated wasting in sub-Saharan Africa. Am J Clin Nutr 2010; 91:1138S-1142S. [PMID: 20147470 PMCID: PMC2844686 DOI: 10.3945/ajcn.2010.28608d] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The twin global epidemics of HIV infection and food scarcity disproportionately affect sub-Saharan Africa, and a significant proportion of patients who require antiretroviral therapy (ART) are malnourished because of a combination of HIV-associated wasting and inadequate nutrient intake. Protein-calorie malnutrition, the most common form of adult malnutrition in the region, is associated with significant morbidity and compounds the immunosuppressive effects of HIV. A low body mass index (BMI), a sign of advanced malnutrition, is an independent predictor of early mortality (<6 mo) after ART initiation in several analyses, and recent studies show an association between early weight gain when receiving ART and improved treatment outcomes. The cause of the observed increase in mortality is uncertain, but it is likely due in part to malnutrition-induced immune system dysfunction, a higher burden of opportunistic infections, and metabolic derangements. In this article, we describe the epidemiology of HIV infection and malnutrition in sub-Saharan Africa, potential causes of increased mortality after ART initiation among patients with a low BMI, recent studies on post-ART weight gain and treatment outcome, and trials of macronutrient supplementation from the region. We close by highlighting priority areas for future research.
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Affiliation(s)
- John R Koethe
- Division of Infectious Diseases, Vanderbilt University, Nashville, TN 37232-2582, USA.
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Koethe JR, Chi BH, Megazzini KM, Heimburger DC, Stringer JSA. Macronutrient supplementation for malnourished HIV-infected adults: a review of the evidence in resource-adequate and resource-constrained settings. Clin Infect Dis 2009; 49:787-98. [PMID: 19624276 PMCID: PMC3092426 DOI: 10.1086/605285] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Access to antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection has expanded rapidly throughout sub-Saharan Africa, but malnutrition and food insecurity have emerged as major barriers to the success of ART programs. Protein-calorie malnutrition (a common form of malnutrition in the region) hastens HIV disease progression, and food insecurity is a barrier to medication adherence. Analyses of patient outcomes have identified a low body mass index after the start of ART as an independent predictor of early mortality, but the causes of a low body mass index are multifactorial (eg, normal anthropometric variation, chronic inadequate food intake, and/or wasting associated with HIV infection and other infectious diseases). Although there is much information on population-level humanitarian food assistance, few data exist to measure the effectiveness of macronutrient supplementation or to identify individuals most likely to benefit. In this report, we review the current evidence supporting macronutrient supplementation for HIV-infected adults, we report on clinical trials in resource-adequate and resource-constrained settings, and we highlight priority areas for future research.
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Affiliation(s)
- John R Koethe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
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Kigozi BK, Sumba S, Mudyope P, Namuddu B, Kalyango J, Karamagi C, Odere M, Katabira E, Mugyenyi P, Ssali F. The effect of AIDS defining conditions on immunological recovery among patients initiating antiretroviral therapy at Joint Clinical Research Centre, Uganda. AIDS Res Ther 2009; 6:17. [PMID: 19630949 PMCID: PMC2731026 DOI: 10.1186/1742-6405-6-17] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Accepted: 07/24/2009] [Indexed: 11/11/2022] Open
Abstract
Background Many HIV-infected patients only access health care once they have developed advanced symptomatic disease resulting from AIDS Defining Conditions (ADCs). We carried out a study to establish the effect of ADCs on immunological recovery among patients initiated on antiretroviral therapy (ART). Methods A retrospective cohort of 427 HIV-1 patients who were initiated on ART between January 2002 and December 2006 was studied. Data on ADCs was retrieved from Joint Clinical Research Centre (JCRC) data base and backed up by chart reviews. We employed Kaplan-Meier survival curves to estimate median time to 50 CD4 cells/μl from the baseline value to indicate a good immunological recovery process. Cox proportional hazard models were used at multivariate analysis. Results The median time to gaining 50 CD4 cells/μl from the baseline value after ART initiation was longer in the ADC (9.3 months) compared to the non-ADC group (6.9 months) (log rank test, p = 0.027). At multivariate analysis after adjusting for age, sex, baseline CD4 count, baseline HIV viral load, total lymphocyte count and adherence level, factors that shortened the median time to immunological recovery after ART initiation were belonging to the non-ADC group (HR = 1.31; 95% CI: 1.03–1.28, p = 0.028), adherence to ART of ≥ 95% (HR = 2.22; 95% CI: 1.57–3.15, p = 0.001) and a total lymphocyte count ≥ 1200 cells/mm3 (HR = 1.84; 95% CI: 1.22–2.78, p = 0.003). A low baseline CD4 count of ≤ 200 cells/μl (HR = 0.52; 95% CI: 0.37–0.77, p = 0.001) was associated with a longer time to immunological recovery. There was no interaction between low CD4 counts and ADC group. Conclusion Patients with ADCs take longer to regain their CD4 counts due to the defect in the immune system. This may prolong their risk of morbidity and mortality.
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Harris RJ, Sterne JAC, Abgrall S, Dabis F, Reiss P, Saag M, Phillips AN, Chêne G, Gill JM, Justice AC, Rockstroh J, Sabin CA, Mocroft A, Bucher HC, Hogg RS, Monforte AD, May M, Egger M. Prognostic Importance of Anaemia in HIV Type-1-Infected Patients Starting Antiretroviral Therapy: Collaborative Analysis of Prospective Cohort Studies. Antivir Ther 2008. [DOI: 10.1177/135965350801300802] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background In HIV type-1-infected patients starting highly active antiretroviral therapy (HAART), the prognostic value of haemoglobin when starting HAART, and of changes in haemoglobin levels, are not well defined. Methods We combined data from 10 prospective studies of 12,100 previously untreated individuals (25% women). A total of 4,222 patients (35%) were anaemic: 131 patients (1.1%) had severe (<8.0 g/dl), 1,120 (9%) had moderate (male 8.0–<11.0 g/dl and female 8.0–<10.0 g/ dl) and 2,971 (25%) had mild (male 11.0–<13.0 g/dl and female 10.0–<12.0 g/dl) anaemia. We separately analysed progression to AIDS or death from baseline and from 6 months using Weibull models, adjusting for CD4+ T-cell count, age, sex and other variables. Results During 48,420 person-years of follow-up 1,448 patients developed at least one AIDS event and 857 patients died. Anaemia at baseline was independently associated with higher mortality: the adjusted hazard ratio (95% confidence interval) for mild anaemia was 1.42 (1.17–1.73), for moderate anaemia 2.56 (2.07–3.18) and for severe anaemia 5.26 (3.55–7.81). Corresponding figures for progression to AIDS were 1.60 (1.37–1.86), 2.00 (1.66–2.40) and 2.24 (1.46–3.42). At 6 months the prevalence of anaemia declined to 26%. Baseline anaemia continued to predict mortality (and to a lesser extent progression to AIDS) in patients with normal haemoglobin or mild anaemia at 6 months. Conclusions Anaemia at the start of HAART is an important factor for short- and long-term prognosis, including in patients whose haemoglobin levels improved or normalized during the first 6 months of HAART.
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Affiliation(s)
| | - Ross J Harris
- Department of Social Medicine, University of Bristol, UK
| | | | - Sophie Abgrall
- INSERM U720, Paris, Université Pierre et Marie Curie-Paris 6, Paris, France and Department of Infectious and Tropical Diseases, Avicenne Hospital, Bobigny, France
| | - François Dabis
- INSERM U330, Université Victor Segalen, Bordeaux, France
| | - Peter Reiss
- HIV Monitoring Foundation and National AIDS Therapy Evaluation Center, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Michael Saag
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of Alabama, Birmingham, AL, USA
| | - Andrew N Phillips
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, UK
| | | | - John M Gill
- Division of Infectious Diseases, University of Calgary, Calgary, AB, Canada
| | - Amy C Justice
- Yale University School of Medicine, New Haven, CT, USA and the VA Connecticut Healthcare System, West Haven, CT, USA
| | - Jürgen Rockstroh
- Medizinische Universitätsklinik – Immunologische Ambulanz, Bonn, Germany
| | - Caroline A Sabin
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, UK
| | - Amanda Mocroft
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, UK
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology, University Hospital Basel, Switzerland
| | - Robert S Hogg
- Division of Epidemiology and Population Health, BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | | | - Margaret May
- Department of Social Medicine, University of Bristol, Bristol, UK
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Artham SM, Lavie CJ, Milani RV, Ventura HO. The obesity paradox: impact of obesity on the prevalence and prognosis of cardiovascular diseases. Postgrad Med 2008; 120:34-41. [PMID: 18654066 DOI: 10.3810/pgm.2008.07.1788] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Obesity has reached global epidemic proportions and is associated with numerous comorbidities such as hypertension (HTN), type 2 diabetes mellitus, dyslipidemia, certain cancers, and chronic kidney disease (CKD). Obesity, via its direct maladaptive effects on cardiac structure and through its impact on conventional risk factors, is strongly associated with cardiovascular (CV) diseases such as heart failure (HF) and coronary heart disease (CHD). Despite these adverse associations, numerous studies indicate an "obesity paradox" in that being overweight or obese is associated with a favorable prognosis in many patients with established CV disease, particularly in patients with HTN, HF, and CHD. This review summarizes the adverse effects of obesity on CV disease risk factors and its role in the genesis of HTN, HF, CHD, and the obesity paradox. It concludes with a discussion on the potential benefits of weight loss in these patient populations.
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Molina PE, Lang CH, McNurlan M, Bagby GJ, Nelson S. Chronic alcohol accentuates simian acquired immunodeficiency syndrome-associated wasting. Alcohol Clin Exp Res 2007; 32:138-47. [PMID: 18028526 DOI: 10.1111/j.1530-0277.2007.00549.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Survival following human immunodeficiency virus (HIV) infection has improved significantly following the advent of highly active antiretroviral therapy. A large percentage of HIV-infected patients consume and abuse alcohol. Erosion of lean body mass is an important contributing factor to patient morbidity and mortality, and is a common feature of both chronic alcohol (ALC) consumption and acquired immunodeficiency syndrome (AIDS). We hypothesized that alcohol-induced loss in lean body mass is likely to exacerbate the AIDS wasting syndrome, particularly at the terminal stage of AIDS (SAIDS). METHODS This study examined the impact of chronic, intra-gastric ALC (5 h/d x 4 d/wk; blood alcohol levels = 55 mM to 60 mM) administration on body composition and muscle mass in simian immunodeficiency virus (SIV)-infected male Rhesus macaques in contrast to SIV-infected isocaloric (22 kcal/kg/d) sucrose (SUC)-infused control animals at the terminal stage of SIV infection. RESULTS At terminal stage, ALC/SIV+ animals had significantly lower body weight, body mass index, and limb muscle area than SUC/SIV+ animals. Both ALC/SIV+ and SUC/SIV+ animals had suppressed expression of insulin-like growth factor-I and increased expression of the ubiquitin ligase muscle-specific RING finger-1 mRNA. ALC increased mRNA expression of atrogin-1 (pre-SIV and at SAIDS) and tumor necrosis factor (TNF)-alpha (SAIDS). These changes were not associated with significant differences in fractional rates of muscle protein synthesis or in overall survival rate. These data show that chronic ALC exacerbated the loss of muscle mass at terminal SAIDS. CONCLUSION Our findings suggest the involvement of TNF-alpha and increased muscle proteolysis via atrogin-1 for the greater erosion of lean body mass at terminal SAIDS in ALC-treated Rhesus macaques.
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Affiliation(s)
- Patricia E Molina
- LSUHSC Department of Physiology and Alcohol Research Center, New Orleans, Louisiana 70112, USA.
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15
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Horwich TB, Fonarow GC. CARDIOVASCULAR AND SURVIVAL PARADOXES IN DIALYSIS PATIENTS: Reverse Epidemiology beyond Dialysis Patients: Chronic Heart Failure, Geriatrics, Rheumatoid Arthritis, COPD, and AIDS. Semin Dial 2007; 20:549-53. [DOI: 10.1111/j.1525-139x.2007.00346.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Kalantar-Zadeh K, Horwich TB, Oreopoulos A, Kovesdy CP, Younessi H, Anker SD, Morley JE. Risk factor paradox in wasting diseases. Curr Opin Clin Nutr Metab Care 2007; 10:433-42. [PMID: 17563461 DOI: 10.1097/mco.0b013e3281a30594] [Citation(s) in RCA: 236] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Emerging data indicate that conventional cardiovascular risk factors (e.g. hypercholesterolemia and obesity) are paradoxically associated with better survival in distinct populations with wasting. We identify these populations and review survival paradoxes and common pathophysiologic mechanisms. RECENT FINDINGS A 'reverse epidemiology' of cardiovascular risk is observed in chronic kidney disease, chronic heart failure, chronic obstructive lung disease, cancer, AIDS and rheumatoid arthritis, and in the elderly. These populations apparently have slowly progressive to full-blown wasting and significantly greater short-term mortality than the general population. The survival paradoxes may result from the time differential between the two competing risk factors [i.e. over-nutrition (long-term killer but short-term protective) versus undernutrition (short-term killer)]. Hemodynamic stability of obesity, protective adipokine profile, endotoxin-lipoprotein interaction, toxin sequestration of fat, antioxidation of muscle, reverse causation, and survival selection may also contribute. SUMMARY The seemingly counterintuitive risk factor paradox is the hallmark of chronic disease states or conditions associated with wasting disease at the population level. Studying similarities among these populations may help reveal common pathophysiologic mechanisms of wasting disease, leading to a major shift in clinical medicine and public health beyond the conventional Framingham paradigm and to novel therapeutic approaches related to wasting and short-term mortality.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Los Angeles Biomedical Research Center at Harbor-UCLA, Torrance, California 90509-2910, USA.
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17
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Langford SE, Ananworanich J, Cooper DA. Predictors of disease progression in HIV infection: a review. AIDS Res Ther 2007; 4:11. [PMID: 17502001 PMCID: PMC1887539 DOI: 10.1186/1742-6405-4-11] [Citation(s) in RCA: 192] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Accepted: 05/14/2007] [Indexed: 01/18/2023] Open
Abstract
During the extended clinically latent period associated with Human Immunodeficiency Virus (HIV) infection the virus itself is far from latent. This phase of infection generally comes to an end with the development of symptomatic illness. Understanding the factors affecting disease progression can aid treatment commencement and therapeutic monitoring decisions. An example of this is the clear utility of CD4+ T-cell count and HIV-RNA for disease stage and progression assessment. Elements of the immune response such as the diversity of HIV-specific cytotoxic lymphocyte responses and cell-surface CD38 expression correlate significantly with the control of viral replication. However, the relationship between soluble markers of immune activation and disease progression remains inconclusive. In patients on treatment, sustained virological rebound to >10,000 copies/mL is associated with poor clinical outcome. However, the same is not true of transient elevations of HIV RNA (blips). Another virological factor, drug resistance, is becoming a growing problem around the globe and monitoring must play a part in the surveillance and control of the epidemic worldwide. The links between chemokine receptor tropism and rate of disease progression remain uncertain and the clinical utility of monitoring viral strain is yet to be determined. The large number of confounding factors has made investigation of the roles of race and viral subtype difficult, and further research is needed to elucidate their significance. Host factors such as age, HLA and CYP polymorphisms and psychosocial factors remain important, though often unalterable, predictors of disease progression. Although gender and mode of transmission have a lesser role in disease progression, they may impact other markers such as viral load. Finally, readily measurable markers of disease such as total lymphocyte count, haemoglobin, body mass index and delayed type hypersensitivity may come into favour as ART becomes increasingly available in resource-limited parts of the world. The influence of these, and other factors, on the clinical progression of HIV infection are reviewed in detail, both preceding and following treatment initiation.
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Affiliation(s)
- Simone E Langford
- Monash University, Melbourne, Australia
- The HIV Netherlands Australia Thailand Research Collaboration, Bangkok, Thailand
| | | | - David A Cooper
- The HIV Netherlands Australia Thailand Research Collaboration, Bangkok, Thailand
- The National Centre in HIV Epidemiology and Clinical Research, Sydney, Australia, University of New South Wales, Sydney, Australia
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18
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Molina PE, McNurlan M, Rathmacher J, Lang CH, Zambell KL, Purcell J, Bohm RP, Zhang P, Bagby GJ, Nelson S. Chronic alcohol accentuates nutritional, metabolic, and immune alterations during asymptomatic simian immunodeficiency virus infection. Alcohol Clin Exp Res 2007; 30:2065-78. [PMID: 17117972 DOI: 10.1111/j.1530-0277.2006.00252.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Alcohol abuse has been reported to have a high prevalence in the human immunodeficiency virus (HIV)-infected population. However, its impact on disease progression is unknown. Studies dissecting the drug-induced or alcohol-induced metabolic derangements that are likely to alter the course of disease progression are lacking. This is particularly important because of the substantial reduction in morbidity and mortality of patients on highly active antiretroviral therapy (HAART). HIV infection has become a more chronic disease during which alcohol-induced metabolic alterations may become more prevalent and pronounced. METHODS The present study used a model of chronic intragastric alcohol administration initiated 3 months before intravenous simian immunodeficiency (SIV) inoculation and continued thereafter throughout the course of SIV infection, to investigate the impact of chronic alcohol binge-like consumption during the initial 10-month asymptomatic phase of SIV infection in nonhuman primate rhesus macaques. Anthropometric, metabolic, biochemical, nutritional, and immune state indicators were examined before infection and at 3-month intervals in asymptomatic chronic alcohol-treated SIV-infected macaques and time-matched isocaloric and uninfected controls. RESULTS Intravenous SIV(DeltaB670) infection resulted in increased viral load, decreased circulating CD4(+)/CD8(+) lymphocyte ratio, and increased lymphocyte proliferation (Ki67/CD3(+)). Chronic alcohol/SIV(+) animals showed a higher viral load at 3 months post-SIV infection as well as a significant and early decrease in caloric intake and nitrogen balance associated with a change in food choice. Rates of skeletal muscle protein synthesis and breakdown, mRNA expression of IGF-I, myostatin, or the ubiquitin ligase muscle atrophy F-box protein (MAFbx) did not differ from basal during the 10-month asymptomatic period of infection. However, muscle TNF-alpha mRNA expression was markedly increased at 10 months post-SIV infection in alcohol/SIV(+) animals. DISCUSSION These findings suggest that chronic alcohol accelerates nutritional and metabolic dysregulation during SIV infection and may favor a skeletal muscle proinflammatory state, possibly conducive to subsequent muscle wasting.
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Affiliation(s)
- Patricia E Molina
- Department of Physiology, LSUHSC, New Orleans, Louisiana 70112, USA.
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19
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Esposito JG, Thomas SG, Kingdon L, Ezzat S. Comparison of body composition assessment methods in patients with human immunodeficiency virus-associated wasting receiving growth hormone. J Clin Endocrinol Metab 2006; 91:2952-9. [PMID: 16757527 DOI: 10.1210/jc.2006-0431] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Bioelectrical impedance spectroscopy (BIS) and skinfold anthropometry (SKF) have been used to monitor body composition among patients with HIV wasting; however, validation of these techniques during recombinant human GH (rhGH) treatment has not been performed. OBJECTIVE Our objective was to evaluate the degree of agreement between criterion measurements of dual-energy x-ray absorptiometry (DXA) and those of BIS and SKF in patients with HIV wasting treated with rhGH. DESIGN AND SETTING We conducted a randomized, double-blinded, placebo-controlled, two-period crossover trial at the University of Toronto and Mount Sinai Hospital (Toronto, Canada). PATIENTS A referred sample of 27 community-dwelling men with HIV-associated weight loss (> or =10% over preceding 12 months) despite optimal antiretroviral therapy participated in the study. INTERVENTION Intervention was one daily injection of rhGH (6 mg) or placebo self-administered for 3 months in a crossover fashion with a 3-month washout. MAIN OUTCOME MEASURES Fat-free mass (FFM) and fat mass (FM) were measured by BIS, SKF, and DXA before and after rhGH and placebo treatment. RESULTS FFM(BIS) was not significantly different from FFM(DXA) after rhGH treatment (P = 0.10). Mean differences (bias +/- sd) according to Bland-Altman analysis were smaller for SKF than for BIS (P < 0.05) at all time points, yet treatment-induced change in FM was better detected with BIS than with SKF. BIS estimates of FFM and FM showed better agreement with those of DXA after rhGH treatment (1.6 +/- 4.6 kg and -2.1 +/- 3.9 kg) compared with baseline (3.8 +/- 3.5 kg and -4.1 +/- 3.6 kg) and placebo (2.7 +/- 4.4 kg and -3.1 +/- 4.6) (P < 0.05). BIS overestimated and SKF underestimated the treatment-induced changes in FFM and FM. CONCLUSIONS SKF was more accurate than BIS when measuring body composition in patients with HIV wasting before and after rhGH treatment; nonetheless, the accuracy of BIS increased after treatment. Change in FM because of treatment was not accurately assessed with SKF.
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Affiliation(s)
- John G Esposito
- Graduate Department of Rehabilitation Science, University of Toronto, Toronto, Ontario, Canada M5G 1V7
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20
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Koutkia P, Berry J, Eaton K, Breu J, Grinspoon S. Increased adrenal androgen secretion with inhibition of 11beta-hydroxylase in HIV-infected women. Am J Physiol Endocrinol Metab 2006; 290:E808-13. [PMID: 16303845 DOI: 10.1152/ajpendo.00418.2005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Adrenal androgen production is reduced in association with disease severity in HIV-infected women. This response may be maladaptive in terms of maintenance of lean body mass, functional status, and immune function. The aim of this study was to assess whether the use of an adrenal enzyme inhibitor of 11beta-hydroxylase might increase androgen production in this population. We conducted a randomized, double-blind, placebo-controlled study of metyrapone (500 mg p.o. qid) or placebo for 2 wk in 10 HIV-infected women with AIDS wasting [weight <90% ideal body weight (IBW) or weight loss >10%] and reduced androgen levels. Basal and ACTH-stimulated androgen, mineralocorticoid, and glucocorticoid levels were measured at baseline and after 14 days of treatment. Subjects were similar in age (40.9 +/- 0.9 yr), weight (91.7 +/- 3.5% IBW) and hormone concentrations at study entry. Total testosterone (84 +/- 54 vs. -0.4 +/- 2 ng/dl, P = 0.024), free testosterone (6.5 +/- 2.8 vs. 0.1 +/- 0.1 pg/ml, P = 0.024), DHEA (5.0 +/- 3.2 vs. -0.6 +/- 0.5 microg/l, P = 0.024), and 11-deoxycortisol (2,145 +/- 820 vs. -14 +/- 22 ng/dl, P = 0.024) levels increased in response to metyrapone compared with placebo treatment. In response to ACTH, significant increases in the DHEA/cortisol ratio (174 +/- 48 vs. 3 +/- 3, P = 0.008) were seen in the metyrapone group compared with placebo. Blood pressure and electrolytes did not change, and signs of adrenal insufficiency were not apparent. These data demonstrate that inhibition of 11beta-hydroxylase with metyrapone increases adrenal androgen secretion in HIV-infected women. Further studies are needed to assess the physiological effects of this strategy to increase anabolic hormone levels in severe stress, including detailed testing to rule out the potential risk of concomitant adrenal insufficiency.
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Affiliation(s)
- Polyxeni Koutkia
- Program in Nutritional Metabolism and Neuroendocrine Unit, Mass General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
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Abstract
Cachexia causes weight loss and increased mortality. It affects more than 5 million persons in the United States. Other causes of weight loss include anorexia, sarcopenia, and dehydration. The pathophysiology of cachexia is reviewed in this article. The major cause appears to be cytokine excess. Other potential mediators include testosterone and insulin-like growth factor I deficiency, excess myostatin, and excess glucocorticoids. Numerous diseases can result in cachexia, each by a slightly different mechanism. Both nutritional support and orexigenic agents play a role in the management of cachexia.
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Affiliation(s)
- John E Morley
- Division of Geriatric Medicine, Saint Louis University School of Medicine, 1042 South Grand Boulevard M238, St Louis, MO 63104, USA.
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Esposito JG, Thomas SG, Kingdon L, Ezzat S. Anabolic growth hormone action improves submaximal measures of physical performance in patients with HIV-associated wasting. Am J Physiol Endocrinol Metab 2005; 289:E494-503. [PMID: 15886228 DOI: 10.1152/ajpendo.00013.2005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Growth hormone (GH) treatment reverses the muscle loss allegedly responsible for diminished aerobic capacity and increased fatigue in patients with HIV-associated wasting. This study examined whether submaximal measures of physical performance can be used as objective measures of the functional impact of GH treatment-induced anabolism. We randomized 27 HIV-positive men [mean (SD) age, 43.9 (7.2) yr; body mass, 71.9 (10.4) kg; BMI, 23.1 (2.8) kg/m2] with unintentional weight loss despite antiretroviral therapy to receive GH (6 mg) or placebo in a double-blinded, placebo-controlled, cross-over trial with a 3-mo washout. Lean body mass (LBM), maximum oxygen uptake (Vo2 peak), ventilatory threshold (VeT), 6-min walk test (6MWT) distance and work, profile of mood states (POMS) fatigue and vigor scores, and Nottingham health profile (NHP) energy and physical mobility scores were measured. LBM significantly increased after 3 mo of GH treatment vs. placebo (means +/- SE, 3.7 +/- 0.6 vs. 0.3 +/- 0.4 kg; P < 0.001). VeT significantly improved (17.6 +/- 3.7 vs. -5.9 +/- 2.5%; P < 0.001), but Vo2 peak did not change significantly. 6MWT distance improved (24.9 +/- 9.7 vs. 19.9 +/- 11.6 m; P > 0.05) and 6MWT work increased significantly more after 3 mo of GH treatment (33.3 +/- 8.8 vs. 16.5 +/- 7.5 kJ; P < 0.05). POMS scores of fatigue and vigor and the NHP score of energy improved, yet the changes were not statistically significant. GH treatment improved VeT linearly to the increase in LBM (r =0.43, P = 0.037) and 6MWT work (r = 0.51, P = 0.008), and the increase in 6MWT work correlated with increase in LBM (r = 0.45, P = 0.024). Improvement in 6MWT work above the median (27.3 kJ) showed a decrease in fatigue (r = -0.62, P = 0.024). We concluded that GH treatment-induced LBM gains in HIV-associated wasting were functionally relevant, as determined by effort-independent submaximal measures of cardiopulmonary exercise testing.
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Affiliation(s)
- John G Esposito
- Graduate Department of Rehabilitation Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Villamor E, Saathoff E, Msamanga G, O'Brien ME, Manji K, Fawzi WW. Wasting during pregnancy increases the risk of mother-to-child HIV-1 transmission. J Acquir Immune Defic Syndr 2005; 38:622-6. [PMID: 15793376 DOI: 10.1097/01.qai.0000143601.48986.47] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine whether wasting during pregnancy, as measured by weight loss and low weight gain, is associated with increased mother-to-child transmission (MTCT) of HIV-1. METHODS This was a cohort study in Dar es Salaam, Tanzania, among 957 HIV-1-infected pregnant women. Weight was measured at the first prenatal visit and every month thereafter until delivery. Weight loss was defined as a weekly rate of weight gain </=0 and low weight gain as a weekly rate >0 and </=166 g/wk. The incidences of presumptive intrauterine transmission (HIV status at birth) and presumptive intrapartum and early breast-feeding transmission (HIV status at 6 weeks) were examined in relation to baseline anthropometric characteristics and weight change during pregnancy using 2xn tables and multivariable binomial regression. RESULTS Compared with women who gained >/=167 g/wk, weight loss during pregnancy was related to higher risk of intrauterine MTCT (adjusted relative risk [RR] = 2.32, 95% CI = 1.23-4.36, P = 0.009), HIV positive at birth or fetal death (RR = 2.13, 95% CI = 1.40-3.24, P = 0.0004), and HIV positive at birth or early neonatal death (RR = 1.96, 95% CI = 1.26-3.07, P = 0.003). The rate of weight gain during the 3rd trimester was inversely related to the risk of intrapartum/early breast-feeding transmission (adjusted P value, test for trend = 0.05). CONCLUSIONS Weight loss during pregnancy increases the risk of early MTCT. Identifying causes of wasting during pregnancy may provide clues for new strategies to prevent MTCT.
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Affiliation(s)
- Eduardo Villamor
- Department of Nutrition, Harvard School of Public Health, Boston, MA 02115, USA.
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Levy AR, McCandless L, Harrigan PR, Hogg RS, Bondy G, Iloeje UH, Mukherjee J, Montaner JS. Changes in lipids over twelve months after initiating protease inhibitor therapy among persons treated for HIV/AIDS. Lipids Health Dis 2005; 4:4. [PMID: 15705191 PMCID: PMC549538 DOI: 10.1186/1476-511x-4-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2004] [Accepted: 02/10/2005] [Indexed: 11/23/2022] Open
Abstract
Background Protease inhibitors are known to alter the lipid profiles in subjects treated for HIV/AIDS. However, the magnitude of this effect on plasma lipoproteins and lipids has not been adequately quantified. Objective To estimate the changes in plasma lipoproteins and triglycerides occurring within 12 months of initiating PI-based antiretroviral therapy among HIV/AIDS afflicted subjects. Methods We included all antiretroviral naïve HIV-infected persons treated at St-Paul's Hospital, British Columbia, Canada, who initiated therapy with protease inhibitor antiretroviral (ARV) drugs between August 1996 and January 2002 and who had at least one plasma lipid measurement. Longitudinal associations between medication use and plasma lipids were estimated using mixed effects models that accounted for repeated measures on the same subjects and were adjusted for age, sex, time dependent CD4+ T-cell count, and time dependent cumulative use of non-nucleoside reverse transcriptase inhibitors and adherence. The cumulative number of prescriptions filled for PIs was considered time dependent. We estimated the changes in the 12 months following any initiation of a PI based regimen. Results A total of 679 eligible subjects were dispensed nucleoside analogues and PI at the initiation of therapy. Over a median 47 months of follow-up (interquartile range (IQR): 29–62), subjects had a median of 3 (IQR: 1–6) blood lipid measurements. Twelve months after treatment initiation of PI use, there was an estimated 20% (95% confidence interval: 17% – 24%) increase in total cholesterol and 22% (12% – 33%) increase in triglycerides. Conclusions Twelve months after treatment initiation with PIs, statistically significant increases in total cholesterol and triglycerides levels were observed in HIV-infected patients under conditions of standard treatment. Our results contribute to the growing body of evidence implicating PIs in the development of blood lipid abnormalities. In conjunction with the predominance or men, high rates of smoking, and aging of the treated HIV-positive population, elevated lipoproteins and triglycerides may mean that patients such as these are at elevated risk for cardiovascular events in the future.
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Affiliation(s)
- Adrian R Levy
- Department of Health Care and Epidemiology, University of British Columbia (UBC), Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences, St. Paul's Hospital, Vancouver, Canada
| | - Lawrence McCandless
- Centre for Health Evaluation & Outcome Sciences, St. Paul's Hospital, Vancouver, Canada
| | - P Richard Harrigan
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada
| | - Robert S Hogg
- Department of Health Care and Epidemiology, University of British Columbia (UBC), Vancouver, Canada
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada
| | - Greg Bondy
- St. Paul's Hospital HIV Metabolic and Lipid Clinic, Vancouver, Canada
| | | | | | - Julio S Montaner
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada
- Department of Medicine, UBC, Vancouver, Canada
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