1
|
Lang R, John Gill M, Coburn SB, Grossman J, Gebo KA, Horberg MA, Mayor AM, Silverberg MJ, Willig AL, Justice AC, Klein MB, Bosch RJ, Rabkin CS, Hogan B, Thorne JE, Moore RD, Althoff KN. The changing prevalence of anemia and risk factors in people with HIV in North America who have initiated ART, 2007-2017. AIDS 2023; 37:287-298. [PMID: 36541641 PMCID: PMC9782731 DOI: 10.1097/qad.0000000000003423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To characterize the prevalence of anemia and risk factors between 2007 and 2017 for moderate/severe anemia among people with HIV (PWH) in North America who have initiated antiretroviral therapy (ART). DESIGN Observational study of participants in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). METHODS We estimated the annual prevalence between 1 January 2007 and 31 December 2017 of mild (11.0-12.9 g/dl men, 11.0-11.9 g/dl women), moderate (8.0-10.9 g/dl regardless of sex) and severe (<8.0 g/dl regardless of sex) anemia. Poisson regression models with robust variance and general estimating equations estimated crude and adjusted prevalence ratios (aPR) with 95% confidence intervals ([-]) comparing risk factors for moderate/severe vs. no/mild anemia between 2007 and 2017. RESULTS Among 73 898 PWH we observed 366 755 hemoglobin measurements following ART initiation, 37 301 (50%) had one or more measures of anemia during follow-up (mild = 17 743 [24%]; moderate = 13 383[18%]; severe = 6175 [8%]). Moderate/severe anemia was more prevalent among women, non-Hispanic Black and Hispanic PWH (vs. non-Hispanic white), those with underweight body mass index (<18.5 kg/m2) and with comorbidities and coinfections. Older age had increased prevalence of moderate/severe anemia among males and decreased prevalence among females. Prevalence of moderate/severe anemia was greater among those with lower CD4+ cell count (≤200 cells/μl) [aPR = 2.11 (2.06-2.17)] unsuppressed HIV viral load (>200 copies/ml) [aPR = 1.26 (1.23-1.29)] and within the first 6 months of ART initiation (vs. >1 year of ART) [aPR = 1.66 (1.61-1.72)]. CONCLUSION The prevalence of anemia among PWH is reduced after ART initiation but remains high. Risk factors differ by sex and include comorbidities and HIV disease severity. The persistent, substantial prevalence of anemia among PWH merits further investigation, targeted screening, and clinical interventions.
Collapse
Affiliation(s)
- Raynell Lang
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
- Department of Medicine, University of Calgary School of Medicine, Calgary, Alberta, Canada
| | - M John Gill
- Department of Medicine, University of Calgary School of Medicine, Calgary, Alberta, Canada
| | - Sally B. Coburn
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer Grossman
- Department of Medicine, University of Calgary School of Medicine, Calgary, Alberta, Canada
| | - Kelly A. Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Michael A. Horberg
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, Rockville, MD, USA
| | - Angel M. Mayor
- Retrovirus Research Center, Internal Medicine Department, Universidad Central del Caribe, Bayamon, Puerto Rico
| | | | - Amanda L. Willig
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Amy C. Justice
- Yale University Schools of Medicine and Public Health, New Haven CT, USA and Veterans Affairs Connecticut Healthcare System, West Haven, CT USA
| | | | | | - Charles S. Rabkin
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Brenna Hogan
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer E. Thorne
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Richard D. Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | | |
Collapse
|
2
|
Abioye AI, Andersen CT, Sudfeld CR, Fawzi WW. Anemia, Iron Status, and HIV: A Systematic Review of the Evidence. Adv Nutr 2020; 11:1334-1363. [PMID: 32383731 PMCID: PMC7490171 DOI: 10.1093/advances/nmaa037] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/29/2019] [Indexed: 12/12/2022] Open
Abstract
People living with HIV (PLWHIV) are at high risk of anemia due to inadequate iron intake, HIV and opportunistic infections, and inflammation, and as a side effect of antiretroviral therapy. Though iron supplementation can reduce iron deficiency anemia (IDA) in the general population, its role in anemia and in the health of PLWHIV is unclear due to concerns that iron supplementation may increase HIV replication and risk of opportunistic infections. We systematically reviewed the evidence on indicators of iron status, iron intake, and clinical outcomes among adults and children with HIV. The evidence suggests that anemia is associated with an increased risk of all-cause mortality and incident tuberculosis among HIV-infected individuals, regardless of anemia type, and the magnitude of the risk is greater with more severe anemia. High serum ferritin is associated with adverse clinical outcomes, although it is unclear if this is due to high iron or inflammation from disease progression. One large observational study found an increased risk of all-cause mortality among HIV-infected adults if they received iron supplementation. Published randomized controlled trials of iron supplementation among PLWHIV tend to have small sample sizes and have been inconclusive in terms of effectiveness and safety. Large randomized trials exploring approaches to safely and effectively provide iron supplementation to PLWHIV are warranted.
Collapse
Affiliation(s)
- Ajibola I Abioye
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | - Christopher R Sudfeld
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Wafaie W Fawzi
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
3
|
Quiros-Roldan E, Castelli F, Lanza P, Pezzoli C, Vezzoli M, Biasiotto G, Zanella I. The impact of antiretroviral therapy on iron homeostasis and inflammation markers in HIV-infected patients with mild anemia. J Transl Med 2017; 15:256. [PMID: 29258550 PMCID: PMC5735890 DOI: 10.1186/s12967-017-1358-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 12/06/2017] [Indexed: 01/13/2023] Open
Abstract
Background Anemia is frequent during HIV infection and is predictive of mortality. Although cART has demonstrated to reduce its prevalence, several patients still experience unresolved anemia. We aimed to characterize iron homeostasis and inflammation in HIV-infected individuals with mild anemia in relation to cART. Methods In this retrospective cohort study, HIV-infected patients with mild
anemia, CD4+ cells > 200/mm3 at baseline, maintaining virological response for 12 months after cART starting were selected within the Standardized Management of Antiretroviral Therapy Cohort (MASTER) cohort. Several inflammation and immune activation markers and iron homeostasis indexes were measured in stored samples, obtained at cART initiation (T0) and 12 months later (T1). Patients were grouped on the basis of hemoglobin values at T1: group A (> 13 g/dl) and B (< 13 g/dl). Wilcoxon rank sum test was used to compare biomarker values. Pearson correlation coefficients were calculated for all variables. Results cART improved CD4+ and CD8+ cell counts and their ratio, but this effect was significant only in group A. Only these patients had mild iron deficiency at T0 and showed higher transferrin and lower percentage of transferrin saturation than patients of group B, but differences disappeared with cART. cART decreased inflammation in all patients, but group B had higher levels of all markers than group A, reaching statistical significance only for IL-8 values at T1 (16 vs 2.9 pg/ml; p = 0.017). Hepcidin and IL-6 levels did not show significant differences between groups. Hemoglobin levels both at T0 and T1 did not correlate with any marker. Conclusions Baseline mild anemia in HIV-infected patients cannot always be resolved with durable efficient cART, possibly due to residual inflammation or immune activation rather than unbalanced iron homeostasis. Further research is needed on cytokine profiling to understand the mechanisms that induce anemia in HIV with suppressive cART. Electronic supplementary material The online version of this article (10.1186/s12967-017-1358-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Eugenia Quiros-Roldan
- University Department of Infectious and Tropical Diseases, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Francesco Castelli
- University Department of Infectious and Tropical Diseases, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Paola Lanza
- University Department of Infectious and Tropical Diseases, University of Brescia and Spedali Civili General Hospital, Brescia, Italy
| | - Chiara Pezzoli
- University Department of Infectious and Tropical Diseases, Spedali Civili General Hospital, Brescia, Italy
| | - Marika Vezzoli
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | | | - Giorgio Biasiotto
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy.,Laboratory of Clinical Chemistry, Department of Diagnostics, Civic Hospital of Brescia, Brescia, Italy
| | - Isabella Zanella
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy. .,Laboratory of Clinical Chemistry, Department of Diagnostics, Civic Hospital of Brescia, Brescia, Italy.
| |
Collapse
|
4
|
Chang HC, Bayeva M, Taiwo B, Palella FJ, Hope TJ, Ardehali H. Short communication: high cellular iron levels are associated with increased HIV infection and replication. AIDS Res Hum Retroviruses 2015; 31:305-12. [PMID: 25291189 DOI: 10.1089/aid.2014.0169] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
HIV is a pandemic disease, and many cellular and systemic factors are known to alter its infectivity and replication. Earlier studies had suggested that anemia is common in HIV-infected patients; however, higher iron was also observed in AIDS patients prior to the introduction of antiretroviral therapy (ART). Therefore, the relationship between iron and viral infection is not well delineated. To address this issue, we altered the levels of cellular iron in primary CD4(+) T cells and showed that higher iron is associated with increased HIV infection and replication. In addition, HIV infection alone leads to increased cellular iron, and several ART drugs increase cellular iron independent of HIV infection. Finally, HIV infection is associated with increased serum iron in HIV-positive patients regardless of treatment with ART. These results establish a relationship between iron and HIV infection and suggest that iron homeostasis may be a viable therapeutic target for HIV.
Collapse
Affiliation(s)
- Hsiang-Chun Chang
- Feinberg Cardiovascular Research Institute, Northwestern University School of Medicine, Chicago, Illinois
| | - Marina Bayeva
- Feinberg Cardiovascular Research Institute, Northwestern University School of Medicine, Chicago, Illinois
| | - Babafemi Taiwo
- Division of Infectious Disease, Department of Medicine, Northwestern University School of Medicine, Chicago, Illinois
| | - Frank J. Palella
- Division of Infectious Disease, Department of Medicine, Northwestern University School of Medicine, Chicago, Illinois
| | - Thomas J. Hope
- Department of Cell and Molecular Biology, Northwestern University School of Medicine, Chicago, Illinois
| | - Hossein Ardehali
- Feinberg Cardiovascular Research Institute, Northwestern University School of Medicine, Chicago, Illinois
| |
Collapse
|
5
|
Lipshultz HM, Hileman CO, Ahuja S, Funderburg NT, McComsey GA. Anaemia is associated with monocyte activation in HIV-infected adults on antiretroviral therapy. Antivir Ther 2015; 20:521-7. [PMID: 25668820 DOI: 10.3851/imp2940] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anaemia has been linked with mortality in HIV infection. The mechanism of anaemia in the era of contemporary antiretroviral therapy is not understood. The aim of this study was to describe the association between anaemia and markers of immune activation and inflammation in a cohort of HIV-infected adults on stable antiretroviral therapy. METHODS We performed a cross-sectional study of HIV-infected adults on antiretroviral therapy with HIV-1 RNA<1,000 copies/ml. Soluble and cellular markers of inflammation and immune activation were measured. Relationships between haemoglobin levels, anaemia (haemoglobin <13 g/dl for men and <12 g/dl for women) and mild anaemia (haemoglobin <14 g/dl for men and <13 g/dl for women) and these markers were explored using multivariable linear regression. RESULTS Among the 147 participants, median age was 46 years, 78% were men, 68% were African American and 29% were Caucasian. Median body mass index (BMI) was 26.7 kg/m(2), nadir and current CD4(+) T-cell counts were 179 and 613 cells/mm(3), respectively, and 78% had HIV-1 RNA<50 copies/ml (range 20-600 copies/ml). Median (IQR) haemoglobin was 14.3 (13.1-15.1) g/dl; 14% were anaemic and 33% had at least mild anaemia. In multivariable analyses, mild anaemia was independently associated with female sex, older age, shorter duration of antiretroviral therapy, lower white blood cell count, higher platelet count, higher sCD14 and a greater number of CD14(dim)CD16(+) cells or 'patrolling' monocytes, which remained significant after further adjusting for race and BMI. CONCLUSIONS Having haemoglobin <14 g/dl for men and <13 g/dl for women was independently associated with monocyte activation (sCD14 and CD14(dim)CD16(+) cells) in HIV-infected adults on stable antiretroviral therapy.
Collapse
|
6
|
Kerkhoff AD, Wood R, Cobelens FG, Gupta-Wright A, Bekker LG, Lawn SD. Resolution of anaemia in a cohort of HIV-infected patients with a high prevalence and incidence of tuberculosis receiving antiretroviral therapy in South Africa. BMC Infect Dis 2014; 14:3860. [PMID: 25528467 PMCID: PMC4300078 DOI: 10.1186/s12879-014-0702-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 12/11/2014] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Anaemia is frequently associated with both HIV-infection and HIV-related tuberculosis (TB) in antiretroviral therapy (ART)-naïve patients in sub-Saharan Africa and is strongly associated with poor prognosis. However, the effect of ART on the resolution of anaemia in patient cohorts with a high prevalence and incidence of tuberculosis is incompletely defined and the impact of TB episodes on haemoglobin recovery has not previously been reported. We therefore examined these issues using data from a well-characterised cohort of patients initiating ART in South Africa. METHODS Prospectively collected clinical and haematological data were retrospectively analysed from patients receiving ART in a South African township ART service. TB diagnoses and time-updated haemoglobin concentrations, CD4 counts and HIV viral loads were recorded. Anaemia severity was classified according to WHO criteria. Multivariable logistic regression analysis was used to determine factors independently associated with anaemia after 12 months of ART. RESULTS Of 1,140 patients with baseline haemoglobin levels, 814 were alive in care and had repeat values available after 12 months of ART. The majority of patients were female (73%), the median CD4 count was 104 cells/uL and 30.5% had a TB diagnosis in the first year of ART. At baseline, anaemia (any severity) was present in 574 (70.5%) patients and was moderate/severe in 346 (42.5%). After 12 months of ART, 218 (26.8%) patients had anaemia of any severity and just 67 (8.2%) patients had moderate/severe anaemia. Independent predictors of anaemia after 12 months of ART included greater severity of anaemia at baseline, time-updated erythrocyte microcytosis and receipt of an AZT-containing regimen. In contrast, prevalent and/or incident TB, gender and baseline and time-updated CD4 cell count and viral load measurements were not independent predictors. CONCLUSIONS Although anaemia was very common among ART-naive patients, the anaemia resolved during the first year of ART in a large majority of patients regardless of TB status without routine use of additional interventions. However, approximately one-quarter of patients remained anaemic after one year of ART and may require additional investigations and/or interventions.
Collapse
Affiliation(s)
- Andrew D Kerkhoff
- George Washington University School of Medicine and Health Sciences, 2300 I St, NW, 20037, Washington, DC, USA.
- Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, the Netherlands.
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Robin Wood
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Frank G Cobelens
- Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, the Netherlands.
- KNCV Tuberculosis Foundation, The Hague, the Netherlands.
| | - Ankur Gupta-Wright
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Stephen D Lawn
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| |
Collapse
|
7
|
Markers of inflammation and activation of coagulation are associated with anaemia in antiretroviral-treated HIV disease. AIDS 2014; 28:1791-6. [PMID: 25003720 DOI: 10.1097/qad.0000000000000344] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The objective of this study is to determine the relationship between inflammatory interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hsCRP)] and coagulation (D-dimer) biomarkers and the presence and type of anaemia among HIV-positive individuals. DESIGN A cross-sectional study. METHODS Combination antiretroviral therapy (cART)-treated adults participating in an international HIV trial with haemoglobin and mean corpuscular volume (MCV) measurements at entry were categorized by presence of anaemia (haemoglobin ≤14 g/dl in men and ≤12 g/dl in women) and, for those with anaemia, by type [microcytic (MCV < 80 fl), normocytic (80-100 fl), macrocytic (>100 fl)]. We analysed the association between inflammation (IL-6 and hsCRP) and coagulation (D-dimer) and haemoglobin, controlling for demographics (age, race and sex), BMI, HIV plasma RNA levels, CD4⁺ T-cell counts (nadir and baseline), Karnofsky score, previous AIDS diagnosis, hepatitis B/C coinfection and use of zidovudine. RESULTS Among 1410 participants, 313 (22.2%) had anaemia. Of these, 4.1, 27.2 and 68.7% had microcytic, normocytic and macrocytic anaemia, respectively. When compared with participants with normal haemoglobin values, those with anaemia were more likely to be older, black, male and on zidovudine. They also had lower baseline CD4⁺ T-cell counts and lower Karnofsky scores. Adjusted relative odds of anaemia per two-fold higher biomarker levels were 1.22 (P = 0.007) for IL-6, 0.99 for hsCRP (P = 0.86) and 1.35 (P < 0.001) for D-dimer. Similar associations were seen in those with normal and high MCV values. CONCLUSION Persistent inflammation and hypercoagulation appear to be associated with anaemia. Routine measurements of haemoglobin might provide insights into the inflammatory state of treated HIV infection.
Collapse
|
8
|
Babiker ZOE, Wingfield T, Galloway J, Snowden N, Ustianowski A. Extreme elevation of ferritin and creatine kinase in primary infection with HIV-1. Int J STD AIDS 2014; 26:68-71. [DOI: 10.1177/0956462414531936] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The diagnosis of primary HIV-1 infection can be challenging, especially in the absence of reported risks or when presenting features are unusual and uncommon. We report an atypical case of primary HIV-1 infection with HIV-1 subtype C in a 61-year old Caucasian man who presented with extreme hyperferritinaemia without iron overload and marked elevation of serum creatine kinase without rhabdomyolysis. In view of his symptomatic seroconversion and low baseline CD4+ T-lymphocyte count, the patient was treated promptly with combination antiretroviral therapy. Subsequently, he made good clinical improvement on treatment and no opportunistic infections were diagnosed at presentation or as part of a later immune reconstitution syndrome. This novel case highlights the importance of clinical suspicion of HIV and suggests that primary HIV-1 infection should be considered in patients presenting with severe hyperferritinaemia or markedly elevated creatine kinase levels. Further studies are required to explain the causative biological mechanisms underlying this rare presentation.
Collapse
Affiliation(s)
| | - Tom Wingfield
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Manchester, UK
- Section of Infection and Immunity, Wellcome Centre for Tropical Medicine, Imperial College, London, UK
| | - James Galloway
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Manchester, UK
| | - Neil Snowden
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Manchester, UK
| | - Andrew Ustianowski
- Department of Infectious Diseases & Tropical Medicine, North Manchester General Hospital, Manchester, UK
| |
Collapse
|
9
|
Kurz K, Fiegl M, Holzner B, Giesinger J, Pircher M, Weiss G, Denz HA, Fuchs D. Fatigue in patients with lung cancer is related with accelerated tryptophan breakdown. PLoS One 2012; 7:e36956. [PMID: 22615854 PMCID: PMC3353990 DOI: 10.1371/journal.pone.0036956] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 04/12/2012] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Patients with cancer often suffer from fatigue and decreased quality of life which might be related to the breakdown of essential amino acid tryptophan. METHODS In 50 patients with lung cancer we examined fatigue and the deterioration of quality of life in patients using the Functional Assessment of Cancer Therapy Anemia (FACT-An) and -Fatigue (FACT-F) subscales of FACT-General and the Mental adjustment to Cancer (MAC) questionnaires. Results were compared with tryptophan breakdown as well as serum concentrations of immune activation markers. RESULTS Scores of psychological tests correlated significantly with tryptophan breakdown and with circulatory markers of inflammation. However, immune activation and tryptophan breakdown were not related to MAC scores. CONCLUSIONS Tryptophan breakdown relates with fatigue and impaired quality of life in patients with lung cancer, while declining tryptophan levels are not associated with patients'coping strategies.
Collapse
Affiliation(s)
- Katharina Kurz
- Division of Biological Chemistry, Biocenter, Medical University, Innsbruck, Austria
- Division of Clinical Immunology and Infectious Diseases, Department of Internal Medicine, Medical University, Innsbruck, Austria
| | - Michael Fiegl
- Division of Hematology and Oncology, Department of Internal Medicine, Medical University, Innsbruck, Austria
| | - Bernhard Holzner
- Department of Psychiatry and Psychotherapy, Medical University, Innsbruck, Austria
| | | | - Marianna Pircher
- Division of Oncology, Hospital Natters, Natters/Innsbruck, Austria
| | - Guenter Weiss
- Division of Clinical Immunology and Infectious Diseases, Department of Internal Medicine, Medical University, Innsbruck, Austria
| | - Hubert A. Denz
- Division of Oncology, Hospital Natters, Natters/Innsbruck, Austria
| | - Dietmar Fuchs
- Division of Biological Chemistry, Biocenter, Medical University, Innsbruck, Austria
| |
Collapse
|
10
|
Choi SY, Kim I, Kim NJ, Lee SA, Choi YA, Bae JY, Kwon JH, Choe PG, Park WB, Yoon SS, Park S, Kim BK, Oh MD. Hematological manifestations of human immunodeficiency virus infection and the effect of highly active anti-retroviral therapy on cytopenia. THE KOREAN JOURNAL OF HEMATOLOGY 2011; 46:253-7. [PMID: 22259631 PMCID: PMC3259517 DOI: 10.5045/kjh.2011.46.4.253] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 12/07/2011] [Accepted: 12/13/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this study is to investigate the hematological manifestations of human immunodeficiency virus (HIV) infection, the risk factors for cytopenia, and the effect of highly active anti-retroviral therapy (HAART) on cytopenia. METHODS Medical records of patients treated for HIV at the Seoul National University Hospital from January 2005 to March 2010 were retrospectively reviewed. To determine the impact of HIV itself, we excluded HIV patients who had other conditions that could have resulted in hematological manifestations. Multiple logistic regression analyses were performed to identify risk factors for cytopenia. RESULTS A total of 621 cases were investigated, and after exclusion, data of 472 patients were analyzed. The frequency of cytopenia was anemia, 3.0% (14/472); neutropenia, 10.0% (47/472); thrombocytopenia, 2.4% (12/472); lymphopenia, 25.7% (121/470); isolated cytopenia, 11.2% (53/472); and bicytopenia, 2.1% (10/472). The leading risk factor for cytopenia identified by multivariate logistic regression methods was AIDS status at initial presentation. After HAART, cytopenia was reversed in the majority of patients (thrombocytopenia, 100%; neutropenia, 91.1%; and anemia, 84.6%). CONCLUSION This study isolated the impact of HIV infection alone on hematologic manifestations and confirmed that these changes were reversible by HAART. Control of the HIV infection will have the main role in the management of hematological manifestations of the virus.
Collapse
Affiliation(s)
- Se Youn Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Wisaksana R, Sumantri R, Indrati AR, Zwitser A, Jusuf H, de Mast Q, van Crevel R, van der Ven A. Anemia and iron homeostasis in a cohort of HIV-infected patients in Indonesia. BMC Infect Dis 2011; 11:213. [PMID: 21827653 PMCID: PMC3199780 DOI: 10.1186/1471-2334-11-213] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 08/09/2011] [Indexed: 12/28/2022] Open
Abstract
Background Anemia is a common clinical finding in HIV-infected patients and iron deficiency or redistribution may contribute to the development of low hemoglobin levels. Iron overload is associated with a poor prognosis in HIV and Hepatitis C virus infections. Iron redistribution may be caused by inflammation but possibly also by hepatitis C co-infection. We examined the prevalence of anemia and its relation to mortality in a cohort of HIV patients in a setting where injecting drug use (IDU) is a main mode of HIV transmission, and measured serum ferritin and sTfR, in relation to anemia, inflammation, stage of HIV disease, ART and HCV infection. Methods Patient characteristics, ART history and iron parameters were recorded from adult HIV patients presenting between September 2007 and August 2009 in the referral hospital for West Java, Indonesia. Kaplan-Meier estimates and Cox's regression were used to assess factors affecting survival. Logistic regression was used to identity parameters associated with high ferritin concentrations. Results Anemia was found in 49.6% of 611 ART-naïve patients, with mild (Hb 10.5 - 12.99 g/dL for men; and 10.5 - 11.99 g/dL for women) anemia in 62.0%, and moderate to severe anemia (Hb < 10.5 g/dL) in 38.0%. Anemia remained an independent factor associated with death, also after adjustment for CD4 count and ART (p = 0.008). Seroprevalence of HCV did not differ in patients with (56.9%) or without anemia (59.6%). Serum ferritin concentrations were elevated, especially in patients with anemia (p = 0.07) and/or low CD4 counts (p < 0.001), and were not related to hsCRP or HCV infection. Soluble TfR concentrations were low and not related to Hb, CD4, hsCRP or ART. Conclusion HIV-associated anemia is common among HIV-infected patients in Indonesia and strongly related to mortality. High ferritin with low sTfR levels suggest that iron redistribution and low erythropoietic activity, rather than iron deficiency, contribute to anemia. Serum ferritin and sTfR should be used cautiously to assess iron status in patients with advanced HIV infection.
Collapse
Affiliation(s)
- Rudi Wisaksana
- Department of Internal Medicine Faculty of Medicine, Padjadjaran University/Hasan Sadikin Hospital, Bandung, Indonesia.
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Visser A, van de Vyver A. Severe Hyperferritinemia in Mycobacteria tuberculosis Infection. Clin Infect Dis 2010; 52:273-4. [DOI: 10.1093/cid/ciq126] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
13
|
Bhargava A, Booysen FLR. Healthcare infrastructure and emotional support are predictors of CD4 cell counts and quality of life indices of patients on antiretroviral treatment in Free State Province, South Africa. AIDS Care 2010; 22:1-9. [PMID: 20390475 DOI: 10.1080/09540120903012585] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
While many AIDS patients in sub-Saharan Africa are receiving antiretroviral treatment (ART) via public clinics, improvements in health status also depend on socioeconomic and psychological factors and quality of healthcare services. Inter-dependence between patients' clinical markers and quality of life indicators should be analyzed using comprehensive models. This longitudinal study compiled socioeconomic and clinical variables at six monthly intervals on patients receiving ART in South Africa; patients' ratings of quality of services and staff in "Assessment" and "Treatment" sites were assessed. Dynamic random effects models were estimated by maximum likelihood for CD4 cell counts and for quality of life indices (EQ-5D and Visual Analogue Scale), incorporating the inter-dependence between plasma HIV RNA levels and CD4 cell counts. The results showed that emotional support received by patients was a significant predictor (P<0.05) of CD4 cell counts and quality of life indices. Ratings of services and staff in Assessment and Treatment sites were significantly associated with CD4 cell counts and quality of life indices; CD4 cell count was a significant predictor of quality of life indices. The results indicated that it is important to compile socioeconomic and psychological variables for AIDS patients and monitor healthcare services for improving their health status and quality of life.
Collapse
Affiliation(s)
- Alok Bhargava
- Department of Economics, University of Houston, TX 77204-5019, USA.
| | | |
Collapse
|
14
|
Northrop-Clewes CA. Interpreting indicators of iron status during an acute phase response--lessons from malaria and human immunodeficiency virus. Ann Clin Biochem 2008; 45:18-32. [PMID: 18275670 DOI: 10.1258/acb.2007.007167] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Iron status is influenced by inflammation when the normal control of iron metabolism is reorganized by the primary mediators of the acute phase response, tumour necrosis factor-alpha and interleukin-1. The objective of this review is to show how indices of iron status, particularly haemoglobin, serum ferritin and soluble transferrin receptor concentrations relate to changes in the acute phase proteins during inflammation. The pattern of acute phase response after elective surgery, not preceded by infection, is used to demonstrate the time course of stimulation of the acute phase proteins. The changes in the concentrations of serum acute phase protein and markers of iron status during treatment for infection are used to demonstrate inter-relationships between the indicators. In many developing countries, asymptomatic malaria and human immunodeficiency virus (HIV) are common and may affect the interpretation of iron indicators during population assessments. Malaria produces an acute phase response and relationships between acute phase protein and indices of iron status indicate an influence of inflammation in both symptomatic and asymptomatic malaria, except when the parasitaemia is less than 1000/microL of blood when ferritin appears to be unaffected. HIV-1 impacts on haemopoiesis and anaemia. Anaemia increases in severity as the disease progresses and it is often a negative prognostic indicator. However, in individuals infected with HIV there may be an atypical acute phase response in the absence of opportunistic infections. Tentative conclusions are drawn concerning the inter-relationships between ferritin and the acute phase proteins, C-reactive protein and alpha-1-acid glycoprotein during an acute phase response.
Collapse
Affiliation(s)
- Christine A Northrop-Clewes
- Division of Nutrition and Physical Activity, International Micronutrient Malnutrition Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA.
| |
Collapse
|
15
|
Initiation of antiretroviral therapy at CD4 cell counts >/=350 cells/mm3 does not increase incidence or risk of peripheral neuropathy, anemia, or renal insufficiency. J Acquir Immune Defic Syndr 2008; 47:27-35. [PMID: 17971714 DOI: 10.1097/qai.0b013e31815acacc] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND US guidelines recommend deferring initiation of highly active antiretroviral therapy (HAART) for most patients with CD4 counts >350 cells/mm in part because of concerns about antiretroviral toxicity. METHODS Incidence rates of peripheral neuropathy, anemia, and renal insufficiency in a cohort of 2165 patients followed more than 3 years (mean) were analyzed in multivariate Cox proportional hazards models by CD4 cell counts at initiation of HAART. A nested cohort of 895 patients restricted to study participants who did or did not start HAART within a CD4 cell count stratum were also compared. RESULTS Incidence and risks of all 3 comorbidities decreased with initiation of HAART at CD4 counts >200 cells/mm versus <200 cells/mm. Incidence and risks of renal insufficiency were similar with HAART initiation at CD4 counts >/=350 cells/mm versus 200 to 349 cells/mm, but risk of peripheral neuropathy and anemia were further decreased in persons starting HAART at a CD4 count >/=350 cells/mm. The incidence of these conditions was highest during the first 6 months of treatment at any CD4 cell count and declined up to 19-fold with further therapy. DISCUSSION Initiating HAART at CD4 cell counts >/=200 cells/mm reduced the incidence and risk of the 3 comorbid conditions and for anemia and peripheral neuropathy as well by starting at CD4 counts >/=350 cells/mm. The incidence of each condition decreased rapidly and remained low with increasing time on HAART.
Collapse
|
16
|
Redd AD, Avalos A, Essex M. Infection of hematopoietic progenitor cells by HIV-1 subtype C, and its association with anemia in southern Africa. Blood 2007; 110:3143-9. [PMID: 17693583 PMCID: PMC2200905 DOI: 10.1182/blood-2007-04-086314] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Reports from southern Africa, an area in which human immunodeficiency virus type 1 (HIV-1) infection is caused almost exclusively by subtype C (HIV-1C), have shown increased rates of anemia in HIV-infected populations compared with similar acquired immunodeficiency syndrome (AIDS) patients in the United States, an area predominantly infected with subtype B (HIV-1B). Recent findings by our group demonstrated a direct association between HIV-1 infection and hematopoietic progenitor cell health in Botswana. Therefore, using a single-colony infection assay and quantitative proviral analysis, we examined whether HIV-1C could infect hematopoietic progenitor cells (HPCs) and whether this phenotype was associated with the higher rates of anemia found in southern Africa. The results show that a significant number of HIV-1C, but not HIV-1B, isolates can infect HPCs in vitro (P < .05). In addition, a portion of HIV-1C-positive Africans had infected progenitor cell populations in vivo, which was associated with higher rates of anemia in these patients (P < .05). This represents a difference in cell tropism between 2 geographically separate and distinct HIV-1 subtypes. The association of this hematotropic phenotype with higher rates of anemia should be considered when examining anti-HIV drug treatment regimens in HIV-1C-predominant areas, such as southern Africa.
Collapse
Affiliation(s)
- Andrew D Redd
- Department of Immunology and Infectious Diseases, Harvard School of Public Health AIDS Initiative, 651 Huntington Avenue, Boston, MA 02115, USA
| | | | | |
Collapse
|
17
|
Mildvan D, Creagh T, Leitz G. Prevalence of anemia and correlation with biomarkers and specific antiretroviral regimens in 9690 human-immunodeficiency-virus-infected patients: findings of the Anemia Prevalence Study. Curr Med Res Opin 2007; 23:343-55. [PMID: 17288689 DOI: 10.1185/030079906x162683] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe anemia prevalence and correlates with biomarkers and antiretroviral therapy (ART) in HIV/AIDS. METHODS Multicenter, cross-sectional study; clinical laboratory data collected at single visits, including hemoglobin (Hb), CD4+ count, HIV-1 RNA. Patients receiving care at US physician offices during the year 2000. Main outcome measure was anemia (Hb < 14 g/dL [men]; < 12 g/dL [women]) and marked anemia (Hb < 11 g/dL [men]; < 10 g/dL [women]) prevalence. Multivariable models examined association of anemia prevalence with HIV-1 biomarkers and ART. RESULTS Among 9690 patients, prevalence of anemia and marked anemia was 36% and 5%, respectively. Among 1721 patients receiving no ART, 39.7% were anemic; among 7252 receiving highly active antiretroviral therapy (HAART), 35.5% were anemic (p = 0.001). Anemia was most prevalent among men (37.3 vs. 32.3%; p = 0.0008), blacks (49 vs. 26% [whites]; p < 0.0001), patients with CD4+ < 200 cells/mm(3) (57 vs. 23% [> or = 500 CD4+]; p < 0.00001), and HIV-1 RNA > 30 000 copies/ml (53 vs. 30% [< 500 copies/ml]; p < 0.00001). Marked anemia was more common in women (6.8 vs. 4.3%; p < 0.0001). Among treated patients, logistic regression analysis controlling for CD4+, HIV-1 RNA, sex, and ethnicity, zidovudine (ZDV)-containing regimens (except combination with saquinavir/ZDV/lamivudine) were associated with increased overall anemia risk (odds ratio, 1.39 : 1.74). No regimen was associated with increased risk for marked anemia. Multivariable logistic regression showed CD4+, sex, and ethnicity more strongly associated with anemia than any ART regimen. CONCLUSION This large, single-visit, cross-sectional, US-based study shows that anemia remains highly prevalent in HIV-infected patients. Data from this analysis suggest low CD4+ count, black ethnicity, and male sex are consistently strongest correlates of overall anemia; women are significantly more likely to have marked anemia.
Collapse
Affiliation(s)
- Donna Mildvan
- Beth Israel Medical Center, New York, NY 10003, USA.
| | | | | |
Collapse
|
18
|
Lai M, d'Onofrio G, Visconti E, Tamburrini E, Cauda R, Leone G. Aetiological factors related to a positive direct antiglobulin test result in human immunodeficiency virus-infected patients. Vox Sang 2006; 90:325-30. [PMID: 16635076 DOI: 10.1111/j.1423-0410.2006.00755.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim of this study was to examine the clinical importance and causes of a positive result in the direct antiglobulin test (DAT) in human immunodeficiency virus-infected (HIV(+)) patients. We therefore studied haematological parameters in outpatient samples, and also analysed the impact of highly active anti-retroviral therapy (HAART) on the DAT results. STUDY DESIGN AND METHODS Haematological parameters, clinical stages, chemo-antibiotic treatments and HAART treatment were studied to determine any relationships with DAT results in 115 consecutive HIV(+) patients. RESULTS Significantly lower haemoglobin (Hb) levels were detected in patients with HIV who had a positive DAT result. Hepatitis C virus (HCV) co-infection (odds ratio 2.529) and trimethoprim-suphamethoxazfole (TMP-SMX) prophylaxis (odds ratio 3.751) had a significant association with DAT positivity. Patients receiving HAART were less likely to have a positive DAT [odds ratio (OR) 0.383; P = 0.035]. Among the patients treated with TMP-SMX, those with a positive DAT had lower Hb levels (11.9 g/dl) than those with a negative DAT (14.2 g/dl; P = 0.04). HCV antibody positivity and TMP-SMX prophylaxis showed a cumulative effect on positive DATs (OR 4.533). The surface exploratory analysis indicated the distribution of the positive DATs in relationship with the CD4(+) count and Hb levels. CONCLUSIONS Significantly lower Hb levels were detected in DAT-positive HIV(+) patients. HCV co-infection and TMP-SMX prophylaxis appear to confer an increased risk of DAT positivity. The presence of red blood cell autoantibodies may be associated with anaemia in HIV disease in the absence of overt haemolysis.
Collapse
Affiliation(s)
- M Lai
- Immunohematology Laboratory, Transfusion Centre Institute of Hematology Catholic University, Roma, Italy.
| | | | | | | | | | | |
Collapse
|
19
|
O'Brien ME, Kupka R, Msamanga GI, Saathoff E, Hunter DJ, Fawzi WW. Anemia is an independent predictor of mortality and immunologic progression of disease among women with HIV in Tanzania. J Acquir Immune Defic Syndr 2005; 40:219-25. [PMID: 16186741 DOI: 10.1097/01.qai.0000166374.16222.a2] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine the association of anemia with mortality and disease progression among a cohort of women with HIV in Dar es Salaam, Tanzania. METHODS Time to all-cause death, AIDS-related death, and a 50% decrease in CD4 cell count among 1078 HIV-positive pregnant women enrolled in a clinical trial of vitamin supplementation from 1995-2003. RESULTS Adjusted models showed that anemia was associated with an increased risk of all-cause mortality (relative hazard [RH]: 2.06, 95% CI: 1.52 to 2.79 for moderate anemia and RH: 3.19, 95% CI: 2.23 to 4.56 for severe anemia) and AIDS-related mortality (RH: 2.21, 95% CI: 1.53 to 3.19 for moderate anemia and RH: 3.47, 95% CI: 2.25 to 5.33 for severe anemia), independent of CD4 cell count, World Health Organization clinical stage, age, pregnancy, vitamin supplementation, and body mass index. Anemia was also associated with a more rapid decline in CD4 counts, measured as time to a 50% drop in CD4 cell count from baseline. Erythrocyte characteristics suggestive of iron deficiency were also associated with all-cause and AIDS-related death and a 50% decline in CD4 cell count. CONCLUSIONS Anemia is an independent predictor of mortality and disease progression in this cohort. Screening for anemia, coupled with prevention and treatment efforts, should be included in HIV care initiatives, particularly those that target women.
Collapse
Affiliation(s)
- Megan E O'Brien
- Department of Nutrition, Harvard School of Public Health, Boston, MA 02115, USA.
| | | | | | | | | | | |
Collapse
|
20
|
Abstract
Neopterin is well established as a reliable marker in HIV-1 infection. Neopterin concentrations measured in urine or serum indicate sensitively the course and progression of the disease as well as efficacy of anti-retroviral therapy. The main trigger for neopterin production is Th1-type cytokine interferon-gamma. During acute HIV-1 infection, enhanced formation of neopterin occurs already at a very early time point, before antibody seroconversion takes place. After this stage, neopterin concentrations in serum and urine closely correlate with virus load in the circulation of HIV-1-infected patients. Data provide evidence for an important role of immune activation and Th1-type cytokine interferon-gamma in the pathogenesis of HIV-1 infection. This review subsumes the importance of neopterin as a marker in HIV-1 infection. Further evidence is increasing, that neopterin derivatives might modulate immune response by interfering with the cellular redox balance, activating redox-sensitive transcription factors, or inducing apoptosis in specific cell types. The possible impact of neopterin derivatives and of other biochemical pathways induced by interferon-gamma such as indoleamine 2,3-dioxygenase in chronic diseases like HIV-1 infection is discussed.
Collapse
Affiliation(s)
- Barbara Wirleitner
- Institute of Medical Chemistry and Biochemistry, Medical University of Innsbruck, Fritz-Pregl-Strasse 3, A-6020 Innsbruck, Austria
| | | | | | | |
Collapse
|
21
|
Reply to D Fuchs et al. Am J Clin Nutr 2003. [DOI: 10.1093/ajcn/78.5.1046a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
22
|
Fuchs D, Schroecksnadel K, Zangerle R. Increase in vitamin B-12 during highly active antiretroviral therapy. Am J Clin Nutr 2003; 78:1046; author reply 1046-7. [PMID: 14594794 DOI: 10.1093/ajcn/78.5.1046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|