1
|
van Eekeren LE, Vadaq N, Vos WAJW, Blaauw MJT, Groenendijk AL, van Lunzen J, Stalenhoef JE, Berrevoets MAH, Verbon A, Weijers G, Netea MG, van der Ven AJAM, de Mast Q, Joosten LAB, Tjwa ETTL. Liver Steatosis is Prevalent in Lean People With HIV and Associated With Exposure to Antiretroviral Treatment-A Cross-sectional Study. Open Forum Infect Dis 2024; 11:ofae266. [PMID: 38868310 PMCID: PMC11167668 DOI: 10.1093/ofid/ofae266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 05/06/2024] [Indexed: 06/14/2024] Open
Abstract
Background Steatotic liver disease is suggested to have a higher prevalence and severity in people with HIV (PHIV), including in those with a normal body mass index (BMI). In this study, we used data from the 2000HIV cohort to (1) assess the prevalence of liver steatosis and fibrosis in lean versus overweight/obese PHIV and (2) assess associations in these subgroups between steatosis and fibrosis with traditional risk factors and HIV-specific characteristics. Methods The 2000HIV study cohort comprises 1895 virally suppressed PHIV that were included between 2019 and 2021 in 4 HIV treatment centers in the Netherlands. The majority (58.5%) underwent vibration-controlled transient elastography for the assessment of liver steatosis and fibrosis. The prevalence of steatosis (controlled attenuation parameter ≥263 dB/m) and fibrosis (liver stiffness measurement ≥7.0 kPa) was estimated. Multiple factors including HIV characteristics and antiretroviral drugs were tested in a logistic regression model for association with steatosis and fibrosis. Analyses were performed separately for lean (Asian descent: BMI < 23 kg/m2, other descent: BMI < 25 kg/m2) and overweight/obese (other BMI) participants. Results Of 1050 PHIV including 505 lean and 545 overweight/obese PHIV, liver steatosis was observed in 37.7% of the overall study population, 19.7% of lean, and 54% of overweight/obese PHIV, whereas fibrosis was observed in 9.0% of the overall study population, 5.9% of lean, and 12.0% of overweight/obese PHIV.All associations with fibrosis and most associations with steatosis concerned metabolic factors such as type 2 diabetes mellitus (overall population: adjusted odds ratio [aOR] for steatosis: 2.3 [1.21-4.4], P = .011; aOR for fibrosis: 3.7 [1.82-7.53], P < .001). Furthermore, in lean PLHIV, liver steatosis was associated with CD4 and CD8 counts at enrollment, dual therapy, and history of treatment with raltegravir (aOR: 3.6 [1.53-8.47], P = .003), stavudine (aOR: 3.73 [1.69-8.2], P = .001), and indinavir (aOR: 3.86 [1.59-9.37], P = .003). These associations were not observed in overweight/obese PHIV. Conclusions Liver steatosis was highly prevalent, affecting approximately one-fifth of lean PHIV and half of overweight/obese PHIV. Fibrosis was observed in a minority. Both steatosis and fibrosis were associated with traditional metabolic risk factors. In addition, (prior) exposure to specific antiretroviral drugs was associated liver steatosis in lean, but not in overweight/obese PHIV. Implementing increased screening protocols could enhance the identification of steatotic liver disease in lean PHIV.
Collapse
Affiliation(s)
- Louise E van Eekeren
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nadira Vadaq
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Marc J T Blaauw
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Internal Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Albert L Groenendijk
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, The Netherlands
| | - Jan van Lunzen
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Marvin A H Berrevoets
- Department of Internal Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Annelies Verbon
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, The Netherlands
| | - Gert Weijers
- Medical UltraSound Imaging Center (MUSIC), Division of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Metabolism and Immunology, Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - André J A M van der Ven
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Quirijn de Mast
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leo A B Joosten
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Medical Genetics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Eric T T L Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
2
|
Gutiérrez-Pérez ME, Urraza-Robledo AI, Miranda-Pérez AA, Molina-Flores CA, Ruíz-Flores P, Delgadillo-Guzmán D, López-Márquez FC. Role of β-Klotho and Malondialdehyde in Metabolic Disorders, HIV Infection, and Antiretroviral Therapy. DNA Cell Biol 2022; 41:691-698. [PMID: 35793534 DOI: 10.1089/dna.2021.1052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Metabolic alterations, resulting from factors such as obesity or infections (HIV), generate inflammation in the body, affecting the immune system and causing oxidative stress. Prolonged exposure to antiretroviral therapy (ART) conditions the appearance of alterations considered risk factors for metabolic syndrome (MetS), affecting the quality of life in people living with HIV/AIDS (PLWHA). β-klotho is a protein that can counteract levels of oxidative stress. The aim was to determine the relation of β-klotho and oxidative stress with metabolic alterations in PLWHA. We hypothesized that levels of β-klotho and malondialdehyde (MDA) are related in PLWHA on ART with overweight/obesity. As a result of comparing cases versus controls, significant differences were obtained in levels of β-klotho (p = 0.011), MDA (p < 0.0001), body mass index (p = 0.001), and weight (p < 0.0001). The presence of MetS in PLWHA was 21.2% and 10.6% according to the World Health Organization and ATP III (National Cholesterol Education Program Adult Treatment Panel III) criteria, respectively. The founded correlations were of β-klotho (r = 0.019) and MDA (r = 0.0001), both with CD4+ cells in PLWHA. In controls, β-klotho was correlated with very low-density lipoprotein (r = 0.035) and atherogenic index (AI; r = 0.037), MDA with AI (r = 0.039), cholesterol, and low-density lipoprotein (r = 0.002). The increase of inflammation in the organism, owing to HIV infection and/or the presence of obesity, conditions metabolic disruption or depletion of elements needed for homeostasis in the human body.
Collapse
Affiliation(s)
- Maria Elena Gutiérrez-Pérez
- Department of Molecular Immunobiology, Faculty of Medicine, Biomedical Research Center, Autonomous University of Coahuila, Torreon, Mexico
| | - Arguiñe Ivonne Urraza-Robledo
- Department of Molecular Immunobiology, Faculty of Medicine, Biomedical Research Center, Autonomous University of Coahuila, Torreon, Mexico.,High Specialty Medical Unit (UMAE), Mexican Social Security Institute (IMSS), Department of Diagnostic Aids Division, Torreon, Mexico
| | - Alberto Alejandro Miranda-Pérez
- Department of Molecular Immunobiology, Faculty of Medicine, Biomedical Research Center, Autonomous University of Coahuila, Torreon, Mexico
| | - Cinthia Analí Molina-Flores
- Department of Molecular Immunobiology, Faculty of Medicine, Biomedical Research Center, Autonomous University of Coahuila, Torreon, Mexico
| | - Pablo Ruíz-Flores
- Department of Molecular Medicine and Genetics, and Faculty of Medicine, Biomedical Research Center, Autonomous University of Coahuila, Torreon, Mexico
| | - Dealmy Delgadillo-Guzmán
- Department of Pharmacology, Faculty of Medicine, Biomedical Research Center, Autonomous University of Coahuila, Torreon, Mexico
| | - Francisco Carlos López-Márquez
- Department of Molecular Immunobiology, Faculty of Medicine, Biomedical Research Center, Autonomous University of Coahuila, Torreon, Mexico
| |
Collapse
|
3
|
Mendicin CCP, Moreira Costa AA, da Silva GJ, Braga LP, Rocha GM, Carmo RA, Guimarães MDC, de Pádua CAM. Metabolic comorbidities and systemic arterial hypertension: the challenge faced by HIV patientson long-term use of antiretroviral therapy. Hosp Pract (1995) 2022; 50:75-81. [PMID: 35040377 DOI: 10.1080/21548331.2022.2030564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Our objective was to estimate the frequency of comorbidities and assess its relationship with exposure factors after a long-term of ART use. METHODS : A cross-sectional study with PLHIV (≥18 years-old), who initiated ART between 2001-2005 and attended an HIV/AIDS public-referral center (Belo Horizonte/Brazil) was performed. Demographic, clinical, therapeutic and lifestyle data were obtained through interviews, medical charts, public database, routine laboratory exams and bone densitometry. The outcome was the number of comorbidities: hyperglycemia, dyslipidemia, systemic arterial-hypertension (SAH) and low bone mineral density (BMD). Absolute/relative frequencies were calculated. Factors associated with the outcome were assessed by quasi-Poisson regression. RESULTS: Of the 98 participants, 53% were male, 79% over 43 years-old. Moderate physical-activity was observed in 82%, overweight/obesity in 50% and 58% used ART based on two nucleoside reverse transcriptase inhibitors (NRTI) plus one non-nucleoside reverse transcriptase inhibitor (NNRTI). After a mean of 15.6 years of ART exposure, 207 comorbidities were identified and 93% participants presented at least one comorbidity (mean=2.1/participant). The most frequent overlapping was composed by two co-occurrences: dyslipidemia+hyperglycemia or dyslipidemia+SAH, n=36 in each co-occurrence. The quasi-Poisson regression showed an increase of 3% in the number of comorbidities per year of age (OR=1.03;95%CI=1.02-1.04) and 84% among PLHIV on moderate physical-activity (ref=heavy physical-activity) (OR=1.84;95%CI=1.08-3.13). CONCLUSIONS Our study shows that the aging slightly contributed to comorbidities. However, the practice of physical-activities is crucial to prevent chronic-diseases. Treatment and preventive measures should be encouraged to diminish the burden of disease and improve quality of life among PLHIV.
Collapse
Affiliation(s)
- Cássia Cristina Pinto Mendicin
- Department of Social Pharmacy, Faculty of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte city, Minas Gerais state, Brazil
| | | | - Gabriella Jomara da Silva
- Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte city, Minas Gerais state, Brazil
| | | | - Gustavo Machado Rocha
- Federal University of São João del-Rei (UFSJ), Divinópolis city, Minas Gerais state, Brazil
| | - Ricardo Andrade Carmo
- Infectious Diseases Reference Center, CTR/DIP Orestes Diniz, Municipal Health Division/ Federal University of Minas Gerais (UFMG), Belo Horizonte city, Minas Gerais state, Brazil
| | - Mark Drew Crosland Guimarães
- Department of Preventive and Social Medicine, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte city, Minas Gerais state, Brazil
| | - Cristiane A Menezes de Pádua
- Department of Social Pharmacy, Faculty of Pharmacy, Federal University of Minas Gerais (UFMG), Belo Horizonte city, Minas Gerais state, Brazil
| |
Collapse
|
4
|
Urraza-Robledo AI, Giralt M, González-Galarza FF, Villarroya F, Miranda Pérez AA, Ruiz Flores P, Gutiérrez Pérez ME, Domingo P, López-Márquez FC. FGF21 serum levels are related to insulin resistance, metabolic changes and obesity in Mexican people living with HIV (PLWH). PLoS One 2021; 16:e0252144. [PMID: 34019585 PMCID: PMC8139451 DOI: 10.1371/journal.pone.0252144] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 05/11/2021] [Indexed: 11/29/2022] Open
Abstract
Background Antiretroviral therapy has significantly improved prognosis in treatment against HIV infection, however, prolonged exposure is associated to cardiovascular diseases, lipodystrophy, type 2 diabetes, insulin resistance, metabolic alteration, as obesity which includes the accumulation of oxidative stress in adipose tissue. FGF21 is a peptide hormone that is known to regulate glucose and lipid metabolism. FGF21 is expressed and secreted primarily in the liver and adipose tissue, promoting oxidation of glucose/fatty acids and insulin sensitivity. Alterations in FGF21 may be associated with the development of insulin resistance, metabolic syndrome and cardiovascular disease. We hypothesized that FGF21 protein levels are associated with metabolic abnormalities, placing special attention to the alterations in relation to the concurrence of overweight/obesity in people living with HIV (PLWH). Design Serum FGF21 was analyzed in 241 subjects, 160 PLWH and 81 unrelated HIV-uninfected subjects as a control group. Clinical records were consulted to obtain CD4+ cell counting and number of viral RNA copies. Serum FGF21 levels were tested for correlation with anthropometric and metabolic parameters; glucose, cholesterol, HDL, LDL, VLDL, triglycerides, insulin and indexes of atherogenesis and insulin resistance (HOMA). Results The participants were classified into four groups: (i) PLWH with normal weight, (ii) PLWH with overweight/obesity, (iii) HIV-uninfected with normal weight, and (iv) HIV-uninfected with overweight/obesity. Insulin levels were higher in normal-weight PLWH than in the HIV-uninfected group but not statistically significant, however, for the overweight/obesity PLWH group, insulin levels were significantly higher in comparison with the other three groups (p<0.0001). For FGF21, serum levels were slightly higher in the overweight/obesity groups in both patients and controls. In HIV-infected subjects, FGF21 levels showed a strong positive correlation with triglycerides, insulin levels and insulin resistance with a p-value <0.0001. In the seronegative group, FGF21 was only correlated with weight and waist circumference, showing an important association of FGF21 levels with the degree of obesity of the individuals. Conclusion Insulin resistance and FGF21 elevations were observed in overweight-obese PLWH. FGF21 elevation could be viewed as a compensation mechanism as, in the control group, FGF21 correlations appeared to be confined to weight and waist circumference. This can be explained based on the action of FGF21 promoting the uptake of glucose in adipose tissue. In PLWH, FGF21 was low, possibly as a result of a change in adiposity leading to a metabolic disruption.
Collapse
Affiliation(s)
- Arguiñe Ivonne Urraza-Robledo
- Center for Biomedical Research, Medicine School Autonomous University of Coahuila (IMSS), Torreón, Mexico
- High Specialty Medical Unit (UMAE) # 71, Mexican Social Security Institute, Ciudad de México, Mexico
| | - Marta Giralt
- Departament de Bioquímica i Biomedicina Molecular and Institut de Biomedicina (IBUB), CIBER Fisiopatología de la Obesidad y Nutrición, Universitat de Barcelona, Barcelona, Spain
| | | | - Francesc Villarroya
- Departament de Bioquímica i Biomedicina Molecular and Institut de Biomedicina (IBUB), CIBER Fisiopatología de la Obesidad y Nutrición, Universitat de Barcelona, Barcelona, Spain
| | | | - Pablo Ruiz Flores
- Center for Biomedical Research, Faculty of Medicine, Autonomous University of Coahuila, Torreón, Mexico
| | | | - Peré Domingo
- Department of Infectious Diseases, Hospital de la Santa Creu i Sant Pau, Institut de Recerca del Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | |
Collapse
|
5
|
Prevalence of dyslipidaemia among HIV-infected patients receiving combination antiretroviral therapy in North Shewa, Ethiopia. PLoS One 2021; 16:e0250328. [PMID: 33905435 PMCID: PMC8078799 DOI: 10.1371/journal.pone.0250328] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 04/05/2021] [Indexed: 11/19/2022] Open
Abstract
Background Data on the burden of dyslipidaemia among people with HIV undergoing antiretroviral therapy (ART) in sub-Saharan Africa are limited and little is known about the factors contributing for poor lipid profiles. The aim of this study was to determine the prevalence of dyslipidaemia and factors associated with lipid levels among HIV-infected patients receiving first-line combination ART in North Shewa, Ethiopia. Methods A cross-sectional study was conducted between April and December 2018 among 392 HIV-infected adults receiving first-line ART for at least six months at the ART clinic of Mehal Meda Hospital in North Shewa, Ethiopia. Blood samples were collected for determination of total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), and CD4 counts. Logistic regression analysis was used to determine factors associated with lipid abnormalities. Results The prevalence of dyslipidaemia was 59.9% (95% CI 55.0–64.7%). High TC, high TG, low HDL-c, and high LDL-c were obtained in 47.3%, 30.9%, 19.4% and 29.6%, respectively. Fifty-four participants (13.8%) had high ratio of TC/HDL-c (TC/HDL-c ratio ≥ 5). Older age was independently associated with high TC (AOR = 2.51, 95% CI 1.64–3.84), high TG (AOR = 2.95, 95% CI 1.85–4.71), low HDL–c (AOR = 2.02, 95% CI 1.17–3.50), and high LDL–c (AOR = 3.37, 95% CI 2.08–5.47). Living in an urban area (AOR = 2.61, 95% CI 1.16–6.14) and smoking (AOR = 3.61, 95% CI 1.06–12.34) were associated with low HDL–c. Participants with longer duration of ART use were more likely to have high TG (AOR = 1.86, 95% CI: 1.13–3.07), low HDL–c (AOR = 3.47, 95% CI: 1.75–6.80), and high LDL–c (AOR = 2.20, 95% CI 1.30–3.71). High BMI was independently associated with higher TC (AOR = 2.43, 95% CI 1.19–4.97), high TG (AOR = 4.17, 95% CI 2.01–8.67) and high LDL–c (AOR = 6.53, 95% CI 3.05–13.98). Conclusions We found a high prevalence of dyslipidaemia among HIV-infected patients receiving first-line ART in North Shewa, Ethiopia. There is a need for monitoring of blood lipid levels in patients with HIV on long term first-line ART with a special attention to be focused on older age, urban residents, longer duration of ART use, high BMI and smokers.
Collapse
|
6
|
Boettiger DC, Kerr S, Chattranukulchai P, Siwamogsatham S, Avihingsanon A. Maintenance of statin therapy among people living with HIV. AIDS 2021; 35:567-574. [PMID: 33252492 DOI: 10.1097/qad.0000000000002769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Statins play a critical role in reducing the elevated risk of atherosclerotic cardiovascular disease (ASCVD) among people living with HIV (PLHIV). However, maintaining statin therapy is difficult and may be impeded further in PLHIV due to the risk of antiretroviral therapy (ART)/statin interactions. We estimated rates of statin discontinuation and reinitiation, and the percentage of days covered by statin use among PLHIV on ART, and investigated factors associated with these outcomes. DESIGN Observational cohort study. METHODS Clinical data from individuals attending the HIV-NAT Centre in Bangkok, Thailand between 2001 and 2020 were analyzed using Kaplan-Meier curves, competing-risk regression, and generalized estimating equations. Discontinuation was defined as statin cessation lasting 90 days. RESULTS Data on 318 PLHIV were included. After 1, 3, and 5 years, 22.3, 50.8, and 61.1% had discontinued statin use, respectively. Among those who discontinued (n = 178), 52.0% reinitiated statin use within 5 years. Factors associated with statin discontinuation were low education level, fewer concomitant medications, and lack of ASCVD. Factors associated with statin reinitiation were older age, diabetes, and high levels of LDL cholesterol. The adjusted mean percentage of days covered by a statin was 86.7, 61.1, and 58.1% in the 6 months prior to 1, 3, and 5 years of follow-up, respectively. CONCLUSION Maintenance of statin therapy is poor among PLHIV on ART but is not associated with using contraindicated antiretroviral/statin combinations. A better understanding of statin use in PLHIV will aid clinicians treating individuals and policy makers designing interventions for population-level ASCVD risk reduction.
Collapse
Affiliation(s)
- David C Boettiger
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Institute for Health and Aging, University of California, San Francisco, San Francisco, California, USA
- Faculty of Medicine, Biostatistics Excellence Centre, Chulalongkorn University, King Chulalongkorn Memorial Hospital
| | - Stephen Kerr
- Faculty of Medicine, Biostatistics Excellence Centre, Chulalongkorn University, King Chulalongkorn Memorial Hospital
- HIV-NAT Research Collaboration/Thai Red Cross AIDS Research Centre
| | | | | | - Anchalee Avihingsanon
- HIV-NAT Research Collaboration/Thai Red Cross AIDS Research Centre
- Tuberculosis Research Unit, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| |
Collapse
|
7
|
The 2-hydroxy-nevirapine metabolite as a candidate for boosting apolipoprotein A1 and for modulating anti-HDL antibodies. Pharmacol Res 2021; 165:105446. [PMID: 33515705 DOI: 10.1016/j.phrs.2021.105446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/09/2021] [Accepted: 01/12/2021] [Indexed: 11/24/2022]
Abstract
The antiretroviral nevirapine (NVP) is associated to a reduction of atherosclerotic lesions and increases in high-density lipoprotein (HDL)-cholesterol. Despite being a hepatotoxic drug, which forbids its re-purposing to other therapeutic areas, not all NVP metabolites have the same potential to induce toxicity. Our aim was to investigate the effects of NVP and its metabolites in an exploratory study, towards the identification of a candidate to boost HDL. A pilot prospective (n = 11) and a cross-sectional (n = 332) clinical study were performed with the following endpoints: HDL-cholesterol and apolipoprotein A1 (ApoA1) levels, anti-HDL and anti-ApoA1 antibodies titers, paraoxonase, arylesterase and lactonase activities of paraoxonase-1, and NVP's metabolite profile. NVP treatment increased HDL-cholesterol, ApoA1 and paraoxonase-1 activities, and lowered anti-HDL and anti-ApoA1 titers. In the prospective study, the temporal modulation induced by NVP was different for each HDL-related endpoint. The first observation was a decrease in the anti-HDL antibodies titers. In the cross-sectional study, the lower titers of anti-HDL antibodies were associated to the proportion of 2-hydroxy-NVP (p = 0.03). In vitro models of hepatocytes were employed to clarify the individual contribution of NVP's metabolites for ApoA1 modulation. Long-term incubations of NVP and 2-hydroxy-NVP in the metabolically competent 3D model caused an increase in ApoA1 reaching 43 % (p < 0.05) and 86 % (p < 0.001), respectively. These results support the contribution of drug biotransformation for NVP-induced HDL modulation, highlighting the role of 2-hydroxy-NVP as ApoA1 booster and its association to lower anti-HDL titers. This biotransformation-guided approach allowed us to identify a non-toxic NVP metabolite as a candidate for targeting HDL.
Collapse
|
8
|
Fidel PL, Moyes D, Samaranayake L, Hagensee ME. Interplay between oral immunity in HIV and the microbiome. Oral Dis 2020; 26 Suppl 1:59-68. [PMID: 32862522 DOI: 10.1111/odi.13515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This Basic Science Workshop addressed the oral microbiome. At the 7th World Workshop on Oral Health & Disease in HIV/AIDS in India in 2014, some aspects of the human microbiome were discussed, and research questions formulated. Since that time, there have been major advances in technology, which have stimulated a number of publications on many aspects of the human microbiome, including the oral cavity. This workshop aimed to summarize current understanding of the "normal" microbiome of the oral cavity compared to that during HIV infection, and how oral immune factors and other clinical variables alter or control the oral microbiome. An important question is whether successful treatment with anti-retroviral therapy, which leads to a significant drop in viral loads and immune reconstitution, is associated with any change or recovery of the oral microbiome. Additionally, the workshop addressed the issue of which parameters are most appropriate/correct to evaluate the oral microbiome and how clinically relevant are shifts/changes in the oral microbiome. The workshop evaluated current knowledge in five research areas related to five basic questions and identified further topics where further research is required.
Collapse
Affiliation(s)
- Paul L Fidel
- LSU Health School of Dentistry, New Orleans, LA, USA
| | - David Moyes
- Centre for Host-Microbiome Interactions, Faculty of Dentistry, Oral and Craniofacial Sciences, King's College London, London, UK
| | | | | |
Collapse
|
9
|
Meena DS, Rai M, Singh SK, Tapadar J, Kumar D. Metabolic changes in the patients on second-line highly active antiretroviral therapy (HAART): A prospective cohort study from north India. J Family Med Prim Care 2020; 9:1550-1554. [PMID: 32509648 PMCID: PMC7266244 DOI: 10.4103/jfmpc.jfmpc_1208_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 11/21/2022] Open
Abstract
Introduction: In India, there is a genetic predisposition to insulin resistance and cardiovascular risk, the impact of ART (antiretroviral therapy) on lipid profile and blood sugar may be significant. The study of potential implications of highly active antiretroviral therapy (HAART)-associated metabolic syndrome is critical to prevent cardiovascular diseases in the Indian population. Aims: This study was done to determine the prevalence of metabolic changes (dyslipidaemia, hyperglycemia and insulin resistance) among HIV patients on second-line ART. Settings and Design: A prospective cohort study. Methods and Materials: We enrolled 150 patients, who were started on second-line HAART. Patients were investigated for fasting blood sugar, lipid profile and insulin level at baseline and after 6 months. Statistical Analysis: The data were analysed using SPSS software (version 20; IBM Corp., Armonk, N.Y., USA). Student's t-test was used to compare numerical variables in the two groups. P value < 0.05 was considered as statistically significant. Results: There was a significant increase in serum cholesterol, LDL and triglyceride in patients with protease inhibitors (PIs) containing regimens. LDL levels were increased from 65 to 80 mg/dL (P = <.003) after treatment. Triglycerides were increased from 138 to 152 mg/dL. (P = <0.001). Median fasting blood sugar was increased from 85 to 96 mg/dL (P = <0.002). HOMA-IR was also significantly increased in the PI group (1.54 vs. 2.1, P <.003). However, serum HDL did not change significantly. Conclusions: Appropriate drug selection with timely switching of ART is crucial to prevent metabolic complications in patients taking long-term PIs.
Collapse
Affiliation(s)
- Durga S Meena
- Department of Medicine, All India Institute of Medical Sciences, Jodhpur, Rajsthan, India
| | - Madhukar Rai
- Department of Medicine, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
| | - Surya K Singh
- Department of Endocrinology, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
| | - Jaya Tapadar
- Department of Medicine, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
| | - Deepak Kumar
- Department of Medicine, All India Institute of Medical Sciences, Jodhpur, Rajsthan, India
| |
Collapse
|
10
|
Back D, Marzolini C. The challenge of HIV treatment in an era of polypharmacy. J Int AIDS Soc 2020; 23:e25449. [PMID: 32011104 PMCID: PMC6996317 DOI: 10.1002/jia2.25449] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/26/2019] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The availability of potent antiretroviral therapy has transformed HIV infection into a chronic disease such that people living with HIV (PLWH) have a near normal life expectancy. However, there are continuing challenges in managing HIV infection, particularly in older patients, who often experience age-related comorbidities resulting in complex polypharmacy and an increased risk for drug-drug interactions. Furthermore, age-related physiological changes may affect the pharmacokinetics and pharmacodynamics of both antiretrovirals and comedications thereby predisposing elderly to adverse drug reactions. This review provides an overview of the therapeutic challenges when treating elderly PLWH (i.e. >65 years). Particular emphasis is placed on drug-drug interactions and other common prescribing issues (i.e. inappropriate drug use, prescribing cascade, drug-disease interaction) encountered in elderly PLWH. DISCUSSION Prescribing issues are common in elderly PLWH due to the presence of age-related comorbidities, organ dysfunction and physiological changes leading to a higher risk for drug-drug interactions, drugs dosage errors and inappropriate drug use. CONCLUSIONS The high prevalence of prescribing issues in elderly PLWH highlights the need for ongoing education on prescribing principles and the optimal management of individual patients. The knowledge of adverse health outcomes associated with polypharmacy and inappropriate prescribing should ensure that there are interventions to prevent harm including medication reconciliation, medication review and medication prioritization according to the risks/benefits for each patient.
Collapse
Affiliation(s)
- David Back
- Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Catia Marzolini
- Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
- Division of Infectious Diseases and Hospital EpidemiologyDepartments of Medicine and Clinical ResearchUniversity Hospital of Basel and University of BaselBaselSwitzerland
| |
Collapse
|
11
|
Mena A, Clavero E, Díaz-Díaz JL, Castro A. Similar plasma lipidomic profile in people living with HIV treated with a darunavir-based or an integrase inhibitor-based antiretroviral therapy. Sci Rep 2019; 9:17184. [PMID: 31748628 PMCID: PMC6868233 DOI: 10.1038/s41598-019-53761-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 11/05/2019] [Indexed: 01/12/2023] Open
Abstract
Cardiovascular disease is an important cause of morbidity and mortality in people living with HIV (PLWH), who commonly experience lipid disturbances. The aim of this study was to determine whether the plasma lipidomic profile differs between PLWH receiving a darunavir-based ART and those receiving integrase inhibitor-based ART. This was a cross-sectional study of unselected patients for whom metabolomic analysis was performed using ultra-high-performance liquid chromatography coupled to mass spectrometry. Data for the two subgroups were compared by calculating the log2 of the fold change for each metabolite and then grouping these into the main lipid families. Sixty-two PLWH aged 49.3 ± 8.6 years (82% men) were included: 12 patients (19.4%) had hypertension, 8 (12.9%) had type 2 diabetes, 25 (41.0%) had dyslipidaemia and 9 (14.5%) were taking statins, without significant differences in all these variables between the two groups. Twenty-five (40.3%) received darunavir-based ART and 37 (59.7%) integrase inhibitor-based ART. Although the differences were not statistically significant, patients treated with darunavir-based ART had higher concentrations of total cholesterol (211 mg/dL vs 194 mg/dL), LDL-cholesterol (132 mg/dL vs 117 mg/dL) and triglycerides (155 mg/dL vs 122 mg/dL), and lower HDL-cholesterol concentration (50 mg/dL vs 52 mg/dL). The main lipid families and metabolites differed slightly between groups (log2-fold change; P-value): ceramides (-0.07; 0.49), phosphatidylinositols (-0.05; 0.63), diacylglycerols (0.10; 0.64), phosphatidylethanolamines (0.03; 0.78), triacylglycerols (0.27; 0.18) and lysophosphatidylethanolamines (0.03; 0.83). In the integrase inhibitor-based group, the use of tenofovir alafenamide fumarate significantly increases the majority of lipid fractions, when compared with tenofovir disoproxil fumarate. The lipidomic profile did not differ between PLWH treated with darunavir-based or integrase inhibitor-based ART. This was especially true for ceramides, which are involved in cardiovascular disease. Further studies are needed to study the impact of ART in lipidomic profile.
Collapse
Affiliation(s)
- Alvaro Mena
- Grupo de Virología Clínica, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complejo Hospitalario Universitario de A Coruña (CHUAC), Sergas. Universidad de A Coruña (UDC), A Coruña, Spain. .,Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain.
| | - Elvira Clavero
- Grupo de Virología Clínica, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complejo Hospitalario Universitario de A Coruña (CHUAC), Sergas. Universidad de A Coruña (UDC), A Coruña, Spain.,Servicio de Medicina Interna, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
| | - José Luis Díaz-Díaz
- Servicio de Medicina Interna, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
| | - Angeles Castro
- Grupo de Virología Clínica, Instituto de Investigación Biomédica de A Coruña (INIBIC)-Complejo Hospitalario Universitario de A Coruña (CHUAC), Sergas. Universidad de A Coruña (UDC), A Coruña, Spain.,Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
| |
Collapse
|
12
|
Cheng HS, Tan WR, Low ZS, Marvalim C, Lee JYH, Tan NS. Exploration and Development of PPAR Modulators in Health and Disease: An Update of Clinical Evidence. Int J Mol Sci 2019; 20:E5055. [PMID: 31614690 PMCID: PMC6834327 DOI: 10.3390/ijms20205055] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/10/2019] [Accepted: 10/10/2019] [Indexed: 12/20/2022] Open
Abstract
Peroxisome proliferator-activated receptors (PPARs) are nuclear receptors that govern the expression of genes responsible for energy metabolism, cellular development, and differentiation. Their crucial biological roles dictate the significance of PPAR-targeting synthetic ligands in medical research and drug discovery. Clinical implications of PPAR agonists span across a wide range of health conditions, including metabolic diseases, chronic inflammatory diseases, infections, autoimmune diseases, neurological and psychiatric disorders, and malignancies. In this review we aim to consolidate existing clinical evidence of PPAR modulators, highlighting their clinical prospects and challenges. Findings from clinical trials revealed that different agonists of the same PPAR subtype could present different safety profiles and clinical outcomes in a disease-dependent manner. Pemafibrate, due to its high selectivity, is likely to replace other PPARα agonists for dyslipidemia and cardiovascular diseases. PPARγ agonist pioglitazone showed tremendous promises in many non-metabolic disorders like chronic kidney disease, depression, inflammation, and autoimmune diseases. The clinical niche of PPARβ/δ agonists is less well-explored. Interestingly, dual- or pan-PPAR agonists, namely chiglitazar, saroglitazar, elafibranor, and lanifibranor, are gaining momentum with their optimistic outcomes in many diseases including type 2 diabetes, dyslipidemia, non-alcoholic fatty liver disease, and primary biliary cholangitis. Notably, the preclinical and clinical development for PPAR antagonists remains unacceptably deficient. We anticipate the future design of better PPAR modulators with minimal off-target effects, high selectivity, superior bioavailability, and pharmacokinetics. This will open new possibilities for PPAR ligands in medicine.
Collapse
Affiliation(s)
- Hong Sheng Cheng
- School of Biological Sciences, Nanyang Technological University Singapore, 60 Nanyang Drive, Singapore 637551, Singapore.
| | - Wei Ren Tan
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Singapore 308232, Singapore.
| | - Zun Siong Low
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Singapore 308232, Singapore.
| | - Charlie Marvalim
- School of Biological Sciences, Nanyang Technological University Singapore, 60 Nanyang Drive, Singapore 637551, Singapore.
| | - Justin Yin Hao Lee
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Singapore 308232, Singapore.
| | - Nguan Soon Tan
- School of Biological Sciences, Nanyang Technological University Singapore, 60 Nanyang Drive, Singapore 637551, Singapore.
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Singapore 308232, Singapore.
| |
Collapse
|
13
|
Livio F, Marzolini C. Prescribing issues in older adults living with HIV: thinking beyond drug-drug interactions with antiretroviral drugs. Ther Adv Drug Saf 2019; 10:2042098619880122. [PMID: 31620274 PMCID: PMC6777047 DOI: 10.1177/2042098619880122] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Françoise Livio
- Service of Clinical Pharmacology, Department of Laboratories, University Hospital of Lausanne, Switzerland
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital of Basel and University of Basel, CH-4031 Basel, Switzerland
| |
Collapse
|
14
|
Silva TAL, Medeiros DC, Medeiros GCBS, Medeiros RCSC, de Souza Araújo J, Medeiros JA, Ururahy MAG, Santos RVT, Medeiros RMV, Leite-Lais L, Dantas PMS. Influence of curcumin supplementation on metabolic and lipid parameters of people living with HIV/AIDS: a randomized controlled trial. Altern Ther Health Med 2019; 19:202. [PMID: 31387592 PMCID: PMC6685220 DOI: 10.1186/s12906-019-2620-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 07/26/2019] [Indexed: 12/27/2022]
Abstract
Background Scientific studies have shown that the potential therapeutic efficacy of curcumin in several diseases is due to its potent antioxidant and anti-inflammatory properties. Consequently, curcumin supplementation seems to be a valuable alternative for HIV-infected individuals. The aim of this study is to evaluate the influence of curcumin supplementation on substrate oxidation at rest, body composition, and the lipid profile of physically active people living with HIV/AIDS under antiretroviral therapy. Methods This double-blind, crossover, randomized clinical trial was comprised of 20 subjects divided into experimental (EG) and control (CG) groups, receiving 1000 mg curcumin/day and placebo, respectively, during a 30-day period. Substrate oxidation at rest was assessed by indirect calorimetry, body composition was measured by dual-energy x-ray absorptiometry, and the lipid profile was evaluated by blood tests. Data analysis was performed by independent samples and paired t-tests to compare the differences between groups and times. A p-value < 0.05 was accepted as significant. Results There were no differences between groups regarding substrate oxidation at rest or body composition. However, serum triglyceride levels were increased after curcumin supplementation (182 vs. 219 mg/dL; p = 0.004). Conclusion Curcumin supplementation promoted the elevation of serum triglyceride levels in HIV-infected subjects. Further studies with a larger sample cohort, different curcumin doses, and longer intervention times are needed to validate current observations. In addition, the influence of physical activity, dietary intake, and genetic polymorphisms must be considered in future studies to better understand the impact of curcumin supplementation on the lipid profile of people living with HIV/AIDS under antiretroviral therapy. Electronic supplementary material The online version of this article (10.1186/s12906-019-2620-7) contains supplementary material, which is available to authorized users.
Collapse
|
15
|
Abstract
Introduction: Combined antiretroviral therapy has transformed HIV infection into a chronic disease thus people living with HIV (PLWH) live longer. As a result, the management of HIV infection is becoming more challenging as elderly experience age-related comorbidities leading to complex polypharmacy and a higher risk for drug-drug or drug-disease interactions. Furthermore, age-related physiological changes affect pharmacokinetics and pharmacodynamics thereby predisposing elderly PLWH to incorrect dosing or inappropriate prescribing and consequently to adverse drug reactions and the subsequent risk of starting a prescribing cascade. Areas covered: This review discusses the demographics of the aging HIV population, physiological changes and their impact on drug response as well as comorbidities. Particular emphasis is placed on common prescribing issues in elderly PLWH including drug-drug interactions with antiretroviral drugs. A PubMed search was used to compile relevant publications until February 2019. Expert opinion: Prescribing issues are highly prevalent in elderly PLWH thus highlighting the need for education on geriatric prescribing principles. Adverse health outcomes potentially associated with polypharmacy and inappropriate prescribing should promote interventions to prevent harm including medication reconciliation, medication review, and medication prioritization according to the risks/benefits for a given patient. A multidisciplinary team approach is recommended for the care of elderly PLWH.
Collapse
Affiliation(s)
- Catia Marzolini
- a Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research , University Hospital of Basel and University of Basel , Basel , Switzerland.,b Department of Molecular and Clinical Pharmacology , University of Liverpool , Liverpool , UK
| | - Françoise Livio
- c Service of Clinical Pharmacology, Department of Laboratories , University Hospital of Lausanne , Lausanne , Switzerland
| |
Collapse
|
16
|
Offor U, Naidu EC, Ogedengbe OO, Jegede AI, Peter AI, Azu OO. Nephrotoxicity and highly active antiretroviral therapy: Mitigating action of Momordica charantia. Toxicol Rep 2018; 5:1153-1160. [PMID: 30627515 PMCID: PMC6319328 DOI: 10.1016/j.toxrep.2018.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 09/03/2018] [Accepted: 09/15/2018] [Indexed: 12/24/2022] Open
Abstract
Momordica charantia (M. charantia) is known for its antioxidant and antidiabetic properties. The aim of this study is to investigate the renoprotective effects of M. charantia in rats following treatment with highly active antiretroviral therapy (HAART) regimen triplavar. Adult male Sprague-Dawley rats weighing 178.1-220.5 g (n = 36) were divided into six groups (A-F) with each group comprising of six (n = 6) rats. The drugs and extract were administered via oral gavage. The therapeutic dose of triplavar was adjusted using the human therapeutic dose equivalent for the rat model. Animals were euthanized on the tenth week with kidneys removed for examination and blood obtained via cardiac puncture. Levels of oxidative stress enzymes (superoxide dismutase-SOD, catalase-CAT, and reduced glutathione-GSH) were significantly lowered in all groups not receiving M. charantia. The levels of thiobarbituric acid reactive substances (TBARS) were increased resulting in free radical formation via auto-oxidation. Renal parameters showed no albuminuria, normal blood urea nitrogen (BUN), serum creatinine (SCr) and electrolytes in groups treated with M. charantia. HAART treated (Group B) showed severe albuminuria, a significantly (p < 0.05) raised BUN and SCr and gross electrolyte disturbances. Blood glucose levels were significantly raised in groups not receiving the adjuvant M. charantia (p < 0.05). Histopathology in HAART treated animals showed glomerular capillary abnormalities and cellular infiltrations while M. charantia treated animals showed an essentially normal glomerular appearance with capillary loops and normal cytoarchitecture. In conclusion M. charantia extract administration improved blood glucose levels, restored renal histology, reinstate renal function, reduce body weight loss and restores hyperglycemia.
Collapse
Key Words
- 6-HD, 6-hydroxydopamine
- AIDS, acquired immune deficiency syndrome
- ALB, albumin
- ANOVA, analysis of variance
- AREC, animal research ethics committee
- BGL, blood glucose levels
- BRU, Biomedical Resource Unit
- BUN, blood urea nitrogen
- BW, body weight
- CAT, catalase
- DETAPAC, diethylenetriamine – penta acetic acid
- DNA, deoxyribonucleic acid
- DTNB, 5, 5'-dithiobis-(2-nitrobenzoic acid)
- GSH, reduced glutathione
- H and E, haematoxylin and eosin
- HAART
- HAART, highly active antiretroviral therapy
- HIV, human immunodeficiency virus
- Histopathology
- KW, kidney weight
- KWBR, kidney weight body ratio
- Kidney
- LPO, lipid peroxidation
- M. charantia, Momordica charantia
- MDA, malondialdehyde
- MT, Masson’s Trichome
- Momordica charantia
- NRTIs, nucleoside reverse transcriptase inhibitors
- Nephrotoxicity
- PAS, Periodic Acid Schiff
- PBS, phosphate buffer solution
- PLWHA, people living with HIV and AIDS
- ROS, reactive oxygen species
- SCr, serum creatinine
- SD, standard deviation
- SDS, sodium dodecyl sulfate
- SOD, superoxide dismutase
- Sprague-Dawley rats
- TBARS, thiobarbituric acid reactive substances
- TCA, trichloroacetic acid
- UKZN, University of KwaZulu Natal
- rpm, revolutions per minute
Collapse
Affiliation(s)
- Ugochukwu Offor
- Department of Clinical Anatomy, School of Laboratory Medicine and Medical Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
| | - Edwin Coleridge Naidu
- Department of Clinical Anatomy, School of Laboratory Medicine and Medical Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
| | - Oluwatosin Olalekan Ogedengbe
- Department of Clinical Anatomy, School of Laboratory Medicine and Medical Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
- Department of Anatomy, College of Medicine and Health Sciences, Afe Babalola University, Ado Ekiti, Nigeria
| | - Ayoola Isaac Jegede
- Department of Clinical Anatomy, School of Laboratory Medicine and Medical Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
| | - Aniekan Imo Peter
- Department of Clinical Anatomy, School of Laboratory Medicine and Medical Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
- Department of Anatomy, Faculty of Basic Medical Sciences, University of Uyo-Nigeria, Nigeria
| | - Onyemaechi Okpara Azu
- Department of Clinical Anatomy, School of Laboratory Medicine and Medical Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
- Department of Anatomy, School of Medicine, University of Namibia, Windhoek, Namibia
| |
Collapse
|
17
|
Mirza FS, Luthra P, Chirch L. Endocrinological aspects of HIV infection. J Endocrinol Invest 2018; 41:881-899. [PMID: 29313284 DOI: 10.1007/s40618-017-0812-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 12/16/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE Patients with human immunodeficiency virus (HIV) are living longer with effective antiretroviral therapies and are enjoying near normal life span. Therefore, they are encountering endocrine issues faced by the general population along with those specific to HIV infection. The purpose of this article is to review the common endocrine aspects of HIV infection, and the early detection and management strategies for these complications. METHODS Recent literature on HIV and endocrine disease was reviewed. RESULTS HIV can influence endocrine glands at several levels. Endocrine glandular function may be altered by the direct effect of HIV viral proteins, through generation of systemic and local cytokines and the inflammatory response and via glandular involvement with opportunistic infections and HIV-related malignancies. Endocrine disorders seen in people with HIV include metabolic issues related to obesity such as diabetes, hyperlipidemia, lipohypertrophy, lipoatrophy and lipodystrophy and contribute significantly to quality of life, morbidity and mortality. In addition, hypogonadism, osteopenia and osteoporosis are also more prevalent in the patients with HIV. Although disorders of hypothalamic-pituitary-adrenal axis resulting in adrenal insufficiency can be life threatening, these along with thyroid dysfunction are being seen less commonly in the antiretroviral therapy (ART) era. ARTs have greatly improved life expectancy in people living with HIV but can also have adverse endocrine effects. CONCLUSIONS Clinicians need to have a high index of suspicion for endocrine abnormalities in people with HIV as they can be potentially life threatening if untreated. Endocrine evaluation should be pursued as in the general population, with focus on prevention, early detection and treatment to improve quality of life and longevity.
Collapse
Affiliation(s)
- F S Mirza
- Division of Endocrinology and Metabolism, Department of Medicine, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030-5456, USA.
- Department of Medicine, UConn Health, Farmington, CT, 06030, USA.
| | - P Luthra
- Division of Endocrinology and Metabolism, Department of Medicine, UConn Health, 263 Farmington Avenue, Farmington, CT, 06030-5456, USA
- Department of Medicine, UConn Health, Farmington, CT, 06030, USA
| | - L Chirch
- Division of Infectious Diseases, UConn Health, Farmington, CT, 06030, USA
- Department of Medicine, UConn Health, Farmington, CT, 06030, USA
| |
Collapse
|
18
|
Enkhmaa B, Anuurad E, Zhang W, Li CS, Kaplan R, Lazar J, Merenstein D, Karim R, Aouizerat B, Cohen M, Butler K, Pahwa S, Ofotokun I, Adimora AA, Golub E, Berglund L. Effect of antiretroviral therapy on allele-associated Lp(a) level in women with HIV in the Women's Interagency HIV Study. J Lipid Res 2018; 59:1967-1976. [PMID: 30012717 DOI: 10.1194/jlr.p084517] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 06/08/2018] [Indexed: 11/20/2022] Open
Abstract
We previously demonstrated an association between lipoprotein (a) [Lp(a)] levels and atherosclerosis in human immunodeficiency virus (HIV)-seropositive women. The effects of antiretroviral therapy (ART) on Lp(a) levels in relation to apo(a) size polymorphism remain unclear. ART effects on allele-specific apo(a) level (ASL), an Lp(a) level associated with individual apo(a) alleles within each allele-pair, were determined in 126 HIV-seropositive women. ART effects were tested by a mixed-effects model across pre-ART and post-ART first and third visits. Data from 120 HIV-seronegative women were used. The mean age was 38 years; most were African-American (∼70%). Pre-ART ASLs associated with the larger (4.6 mg/dl vs. 8.0 mg/dl, P = 0.024) or smaller (13 mg/dl vs. 19 mg/dl, P = 0.041) apo(a) sizes were lower in the HIV-seropositive versus HIV-seronegative group, as was the prevalence of a high Lp(a) level (P = 0.013). Post-ART ASL and prevalence of high Lp(a) or apo(a) sizes and frequency of small size apo(a) (22 kringles) did not differ between the two groups. ART increased Lp(a) level (from 18 to 24 mg/dl, P < 0.0001) and both ASLs (P < 0.001). In conclusion, regardless of genetic control, Lp(a) can be modulated by HIV and its treatment. ART initiation abrogates HIV-induced suppression of Lp(a) levels and ASLs, contributing to promote CVD risk in HIV-seropositive individuals.
Collapse
Affiliation(s)
- Byambaa Enkhmaa
- Departments of Internal Medicine University of California, Davis, Davis, CA 95616
| | - Erdembileg Anuurad
- Departments of Internal Medicine University of California, Davis, Davis, CA 95616
| | - Wei Zhang
- Departments of Internal Medicine University of California, Davis, Davis, CA 95616
| | - Chin-Shang Li
- Public Health Sciences, University of California, Davis, Davis, CA 95616
| | - Robert Kaplan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY 10461
| | - Jason Lazar
- Department of Cardiovascular Disease, State University of New York Downstate Medical Center, Brooklyn, NY 11203
| | - Dan Merenstein
- Department of Family Medicine, Georgetown University Medical Center, Washington, DC 20007
| | - Roksana Karim
- Department Preventive Medicine, University of Southern California, Los Angeles, Los Angeles, CA 90007
| | - Brad Aouizerat
- Department of Oral and Maxillofacial Surgery, New York University, New York, NY 10003
| | - Mardge Cohen
- Department of Medicine, Rush University and Stroger Hospital, Cook County Bureau of Health Services, Chicago, IL 60612
| | - Kenneth Butler
- Division of Geriatric Medicine/Gerontology, University of Mississippi Medical Center, Jackson, MS 39216
| | - Savita Pahwa
- Miami Center for AIDS Research, University of Miami, Miami, FL 33136
| | - Igho Ofotokun
- Department of Medicine, Infectious Diseases, Emory School of Medicine, Atlanta, GA 30307
| | - Adaora A Adimora
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC 27599
| | - Elizabeth Golub
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205
| | - Lars Berglund
- Departments of Internal Medicine University of California, Davis, Davis, CA 95616
| |
Collapse
|
19
|
Metabolic clinic for individuals with HIV/AIDS: a commitment and vision to the future of HIV services. Cardiovasc Endocrinol 2017; 6:109-112. [PMID: 31646127 DOI: 10.1097/xce.0000000000000128] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 05/30/2017] [Indexed: 12/17/2022] Open
Abstract
One of the biggest current challenges in managing an ageing cohort living with the HIV is handling dyslipidaemia, diabetes, metabolic syndrome and nonalcoholic fatty liver disease. Combination antiretroviral therapy decrease mortality and morbidity in HIV patients, but lead to increase in insulin resistance, dyslipidaemia, abnormalities of fat distribution and high risk of cardiovascular disease. Therefore, a metabolic clinic was established for individuals living with HIV in the Milton Keynes University Hospital NHS Foundation Trust. The clinic meets considerable demands by service users and hence has the potential to be popular. This review focuses on the importance of the development of a metabolic clinic for the purpose of audit, research, teaching and exchange of knowledge between HIV specialists and the metabolic team in the management of complex cases. Therefore, the metabolic clinic should be an integral part of HIV services especially as the cohort of the 'older' HIV population increases.
Collapse
|
20
|
Calza L, Magistrelli E, Colangeli V, Borderi M, Bussini L, Bon I, Re MC, Viale P. Substitution of nevirapine or raltegravir for protease inhibitor vs. rosuvastatin treatment for the management of dyslipidaemia in HIV-infected patients on stable antiretroviral therapy (Nevrast study). Infect Dis (Lond) 2017; 49:737-747. [PMID: 28683645 DOI: 10.1080/23744235.2017.1339325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES An observational, prospective, cohort study was performed to compare efficacy and safety of a switch from ritonavir-boosted protease inhibitor (PI/r) to nevirapine or raltegravir with that of rosuvastatin addition to current antiretroviral therapy in HIV-infected patients with hyperlipidaemia. METHODS All HIV-infected patients receiving a stable PI/r-based antiretroviral regimen, with persistently suppressed viremia, naïve to non-nucleoside analogues and to integrase strand transfer inhibitors, with mixed hyperlipidaemia, and who underwent a switch from PI/r to nevirapine (Group A) or raltegravir (Group B) or who started rosuvastatin at 10 mg daily (group C) with unchanged antiretroviral regimen were enrolled into the study. RESULTS Overall, 136 patients were enrolled: 43 patients were included in the group A, 46 in the group B, and 47 in the group C. The mean age was 46.6 years, and 108 (79.4%) were males. After 48 weeks of follow-up, a significantly greater reduction in the mean low-density lipoprotein (LDL) cholesterol level was reported in group C (-28.2%) than in group A (-10.2%; p < .001) and B (-12.4%; p = .021), while a significantly greater reduction in the mean concentration of triglycerides was observed in group A (-31.2%) and B (-35.5%) than in group C (-11.9%; p = .034 and p = .004, respectively). The incidence of adverse events was <10% and comparable across the three groups. CONCLUSION In HIV-positive subjects receiving a PI/r, the initiation of rosuvastatin treatment after 48 weeks yielded a greater decline in LDL cholesterol, while the switch from PI/r to nevirapine or raltegravir led to a greater decline in triglycerides.
Collapse
Affiliation(s)
- Leonardo Calza
- a Department of Medical and Surgical Sciences , "Alma Mater Studiorum" University of Bologna, S. Orsola-Malpighi Hospital , Bologna , Italy
| | - Eleonora Magistrelli
- a Department of Medical and Surgical Sciences , "Alma Mater Studiorum" University of Bologna, S. Orsola-Malpighi Hospital , Bologna , Italy
| | - Vincenzo Colangeli
- a Department of Medical and Surgical Sciences , "Alma Mater Studiorum" University of Bologna, S. Orsola-Malpighi Hospital , Bologna , Italy
| | - Marco Borderi
- a Department of Medical and Surgical Sciences , "Alma Mater Studiorum" University of Bologna, S. Orsola-Malpighi Hospital , Bologna , Italy
| | - Linda Bussini
- a Department of Medical and Surgical Sciences , "Alma Mater Studiorum" University of Bologna, S. Orsola-Malpighi Hospital , Bologna , Italy
| | - Isabella Bon
- b Clinic of Infectious Diseases and Microbiology Unit , "Alma Mater Studiorum" University of Bologna, S. Orsola-Malpighi Hospital , Bologna , Italy
| | - Maria Carla Re
- b Clinic of Infectious Diseases and Microbiology Unit , "Alma Mater Studiorum" University of Bologna, S. Orsola-Malpighi Hospital , Bologna , Italy
| | - Pierluigi Viale
- a Department of Medical and Surgical Sciences , "Alma Mater Studiorum" University of Bologna, S. Orsola-Malpighi Hospital , Bologna , Italy
| |
Collapse
|
21
|
Metabolic concerns in aging HIV-infected persons: from serum lipid phenotype to fatty liver. AIDS 2017; 31 Suppl 2:S147-S156. [PMID: 28471945 DOI: 10.1097/qad.0000000000001483] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
: Among HIV-infected persons, the assessment of nonalcoholic fatty liver disease (NAFLD) provides a window through which overall metabolic health can be evaluated. In this review, we summarize clinical data that support the roles of aging and metabolic dysregulation as factors contributing to fatty liver/NAFLD among HIV-infected persons.Age-related metabolic alterations include hepatic anatomic and functional changes, altered homeostasis of gastrointestinal microbiota and anthropometric changes (such as a shift of body fat depots from the subcutaneous to the visceral compartment) that are often associated with the development of insulin resistance and increased cardiovascular risk.Fatty changes in the liver occur not only with metabolic disruption but also with virus-induced injury. Chronic hepatitis C virus infection is commonly associated with fatty liver, and can be related to both hepatitis C virus genotype and host metabolic features. Similarly, HIV infection is associated with fatty liver as a result of multiple viral and host factors. Clearly, lipodystrophy, dysregulation of the gut-liver axis and HIV infection itself may each contribute simultaneously to NAFLD pathogenesis. Although lifestyle changes are the mainstay of treatment, to date no drug has specifically been approved for use in persons with NAFLD. Moreover, current guidelines provide no specific therapeutic recommendations for persons with NAFLD older than 65 years.Well-designed studies characterizing the epidemiology, pathogenesis, clinical outcomes and potential therapeutic interventions for liver disease and associated metabolic comorbidities in older HIV-infected patients are urgently needed.
Collapse
|
22
|
Smith JM, Flexner C. The challenge of polypharmacy in an aging population and implications for future antiretroviral therapy development. AIDS 2017; 31 Suppl 2:S173-S184. [PMID: 28471948 DOI: 10.1097/qad.0000000000001401] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
: It is estimated that by 2030 nearly three-quarters of persons living with HIV will be 50 years and older. The aging HIV population presents a new clinical concern for HIV providers: adverse effects from polypharmacy. An aging population means more comorbidities and potentially more drug-drug interactions for providers to manage. This review discusses major comorbidities including cardiovascular disease, anticoagulation, hypertension, diabetes mellitus and malignancy and considerations for drug-interactions with antiretrovirals.
Collapse
|
23
|
Lipid testing in infectious diseases: possible role in diagnosis and prognosis. Infection 2017; 45:575-588. [PMID: 28484991 DOI: 10.1007/s15010-017-1022-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 05/04/2017] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Acute infections lead to significant alterations in metabolic regulation including lipids and lipoproteins, which play a central role in the host immune response. In this regard, several studies have investigated the role of lipid levels as a marker of infection severity and prognosis. SCOPE OF REVIEW We review here the role of lipids in immune response and the potential mechanisms underneath. Moreover, we summarize studies on lipid and lipoprotein alterations in acute bacterial, viral and parasitic infections as well as their diagnostic and prognostic significance. Chronic infections (HIV, HBV, HCV) are also considered. RESULTS All lipid parameters have been found to be significantly dearranged during acute infection. Common lipid alterations in this setting include a decrease of total cholesterol levels and an increase in the concentration of triglyceride-rich lipoproteins, mainly very low-density lipoproteins. Also, low-density lipoprotein cholesterol, apolipoprotein A1, low-density lipoprotein cholesterol and apolipoprotein-B levels decrease. These lipid alterations may have prognostic and diagnostic role in certain infections. CONCLUSION Lipid testing may be of help to assess response to treatment in septic patients and those with various acute infections (such as pneumonia, leptospirosis and others). Diagnostically, new onset of altered lipid levels should prompt the clinician to test for underlying infection (such as leishmaniasis).
Collapse
|
24
|
Non LR, Escota GV, Powderly WG. HIV and its relationship to insulin resistance and lipid abnormalities. Transl Res 2017; 183:41-56. [PMID: 28068521 DOI: 10.1016/j.trsl.2016.12.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 11/18/2016] [Accepted: 12/15/2016] [Indexed: 12/19/2022]
Abstract
Antiretroviral therapy has revolutionized the care of people with human immunodeficiency virus (HIV) by reducing morbidity and mortality from acquired immunodeficiency syndrome-related conditions. Despite longer life expectancy, however, HIV-infected individuals continue to have a higher risk of death compared with the general population. This has been attributed to the increasing incidence of noncommunicable diseases, in particular, atherosclerotic cardiovascular diseases. This is driven, in part, by the emergence of metabolic disorders, particularly dyslipidemia, insulin resistance, and lipodystrophy, in those on antiretroviral therapy. The pathogenesis of these metabolic derangements is complex and multifactorial, and could be a consequence of an interplay between traditional age-related risk factors, HIV infection, antiretroviral therapy effects, and the inflammatory state and immune activation in this population. Understanding the contributions of each of these factors could not just impact the current management of these individuals and help mitigate the risk for premature cardiovascular disease, but also shape the future direction of research in HIV.
Collapse
Affiliation(s)
- Lemuel R Non
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Mo.
| | - Gerome V Escota
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Mo
| | - William G Powderly
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Mo
| |
Collapse
|
25
|
Significant association between statin-associated myalgia and vitamin D deficiency among treated HIV-infected patients. AIDS 2017; 31:681-688. [PMID: 28060020 DOI: 10.1097/qad.0000000000001397] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Several studies have shown a significant association between vitamin D deficiency and an increased risk of statin-related symptomatic myalgia in the general population, but there are no data among HIV-infected persons. METHODS A retrospective, cohort study was conducted to assess the incidence of symptomatic myalgia and elevation in serum creatine kinase level among HIV-positive adults on combination antiretroviral therapy and treated with atorvastatin or rosuvastatin for at least 12 months between 2011 and 2015 in our outpatient unit. RESULTS A total of 545 patients (mean age 53.4 years) were enrolled into the study. Atorvastatin was prescribed in 55.8% of patients and rosuvastatin in 44.2%. After a mean duration of statin therapy of 29 months, an isolated symptomatic myalgia was diagnosed in 42 patients (7.7%) and a myalgia associated with elevated creatine kinase level in 25 (4.6%). The mean concentration of 25-hydroxyvitamin D was significantly lower in patients with myalgia (19.4 ng/ml) and with creatine kinase elevation and myalgia (22.8 ng/ml) than in those without muscle toxicity (32.1 ng/ml; P = 0.017 and 0.024, respectively). In stratified multivariable-adjusted logistic regression models, there was a statistically significant association between vitamin D deficiency and occurrence of symptomatic myalgia (P = 0.009) or creatine kinase elevation and myalgia (P = 0.046). Other factors significantly associated with development of myalgia were duration of statin therapy more than 24 months, history of myalgia, and age older than 60 years. DISCUSSION In our observational study, vitamin D deficiency was significantly associated with a statin-induced myalgia among HIV-infected patients on combination antiretroviral therapy, in conformity with data of the general population.
Collapse
|
26
|
Kohanski RA, Deeks SG, Gravekamp C, Halter JB, High K, Hurria A, Fuldner R, Green P, Huebner R, Macchiarini F, Sierra F. Reverse geroscience: how does exposure to early diseases accelerate the age-related decline in health? Ann N Y Acad Sci 2016; 1386:30-44. [PMID: 27907230 DOI: 10.1111/nyas.13297] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 10/21/2016] [Indexed: 02/07/2023]
Abstract
Aging is the major risk factor for both the development of chronic diseases and loss of functional capacity. Geroscience provides links among the biology of aging, the biology of disease, and the physiology of frailty, three fields where enormous progress has been made in the last few decades. While, previously, the focus was on the role of aging in susceptibility to disease and disability, the other side of this relationship, which is the contribution of disease to aging, has been less explored at the molecular/cellular level. Indeed, the role of childhood or early adulthood exposure to chronic disease and/or treatment on accelerating aging phenotypes is well known in epidemiology, but the biological basis is poorly understood. A recent summit co-organized by the National Institutes of Health GeroScience Interest Group and the New York Academy of Sciences explored these relationships, using three chronic diseases as examples: cancer, HIV/AIDS, and diabetes. The epidemiological literature clearly indicates that early exposure to any of these diseases and/or their treatments results in an acceleration of the appearance of aging phenotypes, including loss of functional capacity and accelerated appearance of clinical symptoms of aging-related diseases not obviously related to the earlier event. The discussions at the summit focused on the molecular and cellular relationships between each of these diseases and the recently defined molecular and cellular pillars of aging. Two major conclusions from the meeting include the desire to refine an operational definition of aging and to concomitantly develop biomarkers of aging, in order to move from chronological to physiological age. The discussion also opened a dialogue on the possibility of improving late-life outcomes in patients affected by chronic disease by including age-delaying modalities along with the standard care for the disease in question.
Collapse
Affiliation(s)
- Ronald A Kohanski
- Division of Aging Biology, National Institute on Aging, NIH, Bethesda, Maryland
| | - Steven G Deeks
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Claudia Gravekamp
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | - Jeffrey B Halter
- Geriatrics Center and Institute of Gerontology, University of Michigan, Ann Arbor, Michigan
| | - Kevin High
- Department of Internal Medicine, Section on Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Arti Hurria
- City of Hope Comprehensive Cancer Center and Beckman Research Institute, Duarte, California
| | - Rebecca Fuldner
- Division of Aging Biology, National Institute on Aging, NIH, Bethesda, Maryland
| | - Paige Green
- Biobehavioral and Psychologic Branch, National Cancer Institute, NIH, Bethesda, Maryland
| | - Robin Huebner
- Division of AIDS, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland
| | | | - Felipe Sierra
- Division of Aging Biology, National Institute on Aging, NIH, Bethesda, Maryland
| |
Collapse
|