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Zhang S, Liu W, Ganz T, Liu S. Exploring the relationship between hyperlactatemia and anemia. Trends Endocrinol Metab 2024; 35:300-307. [PMID: 38185594 DOI: 10.1016/j.tem.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 01/09/2024]
Abstract
Hyperlactatemia and anemia commonly coexist and their crosstalk is a longstanding mystery with elusive mechanisms involved in physical activities, infections, cancers, and genetic disorders. For instance, hyperlactatemia leads to iron restriction by upregulating hepatic hepcidin expression. Increasing evidence also points to lactate as a crucial signaling molecule rather than merely a metabolic byproduct. Here, we discuss the mutual influence between anemia and hyperlactatemia. This opinion calls for a reconsideration of the multifaceted roles of lactate and lactylation in anemia and emphasizes the need to fill knowledge gaps, including the dose dependence of lactate's effects, its sources, and its subcellular localization.
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Affiliation(s)
- Shuping Zhang
- Medical Science and Technology Innovation Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong 250117, China
| | - Wei Liu
- Medical Science and Technology Innovation Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong 250117, China; State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
| | - Tomas Ganz
- Center for Iron Disorders, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
| | - Sijin Liu
- Medical Science and Technology Innovation Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong 250117, China; State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China; University of Chinese Academy of Sciences, Beijing 100049, China.
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2
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Judge BS. Metabolic Acidosis. Emerg Med Clin North Am 2022; 40:251-264. [DOI: 10.1016/j.emc.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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3
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Abstract
Over the past 30 years, significant advances have transformed the landscape of human immunodeficiency virus (HIV) care in the emergency department. Diagnosis and management of HIV has improved, resulting in a decline in the incidence of acquired immunodeficiency syndrome (AIDS)-defining infections. Advances in pharmacology have led to fewer serious medication toxicities and more tolerable regimens. Emergency providers have played an increasingly important role in HIV screening and diagnosis of acute infection. Provision of postexposure prophylaxis is expanding from a focus on occupational exposure to include all high-risk cases.
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Masyeni S, Sintya E, Megawati D, Sukmawati NMH, Budiyasa DG, Aryastuti SA, Khairunisa SQ, Arijana I, Nasronudin N. Evaluation of antiretroviral effect on mitochondrial DNA depletion among HIV-infected patients in Bali. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2018; 10:145-150. [PMID: 30104903 PMCID: PMC6072679 DOI: 10.2147/hiv.s166245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Nucleoside reverse transcriptase inhibitors (NRTIs) are the cornerstone of highly active antiretroviral therapy combination regimens for HIV infection. Unfortunately, NRTIs have been noticeably associated with many adverse effects related to mitochondrial toxicity leading to mitochondrial deoxyribonucleic acid (mtDNA) depletion. However, similar mitochondrial dysfunction has recently been found even in antiretroviral therapy-naïve patients, suggesting HIV itself could contribute to this abnormality. In this study, we determine whether mtDNA depletion was present in either antiretroviral therapy-naïve or NRTI-treated patients at Sanjiwani Hospital, Bali, Indonesia. Patients and methods A cross-sectional study was conducted from the peripheral blood mononuclear cells of HIV patients. Specifically, the relative content of mtDNA (mtRNR1 gene) to nuclear DNA (ASPOLG gene) was determined by real-time polymerase chain reaction. Data were analyzed with SPSS 16.0 software and GraphPad Prism 7.02. Results A total of 84 samples (67 on NRTIs and 17 HIV-naïve) were suitable for analysis. We identified 21.4% of the samples (18/84) with mtDNA:nDNA ratio <1. Although it was not significant (P=0.121), the median mtDNA:nDNA ratio of HIV-naïve group was slightly higher (median 1.8; interquartile range [IQR]: 1.1-2.1) than NRTI-treated patients (median 1.5; IQR: 1.3-2.85). Tenofovir-based NRTI was more frequently used (73.13%) than zidovudine-based NRTI (26.86%). The period for which NRTI was used probably contributed to the ratio of mtDNA:nDNA. The median ratio of mtDNA:nDNA zidovudine-treated patients was slightly lower (median 1.2; IQR: 1.08-1.98) when compared to tenofovir-based NRTI (median 1.6; IQR: 1.05-2.10), with the median period of former treatment being significantly longer (P<0.001). Although these data overall indicate that NRTI treatment had no effect on mtDNA:nDNA ratios, patients who undergo more than 12 months of NRTIs treatment show a decrease in the ratio; however, further study is required. Conclusion Almost one-fourth of the samples showed a lower mtDNA:nDNA ratio. The decreasing of the ratio mtDNA:nDNA was most likely present after 12 months of NRTI treatment.
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Affiliation(s)
- Sri Masyeni
- Faculty of Medicine and Health Sciences, University of Warmadewa, Denpasar, Bali, Indonesia,
| | - Erly Sintya
- Faculty of Medicine and Health Sciences, University of Warmadewa, Denpasar, Bali, Indonesia,
| | - Dewi Megawati
- Faculty of Medicine and Health Sciences, University of Warmadewa, Denpasar, Bali, Indonesia,
| | | | - Dewa Ga Budiyasa
- Internal Medicine Department, Sanjiwani Hospital, Gianyar, Bali, Indonesia
| | - Sri Agung Aryastuti
- Faculty of Medicine and Health Sciences, University of Warmadewa, Denpasar, Bali, Indonesia,
| | - Siti Qamariyah Khairunisa
- Indonesia-Japan Collaborative Research Center for Emerging and Reemerging Infectious Diseases, Institute of Tropical Disease, Airlangga University, Surabaya, Indonesia
| | - Igkn Arijana
- Histology Department of Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia
| | - N Nasronudin
- Indonesia-Japan Collaborative Research Center for Emerging and Reemerging Infectious Diseases, Institute of Tropical Disease, Airlangga University, Surabaya, Indonesia
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Bonnet F, Balestre E, Bernardin E, Pellegrin JL, Neau D, Dabis F. Risk Factors for Hyperlactataemia in HIV-Infected Patients, Aquitaine Cohort, 1999–2003. ACTA ACUST UNITED AC 2016; 16:63-7. [PMID: 15739622 DOI: 10.1177/095632020501600106] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objectives of our study were to describe the characteristics of a subset of patients who had been prescribed serum lactate in clinical practice within a large cohort of HIV-infected patients and to determine the factors associated with hyperlactataemia. Hyperlactataemia (⩾T2 mmol/l) was found in 219 [29% (95% confidence interval: 25.3–31.7)] of the 768 HIV-infected participants. In multivariate analysis (logistical regression), an increased risk of hyperlactataemia was associated with increasing age, CD4 count <500/mm3, triglycerides >2.2 mmol/L, lipoatrophy and stavudine use. In a second model coding for the NRTI-based drug combinations, only those including stavudine were associated with an increased risk of hyperlactataemia. In a third model including exposure duration to NRTIs, we estimated a 20% increased risk of hyperlactataemia per year of exposure to didanosine or stavudine. The risk of hyperlactataemia could increase over time in patients treated with these drugs and is also closely associated with increased age, decreased CD4 count, lipodystrophy and increased plasma triglycerides. It could be proposed that patients having one or more of these risk factors undergo regular monitoring of plasma lactate and renal function to prevent lactic acidosis.
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Affiliation(s)
- Fabrice Bonnet
- Service de Médecine Interne et Maladies Infectieuses, Hôpital Saint-André, Bordeaux, France.
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Rodríguez-Mora S, Mateos E, Moran M, Martín MÁ, López JA, Calvo E, Terrón MC, Luque D, Muriaux D, Alcamí J, Coiras M, López-Huertas MR. Intracellular expression of Tat alters mitochondrial functions in T cells: a potential mechanism to understand mitochondrial damage during HIV-1 replication. Retrovirology 2015; 12:78. [PMID: 26376973 PMCID: PMC4571071 DOI: 10.1186/s12977-015-0203-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 08/26/2015] [Indexed: 01/22/2023] Open
Abstract
Background HIV-1 replication results in mitochondrial damage that is enhanced during antiretroviral therapy (ART). The onset of HIV-1 replication is regulated by viral protein Tat, a 101-residue protein codified by two exons that elongates viral transcripts. Although the first exon of Tat (aa 1–72) forms itself an active protein, the presence of the second exon (aa 73–101) results in a more competent transcriptional protein with additional functions. Results Mitochondrial overall functions were analyzed in Jurkat cells stably expressing full-length Tat (Tat101) or one-exon Tat (Tat72). Representative results were confirmed in PBLs transiently expressing Tat101 and in HIV-infected Jurkat cells. The intracellular expression of Tat101 induced the deregulation of metabolism and cytoskeletal proteins which remodeled the function and distribution of mitochondria. Tat101 reduced the transcription of the mtDNA, resulting in low
ATP production. The total amount of mitochondria increased likely to counteract their functional impairment. These effects were enhanced when Tat second exon was expressed. Conclusions Intracellular Tat altered mtDNA transcription, mitochondrial content and distribution in CD4+ T cells. The importance of Tat second exon in non-transcriptional functions was confirmed. Tat101 may be responsible for mitochondrial dysfunctions found in HIV-1 infected patients. Electronic supplementary material The online version of this article (doi:10.1186/s12977-015-0203-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sara Rodríguez-Mora
- Unidad de Inmunopatología del SIDA, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain.
| | - Elena Mateos
- Unidad de Inmunopatología del SIDA, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain.
| | - María Moran
- Laboratorio de Enfermedades Raras: mitocondriales y neuromusculares, Instituto de Investigación Hospital 12 de Octubre, "i + 12", Madrid, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) U723, Madrid, Spain.
| | - Miguel Ángel Martín
- Laboratorio de Enfermedades Raras: mitocondriales y neuromusculares, Instituto de Investigación Hospital 12 de Octubre, "i + 12", Madrid, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER) U723, Madrid, Spain.
| | - Juan Antonio López
- Unidad de Proteómica, Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain.
| | - Enrique Calvo
- Unidad de Proteómica, Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain.
| | - María Carmen Terrón
- Unidad de Microscopía Electrónica y Confocal, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain.
| | - Daniel Luque
- Unidad de Microscopía Electrónica y Confocal, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain.
| | - Delphine Muriaux
- Unité de Virologie Humaine - INSERM U758/École Normale Supérieure, Lyon, France. .,Laboratoire de Domaines Membranaires et Assemblage Viral, Centre d'études d'agents Pathogènes et Biotechnologies pour la Santé, Montpellier, France.
| | - José Alcamí
- Unidad de Inmunopatología del SIDA, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain.
| | - Mayte Coiras
- Unidad de Inmunopatología del SIDA, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain.
| | - María Rosa López-Huertas
- Unidad de Inmunopatología del SIDA, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain. .,Unité de Virologie Humaine - INSERM U758/École Normale Supérieure, Lyon, France.
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Abstract
There are an estimated 40 million HIV infected individuals worldwide, with chronic liver disease being the 2nd leading cause of mortality in this population. Elevated liver functions are commonly noted in HIV patients and the etiologies are varied. Viral hepatitis B and C, fatty liver and drug induced liver injury are more common. Treatment options for viral hepatitis C are rapidly evolving and are promising, but treatments are limited for the other conditions and is primarily supportive. Opportunistic infections of the liver are now uncommon. Irrespective of etiology, management requires referral to specialized centers and with due diligence mortality can be reduced.
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Margolis AM, Heverling H, Pham PA, Stolbach A. A review of the toxicity of HIV medications. J Med Toxicol 2014; 10:26-39. [PMID: 23963694 DOI: 10.1007/s13181-013-0325-8] [Citation(s) in RCA: 237] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Antiretroviral therapy has changed human immunodeficiency virus (HIV) infection from a near-certainly fatal illness to one that can be managed chronically. More patients are taking antiretroviral drugs (ARVs) for longer periods of time, which naturally results in more observed toxicity. Overdose with ARVs is not commonly reported. The most serious overdose outcomes have been reported in neonates who were inadvertently administered supratherapeutic doses of HIV prophylaxis medications. Typical ARV regimens include a "backbone" of two nucleoside reverse transcriptase inhibitors (NRTI) and a "base" of either a protease inhibitor (PI) or nonnucleoside reverse transcriptase inhibitor. New classes of drugs called entry inhibitors and integrase inhibitors have also emerged. Older NRTIs were associated with mitochondrial toxicity, but this is less common in the newer drugs, emtricitabine, lamivudine, and tenofovir. Mitochondrial toxicity results from NRTI inhibition of a mitochondrial DNA polymerase. Mitochondrial toxicity manifests as myopathy, neuropathy, hepatic failure, and lactic acidosis. Routine lactate assessment in asymptomatic patients is not indicated. Lactate concentration should be obtained in patients taking NRTIs who have fatigue, nausea, vomiting, or vague abdominal pain. Mitochondrial toxicity can be fatal and is treated by supportive care and discontinuing NRTIs. Metabolic cofactors like thiamine, carnitine, and riboflavin may be helpful in managing mitochondrial toxicity. Lipodystrophy describes changes in fat distribution and lipid metabolism that have been attributed to both PIs and NRTIs. Lipodystrophy consists of loss of fat around the face (lipoatrophy), increase in truncal fat, and hypertriglyceridemia. There is no specific treatment of lipodystrophy. Clinicians should be able to recognize effects of chronic toxicity of ARVs, especially mitochondrial toxicity.
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Affiliation(s)
- Asa M Margolis
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, New York, NY, USA
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9
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Sitole L, Steffens F, Krüger TPJ, Meyer D. Mid-ATR-FTIR spectroscopic profiling of HIV/AIDS sera for novel systems diagnostics in global health. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2014; 18:513-23. [PMID: 24937213 DOI: 10.1089/omi.2013.0157] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Global health, whether in developed or developing countries, is in need of robust systems diagnostics for major diseases, such as HIV/AIDS, impacting the world populations. Fourier transform Infrared (FTIR) spectroscopy of serum is a quick and reagent-free methodology with which to analyze metabolic alterations such as those caused by disease or treatment. In this study, Attenuated Total Reflectance Fourier-Transform (ATR-FTIR) Spectroscopy was investigated as a means of distinguishing HIV-infected treatment-experienced (HIV(pos) ART(pos), n=39) and HIV-infected-treatment-naïve (HIV(pos) ART(neg), n=16) subjects from uninfected control subjects (n=30). Multivariate pattern recognition techniques, including partial least squares discriminant analysis (PLS-DA) and orthogonal partial least squares discriminant analysis (OPLS-DA), successfully distinguished sample classes, while univariate approaches identified significant differences (p<0.05) after Benjamini-Hochberg corrections. OPLS-DA discriminated between all groups with sensitivity, specificity, and accuracy of >90%. Compared to uninfected controls, HIV(pos) ART(pos) and HIV(pos) ART(neg) subjects displayed significant differences in spectral regions linked to lipids/fatty acids (3010 cm(-1)), carbohydrates (1299 cm(-1); 1498 cm(-1)), glucose (1035 cm(-1)), and proteins (1600 cm(-1); 1652 cm(-1)). These are all molecules shown by conventional biochemical analysis to be affected by HIV/ART interference. The biofluid metabolomics approach applied here successfully differentiated global metabolic profiles of HIV-infected patients and uninfected controls and detected potential biomarkers for development into indicators of host response to treatment and/or disease progression. Our findings therefore contribute to ongoing efforts for capacity-building in global health for robust omics science and systems diagnostics towards major diseases impacting population health.
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Affiliation(s)
- Lungile Sitole
- 1 Department of Biochemistry, University of Pretoria , Pretoria, South Africa
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10
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Abstract
We studied blood lactate levels in 253 South African children on antiretroviral therapy. The prevalence of hyperlactatemia was 68% and severity was mild in most cases (69%). There was no association of symptoms and/or signs with hyperlactatemia. Independent predictors were lipo-dystrophy, time on antiretroviral therapy and baseline CD4 count. Increased awareness of hyperlactatemia in African children on antiretroviral therapy is warranted.
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Mamiafo CT, Moor VJA, Nansseu JRN, Pieme CA, Tayou C, Yonkeu JN. Hyperlactatemia in a group of HIV patients living in Yaounde-Cameroon. AIDS Res Ther 2014; 11:2. [PMID: 24428886 PMCID: PMC3899605 DOI: 10.1186/1742-6405-11-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 01/10/2014] [Indexed: 01/09/2023] Open
Abstract
Background and aim Prolonged exposure to highly active antiretroviral therapy (HAART) is associated with adverse effects such as hyperlactatemia. We determined the prevalence and risk factors for developing hyperlactatemia among human immunodeficiency virus (HIV)-infected cameroonians on antiretroviral therapy (ART). Methods We conducted a cross-sectional study from January to April 2012 involving 91 HIV-infected patients receiving ART for at least 12 months and 30 HIV-infected patients who have never received ART (ART-naïve patients). Plasma lactate levels were determined after at least 12 hours of overnight fasting and hyperlactatemia defined as lactate concentrations ≥ 3 mmol/L. The prevalence of hyperlactatemia was determined and the risk factors were analyzed by a multivariate logistic regression model. Results The mean lactataemia was significantly higher in the group of HIV patients currently taking ART than in the ART-naïve one (2.3 ± 1.3 and 1.7 ± 0.7 mmol/L respectively, p = 0.002). Patients on first line ART regimens had significantly higher lactatemia than those on second line regimens (2.5 ± 1.5 and 1.9 ± 0.7 mmol/L respectively, p = 0.014). The prevalence of hyperlactatemia in HIV patients receiving ART and in ART-naïve HIV patients was respectively 18.7 and 6.7% (p = 0.095). ART-exposure (adjusted odds ratio (aOR) 5.44, 95% confidence interval (CI) 1.06 – 27.84; p = 0.042) and being on a first line regimen (aOR 16.22, 95% CI 1.57 – 167.91; p = 0.019) were independent strong predictors of hyperlactatemia. Conclusion Hyperlactatemia was not rare in our study population. Being on a first line regimen constitutes an important risk factor for developing hyperlactatemia. Measurement of plasma lactate may be useful in optimizing the management of HIV-positive persons on ART.
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Chagoma N, Mallewa J, Kaunda S, Njalale Y, Kampira E, Mukaka M, Heyderman RS, van Oosterhout JJ. Longitudinal lactate levels from routine point-of-care monitoring in adult Malawian antiretroviral therapy patients: associations with stavudine toxicities. Trans R Soc Trop Med Hyg 2013; 107:615-9. [PMID: 23926161 PMCID: PMC4023278 DOI: 10.1093/trstmh/trt074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction Stavudine is still widely used in under-resourced settings such as Malawi due to its low price. It frequently causes peripheral neuropathy and lipodystrophy and increases the risk of lactic acidosis and other high lactate syndromes. Methods We studied the association of longitudinal lactate levels, obtained by routine, 3-monthly point-of-care monitoring, with peripheral neuropathy, lipodystrophy and high lactate syndromes in adult Malawians who were in the second year of stavudine containing antiretroviral therapy (ART). Results Point-of-care lactate measurements were feasible in a busy urban ART clinic. Of 1170 lactate levels collected from 253 patients over the course of one year, 487 (41.8%) were elevated (>2.2mg/dl), 58 (5.0%) were highly elevated (>3.5mg/dl). At least one elevated lactate level occurred in 210 (83.0%) of patients and sustained hyperlactatemia in 65 (26.4%). In random effects analyses lipodystrophy and peripheral neuropathy were associated with higher lactate levels. Only five patients developed high lactate syndromes (one lactic acidosis) of whom no preceding lactate measurements were available because events had started before enrolment. Lactate levels significantly decreased over time and no high lactate syndromes were observed after the 15th month on ART. Conclusion Lipodystrophy and peripheral neuropathy were associated with higher lactate levels. Lactate levels decreased over time, coinciding with absence of new high lactate syndromes after the 15th month on ART.
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Affiliation(s)
- Newton Chagoma
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine
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Tan DHS, Walmsley SL. Management of persons infected with human immunodeficiency virus requiring admission to the intensive care unit. Crit Care Clin 2013; 29:603-20. [PMID: 23830655 DOI: 10.1016/j.ccc.2013.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Rates of admission to the intensive care unit (ICU) for persons infected with human immunodeficiency virus (HIV) remain relatively unchanged in the modern era despite advances in antiretroviral therapy (ART) and improvements in ICU survival. Critical care may be required for patients with HIV because of severe opportunistic infections or malignancy, antiretroviral drug toxicity, or critical illness seemingly unrelated to HIV, and each of these scenarios may present different management challenges. In this article, the epidemiology of HIV-related ICU admission is reviewed and key management issues are discussed.
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Affiliation(s)
- Darrell H S Tan
- Division of Infectious Diseases, University Health Network, Faculty of Medicine, University of Toronto, 585 University Avenue, 13 N, Toronto, Ontario M5G 2N2, Canada.
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Voss JG, Dobra A, Morse C, Kovacs JA, Danner RL, Munson PJ, Logan C, Rangel Z, Adelsberger JW, McLaughlin M, Adams LD, Raju R, Dalakas MC. Fatigue-related gene networks identified in CD(14)+ cells isolated from HIV-infected patients: part I: research findings. Biol Res Nurs 2013; 15:137-51. [PMID: 23324479 DOI: 10.1177/1099800411421957] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Human immunodeficiency virus (HIV)-related fatigue (HRF) is multicausal and potentially related to mitochondrial dysfunction caused by antiretroviral therapy with nucleoside reverse transcriptase inhibitors (NRTIs). METHODOLOGY The authors compared gene expression profiles of CD14(+) cells of low versus high fatigued, NRTI-treated HIV patients to healthy controls (n = 5/group). The authors identified 32 genes predictive of low versus high fatigue and 33 genes predictive of healthy versus HIV infection. The authors constructed genetic networks to further elucidate the possible biological pathways in which these genes are involved. RELEVANCE FOR NURSING PRACTICE: Genes including the actin cytoskeletal regulatory proteins Prokineticin 2 and Cofilin 2 along with mitochondrial inner membrane proteins are involved in multiple pathways and were predictors of fatigue status. Previously identified inflammatory and signaling genes were predictive of HIV status, clearly confirming our results and suggesting a possible further connection between mitochondrial function and HIV. Isolated CD14(+) cells are easily accessible cells that could be used for further study of the connection between fatigue and mitochondrial function of HIV patients. IMPLICATION FOR PRACTICE The findings from this pilot study take us one step closer to identifying biomarker targets for fatigue status and mitochondrial dysfunction. Specific biomarkers will be pertinent to the development of methodologies to diagnosis, monitor, and treat fatigue and mitochondrial dysfunction.
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Affiliation(s)
- Joachim G Voss
- Biobehavioral Nursing & Health Systems Department, University of Washington, School of Nursing, Seattle, WA 98195, USA.
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15
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Audiological monitoring for ototoxic tuberculosis, human immunodeficiency virus and cancer therapies in a developing world setting. The Journal of Laryngology & Otology 2012; 126:548-51. [PMID: 22459550 DOI: 10.1017/s0022215112000357] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ototoxic drugs are widely used in the developing world, without audiological monitoring. Epidemiological data on ototoxic deafness are lacking for developing countries. The public health aspect of ototoxicity is often overlooked, to the detriment of the individual patient. This paper reviews ototoxic hearing loss, particularly in sub-Saharan Africa, and also assesses the impact of treatments for tuberculosis, cancer and human immunodeficiency virus (the latter including highly active antiretroviral therapy) on ototoxic hearing loss. The paper also discusses obstacles to audiological monitoring for ototoxicity in the developing world, and the potential of audiology screening using applications for mobile devices.
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16
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Feeney ER, Chazallon C, O'Brien N, Meiffrédy V, Goodall RL, Aboulker JP, Cooper DA, Yeni P, Mallon PWG. Hyperlactataemia in HIV-infected subjects initiating antiretroviral therapy in a large randomized study (a substudy of the INITIO trial). HIV Med 2011; 12:602-9. [PMID: 21599820 DOI: 10.1111/j.1468-1293.2011.00934.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the predictive value of clinical and molecular risk factors, including peripheral blood mononuclear cell (PBMC) mitochondrial DNA (mtDNA) and mitochondrial RNA (mtRNA), for the development of lactic acidosis (LA) and symptomatic hyperlactataemia (SHL). METHODS In a substudy of a large multicentre, randomized trial of three antiretroviral regimens, all containing didanosine (ddI) and stavudine (d4T), in antiretroviralnaïve, HIV-1-infected patients, patients with LA/SHL ('cases') were compared with those without LA/SHL in a univariate analysis, with significant parameters analysed in a multivariate model. In a molecular substudy, PBMC mtDNA and mtRNA from cases and matched controls at baseline and time of event were examined. RESULTS In 911 subjects followed for a median of 192 weeks, 24 cases were identified (14 SHL and 10 LA). In univariate analysis, cases were more likely to be female (P=0.05) and to have a high body mass index (BMI) (P=0.02). In multivariate analyses, only BMI remained an independent predictor of the development of LA/SHL (P=0.03). Between cases and controls there was no significant difference in mtDNA copy number at baseline (389 vs. 411 copies/cell, respectively; P=0.60) or at time of event (329 vs. 474 copies/cell, respectively; P=0.21), in the change in mtDNA copy number from baseline to event (-65 vs. +113 copies/cell, respectively; P=0.12), in mtRNA expression at baseline or time of event, or in the change in mtRNA expression from baseline to event. CONCLUSION The development of LA/SHL was associated with increased BMI, but PBMC mtDNA and mtRNA did not predict LA/SHL. This demonstrates the ineffectiveness of routine measurement of PBMC mtDNA in patients on ddI and d4T as a means of predicting development of LA/SHL.
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Affiliation(s)
- E R Feeney
- HIV Molecular Research Group, School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland.
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Cost-effectiveness of antiretroviral regimens in the World Health Organization's treatment guidelines: a South African analysis. AIDS 2011; 25:211-20. [PMID: 21124202 DOI: 10.1097/qad.0b013e328340fdf8] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE the World Health Organization (WHO) recently changed its first-line antiretroviral treatment guidelines in resource-limited settings. The cost-effectiveness of the new guidelines is unknown. DESIGN comparative effectiveness and cost-effectiveness analysis using a model of HIV disease progression and treatment. METHODS using a simulation of HIV disease and treatment in South Africa, we compared the life expectancy, quality-adjusted life expectancy, lifetime costs, and cost-effectiveness of five initial regimens. Four are currently recommended by the WHO: tenofovir/lamivudine/efavirenz; tenofovir/lamivudine/nevirapine; zidovudine/lamivudine/efavirenz; and zidovudine/lamivudine/nevirapine. The fifth is the most common regimen in current use: stavudine/lamivudine/nevirapine. Virologic suppression and toxicities determine regimen effectiveness and cost-effectiveness. RESULTS choice of first-line regimen is associated with a difference of nearly 12 months of quality-adjusted life expectancy, from 135.2 months (tenofovir/lamivudine/efavirenz) to 123.7 months (stavudine/lamivudine/nevirapine). Stavudine/lamivudine/nevirapine is more costly and less effective than zidovudine/lamivudine/nevirapine. Initiating treatment with a regimen containing tenofovir/lamivudine/nevirapine is associated with an incremental cost-effectiveness ratio of $1045 per quality-adjusted life year compared with zidovudine/lamivudine/nevirapine. Using tenofovir/lamivudine/efavirenz was associated with the highest survival, fewest opportunistic diseases, lowest rate of regimen substitution, and an incremental cost-effectiveness ratio of $5949 per quality-adjusted life year gained compared with tenofovir/lamivudine/nevirapine. Zidovudine/lamivudine/efavirenz was more costly and less effective than tenofovir/lamivudine/nevirapine. Results were sensitive to the rates of toxicities and the disutility associated with each toxicity. CONCLUSION among the options recommended by WHO, we estimate only three should be considered under normal circumstances. Choice among those depends on available resources and willingness to pay. Stavudine/lamivudine/nevirapine is associated with the poorest quality-adjusted survival and higher costs than zidovudine/lamivudine/nevirapine.
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Dlamini J, Ledwaba L, Mokwena N, Mokhathi T, Orsega S, Tsoku M, Kowo H, Proschan M, Khabo P, Maja P, Hadigan C. Lactic acidosis and symptomatic hyperlactataemia in a randomized trial of first-line therapy in HIV-infected adults in South Africa. Antivir Ther 2011; 16:605-9. [DOI: 10.3851/imp1790] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Arenas-Pinto A, Grant A, Bhaskaran K, Copas A, Carr A, Worm SW, Martinez E, Reiss P, Dunn D, Weber R, Hoy J, Weller I. Risk factors for fatality in HIV-infected patients with dideoxynucleoside-induced severe hyperlactataemia or lactic acidosis. Antivir Ther 2011; 16:219-26. [PMID: 21447871 DOI: 10.3851/imp1739] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Lactic acidosis (LA) and severe hyperlactataemia (HL) are infrequent but serious complications of antiretroviral therapy that have been associated with a high fatality rate. METHODS In a multinational retrospective cohort study, LA was defined as arterial blood pH<7.35, bicarbonate <20 mmol/l and lactate above normal, and HL as confirmed blood lactate >5 mmol/l. Logistic regression was used to identify factors associated with fatality. Sensitivity and specificity of different case definitions as predictors of death were compared. RESULTS The overall case-fatality rate was 19/110 (17.3%), but among acidotic patients it was 33% (16/49 cases). There were 10 asymptomatic patients and none of them died as a consequence of the event. The median lactate for fatal, non-fatal and all patients was 8.3 mmol/l (IQR 7.2-13.1), 6.4 mmol/l (IQR 5.4-7.8) and 6.7 mmol/l (IQR 5.5-8.1), respectively. After adjusting for age and current CD4(+) T-cell count, lactate >7 mmol/l (OR 6.27, 95% CI 1.13-34.93), blood bicarbonate <12 mmol/l (OR 10.02 relative to >18 mmol/l, 95% CI 1.33-75.65) and concurrent opportunistic infections (OR 8.69, 95% CI 1.45-52.22) were independently associated with case fatality. Blood lactate >7 mmol/l showed a sensitivity of 84% for fatality with a specificity of 60%, whereas bicarbonate <12 mmol/l showed a better specificity (85%) but a poorer sensitivity (42%). Bicarbonate <18 mmol/l appears to be as good as lactate <7 mmol/l at predicting death (sensitivity 90% and specificity 54%). CONCLUSIONS Our data suggest that blood lactate >7 mmol/l and blood bicarbonate <18 mmol/l appear to predict death and might help clinicians in selecting patients who may benefit from more intense monitoring.
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Li Vecchi V, Soresi M, Colomba C, Mazzola G, Colletti P, Mineo M, Di Carlo P, La Spada E, Vizzini G, Montalto G. Transient elastography: A non-invasive tool for assessing liver fibrosis in HIV/HCV patients. World J Gastroenterol 2010; 16:5225-32. [PMID: 21049556 PMCID: PMC2975093 DOI: 10.3748/wjg.v16.i41.5225] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the prevalence of advanced liver fibrosis (ALF) in human immunodeficiency virus (HIV), hepatitis C virus (HCV) and HIV/HCV patients using transient elastography, and to identify factors associated with ALF.
METHODS: Between September 2008 and October 2009, 71 HIV mono-infected, 57 HIV/HCV co-infected and 53 HCV mono-infected patients on regular follow-up at our Center were enrolled in this study. Alcohol intake, the main parameters of liver function, presence of HCV-RNA, HIV-RNA, duration of highly active anti-retroviral therapy (HAART) and CD4 cell count were recorded. ALF was defined as liver stiffness (LS) ≥ 9.5 kPa. To estimate liver fibrosis (LF) a further 2 reliable biochemical scores, aspartate aminotransferase platelet ratio index (APRI) and FIB-4, were also used.
RESULTS: LS values of co-infected patients were higher than in either HIV or HCV mono-infected patients (χ2MH = 4, P < 0.04). In fact, LS ≥ 9.5 was significantly higher in co-infected than in HIV and HCV mono-infected patients (χ2 = 5, P < 0.03). Also APRI and the FIB-4 index showed more LF in co-infected than in HIV mono-infected patients (P < 0.0001), but not in HCV mono-infected patients. In HIV⁄HCV co-infected patients, the extent of LS was significantly associated with alcohol intake (P < 0.04) and lower CD4+ cell count (P < 0.02). In HCV patients, LS was correlated with alcohol intake (P < 0.001) and cholesterol levels (P < 0.03). Body mass index, diabetes, HCV- and HIV-viremia were not significantly correlated with LS. In addition, 20% of co-infected patients had virologically unsuccessful HAART; in 50% compliance was low, CD4+ levels were < 400 cells/mm3 and LS was > 9.5 kPa. There was no significant correlation between extent of LF and HAART exposure or duration of HAART exposure, in particular with specific dideoxynucleoside analogues.
CONCLUSION: ALF was more frequent in co-infected than mono-infected patients. This result correlated with lower CD4 levels. Protective immunological effects of HAART on LF progression outweigh its hepatotoxic effects.
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Koczor CA, Lewis W. Nucleoside reverse transcriptase inhibitor toxicity and mitochondrial DNA. Expert Opin Drug Metab Toxicol 2010; 6:1493-504. [PMID: 20929279 DOI: 10.1517/17425255.2010.526602] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE OF THE FIELD HIV/AIDS is a worldwide epidemic. While there remains no cure for the HIV-1 infection, nucleoside reverse transcriptase inhibitors (NRTIs) have helped transform the HIV-1 infection from a lethal disease into a chronic illness. Though NRTIs inhibit HIV-1 replication, they exhibit side effects in human tissues that appear to result from NRTI inhibition of human mitochondrial polymerase γ (pol γ). AREAS COVERED IN THIS REVIEW this review discusses the current knowledge of NRTI-induced toxicity, specifically the inhibition of pol γ and the mitochondrial toxicity from incorporation of NRTIs into mitochondrial DNA. Details are discussed about general mechanisms of NRTI toxicity and how specific tissue toxicities in mitochondria relate to clinical manifestation. WHAT THE READER WILL GAIN a detailed knowledge of the mitochondrial toxicity resulting from NRTI-inclusive therapies and related tissue toxicities are provided. This review presents both the molecular effects of NRTI usage on mitochondrial genetic homeostasis and energy metabolism as well as the clinical manifestations associated with NRTI toxicities. TAKE HOME MESSAGE NRTIs remain a critical component of current HIV-1 treatment regimens. Future NRTIs should provide higher specificity for HIV-RT and lower incorporation by pol γ to minimize mitochondrial toxicity. Alternatively, therapeutic interventions to prevent or alleviate mitochondrial toxicity should be addressed.
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Somarriba G, Neri D, Schaefer N, Miller TL. The effect of aging, nutrition, and exercise during HIV infection. HIV AIDS (Auckl) 2010; 2:191-201. [PMID: 22096398 PMCID: PMC3218696 DOI: 10.2147/hiv.s9069] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Medical advances continue to change the face of human immunodeficiency virus- acquired immunodeficiency syndrome (HIV/AIDS). As life expectancy increases, the number of people living with HIV rises, presenting new challenges for the management of a chronic condition. Aging, nutrition, and physical activity can influence outcomes in other chronic conditions, and emerging data show that each of these factors can impact viral replication and the immune system in HIV. HIV infection results in a decline of the immune system through the depletion of CD4+ T cells. From initial infection, viral replication is a continuous phenomenon. Immunosenescence, a hallmark of aging, results in an increased susceptibility to infections secondary to a delayed immune response, and this phenomenon may be increased in HIV-infected patients. Optimal nutrition is an important adjunct in the clinical care of patients with HIV. Nutritional interventions may improve the quality and span of life and symptom management, support the effectiveness of medications, and improve the patient's resistance to infections and other disease complications by altering immunity. Moderate physical activity can improve many immune parameters, reduce the risk of acute infection, and combat metabolic abnormalities. As people with HIV age, alternative therapies such as nutrition and physical activity may complement medical management.
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Affiliation(s)
- Gabriel Somarriba
- Division of Pediatric Clinical Research, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Daniela Neri
- Division of Pediatric Clinical Research, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Natasha Schaefer
- Division of Pediatric Clinical Research, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Tracie L Miller
- Division of Pediatric Clinical Research, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida, USA
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Abstract
Highly active antiretroviral therapy (HAART)-related hepatotoxicity complicates the management of patients infected with human immunodeficiency virus (HIV), increases medical costs, alters the prescription patterns, and affects the guideline recommendations. Among the clinical consequences derived from HAART-related liver toxicity, hypersensitivity reactions and lactic acidosis are recognized as acute events with potential to evolve into fatal cases, whereas there seems to be other syndromes not as well characterized but of equal concern as possible long-term liver complications. Belonging to the latter category of syndrome, HAART-related nonalcoholic steatohepatitis, liver fibrosis, portal hypertension, and nodular regenerative hyperplasia are discussed in this review. Updated information on liver toxicity of current antiretroviral drugs, including the most recently licensed, is provided. Management and prevention of liver toxicity among HIV-infected patients treated with HAART are reviewed as well.
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Affiliation(s)
- Marina Núñez
- Department of Internal Medicine, Wake Forest University Health Sciences, Winston Salem, NC 27157, USA.
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Minga A, Lewden C, Dohoun L, Abo Y, Emieme A, Coulibaly A, Salamon R, Eholié S, Anglaret X, Danel C. Short communication: Severe symptomatic hyperlactatemia among HIV type 1-infected adults on antiretroviral therapy in Côte d'Ivoire. AIDS Res Hum Retroviruses 2010; 26:991-5. [PMID: 20707728 DOI: 10.1089/aid.2009.0309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Stavudine is no longer recommended for use in first-line antiretroviral therapy (ART), but it remains in high demand worldwide because it is affordable. We report the clinical presentation and incidence of severe hyperlactatemia (SL) in HIV-infected adults who initiated ART between April 2005 and May 2009 in Côte d'Ivoire, West Africa. In a prospective cohort study at the HIV care center affiliated with the National Centre for Blood Transfusion, we used standardized forms to record baseline and follow-up data. We measured serum lactate levels for all adults on ART who showed signs of hyperlactatemia. SL was defined as serum lactate >2.5 mmol/liter. Overall, 806 adults initiated ART. Among the 591 patients (73%) on stavudine-containing regimens, 394 were women (67%); the median pre-ART CD4 count was 150/mm3 and the median body mass index was 20.9 kg/m2. These patients were followed for a median of 28 months. We detected SL only among patients taking stavudine. The incidence of SL was 0.55/100 person-years (PY) (95% CI 0.47-0.63) overall and 0.85/100 PY among women (95% CI 0.75-0.95). Among the eight patients with SL, 100% lost >9% of body weight before diagnosis, 100% had serum lactate >4 mmol/liter (range 4.2-12.1), 50% had pre-ART BMI >25 kg/m2, and three patients died (38%), accounting for 6.4% of deaths among patients taking stavudine. As long as HIV clinicians continue to use stavudine in sub-Saharan Africa, they should watch out for acute unexplained weight loss in patients taking ART, particularly among women and patients with high pre-ART BMI.
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Affiliation(s)
- Albert Minga
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
| | - Charlotte Lewden
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
| | | | - Yao Abo
- Programme PAC-CI, Abidjan, Côte d'Ivoire
| | | | - Ali Coulibaly
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Abidjan, Côte d'Ivoire
| | - Roger Salamon
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
| | - Serge Eholié
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- Service des Maladies Infectieuses et Tropicales, CHU de Treichville, Abidjan, Côte d'Ivoire
| | - Xavier Anglaret
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
| | - Christine Danel
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
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Kestler MH, Gardner EM, Cohn DL. Hepatic non-Hodgkin's lymphoma with lactic acidosis in HIV-infected patients: report of 2 cases. ACTA ACUST UNITED AC 2010; 9:301-5. [PMID: 20739590 DOI: 10.1177/1545109710377803] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report 2 patients with HIV-associated non-Hodgkin's lymphoma with massive hepatic involvement and lactic acidosis. The lactic acidosis was likely caused by excessive tumor lactate production coupled with impaired hepatic clearance. Although 1 patient died rapidly, the other survived for 7 months after receiving urgent combination chemotherapy. Clinicians should be aware of this condition and the importance of its early diagnosis and treatment.
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Affiliation(s)
- Mary H Kestler
- Department of Medicine, Division of Infectious Diseases, University of Colorado Denver, Aurora, CO, USA
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Hernández Pérez E, Dawood H. Stavudine-induced hyperlactatemia/lactic acidosis at a tertiary communicable diseases clinic in South Africa. ACTA ACUST UNITED AC 2010; 9:109-12. [PMID: 20484736 DOI: 10.1177/1545109710361536] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine the incidence, presentation, and outcome of hyperlactatemia and lactic acidosis. DESIGN AND METHODS SETTING: Grey's Hospital, a tertiary level referral institution. STUDY POPULATION A chart review of 1719 patients commenced on highly active antiretroviral therapy (HAART) between August 1, 2004, and July 31, 2006. A total of 1000 patients (615 females) received stavudine (d4T)/lamivudine (3TC)/efavirenz (EFV), 719 patients (598 females) received d4T/ 3TC/nevirapine (NVP). RESULTS Of the 1719 patients, 152 (8.84%) had an elevated plasma venous lactate (>2.2 mmol/L), 45 patients required admission for lactic acidosis. The overall incidence rate was 13.5 cases per 1000 patient years. The most common presenting symptoms were loss of weight (95%), abdominal pain (78.9%), loss of appetite, and paresthesias (63.8%). The median body mass index (BMI) at commencement of HAART and at onset of symptoms was 24.5 and 26, respectively. A median serum lactate level of 6.08 mmol/L (range 2.3-19.7 mmol/L) was observed at the onset of symptoms. CONCLUSIONS High BMI at treatment initiation did not always predict hyperlactatemia. All patients who died had a baseline CD4 count <10 cells/mm(3) at HAART initiation.
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Affiliation(s)
- Ernesto Hernández Pérez
- Infectious Diseases Unit, Department of Medicine, Grey's Hospital, Pietermaritzburg, South Africa
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Modayil RR, Harugeri A, Parthasarathi G, Ramesh M, Prasad R, Naik V, Giriyapura V. Adverse drug reactions to antiretroviral therapy (ART): an experience of spontaneous reporting and intensive monitoring from ART centre in India. Pharmacoepidemiol Drug Saf 2010; 19:247-55. [PMID: 20066675 DOI: 10.1002/pds.1907] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
PURPOSE To assess the nature, severity, predictability and preventability of adverse drug reactions (ADRs) and to identify risk factors for antiretroviral ADRs. METHODS Enrolled ambulatory patients were intensively monitored for ADRs. Spontaneously reported ADRs by clinicians were also included. Predictability was assessed based on history of previous exposure to the drug or literature incidence of ADRs. Preventability was assessed using Schumock and Thornton criteria and severity was assessed using modified Hartwig and Siegel scale. Bivariate analysis and subsequently multivariate logistic regression were used to identify the risk factors for ADRs. Data from spontaneous reporting was assessed using Bayesian neural network method for possible ADR signals. RESULTS Monitoring by active surveillance indentified 159 (52.82%) ADRs from 400 patients. One hundred and forty-two (47.17%) reactions were spontaneously reported. Anaemia and vomiting were the most commonly observed ADRs. The ADRs were severe in 10.9% of cases. A total of 88% ADRs were definitely/probably preventable. Use of Zidovudine+Lamivudine with Nevirapine or Efavirenz, CD4 <200 cells/microl, female gender, tuberculosis and illiteracy were observed as risk factors for ADRs by bivariate analysis. Concurrent tuberculosis was the only influential risk factor for development of ADRs identified by multivariate logistic regression. CONCLUSION Prevalence of ADRs in intensively monitored patients was found to be 39.7%. Tuberculosis in HIV patients is an influential risk factor for occurrence of ADRs. With the increasing access to antiretrovirals in India, ADRs to antiretrovirals require monitoring and reporting.
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Hooker DJ, Cherry CL. Apoptosis: a clinically useful measure of antiretroviral drug toxicity? Expert Opin Drug Metab Toxicol 2010; 5:1543-53. [PMID: 19785516 DOI: 10.1517/17425250903282781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Antiretroviral therapy (ART) has improved life expectancy with HIV infection, but long-term toxicities associated with these medications are now a major global disease burden. There is a clear need to develop useful methods for monitoring patients on antiretroviral drugs for early signs of toxicity. Assays with predictive utility -- allowing therapy to be changed before serious end organ damage occurs -- would be ideal. Attempts to develop biochemical methods of monitoring ART toxicity have concentrated on the mitochondrial toxicity of nucleoside analogue reverse transcriptase inhibitors and have not generally lead to assays with widespread clinical applications. For example, plasma lactate and peripheral blood measurements of mitochondrial DNA associate with exposure to potentially toxic nucleoside analogue reverse transcriptase inhibitors but have not reliably predicted clinical toxicity. Better assays are needed, including markers of toxicity from additional drug classes. Apoptosis may be a potential marker of ART toxicity. Increased apoptosis has been demonstrated both in vitro and in vivo in association with various antiretroviral drug classes and a range of clinical toxicities. However, quantifying apoptosis on biopsy specimens of tissue (such as adipose tissue) is impractical for patient monitoring. Novel assays have been described that can quantify apoptosis using minute tissue samples and initial results from clinical samples suggest peripheral blood may have utility in predicting ART toxicities. The limitations and potential of such techniques for monitoring patients for drug side effects will be discussed.
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Anuurad E, Semrad A, Berglund L. Human immunodeficiency virus and highly active antiretroviral therapy-associated metabolic disorders and risk factors for cardiovascular disease. Metab Syndr Relat Disord 2009; 7:401-10. [PMID: 19355810 DOI: 10.1089/met.2008.0096] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The successful introduction of highly active antiretroviral therapy (HAART), a combination of potent antiretroviral agents, including protease inhibitors, nucleoside reverse transcriptase inhibitors, and nonnucleoside reverse transcriptase inhibitors, has impacted positively on morbidity and mortality among human immunodeficiency virus (HIV)-positive patients. Over time, HAART has been associated with a number of metabolic and anthropometric abnormalities, including dyslipidemia and insulin resistance as well as subcutaneous fat loss and abdominal obesity, potentially contributing to cardiovascular risk. Recent studies have more firmly established that both HIV infection and HAART might increase the risk of clinical cardiovascular events. Furthermore, whereas HIV/HAART is associated with multiple aspects of endocrine dysfunction, there has been less focus on bone disease, although some studies indicate a higher prevalence of osteoporosis among HIV-positive subjects compared to HIV-negative controls. The relationship between bone and fat metabolism under HIV-positive conditions deserves further attention, and available data suggest the possibility of an intriguing connection. In the future, an increasing population of aging HIV-positive patients with a spectrum of antiretroviral therapies and accumulation of endocrine abnormalities and conventional cardiovascular risk factors will present preventive and therapeutic challenges to our health-care system.
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Affiliation(s)
- Erdembileg Anuurad
- Department of Medicine, University of California Davis, Sacramento, California 95817, USA
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Genetic and Functional Mitochondrial Assessment of HIV-Infected Patients Developing HAART-Related Hyperlactatemia. J Acquir Immune Defic Syndr 2009; 52:443-51. [DOI: 10.1097/qai.0b013e3181bd564c] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Maagaard A, Kvale D. Long term adverse effects related to nucleoside reverse transcriptase inhibitors: Clinical impact of mitochondrial toxicity. ACTA ACUST UNITED AC 2009; 41:808-17. [DOI: 10.3109/00365540903186181] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Osler M, Stead D, Rebe K, Meintjes G, Boulle A. Risk factors for and clinical characteristics of severe hyperlactataemia in patients receiving antiretroviral therapy: a case-control study. HIV Med 2009; 11:121-9. [PMID: 19702629 DOI: 10.1111/j.1468-1293.2009.00754.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Symptomatic hyperlactataemia and lactic acidosis (SHLA) are potentially life-threatening complications associated with stavudine (d4T), an antiretroviral therapy (ART) drug widely used in developing countries. METHODS Cases comprised all symptomatic patients with measured lactates >or= 5 mmol/L referred to a South African hospital between August 2003 and November 2005. Matched controls were selected according to facility and duration on ART. RESULTS Seventy-one cases and 142 controls were included in the study. The majority of cases presented between 6 and 18 months on ART. Female sex [adjusted odds ratio (AOR) 23.4; 95% confidence interval (CI) 4.0-136.6], a baseline weight between 60 and 75 kg (AOR 4.5; 95% CI 1.4-14.1) or, in particular, >or= 75 kg (AOR 19.4; 95% CI 4.1-82.5) at ART initiation and gaining >or= 6 kg in the first 3 months on therapy (AOR 3.5; 95% CI 1.3-9.5) were independent risk factors identifying patients who may subsequently develop SHLA. Weight loss of >or= 2 kg (AOR 6.1; 95% CI 2.0-18.3), a rise in alanine aminotransferase (ALT) >or= 10 U/L (AOR 3.1; 95% CI 1.1-8.9), the presence of at least one of three major symptoms (vomiting, nausea and abdominal pains) of SHLA (AOR 12.6; 95% CI 3.3-47.2) and peripheral neuropathy (AOR 3.4; 95% CI 1.1-9.8) were the clinical parameters that were most able to identify patients with early manifestations of SHLA. CONCLUSIONS This is the first case-control study for SHLA in Southern Africa. Given these findings, we advise that stavudine is avoided in overweight women. Weight loss, a rise in ALT, peripheral neuropathy and/or gastrointestinal symptoms should prompt healthcare workers to assess for SHLA, especially at between 6 and 18 months on ART.
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Affiliation(s)
- Meg Osler
- Infectious Disease Epidemiology Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
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Govindarajan R, Leung GPH, Zhou M, Tse CM, Wang J, Unadkat JD. Facilitated mitochondrial import of antiviral and anticancer nucleoside drugs by human equilibrative nucleoside transporter-3. Am J Physiol Gastrointest Liver Physiol 2009; 296:G910-22. [PMID: 19164483 PMCID: PMC2670673 DOI: 10.1152/ajpgi.90672.2008] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Human equilibrative nucleoside transporter-3 (hENT3) was recently reported as a pH-dependent, intracellular (lysosomal) transporter capable of transporting anti-human immunodeficiency virus (HIV) dideoxynucleosides (ddNs). Because most anti-HIV ddNs (e.g., zidovudine, AZT) exhibit clinical mitochondrial toxicity, we investigated whether hENT3 facilitates transport of anti-HIV ddNs into the mitochondria. Cellular fractionation and immunofluorescence microscopy studies in several human cell lines identified a substantial presence of hENT3 in the mitochondria, with additional presence at the cell surface of two placental cell lines (JAR, JEG3). Mitochondrial or cell surface hENT3 expression was confirmed in human hepatocytes and placental tissues, respectively. Unlike endogenous hENT3, yellow fluorescent protein (YFP)-tagged hENT3 was partially directed to the lysosomes. Xenopus oocytes expressing NH2-terminal-deleted hENT3 (expressed at the cell surface) showed pH-dependent interaction with several classes of nucleosides (anti-HIV ddNs, gemcitabine, fialuridine, ribavirin) that produce mitochondrial toxicity. Transport studies in hENT3 gene-silenced JAR cells showed significant reduction in mitochondrial transport of nucleosides and nucleoside drugs. Our data suggest that cellular localization of hENT3 is cell type dependent and the native transporter is substantially expressed in mitochondria and/or cell surface. hENT3-mediated mitochondrial transport may play an important role in mediating clinically observed mitochondrial toxicity of nucleoside drugs. In addition, our finding that hENT3 is a mitochondrial transporter is consistent with the recent finding that mutations in the hENT3 gene cause an autosomal recessive disorder in humans called the H syndrome.
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Affiliation(s)
- Rajgopal Govindarajan
- Department of Pharmaceutics, University of Washington, Seattle, Washington; and Division of Gastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - George P. H. Leung
- Department of Pharmaceutics, University of Washington, Seattle, Washington; and Division of Gastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mingyan Zhou
- Department of Pharmaceutics, University of Washington, Seattle, Washington; and Division of Gastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chung-Ming Tse
- Department of Pharmaceutics, University of Washington, Seattle, Washington; and Division of Gastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joanne Wang
- Department of Pharmaceutics, University of Washington, Seattle, Washington; and Division of Gastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jashvant D Unadkat
- Department of Pharmaceutics, University of Washington, Seattle, Washington; and Division of Gastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Shikuma CM, Gerschenson M, Chow D, Libutti DE, Willis JH, Murray J, Capaldi RA, Marusich M. Mitochondrial oxidative phosphorylation protein levels in peripheral blood mononuclear cells correlate with levels in subcutaneous adipose tissue within samples differing by HIV and lipoatrophy status. AIDS Res Hum Retroviruses 2008; 24:1255-62. [PMID: 18844460 DOI: 10.1089/aid.2007.0262] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Depletion of mitochondrial DNA (mtDNA) and mtDNA-encoded respiratory chain proteins in subcutaneous (SC) fat from patients with HIV lipoatrophy have clearly demonstrated the role of mitochondrial dysfunction in this syndrome. Research in HIV lipoatrophy, however, has been severely hampered by the lack of a suitable surrogate marker in blood or other easily obtained clinical specimens as fat biopsies are invasive and mtDNA levels in peripheral blood mononuclear cells (PBMC) do not consistently correlate with the disease process. We used a simple, rapid, quantitative 2-site dipstick immunoassay to measure OXPHOS enzymes Complex I (CI) and Complex IV (CIV), and rtPCR to measure mtDNA in 26 matched SC fat and PBMC specimens previously banked from individuals on potent antiretroviral (ARV) therapy with HIV lipoatrophy, on similar ARV therapy without lipoatrophy, and in HIV seronegative controls. Significant correlations were found between the respective PBMC and fat levels for both CI (r = 0.442, p = 0.024) and for CIV (r = 0.507, p = 0.008). Both CI and CIV protein levels were also significantly reduced in both PBMCs and fat in lipoatrophic subjects compared to HIV seronegative controls (p < or = 0.05), while a comparative reduction in mtDNA levels in lipoatrophic subjects was observed only in fat. We conclude that CI and CIV levels in PBMCs correlate to their respective levels in fat and may have utility as surrogate markers of mitochondrial dysfunction in lipoatrophy.
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Affiliation(s)
- Cecilia M. Shikuma
- Hawaii AIDS Clinical Research Program, John A. Burns School of Medicine, University of Hawaii–Manoa, Honolulu, Hawaii 96816
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii–Manoa, Honolulu, Hawaii 96816
| | - Mariana Gerschenson
- Hawaii AIDS Clinical Research Program, John A. Burns School of Medicine, University of Hawaii–Manoa, Honolulu, Hawaii 96816
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii–Manoa, Honolulu, Hawaii 96816
| | - Dominic Chow
- Hawaii AIDS Clinical Research Program, John A. Burns School of Medicine, University of Hawaii–Manoa, Honolulu, Hawaii 96816
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii–Manoa, Honolulu, Hawaii 96816
- Department of Pediatrics, John A. Burns School of Medicine, University of Hawaii–Manoa, Honolulu, Hawaii 96816
| | - Daniel E. Libutti
- Hawaii AIDS Clinical Research Program, John A. Burns School of Medicine, University of Hawaii–Manoa, Honolulu, Hawaii 96816
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Sundaram M, Srinivas CN, Shankar EM, Deepak M, Murugavel KG, Balakrishnan P, Solomon S, Kumarasamy N. Co-factors for abnormal lactate levels among persons with HIV disease at a tertiary HIV care setting in South India. Food Chem Toxicol 2008; 46:2823-5. [PMID: 18586371 DOI: 10.1016/j.fct.2008.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Revised: 04/28/2008] [Accepted: 05/16/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND The co-factors underlying abnormal lactate level remains to be determined in resource-limited settings. In a cross-sectional study conducted between January 2004 and July 2006, we determined the proportion of HIV-infected persons with abnormal lactate levels and correlated the association of certain co-factors of abnormal lactate levels at a tertiary HIV care centre in Chennai, Southern India. METHODS Lactate was estimated by the enzymatic method using an Olympus AU 400 autoanalyzer. Absolute CD4+T lymphocyte count was determined by the Guava personal cell analyser (Guava Technologies Inc., Hayward, CA, USA). Subjects were classified to have normal or abnormal values of lactate based on the reference interval (0.3-2.2 mmol/L). A p value 0.05 was considered statistically significant. RESULTS A total of 225 HIV-infected individuals (HAART experienced 213 (95%) and HAART naïve (5%)) were included in the analysis. Mean age was 34+/-8 and 36+/-9 years for the individuals with normal and abnormal lactate levels respectively. Of these 185 (82%) had normal (0.3-2.2 mmol/L) and 40 (18%) had abnormal (>2.2 mmol/L) lactate levels. Significant difference in relation to female gender was observed between the normal and abnormal groups (p=0.03). Among the abnormal group, 39 (97.5%) subjects were HAART experienced compared to 174 (94.1%) normal group. Among the abnormal group, 24 (60%) individuals had a CD4 count of <200 cells/microL as compared to 76 (41.1%) normal subjects. CONCLUSION Female gender should be carefully monitored with respect to their clinical, laboratory and biological data to diminish the occurrence of lactic acidosis.
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Affiliation(s)
- Muthu Sundaram
- YRG Centre for AIDS Research and Education (YRG CARE), Voluntary Health Services, Rajiv Gandhi Salai, Chennai 600 113, India
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Makinson A, Moing VL, Kouanfack C, Laurent C, Delaporte E. Safety of stavudine in the treatment of HIV infection with a special focus on resource-limited settings. Expert Opin Drug Saf 2008; 7:283-93. [PMID: 18462186 DOI: 10.1517/14740338.7.3.283] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Western randomized trials and prospective cohorts in resource-limited settings have proven virological success with stavudine-based highly active antiretroviral therapy. However, stavudine is no longer recommended in first-line treatments in these two settings due to its intrinsic toxicities and side effects. Yet it remains a cornerstone of treatment in resource-limited settings, due to lack of alternatives and its availability in generic fixed-dose combinations. OBJECTIVE To review the toxic effects of stavudine and their prevention and management strategies, especially in resource-limited settings. METHODS Data from clinical and pharmacological trials in Western countries, as well as prospective cohorts in resource-limited settings, were reviewed. CONCLUSION Initiating or switching to less toxic nucleoside analogues whenever possible, or lowering stavudine doses to 30 mg b.i.d., is strongly recommended.
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Affiliation(s)
- Alain Makinson
- University Hospital, Department of Infectious and Tropical Diseases, Montpellier, France
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Manosuthi W, Prasithsirikul W, Chumpathat N, Suntisuklappon B, Athichathanabadi C, Chimsuntorn S, Sungkanuparph S. Risk factors for mortality in symptomatic hyperlactatemia among HIV-infected patients receiving antiretroviral therapy in a resource-limited setting. Int J Infect Dis 2008; 12:582-6. [PMID: 18337140 DOI: 10.1016/j.ijid.2007.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Accepted: 12/13/2007] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES To determine the mortality rate and risk factors after experiencing symptomatic hyperlactatemia in HIV-infected patients receiving antiretroviral therapy (ART). METHODS A retrospective cohort study was conducted among patients who were diagnosed with symptomatic hyperlactatemia (lactate >2.5mmol/l) between January 2004 and April 2006. All patients were followed until 3 months after the diagnosis. RESULTS One hundred and twenty-five patients were included in the study. The mean+/-standard deviation (SD) age was 39.9+/-10.1 years and body weight was 58.2+/-16.9kg; 60.8% were male. Symptomatic hyperlactatemia in 114 (91.2%) was associated with receiving d4T, in five (4.0%) with d4T+ddI, in four (3.2%) with ZDV+ddI, and in two (1.6%) with ddI (d4T, stavudine; ddI, didanosine; ZDV, zidovudine). The median duration of ART was 13 months. Nine (7.2%) patients died. Patients who died had a higher mean lactate level (8.0 vs. 5.1mmol/l) and mean alanine aminotransferase (ALT; 164 vs. 48U/l) at the time of diagnosis when compared to those who survived (p<0.05). Patients who died had a lower mean weight than those who survived (48 vs. 59kg, p=0.008). By logistic regression, mortality was associated with patients whose body weight was <45kg (p=0.014, odds ratio (OR) 9.090, 95% confidence interval (CI) 1.575-52.632) and whose serum lactate was >10mmol/l (p=0.004, OR 20.372, 95% CI 2.610-159.001). CONCLUSIONS The mortality rate of symptomatic hyperlactatemia among HIV-infected patients receiving ART is substantial. Almost all patients received d4T. Patients who have a low body weight and high serum lactate level are at a higher risk of mortality.
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Affiliation(s)
- Weerawat Manosuthi
- Department of Medicine, Bamrasnaradura Infectious Diseases Institute, Ministry of Public Health, Tiwanon Road, Nonthaburi, 11000, Thailand.
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Falutz J. Therapy insight: Body-shape changes and metabolic complications associated with HIV and highly active antiretroviral therapy. ACTA ACUST UNITED AC 2008; 3:651-61. [PMID: 17710086 DOI: 10.1038/ncpendmet0587] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2006] [Accepted: 05/25/2007] [Indexed: 12/28/2022]
Abstract
Increasingly effective therapies for HIV infection are now available. These treatments, referred to collectively as highly active antiretroviral therapy, comprise various combinations of anti-HIV drugs from different drug classes. Recently, a range of metabolic complications have emerged as important toxicities in treated patients. Complications present as abnormalities of body-fat mass distribution in association with an often significant dyslipidemia and glucose homeostasis dysregulation. The body-shape changes, manifesting as peripheral lipoatrophy or central lipohypertrophy, can have a negative impact on quality of life and consequently on adherence to treatment. The combination of central lipohypertrophy, dyslipidemia and insulin resistance is associated with accelerated rates of atherosclerosis and other potentially significant long-term effects. The pathogenesis of these effects is complex and is still being actively investigated. Possible contributing factors relate to host characteristics, HIV viral parameters and specific effects of anti-HIV drugs on adipose-tissue biology and on intermediary metabolism. Management of these complications involves manipulation of the anti-HIV drugs using an understanding of their particular effects on lipid and glucose metabolism, in association with standard therapeutic interventions. Individualized approaches, taking into consideration quality-of-life issues, and assessment of potential cardiovascular risks, are now an important component of effective care of HIV-infected patients.
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Affiliation(s)
- Julian Falutz
- Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada.
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Higher-than-expected rates of lactic acidosis among highly active antiretroviral therapy-treated women in Botswana: preliminary results from a large randomized clinical trial. J Acquir Immune Defic Syndr 2008; 46:318-22. [PMID: 18090299 DOI: 10.1097/qai.0b013e3181568e3f] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The ability of nucleoside reverse transcriptase inhibitors (NRTIs) to inhibit human mitochondrial polymerase-gamma results in impaired synthesis of mitochondrial enzymes that generate adenosine triphosphate (ATP) by oxidative phosphorylation. This has been associated with several long-term mitochondrial toxicities, which include lactic acidosis and pancreatitis, peripheral neuropathy, and lipoatrophy. METHODS Enrolled highly active antiretroviral therapy (HAART)-treated adults have completed nearly 2 years of follow-up as part of the ongoing randomized clinical trial Adult Antiretroviral Treatment and Drug Resistance (Tshepo) study. All patients were intensively screened for the presence of ARV-related toxicities. RESULTS Six hundred fifty adults (69% female) were initiated on NRTI-based HAART. Overall, 2.0% of patients developed moderate to severe symptomatic hyperlactatemia, with 7 (1.0%), all female, diagnosed with lactic acidosis. Female gender (P = 0.008) and being overweight, namely having a body mass index (BMI) of greater than 25 (P = 0.001), were predictive for the development of moderate to severe symptomatic hyperlactatemia or lactic acidosis. Older age (age >40 years) showed a statistical trend (P = 0.053) as a predictor for the development of toxicity, whereas exposure to d4T and/or ddI for 6 or more months was not predictive (P = 0.102). Those diagnosed with lactic acidosis had a mean BMI of 32.38 (interquartile range [IQR] = 29.4 to 35) at the time of toxicity and had been receiving HAART for a mean of 12.1 months (IQR = 7 to 20.8). Four of the 7 (57%) died of lactic acidosis and/or hemorrhagic pancreatitis; these 4 patients also had a comorbid diagnosis of severe clinical pancreatitis with grade 3/4 lipase elevations and abdominal symptoms at the time of their demise. CONCLUSIONS Rates of lactic acidosis appear to be higher in southern Africa when compared with rates previously described elsewhere. Risk factors for the development of moderate to severe symptomatic hyperlactatemia or lactic acidosis appear to be multifactorial but include female gender and having a BMI of greater than 25. Additional studies are ongoing to evaluate for other possible risk factors, such as host genetic differences.
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Risk factors for lactic acidosis and severe hyperlactataemia in HIV-1-infected adults exposed to antiretroviral therapy. AIDS 2007; 21:2455-64. [PMID: 18025882 DOI: 10.1097/qad.0b013e3282f08cdc] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe hyperlactataemia and lactic acidosis are rare serious complications of antiretroviral therapy (ART). METHODS Lactic acidosis was defined as pH < 7.35, bicarbonate < 20 mmol/l and raised lactate; hyperlactataemia as two consecutive lactates > 5 mmol/l. The case-control study of 110 cases and 220 controls(two randomly selected from treated patients by centre and calendar year) from centres in 10 countries included 40 (36.4%) female cases and 40 female controls (18.2%) (P < 0.001). Median age was 42.4 years [interquartile range (IQR, 36.0-52.5] for cases and 40 (IQR, 35.0-47.1) for controls (P = 0.013). More cases were nonwhite (41.9%) than controls (31.2%) (P = 0.032). Cases had a shorter duration of exposure to dideoxynucleosides. RESULTS After adjusting for age, gender and current CD4 cell count, hyperlactataemia/lactic acidosis remained associated with exposure to didanosine in every category of exposure duration but was most strongly associated with exposure < 12 months. In a separate multivariable model, apart from exposure to stavudine, didanosine, or even more strongly both, age above 40 years [odds ratio (OR), 2.6; 95% confidence interval (CI), 1.08-6.29], female gender (OR, 5.97; 95% CI, 1.92-18.5) and advanced immunosuppression were independent associations (CD4 cell count 200-349, 100-199 and < 100 cells/mul: OR, 3.89, 7.58 and 8.11, respectively). INTERPRETATION Hyperlactataemia/lactic acidosis was associated with exposure to dideoxynucleosides, female gender, advanced immunosuppression and possibly ethnicity. This has important consequences for choice of ART in resource-limited settings. The association with shorter duration of exposure may support the hypothesis of susceptibility in a small proportion of patients.
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Duong M, Dumas JP, Buisson M, Martha B, Piroth L, Grappin M, Waldner A, Chavanet P, Portier H. Limitation of exercise capacity in nucleoside-treated HIV-infected patients with hyperlactataemia. HIV Med 2007; 8:105-11. [PMID: 17352767 DOI: 10.1111/j.1468-1293.2007.00439.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Inhibition of DNA polymerase gamma by nucleoside reverse transcriptase inhibitors (NRTIs) can cause mitochondrial dysfunction and cellular toxicity. Hyperlactataemia, which is a consequence of a shift in the metabolism of pyruvate, is an indicator of nucleoside-related mitochondrial toxicity. METHODS We evaluated exercise and oxidative capacities as well as circulatory and ventilatory responses to exercise in 24 HIV-infected patients on NRTIs presenting hyperlactataemia [mean (+/-standard deviation) fasted lactate=3.5+/-1.1 mmol/L]; 27 NRTI-treated patients with normal baseline lactate concentrations were used as controls (mean fasted lactate=1.6+/-0.3 mmol/L). RESULTS In the patients with hyperlactataemia, the average peak work capacity (1.7+/-0.6 W/kg) and peak oxygen consumption (VO(2)) (21+/-4 mL/kg/min) were significantly lower (P<0.01) than in control subjects (work, 2.1+/-0.4 W/kg; VO(2), 25+/-4 mL/kg/min). The capacity to increase oxygen extraction during exercise was significantly diminished in the hyperlactataemia group, as shown by a low peak systemic arteriovenous oxygen difference (a-vO(2)) difference compared with controls (11+/-3 vs 14+/-3 mL/dL; P=0.008), and as indicated by a linear correlation between VO(2) and systemic a-vO(2) difference (r(2)=0.76). During exercise, the increases in cardiac output relative to VO(2) (mean Delta cardiac output (Q)/DeltaVO(2)=8+/-3.6) and ventilation (mean Delta ventilation (VE)/DeltaVO(2)=48.6+/-13.2) were significantly higher in hyperlactataemia patients compared with controls (mean cardiac output Delta(Q)/DeltaVO(2)=6+/-2; mean DeltaVE/DeltaVO(2)=42+/-12.7; P=0.03). CONCLUSIONS The degree of exercise limitation in patients with nucleoside-related mitochondrial toxicity correlates directly with the severity of impaired muscle oxidative phosphorylation, as indicated by the capacity for muscle oxygen extraction. Exaggerated circulatory and ventilatory responses to exercise are direct consequences of the level of impaired muscle oxidative phosphorylation.
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Affiliation(s)
- M Duong
- Service des Maladies Infectieuses, Hôpital Universitaire du Bocage, Dijon, France.
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Venhoff N, Walker UA. Mitochondrial disease in the offspring as a result of antiretroviral therapy. Expert Opin Drug Saf 2007; 5:373-81. [PMID: 16610967 DOI: 10.1517/14740338.5.3.373] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Nucleoside analogue reverse transcriptase inhibitors (NRTIs) have substantially lowered the risk of the mother-to-child transmission of HIV. Evidence of mitochondrial toxicity in vitro, in animal models and in adult HIV-infected patients, has raised concern about the perinatal safety of these antiretrovirals. In zidovudine-exposed, but HIV-uninfected infants, transient anaemia and additional long-term blood abnormalities (neutropenia, thrombopenia and lymphopenia) and hyperlactatemia have been documented. The overall risk of mortality and congenital abnormalities does not appear to be increased, but rare mitochondrial events cannot be excluded for lack of statistical power. French data suggest an above background incidence of mitochondrial symptomatology. Preclinical data demonstrate zidovudine also to be a carcinogen. Long-term systematic follow-up of exposed babies in large cohorts is needed, as are randomised trials with NRTIs carrying a lower risk of mitochondrial toxicity.
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Affiliation(s)
- Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medizinische Universitätsklinik, Hugstetterstr. 55, D-79106 Freiburg, Germany
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Venhoff N, Setzer B, Melkaoui K, Walker UA. Mitochondrial Toxicity of Tenofovir, Emtricitabine and Abacavir Alone and in Combination with Additional Nucleoside Reverse Transcriptase Inhibitors. Antivir Ther 2007. [DOI: 10.1177/135965350701200704] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Some nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) combinations cause additive or synergistic interactions in vitro and in vivo. Methods We evaluated the mitochondrial toxicity of tenofovir (TFV), emtricitabine (FTC) and abacavir as carbovir (CBV) alone, with each other, and in combination with additional NRTIs. HepG2 human hepatoma cells were incubated with TFV, FTC, CBV, didanosine (ddI), stavudine (d4T), lamivudine (3TC) and zidovudine (AZT) at concentrations equivalent to 1 and 10x clinical steady-state peak plasma levels (Cmax). NRTIs were also used in double and triple combinations. Cell growth, lactate production, intracellular lipids, mtDNA and the mtDNA-encoded respiratory chain subunit II of cytochrome c oxidase (COXII) were monitored for 25 days. Results TFV and 3TC had no or minimal toxicity. FTC moderately reduced hepatocyte proliferation independent of effects on mtDNA. ddI and d4T induced a time- and dose-dependent loss of mtDNA and COXII, decreased cell growth and increased levels of lactate and intracellular lipids. CBV and AZT strongly impaired hepatocyte proliferation and increased lactate and lipid production, but did not induce mtDNA depletion. The dual combination of TFV plus 3TC had only minimal toxicity; TFV plus FTC slightly reduced cell proliferation without affecting mitochondrial parameters. All other combinations exhibited more pronounced adverse effects on mitochondrial endpoints. Toxic effects on mitochondrial parameters were observed in all combinations with ddI, d4T, AZT or CBV. TFV and 3TC both attenuated ddI-related cytotoxicity, but worsened the effects of CBV and AZT. Conclusions The data demonstrate unpredicted interactions between NRTIs with respect to toxicological endpoints and provide an argument against the liberal use of NRTI cocktails without first obtaining data from clinical trials.
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Affiliation(s)
- Nils Venhoff
- Medizinische Universitätsklinik, Department of Rheumatology & Clinical Immunology, Freiburg, Germany
| | - Bernhard Setzer
- Medizinische Universitätsklinik, Department of Rheumatology & Clinical Immunology, Freiburg, Germany
| | - Kerstina Melkaoui
- Medizinische Universitätsklinik, Department of Rheumatology & Clinical Immunology, Freiburg, Germany
| | - Ulrich A Walker
- Medizinische Universitätsklinik, Department of Rheumatology & Clinical Immunology, Freiburg, Germany
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Abstract
Antiretroviral therapy (ART) for HIV infection frequently has been associated with elevated liver enzyme levels. Determining the cause of elevated liver enzyme levels in patients who have HIV is difficult because ART usually consists of three different drugs, patients may be taking additional hepatotoxic medications and patients who have HIV often suffer from other liver diseases. Several agents, however, are recognized as having noteworthy and specific patterns of toxicity. This article reviews the different HIV drug classes, incidence of elevated liver enzyme values by class and by individual drug, risk factors, specific toxicities, and possible mechanisms of injury.
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Affiliation(s)
- Mamta K Jain
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9113, USA.
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Zou W, Berglund L. HIV and highly active antiretroviral therapy: dyslipidemia, metabolic aberrations, and cardiovascular risk. ACTA ACUST UNITED AC 2007; 10:96-103; quiz 104-5. [PMID: 17392622 DOI: 10.1111/j.1520-037x.2007.03071.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Wei Zou
- Department of Medicine, Division of Endocrinology, Clinical Nutrition, and Vascular Medicine, University of California School of Medicine, Sacramento, CA 95812, USA
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Bolhaar MG, Karstaedt AS. A High Incidence of Lactic Acidosis and Symptomatic Hyperlactatemia in Women Receiving Highly Active Antiretroviral Therapy in Soweto, South Africa. Clin Infect Dis 2007; 45:254-60. [PMID: 17578788 DOI: 10.1086/518976] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2006] [Accepted: 03/18/2007] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Lactic acidosis and symptomatic hyperlactatemia may complicate nucleoside reverse-transcriptase inhibitor use. Females may be at increased risk for such complications. Our study evaluated the incidence of lactic acidosis and symptomatic hyperlactatemia by sex, analyzed clinical features, and described the safety of reintroducing highly active antiretroviral therapy (HAART) with zidovudine replacing stavudine. METHODS A retrospective cohort analysis was performed for 1735 adults (63% of whom were female) who initiated HAART from April 2004 through August 2005 in Soweto, South Africa, with follow-up until February 2006. Patients with lactate levels > or =4.5 mmol/L and no potential cause of elevated lactic acidosis other than receipt of HAART were included in the study. RESULTS A total of 23 patients (22 of whom were female) experienced lactic acidosis. The overall incidence was 10.6 cases per 1000 patient-years; the incidence was 16.1 cases per 1000 patient-years in female patients and 1.2 cases per 1000 patient-years in male patients. Seven (30.4%) of the patients died. Eight (34.8%) of the patients were obese (body mass index [calculated as weight in kilograms divided by the square of height in meters], >30) at HAART initiation. Forty-four patients (37 of whom were female) had symptomatic hyperlactatemia. The overall incidence was 20.2 cases per 1000 patient-years, with an incidence of 27.0 cases per 1000 patient-years in female patients and 8.7 cases per 1000 patient-years in male patients. None of the patients died. Nine (20.4%) of the patients were obese at HAART initiation. Sixty-six of 67 patients were receiving stavudine, and 5 patients were receiving didanosine. Among 56 patients who restarted HAART with zidovudine for a cumulative nucleoside reverse-transcriptase inhibitor reexposure of 44.6 patient-years--including 41 patients who received treatment for > or =9 months--there were no relapses. CONCLUSION Women in Soweto, South Africa, have a higher frequency of symptomatic hyperlactatemia and lactic acidosis than has been reported for patients in other study groups. In cases associated with stavudine use, restarting HAART with zidovudine seemed to be safe and effective for patients with limited nucleoside reverse-transcriptase inhibitor alternatives.
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Affiliation(s)
- M G Bolhaar
- Division of Infectious Diseases, Department of Medicine, University of the Witwatersrand and Chris Hani Baragwanath Hospital, Johannesburg, South Africa
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Santos Corraliza E, Fuertes Martín A. Tratamiento antirretroviral y toxicidad mitocondrial. Med Clin (Barc) 2007; 128:311-6. [PMID: 17338866 DOI: 10.1157/13099580] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The introduction of highly active antiretroviral therapy for the treatment of human immunodeficiency virus (HIV) infection has led to substantial reduction in morbidity and near-complete suppression of HIV-1 replication. This progress has been tempered by a growing number of new adverse effects. Mitochondrial toxicity is one aspect of these long-term toxicities of antiretroviral drugs, with the role of nucleoside analogs being particularly underlined. Some cases of impaired mitochondrial function have been clearly identified, such as pancreatitis, neuropathy, miopathy and lactic acidosis. Beyond the inhibition of DNA polymerase-g using nucleoside analogs, it appears that several physiopathologic mechanisms interact to explain the observed toxicity. At present there is no reliable method to detect subclinical mitochondrial toxicity. There is no proven effective therapy for antiretroviral therapy-associated mitochondrial toxicity other than ceasing the implicated agent, and even with this strategy, resolution of symptoms may be incomplete. Therefore, investigation of mitochondrial toxicity of new compounds or new combinations is of growing interest for the clinical application of antiretroviral agents.
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Liver-Related Complications in HIV-Infected Individuals. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2007. [DOI: 10.1097/01.idc.0000246152.78893.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Boulassel MR, Morales R, Murphy T, Lalonde RG, Klein MB. Gender and long-term metabolic toxicities from antiretroviral therapy in HIV-1 infected persons. J Med Virol 2006; 78:1158-63. [PMID: 16847953 DOI: 10.1002/jmv.20676] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Gender differences in a large population-based cohort of HIV-1 infected patients (245 women and 723 men) were examined with respect to the incidence of metabolic and morphologic alterations after initiation of highly active antiretroviral therapy (HAART). Patients initiated HAART between January 1996 and December 2003. The outcome measures were the incidence of hyperglycemia, hypercholesterolemia, symptomatic lactic acidosis, treatment-limiting lipodystrophy, and hypersensitivity reaction. Cox proportional hazards models were used to estimate the crude and adjusted hazard ratios of reaching the endpoints for exposures and covariates. Women were younger than men (35 +/- 9.8 vs. 40 +/- 8.2 years, P < 0.001) and more frequently from Haiti or Africa (59%), whereas 76% of men were Canadian-born. Type of initial HAART regimen did not differ between women and men. There were no gender differences in the overall incidence of hyperglycemia, hypercholesterolemia, or treatment-limiting lipodystrophy, even after adjusting for age, CD4 cell count, viral load, time since HIV diagnosis, history of AIDS-defining illness and year of HAART initiation. In contrast, women had significantly higher risk of developing lactic acidosis than men (P = 0.0009). Hypersensitivity reactions were also more frequent in women than men (adjusted hazard ratio = 4.4 (95% CI: 2.1-9.3)). Collectively, these data suggest that metabolic toxicities after HAART do not differ by gender but that lactic acidosis and hypersensitivity reactions are more frequent in women than men.
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Affiliation(s)
- Mohamed-Rachid Boulassel
- Immunodeficiency Service, Montreal Chest Institute, McGill University Health Centre, Montreal, Quebec, Canada.
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