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Littwitz-Salomon E, Moreira D, Frost JN, Choi C, Liou KT, Ahern DK, O'Shaughnessy S, Wagner B, Biron CA, Drakesmith H, Dittmer U, Finlay DK. Metabolic requirements of NK cells during the acute response against retroviral infection. Nat Commun 2021; 12:5376. [PMID: 34508086 PMCID: PMC8433386 DOI: 10.1038/s41467-021-25715-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 08/21/2021] [Indexed: 02/07/2023] Open
Abstract
Natural killer (NK) cells are important early responders against viral infections. Changes in metabolism are crucial to fuel NK cell responses, and altered metabolism is linked to NK cell dysfunction in obesity and cancer. However, very little is known about the metabolic requirements of NK cells during acute retroviral infection and their importance for antiviral immunity. Here, using the Friend retrovirus mouse model, we show that following infection NK cells increase nutrient uptake, including amino acids and iron, and reprogram their metabolic machinery by increasing glycolysis and mitochondrial metabolism. Specific deletion of the amino acid transporter Slc7a5 has only discrete effects on NK cells, but iron deficiency profoundly impaires NK cell antiviral functions, leading to increased viral loads. Our study thus shows the requirement of nutrients and metabolism for the antiviral activity of NK cells, and has important implications for viral infections associated with altered iron levels such as HIV and SARS-CoV-2. Metabolic alterations control the fate and function of immune cells in response to infections, but the function of NK cell metabolism in the context of acute viral infections is unclear. Here the authors show that acute NK cell responses to Friend retrovirus involve increased glycolysis and mitochondrial metabolism and require amino acid transport as well as iron sufficiency.
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Affiliation(s)
- Elisabeth Littwitz-Salomon
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, 152-160 Pearse Street, Dublin, 2, Ireland.
| | - Diana Moreira
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, 152-160 Pearse Street, Dublin, 2, Ireland
| | - Joe N Frost
- MRC Human Immunology Unit, MRC Weatherall, Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Chloe Choi
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, 152-160 Pearse Street, Dublin, 2, Ireland
| | - Kevin T Liou
- Department of Molecular Microbiology and Immunology, Brown University, Box G-B, 171 Meeting Street, Providence, RI, 02912, USA
| | - David K Ahern
- MRC Human Immunology Unit, MRC Weatherall, Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Simon O'Shaughnessy
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, 152-160 Pearse Street, Dublin, 2, Ireland
| | - Bernd Wagner
- Department of Clinical Chemistry, University Hospital Essen, Essen, Germany
| | - Christine A Biron
- Department of Molecular Microbiology and Immunology, Brown University, Box G-B, 171 Meeting Street, Providence, RI, 02912, USA
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall, Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Ulf Dittmer
- Institute for Virology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - David K Finlay
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, 152-160 Pearse Street, Dublin, 2, Ireland. .,School of Pharmacy and Pharmaceutical Sciences, Trinity Biomedical Sciences Institute, Trinity College Dublin, 152-160 Pearse Street, Dublin, 2, Ireland.
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2
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Mate A, Reyes-Goya C, Santana-Garrido Á, Sobrevia L, Vázquez CM. Impact of maternal nutrition in viral infections during pregnancy. Biochim Biophys Acta Mol Basis Dis 2021; 1867:166231. [PMID: 34343638 PMCID: PMC8325560 DOI: 10.1016/j.bbadis.2021.166231] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 07/05/2021] [Accepted: 07/23/2021] [Indexed: 12/11/2022]
Abstract
Other than being a physiological process, pregnancy is a condition characterized by major adaptations of maternal endocrine and metabolic homeostasis that are necessary to accommodate the fetoplacental unit. Unfortunately, all these systemic, cellular, and molecular changes in maternal physiology also make the mother and the fetus more prone to adverse outcomes, including numerous alterations arising from viral infections. Common infections during pregnancy that have long been recognized as congenitally and perinatally transmissible to newborns include toxoplasmosis, rubella, cytomegalovirus, and herpes simplex viruses (originally coined as ToRCH infections). In addition, enterovirus, parvovirus B19, hepatitis virus, varicella-zoster virus, human immunodeficiency virus, Zika and Dengue virus, and, more recently, coronavirus infections including Middle Eastern respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS) infections (especially the novel SARS-CoV-2 responsible for the ongoing COVID-19 pandemic), constitute relevant targets for current research on maternal-fetal interactions in viral infections during pregnancy. Appropriate maternal education from preconception to the early postnatal period is crucial to promote healthy pregnancies in general and to prevent and/or reduce the impact of viral infections in particular. Specifically, an adequate lifestyle based on proper nutrition plans and feeding interventions, whenever possible, might be crucial to reduce the risk of virus-related gestational diseases and accompanying complications in later life. Here we aim to provide an overview of the emerging literature addressing the impact of nutrition in the context of potentially harmful viral infections during pregnancy.
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Affiliation(s)
- Alfonso Mate
- Departamento de Fisiología, Facultad de Farmacia, Universidad de Sevilla, 41012 Sevilla, Spain; Epidemiología Clínica y Riesgo Cardiovascular, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/Consejo Superior de Investigaciones Científicas/Universidad de Sevilla, 41013 Sevilla, Spain.
| | - Claudia Reyes-Goya
- Departamento de Fisiología, Facultad de Farmacia, Universidad de Sevilla, 41012 Sevilla, Spain
| | - Álvaro Santana-Garrido
- Departamento de Fisiología, Facultad de Farmacia, Universidad de Sevilla, 41012 Sevilla, Spain; Epidemiología Clínica y Riesgo Cardiovascular, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/Consejo Superior de Investigaciones Científicas/Universidad de Sevilla, 41013 Sevilla, Spain
| | - Luis Sobrevia
- Departamento de Fisiología, Facultad de Farmacia, Universidad de Sevilla, 41012 Sevilla, Spain; Cellular and Molecular Physiology Laboratory (CMPL), Department of Obstetrics, Division of Obstetrics and Gynaecology, Pontificia Universidad Católica de Chile, Santiago 8330024, Chile; Medical School (Faculty of Medicine), São Paulo State University (UNESP), Brazil; University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine and Biomedical Sciences, University of Queensland, Herston, QLD 4029, Australia; Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen (UMCG), 9713GZ Groningen, the Netherlands
| | - Carmen M Vázquez
- Departamento de Fisiología, Facultad de Farmacia, Universidad de Sevilla, 41012 Sevilla, Spain; Epidemiología Clínica y Riesgo Cardiovascular, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/Consejo Superior de Investigaciones Científicas/Universidad de Sevilla, 41013 Sevilla, Spain
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3
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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.
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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
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4
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Haider BA, Spiegelman D, Hertzmark E, Sando D, Duggan C, Makubi A, Sudfeld C, Aris E, Chalamilla GE, Fawzi WW. Anemia, Iron Deficiency, and Iron Supplementation in Relation to Mortality among HIV-Infected Patients Receiving Highly Active Antiretroviral Therapy in Tanzania. Am J Trop Med Hyg 2020; 100:1512-1520. [PMID: 31017077 DOI: 10.4269/ajtmh.18-0096] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Anemia in HIV-infected patients improves with highly active antiretroviral therapy (HAART); however, it may still be associated with mortality among patients receiving treatment. We examined the associations of anemia severity and iron deficiency anemia (IDA) at HAART initiation and during monthly prospective follow-up with mortality among 40,657 adult HIV-infected patients receiving HAART in Dar es Salaam, Tanzania. Proportional hazards models were used to examine the associations of anemia severity and IDA at HAART initiation and during follow-up with mortality. A total of 6,261 deaths were reported. Anemia severity at HAART initiation and during follow-up was associated with an increasing risk of mortality (trend tests P < 0.001). There was significantly higher mortality risk associated with IDA at HAART initiation and during follow-up versus no anemia or iron deficiency (both P < 0.001). These associations differed significantly by gender, body mass index, and iron supplement use (all interaction test P < 0.001). The magnitude of association was stronger among men. Mortality risk with severe anemia was 13 times greater versus no anemia among obese patients, whereas it was only two times greater among underweight patients. Higher mortality risk was observed among iron supplement users, irrespective of anemia severity. Anemia and IDA were significantly associated with a higher mortality risk in patients receiving HAART. Iron supplementation indicated an increased mortality risk, and its role in HIV infections should be examined in future studies. Given the low cost of assessing anemia, it can be used frequently to identify high-risk patients in resource-limited settings.
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Affiliation(s)
- Batool A Haider
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts.,Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
| | - Donna Spiegelman
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts.,Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts.,Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts.,Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
| | - Ellen Hertzmark
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - David Sando
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Christopher Duggan
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts.,Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
| | - Abel Makubi
- School of Medicine, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania.,Management and Development for Health, Dar es Salaam, Tanzania
| | - Christopher Sudfeld
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts
| | - Eric Aris
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Guerino E Chalamilla
- Management and Development for Health, Dar es Salaam, Tanzania.,Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts.,Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts.,Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
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5
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Owusu EDA, Visser BJ, Nagel IM, Mens PF, Grobusch MP. The interaction between sickle cell disease and HIV infection: a systematic review. Clin Infect Dis 2014; 60:612-26. [PMID: 25344542 DOI: 10.1093/cid/ciu832] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Human immunodeficiency virus (HIV) and sickle cell disease (SCD) are regarded as endemic in overlapping geographic areas; however, for most countries only scarce data on the interaction between HIV and SCD and disease burden exist. HIV prevalence in SCD patients varies between 0% and 11.5% in published studies. SCD has been suggested to reduce disease progression of HIV into AIDS. Various interactions of antiretroviral therapy with SCD exist. Both SCD and HIV act as common risk factors for stroke, avascular necrosis, severe splenic dysfunction, pulmonary arterial hypertension, and sepsis, which may result in synergistic increase in risk of developing these diseases. No treatment guidelines regarding SCD with HIV coinfection were identified. Available evidence is mainly based on small clinical studies, thus making strong recommendations difficult. An increased effort to elucidate the precise interactions is warranted to better understand both diseases and effect more adequate treatment approaches, especially in view of their geographical coprevalence.
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Affiliation(s)
- Ewurama D A Owusu
- Department of Medical Laboratory Sciences, School of Allied Health Sciences, College of Health Sciences, University of Ghana, Accra Center of Tropical Medicine and Travel Medicine, Academic Medical Center, University of Amsterdam KIT Biomedical Research, Department of Parasitology, Amsterdam, The Netherlands
| | - Benjamin J Visser
- Center of Tropical Medicine and Travel Medicine, Academic Medical Center, University of Amsterdam Centre de Recherches Médicales de Lambaréné, Albert Schweitzer Hôpital, Lambaréné, Gabon Institute of Tropical Medicine, University of Tübingen, Germany
| | - Ingeborg M Nagel
- Medical Library, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Petra F Mens
- Center of Tropical Medicine and Travel Medicine, Academic Medical Center, University of Amsterdam KIT Biomedical Research, Department of Parasitology, Amsterdam, The Netherlands
| | - Martin P Grobusch
- Center of Tropical Medicine and Travel Medicine, Academic Medical Center, University of Amsterdam Centre de Recherches Médicales de Lambaréné, Albert Schweitzer Hôpital, Lambaréné, Gabon Institute of Tropical Medicine, University of Tübingen, Germany
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6
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Walsh CM, Hattingh Z, Veldman FJ, Bester CJ. Iron status and anaemia of chronic disease in HIV-infected African women in Mangaung, Bloemfontein. S Afr Fam Pract (2004) 2014. [DOI: 10.1080/20786204.2010.10873936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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7
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Crist MB, Melekhin VV, Bian A, Shintani A, Milne GL, Kallianpur AR, Dageforde LA, Haas DW, Hulgan T. Higher serum iron is associated with increased oxidant stress in HIV-infected men. J Acquir Immune Defic Syndr 2013; 64:367-73. [PMID: 24169121 PMCID: PMC3816092 DOI: 10.1097/qai.0b013e3182a60f36] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND F₂-isoprostanes (F₂-IsoP) are oxidant stress biomarkers that are higher in HIV-infected women than men. We explored whether the effect of hemoglobin (Hgb), serum iron, or anemia on F₂-IsoP is different between HIV-infected women and men. METHODS Plasma F₂-IsoP were quantified by gas chromatography/mass spectrometry; clinical and laboratory data were collected at enrollment or from the medical record. Multivariable linear regression was used to assess associations between F₂-IsoP and Hgb, anemia as a dichotomous variable, and serum iron with adjustment for age, sex, race, body mass index, CD4 lymphocyte count, self-reported current smoking status, and antiretroviral therapy. RESULTS Compared with men, women had lower Hgb [median: 12.7 (interquartile range: 11.8-13.9) vs. 14.9 (13.7-15.8) g/dL, P < 0.001], lower iron levels [75 (47-97) vs. 90 (69-121) µg/dL, P = 0.004], more anemia (29% vs. 10%, P < 0.001), and higher levels of F₂-IsoP [42 (32-62) vs. 36 (25-46) pg/mL, P < 0.001]. The relationship between iron and F₂-IsoP differed significantly between men and women (interaction P = 0.02). Men had a 21% (95% confidence interval: 8 to 36) increase in F₂-IsoP per interquartile increase in iron (P = 0.001), whereas no relationship was seen among women [-4% (-17 to 13, P = 0.65]. CONCLUSIONS Although women have overall higher F₂-IsoP than men, a relationship between circulating F₂-IsoP and iron levels was observed in men but not in women with HIV infection. The association between female sex and higher F₂-IsoP is not explained by iron or Hgb levels because the association persists when controlling for these factors. The role of iron in oxidant stress and sex-specific differences among HIV-infected individuals require further study.
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Affiliation(s)
- Matthew B. Crist
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Vlada V. Melekhin
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ayumi Shintani
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ginger L. Milne
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Asha R. Kallianpur
- Departments Genomic Medicine and Medicine, Cleveland Clinic Foundation/Lerner Research Institute, Cleveland, Ohio
| | - Leigh Anne Dageforde
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - David W. Haas
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Todd Hulgan
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
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8
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Kruger HS, Balk LJ, Viljoen M, Meyers TM. Positive association between dietary iron intake and iron status in HIV-infected children in Johannesburg, South Africa. Nutr Res 2012; 33:50-8. [PMID: 23351410 DOI: 10.1016/j.nutres.2012.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 11/03/2012] [Accepted: 11/12/2012] [Indexed: 11/25/2022]
Abstract
Anemia is a common complication of pediatric HIV infection and is associated with suboptimal cognitive performance and growth failure. Routine iron supplementation is not provided to South African HIV-infected children. We hypothesized that dietary iron intake without supplementation is sufficient to protect against iron deficiency (ID) in HIV-infected children receiving highly active antiretroviral therapy. In this prospective study, the difference between dietary intakes of iron-deficient children (soluble transferrin receptor >9.4 mg/L) and iron-sufficient children after 18 months on highly active antiretroviral therapy was examined. The association between iron intake and hemoglobin (Hb) concentration was also assessed. Longitudinal data collected for 18 months from 58 HIV-infected African children were assessed by generalized estimation equations, with adjustment for demographic information, dietary intakes, growth parameters, and CD4%. After adjustment for covariates, the longitudinal association between dietary iron intake and Hb concentration remained significant. This association shows that for every 1-mg increase in iron intake per day, Hb increases by 1.1 g/L (P < .001). Mean Hb increased significantly after 18 months of follow-up (106 ± 14 to 129 ± 14 g/L, P < .01), but soluble transferrin receptor also increased (7.7 ± 2.7 to 8.9 ± 3.0 mg/L, P < .01). The incidence of ID increased from 15.2% at baseline to 37.2% after 18 months. Children with animal protein intakes greater than >20 g/d had significantly lower odds for ID at 18 months than did children with lower intakes (odds ratio, 0.40; 95% confidence interval, 0.21-0.77). Dietary iron intake was insufficient to protect against ID, pointing to a need for low-dose iron supplementation for iron-deficient HIV-infected children and interventions to increase the consumption of animal protein.
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Affiliation(s)
- Herculina S Kruger
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa.
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9
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Jonker FAM, Calis JCJ, Phiri K, Brienen EAT, Khoffi H, Brabin BJ, Verweij JJ, van Hensbroek MB, van Lieshout L. Real-time PCR demonstrates Ancylostoma duodenale is a key factor in the etiology of severe anemia and iron deficiency in Malawian pre-school children. PLoS Negl Trop Dis 2012; 6:e1555. [PMID: 22514750 PMCID: PMC3295794 DOI: 10.1371/journal.pntd.0001555] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 01/19/2012] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Hookworm infections are an important cause of (severe) anemia and iron deficiency in children in the tropics. Type of hookworm species (Ancylostoma duodenale or Necator americanus) and infection load are considered associated with disease burden, although these parameters are rarely assessed due to limitations of currently used diagnostic methods. Using multiplex real-time PCR, we evaluated hookworm species-specific prevalence, infection load and their contribution towards severe anemia and iron deficiency in pre-school children in Malawi. METHODOLOGY AND FINDINGS A. duodenale and N. americanus DNA loads were determined in 830 fecal samples of pre-school children participating in a case control study investigating severe anemia. Using multiplex real-time PCR, hookworm infections were found in 34.1% of the severely anemic cases and in 27.0% of the non-severely anemic controls (p<0.05) whereas a 5.6% hookworm prevalence was detected by microscopy. Prevalence of A. duodenale and N. americanus was 26.1% and 4.9% respectively. Moderate and high load A. duodenale infections were positively associated with severe anemia (adjusted odds ratio: 2.49 (95%CI 1.16-5.33) and 9.04 (95%CI 2.52-32.47) respectively). Iron deficiency (assessed through bone marrow examination) was positively associated with intensity of A. duodenale infection (adjusted odds ratio: 3.63 (95%CI 1.18-11.20); 16.98 (95%CI 3.88-74.35) and 44.91 (95%CI 5.23-385.77) for low, moderate and high load respectively). CONCLUSIONS/SIGNIFICANCE This is the first report assessing the association of hookworm load and species differentiation with severe anemia and bone marrow iron deficiency. By revealing a much higher than expected prevalence of A. duodenale and its significant and load-dependent association with severe anemia and iron deficiency in pre-school children in Malawi, we demonstrated the need for quantitative and species-specific screening of hookworm infections. Multiplex real-time PCR is a powerful diagnostic tool for public health research to combat (severe) anemia and iron deficiency in children living in resource poor settings.
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Affiliation(s)
- Femkje A M Jonker
- Global Child Health Group, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands.
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10
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Mehta S, Mugusi FM, Bosch RJ, Aboud S, Chatterjee A, Finkelstein JL, Fataki M, Kisenge R, Fawzi WW. A randomized trial of multivitamin supplementation in children with tuberculosis in Tanzania. Nutr J 2011; 10:120. [PMID: 22039966 PMCID: PMC3229564 DOI: 10.1186/1475-2891-10-120] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 10/31/2011] [Indexed: 12/04/2022] Open
Abstract
Background Children with tuberculosis often have underlying nutritional deficiencies. Multivitamin supplementation has been proposed as a means to enhance the health of these children; however, the efficacy of such an intervention has not been examined adequately. Methods 255 children, aged six weeks to five years, with tuberculosis were randomized to receive either a daily multivitamin supplement or a placebo in the first eight weeks of anti-tuberculous therapy in Tanzania. This was only 64% of the proposed sample size as the trial had to be terminated prematurely due to funding constraints. They were followed up for the duration of supplementation through clinic and home visits to assess anthropometric indices and laboratory parameters, including hemoglobin and albumin. Results There was no significant effect of multivitamin supplementation on the primary endpoint of the trial: weight gain after eight weeks. However, significant differences in weight gain were observed among children aged six weeks to six months in subgroup analyses (n = 22; 1.08 kg, compared to 0.46 kg in the placebo group; 95% CI = 0.12, 1.10; p = 0.01). Supplementation resulted in significant improvement in hemoglobin levels at the end of follow-up in children of all age groups; the median increase in children receiving multivitamins was 1.0 g/dL, compared to 0.4 g/dL in children receiving placebo (p < 0.01). HIV-infected children between six months and three years of age had a significantly higher gain in height if they received multivitamins (n = 48; 2 cm, compared to 1 cm in the placebo group; 95% CI = 0.20, 1.70; p = 0.01; p for interaction by age group = 0.01). Conclusions Multivitamin supplementation for a short duration of eight weeks improved the hematological profile of children with tuberculosis, though it didn't have any effect on weight gain, the primary outcome of the trial. Larger studies with a longer period of supplementation are needed to confirm these findings and assess the effect of multivitamins on clinical outcomes including treatment success and growth failure. Clinicaltrials.gov Identifier NCT00145184
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Affiliation(s)
- Saurabh Mehta
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA.
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11
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Abstract
BACKGROUND Anemia is common in persons with HIV infection and is associated with poor prognosis. There is a need to assess the effects of anemia treatments, and to determine whether these interventions are beneficial. OBJECTIVES To determine the efficacy and safety of treatments for anemia in people with HIV infection and AIDS. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 10, 2010), MEDLINE (1980-November 25, 2010), EMBASE (1980-November 25, 2010), LlLACS (1982 to November 25, 2010), Africa Index Medicus (up to November 9, 2010), ISI Web of Knowledge (2005 to October 9, 2010), Scirus (October 9, 2010) reference lists of relevant articles. We asked the Cochrane HIV/AIDS and Pregnancy and Childbirth Groups to check their Specialised Registers. We also checked the reference lists of all trials identified by the above methods. SELECTION CRITERIA Randomized trials assessing the effects of treatments for anemia in people diagnosed with HIV infection. There were no age restrictions. DATA COLLECTION AND ANALYSIS Two authors independently assessed relevant studies for inclusion. Data extraction and quality assessment of relevant studies was performed by two authors and checked by the other two authors. MAIN RESULTS Six trials with a high risk of bias, including 537 patients, met the inclusion criteria. These trials only covered recombinant Human erythropoietin alfa (rHuEPO). Two of them including adult and paediatric participants (84 participants and 4 events) comparing rHuEPO to placebo did not reduce the risk of mortality with a follow up to 12 weeks (pooled RR 0.56, 95% confidence interval (CI) 0.08 to 4.05, I(2) = 0%). Any trials that compared rHuEPO to placebo did not show any benefit on hematological values response, number of patients transfused, or number of packed red cell transfused. Two trial compared the effects of two rHuEPO dosing regimens on hemoglobin value and quality of life, but the effects are unclear. Three RCT reported high risk of attrition bias; therefore, were not included in a meta-analysis. AUTHORS' CONCLUSIONS This updated Cochrane review provides evidence that rHuEPO compared with placebo does not reduce mortality, does not reduce transfusion requirements, did not increase hemoglobin levels, and did not improve quality of life in HIV-infected patients with anemia. The results are based on six RCTs with high risk of bias. Therefore prescription of this intervention for treating anemia in patients with AIDS is not justified, unless new evidence from a large high quality trial alters this conclusion.
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Affiliation(s)
- Arturo J Martí-Carvajal
- Universidad de Carabobo and Iberoamerican Cochrane Network, Valencia, Edo. Carabobo, Venezuela
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de Pee S, Semba RD. Role of Nutrition in HIV Infection: Review of Evidence for more Effective Programming in Resource-Limited Settings. Food Nutr Bull 2010. [DOI: 10.1177/15648265100314s403] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background HIV infection and malnutrition negatively reinforce each other. Objective For program guidance, to review evidence on the relationship of HIV infection and malnutrition in adults in resource-limited settings. Results and conclusions Adequate nutritional status supports immunity and physical performance. Weight loss, caused by low dietary intake (loss of appetite, mouth ulcers, food insecurity), malabsorption, and altered metabolism, is common in HIV infection. Regaining weight, particularly muscle mass, requires antiretroviral therapy (ART), treatment of opportunistic infections, consumption of a balanced diet, physical activity, mitigation of side effects, and perhaps appetite stimulants and growth hormone. Correcting nutritional status becomes more difficult as infection progresses. Studies document widespread micronutrient deficiencies among HIV-infected people. However, supplement composition, patient characteristics, and treatments vary widely across intervention studies. Therefore, the World Health Organization (WHO) recommends ensuring intake of 1 Recommended Nutrient Intake (RNI) of each required micronutrient, which may require taking micronutrient supplements. Few studies have assessed the impact of food supplements. Because the mortality risk in patients receiving ART increases with lower body mass index (BMI), improving the BMI seems important. Whether this requires provision of food supplements depends on the patient's diet and food security. It appears that starting ART improves BMI and that ready-to-use fortified spreads and fortified-blended foods further increase BMI (the effect is somewhat less with fortified-blended foods). The studies are too small to assess effects on mortality. Once ART has been established and malnutrition treated, the nutritional quality of the diet remains important, also because of ART's long-term metabolic effects (dyslipidemia, insulin resistance, obesity). Food insecurity should also be addressed if it prevents adequate energy intake and reduces treatment initiation and adherence (due to the opportunity costs of obtaining treatment and mitigating side effects).
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Abstract
The immune system requires several essential micronutrients to maintain an effective immune response. HIV infection destroys the immune system and promotes nutritional deficiencies, which further impair immunity. This article reviews the role of several micronutrients (vitamins A, C, E and D, the B vitamins, and minerals, selenium, iron and zinc) that are relevant for maintaining immune function. In addition, the deficiencies of these micronutrients have been associated with faster progression of HIV-1 disease. This review examines the evidence from observational studies of an association between micronutrient status and HIV disease, as well as the effectiveness of micronutrient supplementation on HIV-disease progression, pregnancy outcomes and nutritional status, among others, utilizing randomized clinical trials. Each micronutrient is introduced with a summary of its functions in human physiology, followed by the presentation of studies conducted in HIV-infected patients in relation to this specific micronutrient. Overall findings and recommendations are then summarized.
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Affiliation(s)
- Adriana Campa
- Florida International University, Stempel College of Public Health & Social Work, University Park, HLS-1–337, Miami, FL 33199, USA
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Abstract
BACKGROUND The most prevalent haematologic disturbance associated with HIV in children (apart from CD4 lymphocytopenia) is anaemia. Anaemia associated with HIV arises from multiple mechanisms, including the direct inhibitory effect of HIV on red cell precursors, other locally prevalent and/or opportunistic infections, micronutrient deficiency, anaemia of chronic disease, and as a consequence of medicines given for HIV and/or other concurrent illnesses. Iron deficiency is the most common cause of nutritional anaemia globally. There is significant geographical overlap of areas of the world where iron deficiency anaemia (IDA) and paediatric HIV are distributed. Given the high prevalence of IDA, it is likely that many HIV-infected children also are iron deficient. The contribution of iron deficiency to anaemia in HIV-infected children has been described but is incompletely understood. Currently, iron supplementation for anaemic infants and children is routinely practiced without any obvious effect in most developing countries, which bear most of the burden of global paediatric HIV infections.Because iron deficiency and IDA are common in HIV-infected children in high-prevalence areas and because there are concerns about possible deleterious effects of iron, this review aims to assess the evidence for iron supplementation for reducing morbidity and mortality in HIV-infected children. OBJECTIVES To determine whether iron supplementation improves clinical, immunologic, and virologic outcomes in children infected with HIV SEARCH STRATEGY: We used the comprehensive search strategy developed specifically by the Cochrane HIV/AIDS Review Group to identify HIV/AIDS randomised controlled trials, and searched the following electronic databases: MEDLINE (searched November 2007); Embase (searched December 2007); and CENTRAL (December 2007). This search was supplemented with a search of AIDSearch (searched December 2007) and NLM Gateway (searched December 2007) to identify relevant conference abstracts, as well as a search of the reference lists of all eligible articles. The search was not limited by language or publication status. SELECTION CRITERIA Randomised controlled trials (RCTs) of iron supplementation in any form and dose in HIV-infected children aged 12 years and younger. DATA COLLECTION AND ANALYSIS We independently screened the results of the search to select potentially relevant studies and to retrieve the full articles. We independently applied the inclusion criteria to the potentially relevant studies. No studies were identified that fulfilled the selection criteria. MAIN RESULTS No RCTs of iron supplementation in HIV-infected children were found. IMPLICATIONS FOR CLINICAL PRACTICE The current clinical practice of iron supplementation in HIV-infected children is based on weak evidence comprising observational studies and expert opinions. IMPLICATIONS FOR RESEARCH High-quality RCTs of iron supplementation are urgently required, especially in areas with significant overlap of high prevalence of HIV, iron deficiency anaemia, and malaria. Policy makers should prioritise funding for these trials.
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Affiliation(s)
- Ifedayo Adetifa
- Tuberculosis Office, Medical Research Council Laboratories, Atlantic Boulevard, Fajara, PO Box 273, Banjul, Gambia.
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Elevated iron stores are associated with HIV disease severity and mortality among postpartum women in Zimbabwe. Public Health Nutr 2008; 12:1321-9. [PMID: 19000344 DOI: 10.1017/s136898000800390x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The relationship between Fe status and HIV infection is complex and poorly understood. While anaemia is a major complication of HIV infection, higher Fe stores may be associated with disease progression. There is limited and conflicting data available from Africa. DESIGN Cross-sectional and prospective cohort study. SETTING, SUBJECTS AND METHODS: We examined the association between postpartum Fe status (Hb, serum ferritin (SF) and transferrin receptor (TfR)) and viral load (VL) and HIV-related mortality in 643 HIV-positive Zimbabwean women over a period of 12 months. RESULTS In non-anaemic women a log10 increase in SF was associated with a 2.3-fold increase in VL (P = 0.019); this association was absent in anaemic women. In prospective analyses, a log10 increase in SF was associated with a 4-fold increase in mortality by 12 months (P = 0.002). Hb was negatively associated with VL (P = 0.001) and mortality (P = 0.047). The adverse associations between SF and both VL and mortality were found at SF concentrations > 45 microg/l (P < 0.05). Controlling for alpha1 acid glycoprotein, a marker of inflammation, attenuated the association between both SF and VL and mortality, but these remained significant. CONCLUSIONS These results are consistent with the hypothesis that high Fe stores have adverse consequences in HIV infection. If adverse consequences are real, our data suggest that they occur at SF concentrations exceeding those consistent with adequate Fe nutriture.
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Maffettone C, De Martino L, Irace C, Santamaria R, Pagnini U, Iovane G, Colonna A. Expression of iron-related proteins during infection by bovine herpes virus type-1. J Cell Biochem 2008; 104:213-23. [PMID: 17990282 DOI: 10.1002/jcb.21618] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Bovine herpesvirus 1 (BHV-1), a dsDNA animal virus, is an economically important pathogen of cattle and the aetiological agent of many types of disease. The efficient replication of a DNA virus is strictly dependent on iron since this metal plays a crucial role in the catalytic center of viral ribonucleotide reductase. Consequently, iron metabolism is an important area for virus/host interaction and a large body of evidence suggests that viral infection is potentially influenced by the iron status of the host. The aim of the present study was to address the effects of BHV-1 on iron metabolism in Madin-Darby bovine kidney (MDBK) cells at different times of post-infection. For this purpose, cell viability, iron regulatory proteins (IRPs) activity and levels, transferrin receptor 1 (TfR-1), ferritin expression and LIP were evaluated. Our data demonstrate that a productive BHV-1 infection in MDBK cells determines an overall decrease of IRPs RNA-binding activity without affecting their expression. As consequence of this modulation, an increased ferritin mRNA translation and a decreased TfR-1 mRNA translation were also observed. Moreover, the LIP level was decreased following viral infection. These results are consistent with the hypothesis that by reducing the iron up-take and by enhancing the sequestration of free iron, animal cells will limit the iron availability for virus proliferation. Therefore, the results presented herein support the view that iron metabolism could be critical for the interaction between DNA viruses, such as BHV-1, and mammalian cells. Delineation of the interplay among pathogen and host may provide new antimicrobial agents.
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Affiliation(s)
- Carmen Maffettone
- Dipartimento di Farmacologia Sperimentale, Università di Napoli Federico II, via D. Montesano 49, I-80131 Napoli, Italy
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Semba RD, Ricketts EP, Mehta S, Netski D, Thomas D, Kirk G, Wu AW, Vlahov D. Effect of micronutrients and iron supplementation on hemoglobin, iron status, and plasma hepatitis C and HIV RNA levels in female injection drug users: a controlled clinical trial. J Acquir Immune Defic Syndr 2007; 45:298-303. [PMID: 17414930 DOI: 10.1097/qai.0b013e318050d698] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Iron deficiency is common among female injection drug users, but it is unclear whether iron supplementation can reduce anemia and improve iron status without increasing plasma hepatitis C virus (HCV) or HIV RNA levels. METHODS We conducted a phase 3, double-blind, randomized, controlled clinical trial of daily micronutrients with 18 mg of iron (iron group) versus micronutrients without iron (control group) for 12 months among hepatitis C-positive female injection drug users in Baltimore, Maryland. The main outcome measures were hemoglobin, markers of iron status, plasma HCV RNA, plasma HIV RNA, and liver enzymes at 6 and 12 months of follow-up. RESULTS Four hundred fifty-eight women (320 HIV-negative and 138 HIV-positive) enrolled in the trial. There were no significant differences in the proportion of women with anemia, ferritin<30 ng/mL, log10 plasma HCV RNA, or log10 plasma HIV RNA between treatment groups at enrollment. The proportion with anemia in the iron and control groups, respectively, was 20.7% versus 31.3% (P=0.026) at 6 months and 26.2% versus 30.4% (P=0.5) at 12 months; with ferritin<30 ng/mL, the proportion was 29.2% versus 55.5% (P<0.0001) at 6 months and 26.2% versus 46.9% (P=0.0018) at 12 months. In the iron and control groups, respectively, mean log10 plasma HCV RNA (IU/mL) was 5.2 versus 5.2 (P=0.86) at 6 months and 5.4 versus 5.3 (P=0.6) at 12 months. Among HIV-positive subjects, mean log10 plasma RNA (copies/mL) in the iron and placebo groups, respectively, was 3.8 versus 3.7 (P=0.75) at 6 months and 3.7 versus 4.1 (P=0.19) at 12 months. There were no significant differences in liver enzyme levels between the treatment groups at enrollment, 6 months, and 12 months. CONCLUSIONS A daily micronutrient supplement with iron can reduce anemia and improve iron status in female injection drug users without increasing plasma HCV or HIV RNA levels or altering liver enzymes.
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Affiliation(s)
- Richard D Semba
- Department of Ophthalmology, Johns Hopkins Medical Institutions, Baltimore, MD 21205, USA.
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18
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Fawzi WW, Msamanga GI, Kupka R, Spiegelman D, Villamor E, Mugusi F, Wei R, Hunter D. Multivitamin supplementation improves hematologic status in HIV-infected women and their children in Tanzania. Am J Clin Nutr 2007; 85:1335-43. [PMID: 17490971 DOI: 10.1093/ajcn/85.5.1335] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Anemia is a frequent complication among HIV-infected persons and is associated with faster disease progression and mortality. OBJECTIVE We examined the effect of multivitamin supplementation on hemoglobin concentrations and the risk of anemia among HIV-infected pregnant women and their children. DESIGN HIV-1-infected pregnant women (n = 1078) from Dar es Salaam, Tanzania, were enrolled in a double-blind trial and provided daily supplements of preformed vitamin A and beta-carotene, multivitamins (vitamins B, C, and E), preformed vitamin A and beta-carotene + multivitamins, or placebo. All women received iron and folate supplements only during pregnancy according to local standard of care. The median follow-up time for hemoglobin measurement for mothers was 57.3 mo [interquartile range (IQR): 28.6-66.8] and for children it was 28.0 mo (IQR: 5.3-41.7). RESULTS During the whole period, hemoglobin concentrations among women who received multivitamins were 0.33 g/dL higher than among women who did not receive multivitamins (P=0.07). Compared with placebo, multivitamin supplementation resulted in a hemoglobin increase of 0.59 g/dL during the first 2 y after enrollment (P=0.0002). Compared with placebo, the children born to mothers who received multivitamins had a reduced risk of anemia. In this group, the risk of macrocytic anemia was 63% lower than in the placebo group (relative risk: 0.37: 95% CI: 0.18, 0.79; P=0.01). CONCLUSION Multivitamin supplementation provided during pregnancy and in the postpartum period resulted in significant improvements in hematologic status among HIV-infected women and their children, which provides further support for the value of multivitamin supplementation in HIV-infected adults.
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Affiliation(s)
- Wafaie W Fawzi
- Department of Nutrition, Harvard School of Public Health, Boston, MA 02115, USA.
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Sahiratmadja E, Wieringa FT, van Crevel R, de Visser AW, Adnan I, Alisjahbana B, Slagboom E, Marzuki S, Ottenhoff THM, van de Vosse E, Marx JJM. Iron deficiency and NRAMP1 polymorphisms (INT4, D543N and 3'UTR) do not contribute to severity of anaemia in tuberculosis in the Indonesian population. Br J Nutr 2007; 98:684-90. [PMID: 17466092 DOI: 10.1017/s0007114507742691] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Fe-deficiency anaemia is the most common cause of anaemia in developing countries. In these settings, many chronic infections, including tuberculosis (TB), are highly prevalent. Fe is an essential nutrient for both host and mycobacteria that play a pivotal role in host immunity and mycobacterial growth. A case-control study was performed in a TB-endemic region in Jakarta, Indonesia, among 378 pulmonary TB patients and 436 healthy controls from the same neighbourhood with the same socio-economic status. In a number of these subjects the Fe status could be explored. The distribution of three polymorphisms in the natural resistance-associated macrophage protein gene (NRAMP1) including INT4, D543N and 3'UTR was examined for a possible association with susceptibility to TB. Anaemia (corrected for sex) was present in 63.2 % of active TB compared with 6.8 % of controls, with female patients more often affected. Anaemia was more pronounced in advanced TB as diagnosed by chest radiography. Lower Hb concentrations in TB patients were accompanied by lower plasma Fe concentrations, lower Fe-binding capacity and higher plasma ferritin. After successful TB therapy, Fe parameters improved towards control values and Hb levels normalised, even without Fe supplementation. NRAMP1 gene polymorphisms were not associated with TB susceptibility, TB severity or anaemia. In conclusion, most active TB patients had anaemia, which was probably due to inflammation and not to Fe deficiency since TB treatment without Fe supplementation was sufficient to restore Hb concentration.
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Drain PK, Kupka R, Mugusi F, Fawzi WW. Micronutrients in HIV-positive persons receiving highly active antiretroviral therapy. Am J Clin Nutr 2007; 85:333-45. [PMID: 17284727 DOI: 10.1093/ajcn/85.2.333] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
In HIV-infected persons, low serum concentrations of vitamins and minerals, termed micronutrients, are associated with an increased risk of HIV disease progression and mortality. Micronutrient supplements can delay HIV disease progression and reduce mortality in HIV-positive persons not receiving highly active antiretroviral therapy (HAART). With the transition to more universal access to HAART, a better understanding of micronutrient deficiencies and the role of micronutrient supplements in HIV-positive persons receiving HAART has become a priority. The provision of simple, inexpensive micronutrient supplements as an adjunct to HAART may have several cellular and clinical benefits, such as a reduction in mitochondrial toxicity and oxidative stress and an improvement in immune reconstitution. We reviewed observational and trial evidence on micronutrients in HIV-positive persons receiving HAART to summarize the current literature and suggest future research priorities. A small number of observational studies have suggested that some, but not all, micronutrients may become replete after HAART initiation, and few intervention studies have found that certain micronutrients may be a beneficial adjunct to HAART. However, most of these studies had some major limitations, including a small sample size, a short duration of follow-up, a lack of adjustment for inflammatory markers, and an inadequate assessment of HIV-related outcomes. Therefore, few data are available to determine whether HAART ameliorates micronutrient deficiencies or to recommend or refute the benefit of providing micronutrient supplements to HIV-positive persons receiving HAART. Because micronutrient supplementation may cause harm, randomized placebo-controlled trials are needed. Future research should determine whether HAART initiation restores micronutrient concentrations, independent of inflammatory markers, and whether micronutrient supplements affect HIV-related outcomes in HIV-positive persons receiving HAART.
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Affiliation(s)
- Paul K Drain
- University of Washington School of Medicine, Seattle, WA 98195, USA.
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Abstract
BACKGROUND Anemia is a common clinical disease in persons with HIV infection and is associated with poor prognosis. There is a need to assess the effects of anemia treatments, and to determine whether these interventions are beneficial. OBJECTIVES To determine the efficacy and safety of treatments for anemia in people with HIV infection and AIDS. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE (1980-July 2005), EMBASE (1980-July 2005), LlLACS (1982 to July 2005), reference lists of relevant articles and contact with authors. See Cochrane HIV/AIDS Group search strategy. SELECTION CRITERIA Randomized trials assessing the effects of treatments for anemia in people diagnosed with HIV infection. There were no age restrictions. DATA COLLECTION AND ANALYSIS Both authors independently assessed relevant studies for inclusion. Data extraction and quality assessment of relevant studies was performed by one author and checked by the other author. MAIN RESULTS We included four trials, but focused on the results based on three trials with acceptable attrition rate. None of the trials reported data on death. The two trials that compared recombinant human erythropoietin (rHuEPO) to placebo did not show any benefit on hematological values response, number of patients transfused, or number of packed red cell transfused. One trial compared the effects of two rHuEPO dosing regimens on hemoglobin value and quality of life, but the effects are unclear. AUTHORS' CONCLUSIONS There is a lack of reliable evidence on interventions for treating anemia in patients with HIV infection. This Cochrane review has found some evidence that rHuEPO reduces transfusion requirements, increases hemoglobin levels, and improves quality of life in HIV-infected patients with anemia. However, this is based on evidence from randomized trials with weak or poor methodological quality. There is a need for randomized trials of high methodological quality to evaluate the effect of interventions on anemia in persons infected with human immunodeficiency virus.
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Affiliation(s)
- A J Martí-Carvajal
- Departamento de Salud Pública, Universidad de Carabobo, Valencia, Edo. Carabobo, Venezuela, 2006.
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Iannotti LL, Tielsch JM, Black MM, Black RE. Iron supplementation in early childhood: health benefits and risks. Am J Clin Nutr 2006; 84:1261-76. [PMID: 17158406 PMCID: PMC3311916 DOI: 10.1093/ajcn/84.6.1261] [Citation(s) in RCA: 212] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The prevalence of iron deficiency among infants and young children living in developing countries is high. Because of its chemical properties--namely, its oxidative potential--iron functions in several biological systems that are crucial to human health. Iron, which is not easily eliminated from the body, can also cause harm through oxidative stress, interference with the absorption or metabolism of other nutrients, and suppression of critical enzymatic activities. We reviewed 26 randomized controlled trials of preventive, oral iron supplementation in young children (aged 0-59 mo) living in developing countries to ascertain the associated health benefits and risks. The outcomes investigated were anemia, development, growth, morbidity, and mortality. Initial hemoglobin concentrations and iron status were considered as effect modifiers, although few studies included such subgroup analyses. Among iron-deficient or anemic children, hemoglobin concentrations were improved with iron supplementation. Reductions in cognitive and motor development deficits were observed in iron-deficient or anemic children, particularly with longer-duration, lower-dose regimens. With iron supplementation, weight gains were adversely affected in iron-replete children; the effects on height were inconclusive. Most studies found no effect on morbidity, although few had sample sizes or study designs that were adequate for drawing conclusions. In a malaria-endemic population of Zanzibar, significant increases in serious adverse events were associated with iron supplementation, whereas, in Nepal, no effects on mortality in young children were found. More research is needed in populations affected by HIV and tuberculosis. Iron supplementation in preventive programs may need to be targeted through identification of iron-deficient children.
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Affiliation(s)
- Lora L Iannotti
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
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Kallianpur AR, Hulgan T, Canter JA, Ritchie MD, Haines JL, Robbins GK, Shafer RW, Clifford DB, Haas DW. Hemochromatosis (HFE) gene mutations and peripheral neuropathy during antiretroviral therapy. AIDS 2006; 20:1503-13. [PMID: 16847405 DOI: 10.1097/01.aids.0000237366.56864.3c] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Peripheral neuropathy (PN) often complicates nucleoside reverse transcriptase inhibitor (NRTI) therapy of HIV infection and may involve mitochondrial dysfunction. Since iron deficiency is associated with some types of PN, and iron is essential for mitochondrial function, we tested the hypothesis that hemochromatosis (HFE) gene mutations influence susceptibility to NRTI-induced PN. DESIGN Case-control study involving multicenter, AIDS Clinical Trials Group (ACTG) protocol 384 and ACTG Human DNA Repository specimens. METHODS Study participants were randomized to receive three- or four-drug antiretroviral therapy with didanosine (ddI) plus stavudine (d4T) or zidovudine plus lamivudine, given with efavirenz, nelfinavir, or both, with up to three years of follow-up. PN was ascertained based on signs and symptoms. HFE C282Y and H63D genotypes were determined, and associations with PN were assessed using logistic regression. RESULTS : Of 509 participants, 147 (29%) developed PN, 73% of whom had been randomized to receive ddI plus d4T. Among ddI/d4T-ever-treated individuals, HFE C282Y heterozygotes developed PN on ddI/d4T significantly less often than C282Y non-carriers, adjusting for age, CD4 lymphocyte count and viral load at baseline, and concomitant antiretroviral drugs [6% vs. 35%, respectively, in whites; adjusted odds ratio (OR), 0.17; 95% confidence interval (CI) 0.03-0.83; P = 0.021]. Regardless of race/ethnicity, ddI/d4T-associated PN was uncommon in C282Y heterozygotes [race-adjusted OR, 0.30; 95% CI 0.09-0.96); P = 0.042]. CONCLUSIONS Iron-loading HFE mutations such as C282Y are associated with a decreased risk of PN during antiretroviral therapy. This finding has potential implications for the prediction and prevention of NRTI-associated PN, particularly in populations at risk of iron deficiency.
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Affiliation(s)
- Asha R Kallianpur
- Department of Medicine, Divisions of General Internal Medicine & Public Health, Nashville, TN, USA.
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Miller MF, Stoltzfus RJ, Iliff PJ, Malaba LC, Mbuya NV, Humphrey JH. Effect of maternal and neonatal vitamin A supplementation and other postnatal factors on anemia in Zimbabwean infants: a prospective, randomized study. Am J Clin Nutr 2006; 84:212-22. [PMID: 16825698 DOI: 10.1093/ajcn/84.1.212] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Anemia is prevalent in infants in developing countries. Its etiology is multifactorial and includes vitamin A deficiency. OBJECTIVE Our primary aim was to measure the effect of maternal or neonatal vitamin A supplementation (or both) on hemoglobin and anemia in Zimbabwean infants. Our secondary aim was to identify the underlying causes of postnatal anemia. DESIGN A randomized, placebo-controlled trial was conducted in 14 110 mothers and their infants; 2854 infants were randomly selected for the anemia substudy, of whom 1592 were successfully observed for 8-14 mo and formed the study sample. Infants were randomly assigned within 96 h of delivery to 1 of 4 treatment groups: mothers and infants received vitamin A; mothers received vitamin A and infants received placebo; mothers received placebo and infants received vitamin A; and mothers and infants received placebo. The vitamin A doses were 400,000 and 50,000 IU in the mothers and infants, respectively. RESULTS Vitamin A supplementation had no effect on hemoglobin or anemia (hemoglobin <105 g/L) in unadjusted or adjusted analyses. Infant HIV infection independently increased anemia risk >6-fold. Additional predictors of anemia in HIV-negative and -positive infants were male sex and lower total body iron at birth. In addition, in HIV-positive infants, the risk of anemia increased with early infection, low maternal CD4+ lymphocyte count at recruitment, and frequent morbidity. Six-month plasma ferritin concentrations <12 microg/L were a risk factor in HIV-negative but not in HIV-positive infants. Maternal HIV infection alone did not cause anemia. CONCLUSION Prevention of infantile anemia should include efforts to increase the birth endowment of iron and prevent HIV infection.
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Affiliation(s)
- Melissa F Miller
- Cancer Prevention Fellowship Program, Division of Cancer Prevention, National Cancer Institute, Bethesda, MD, USA.
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25
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Miceli MH, Dong L, Grazziutti ML, Fassas A, Thertulien R, Van Rhee F, Barlogie B, Anaissie EJ. Iron overload is a major risk factor for severe infection after autologous stem cell transplantation: a study of 367 myeloma patients. Bone Marrow Transplant 2006; 37:857-64. [PMID: 16532017 DOI: 10.1038/sj.bmt.1705340] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We evaluated the risk factors for infection of 367 consecutive myeloma patients who underwent high-dose melphalan and autologous stem cell transplantation (ASCT). Examination of bone marrow iron stores (BMIS) prior to ASCT was used to evaluate body iron stores. Other variables included age, sex, active smoking, myeloma remission status, severity of mucositis and duration of severe neutropenia post-ASCT (<100 absolute neutrophils counts (ANC)/microl). Median age was 56 years; 61% of patients were males. 140 episodes of severe infections occurred in 116 patients, including bacteremia (73), pneumonia (40), severe colitis (25) and bacteremia with septic shock (two). The infection incidence per 1,000 days at risk was 45.2. Pre-ASCT risk factors for severe infection by univariate analysis were increased BMIS (OR=2.686; 95% CI 1.707-4.226; P<0.0001), smoking (OR=1.565; 95% CI 1.005-2.437; P=0.0474) and male gender (OR=1.624; 95% CI 1.019-2.589; P=0.0414). Increased BMIS (OR=2.716; 95% CI 1.720-4.287; P<0.0001) and smoking (OR=1.714; 95% CI 1.081-2.718; P=0.022) remained significant by multivariate analysis. Duration of ANC <100 micro/l (OR=1.129; 95% CI 1.039-1.226; P=0.0069 and OR=1.127; 95% CI 1.038-1.224; P=0.0045 by both univariate and multivariate analysis, respectively) was the only post-ASCT risk factor for infection. Increased pre-transplant BMIS and smoking are significant predictors of severe infection after myeloablative chemotherapy followed by ASCT in myeloma patients.
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Affiliation(s)
- M H Miceli
- Myeloma Institute for Research and Therapy, The University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA
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Fawzi W, Msamanga G, Spiegelman D, Hunter DJ. Studies of vitamins and minerals and HIV transmission and disease progression. J Nutr 2005; 135:938-44. [PMID: 15795466 DOI: 10.1093/jn/135.4.938] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
HIV-1 infection is having a devastating impact on people in developing countries. Poor nutrition and HIV-related adverse health outcomes contribute to a vicious cycle that may be slowed down by using nutritional interventions, including vitamins and minerals. Among children, periodic supplementation with vitamin A starting at 6 mo of age has been shown to be beneficial in reducing mortality and morbidity among both HIV-infected and uninfected children. Limited data exist on the role of other nutrient supplements among children. Among HIV-infected adults, the safety and the efficacy of vitamin A supplements need further study, although adequate dietary intake of this essential nutrient is recommended. Multivitamin supplements were efficacious in reducing adverse pregnancy outcomes and early childhood infections, and is currently provided to pregnant HIV-infected pregnant women in many programs. The efficacy of such supplements among HIV-negative pregnant women needs further study. Daily multivitamin supplements were found to reduce HIV disease progression among men and women in several observational studies and randomized trials, and to provide an important low-cost intervention that could be provided to adults in early stages of HIV disease to prolong the time before antiretroviral therapy is recommended. Next, research priorities include examining the roles of minerals, including selenium, in HIV infection, as well as determining the safety and the efficacy of micronutrient supplements among individuals who are advanced in their disease and who are receiving antiretroviral therapy.
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Affiliation(s)
- Wafaie Fawzi
- Department of Nutrition, Harvard School of Public Health, Boston, MA, USA.
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Abstract
The emergence of new infectious diseases and old diseases with new pathogenic properties is a burgeoning worldwide problem. Severe acute respiratory syndrome (SARS) and acquired immune deficiency syndrome (AIDS) are just two of the most widely reported recent emerging infectious diseases. What are the factors that contribute to the rapid evolution of viral species? Various hypotheses have been proposed, all involving opportunities for virus spread (for example, agricultural practices, climate changes, rainforest clearing or air travel). However, the nutritional status of the host, until recently, has not been considered a contributing factor to the emergence of infectious disease. In this review, we show that host nutritional status can influence not only the host response to the pathogen, but can also influence the genetic make-up of the viral genome. This latter finding markedly changes our concept of host–pathogen interactions and creates a new paradigm for the study of such phenomena.
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Affiliation(s)
- Melinda A Beck
- Department of Pediatrics and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, NC 27599, USA.
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28
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Abstract
The need to consider using dapsone in pregnant women for its antimalarial activity is becoming greater in areas where Plasmodium falciparum resistance to chloroquine and pyrimethamine-sulfadoxine is rapidly increasing. Dapsone in combination with other antimalarials might provide a valuable alternative for both treatment and prophylaxis. This review assesses the clinical pharmacology of dapsone and its adverse drug reactions in relation to haemolysis, glucose-6-phosphate dehydrogenase (G6PD) deficiency, blood dyscrasias and methaemoglobinaemia. Studies are summarised reporting its use in leprosy, dermatological and other conditions, and malaria, in relation to maternal and infant outcomes. A total of 924 pregnancies were identified during which dapsone therapy was taken. Only limited data are available and this precludes a meaningful quantitative benefit-risk analysis. Mild degrees of haemolysis consistently occur with continued therapy, although adverse effects may be less likely with intermittent treatment, as most reported adverse effects have occurred with long-term use of dapsone. There are a number of gaps in knowledge where more data are needed. These include no data on pharmacokinetics in pregnancy and whether these are altered with co-administration of chlorproguanil. Potential complications in women with severe anaemia are unknown and there is no information on haemolytic effects in women or the fetus with G6PD deficiency. The use of dapsone in HIV-infected women in malarious areas could carry increased risks because of the immunosuppressive actions of the drug. Trials of dapsone therapy in pregnancy should be considered in malarious areas where there is good reason for its deployment. Controlled trials have provided data on maternal tolerance, and dapsone in combination with other antimalarial drugs can offer clear benefit in terms of improved birthweight. The use of dapsone combinations should be considered when no good alternative is available and the threat of malaria is the greater risk.
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Affiliation(s)
- Bernard J Brabin
- Liverpool School of Tropical Medicine, Child and Reproductive Health Group, UK.
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Clark TD, Mmiro F, Ndugwa C, Perry RT, Jackson JB, Melikian G, Semba RD. Risk factors and cumulative incidence of anaemia among human immunodeficiency virus-infected children in Uganda. ANNALS OF TROPICAL PAEDIATRICS 2002; 22:11-7. [PMID: 11926044 DOI: 10.1179/027249302125000102] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Anaemia has not been well characterised among HIV-infected children in sub-Saharan Africa. Baseline prevalence and cumulative incidence of anaemia (haemoglobin < 110 g/L) were 91.7% and 100% and, for moderate anaemia (haemoglobin < 90 g/L), were 35.1% and 58.4%, respectively, among 225 HIV-infected children followed from 9 to 36 months of age. Hospitalisation, suspected tuberculosis, malaria and height-for-age Z-score <-2 were significantly associated with moderate anaemia. Moderate anaemia and weight-for-height Z-score <-2 were associated with mortality. Anaemia is common and associated with increased mortality in HIV-infected children.
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Affiliation(s)
- T D Clark
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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30
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Totin D, Ndugwa C, Mmiro F, Perry RT, Jackson JB, Semba RD. Iron deficiency anemia is highly prevalent among human immunodeficiency virus-infected and uninfected infants in Uganda. J Nutr 2002; 132:423-9. [PMID: 11880566 DOI: 10.1093/jn/132.3.423] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Although anemia is a common finding among human immunodeficiency (HIV)-infected infants in sub-Saharan Africa, the factors contributing to the pathogenesis of anemia have not been well characterized. We sought to characterize the relative contribution of iron deficiency and chronic disease to the anemia among infants. Hemoglobin, ferritin, erythropoietin, tumor necrosis factor-alpha (TNF-alpha), neopterin, CD4(+) lymphocyte count and plasma HIV load were measured in 165 HIV-infected and 39 uninfected 9-mo-old infants seen in an outpatient pediatric clinic in Kampala, Uganda. Among HIV-infected and uninfected infants, the prevalence of anemia (hemoglobin < 110 g/L) was 90.9 and 76.9%, respectively (P = 0.015), and the prevalence of iron deficiency anemia (hemoglobin < 110 g/L and ferritin < 12 microg/L) was 44.3 and 45.4%, respectively (P = 0.92). The relatively higher prevalence of anemia among HIV-infected infants was attributed to the anemia of chronic disease. Among infants with and without iron deficiency, the fitted regression line was log(10) plasma erythropoietin = 2.86 - 0.016.hemoglobin, and log(10) plasma erythropoietin = 4.11 - 0.028.hemoglobin, respectively, with a difference in the slope of the regression lines between log(10) erythropoietin and hemoglobin among infants with and without iron deficiency (P = 0.049). Infants in Uganda have an extremely high prevalence of anemia, and nearly half of the anemia is due to iron deficiency. The erythropoietin response to anemia appears to be upregulated among infants with iron deficiency.
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Affiliation(s)
- Dana Totin
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Semba RD, Shah N, Strathdee SA, Vlahov D. High prevalence of iron deficiency and anemia among female injection drug users with and without HIV infection. J Acquir Immune Defic Syndr 2002; 29:142-4. [PMID: 11832682 DOI: 10.1097/00042560-200202010-00005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Anemia is associated with increased progression of disease and higher mortality during HIV infection. OBJECTIVE To determine the prevalence of iron deficiency and iron deficiency anemia among female injection drug users (IDUs) with and without HIV infection. METHODS Hemoglobin and plasma ferritin were measured in a cross-sectional study of a cohort of female IDUs followed in Baltimore, Maryland. RESULTS Among 136 HIV-positive and 61 HIV-negative women, the prevalence of anemia was 44.1% and 26.2% ( p <.02), the prevalence of iron deficiency was 37.5% and 42.6% ( p =.49), and the prevalence of iron deficiency anemia was 20.6% and 14.7% ( p =.33), respectively. The overall prevalence of hepatitis C infection was 90.5%. Iron deficiency anemia accounted for 46.7% and 56.1% of the anemia among HIV-positive and HIV-negative female IDUs. CONCLUSIONS Iron deficiency accounts for about half of the anemia among female IDUS. Although iron supplementation is indicated for anemia patients, such treatment should be approached with caution in women coinfected with HIV and hepatitis C virus, because iron supplementation and overload have been associated with increased progression of HIV infection, worsening of hepatitis C virus infection, and higher mortality.
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Affiliation(s)
- Richard D Semba
- Department of Ophthalmology, School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.
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