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Freiberger RN, López CAM, Palma MB, Cevallos C, Sviercz FA, Jarmoluk P, García MN, Quarleri J, Delpino MV. HIV Modulates Osteoblast Differentiation via Upregulation of RANKL and Vitronectin. Pathogens 2024; 13:800. [PMID: 39338991 PMCID: PMC11435243 DOI: 10.3390/pathogens13090800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Revised: 09/06/2024] [Accepted: 09/13/2024] [Indexed: 09/30/2024] Open
Abstract
Bone loss is a prevalent characteristic among people with HIV (PWH). We focused on mesenchymal stem cells (MSCs) and osteoblasts, examining their susceptibility to different HIV strains (R5- and X4-tropic) and the subsequent effects on bone tissue homeostasis. Our findings suggest that MSCs and osteoblasts are susceptible to R5- and X4-tropic HIV but do not support productive HIV replication. HIV exposure during the osteoblast differentiation process revealed that the virus could not alter mineral and organic matrix deposition. However, the reduction in runt-related transcription factor 2 (RUNX2) transcription, the increase in the transcription of nuclear receptor activator ligand kappa B (RANKL), and the augmentation of vitronectin deposition strongly suggested that X4- and R5-HIV could affect bone homeostasis. This study highlights the HIV ability to alter MSCs' differentiation into osteoblasts, critical for maintaining bone and adipose tissue homeostasis and function.
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Affiliation(s)
- Rosa Nicole Freiberger
- Laboratorio de Inmunopatología Viral, Instituto de Investigaciones Biomédicas en Retrovirus y Sida (INBIRS), Universidad de Buenos Aires, Consejo de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires 1121, Argentina
| | - Cynthia Alicia Marcela López
- Laboratorio de Inmunopatología Viral, Instituto de Investigaciones Biomédicas en Retrovirus y Sida (INBIRS), Universidad de Buenos Aires, Consejo de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires 1121, Argentina
| | - María Belén Palma
- Cátedra de Citología, Histología y Embriología, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata 1900, Argentina
- Laboratorio de Investigación Aplicada a Neurociencias (LIAN), Fleni, Consejo de Investigaciones Científicas y Técnicas (CONICET), Escobar 1625, Argentina
| | - Cintia Cevallos
- Laboratorio de Inmunopatología Viral, Instituto de Investigaciones Biomédicas en Retrovirus y Sida (INBIRS), Universidad de Buenos Aires, Consejo de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires 1121, Argentina
| | - Franco Agustin Sviercz
- Laboratorio de Inmunopatología Viral, Instituto de Investigaciones Biomédicas en Retrovirus y Sida (INBIRS), Universidad de Buenos Aires, Consejo de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires 1121, Argentina
| | - Patricio Jarmoluk
- Laboratorio de Inmunopatología Viral, Instituto de Investigaciones Biomédicas en Retrovirus y Sida (INBIRS), Universidad de Buenos Aires, Consejo de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires 1121, Argentina
| | - Marcela Nilda García
- Cátedra de Citología, Histología y Embriología, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata 1900, Argentina
| | - Jorge Quarleri
- Laboratorio de Inmunopatología Viral, Instituto de Investigaciones Biomédicas en Retrovirus y Sida (INBIRS), Universidad de Buenos Aires, Consejo de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires 1121, Argentina
| | - M Victoria Delpino
- Laboratorio de Inmunopatología Viral, Instituto de Investigaciones Biomédicas en Retrovirus y Sida (INBIRS), Universidad de Buenos Aires, Consejo de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires 1121, Argentina
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Sviercz FA, Jarmoluk P, Cevallos CG, López CAM, Freiberger RN, Guano A, Adamczyk A, Ostrowski M, Delpino MV, Quarleri J. Massively HIV-1-infected macrophages exhibit a severely hampered ability to differentiate into osteoclasts. Front Immunol 2023; 14:1206099. [PMID: 37404829 PMCID: PMC10315468 DOI: 10.3389/fimmu.2023.1206099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/05/2023] [Indexed: 07/06/2023] Open
Abstract
Introduction Osteoclasts play a crucial role in bone resorption, and impairment of their differentiation can have significant implications for bone density, especially in individuals with HIV who may be at risk of altered bone health. The present study aimed to investigate the effects of HIV infection on osteoclast differentiation using primary human monocyte-derived macrophages as precursors. The study focused on assessing the impact of HIV infection on cellular adhesion, cathepsin K expression, resorptive activity, cytokine production, expression of co-receptors, and transcriptional regulation of key factors involved in osteoclastogenesis. Methods Primary human monocyte-derived macrophages were utilized as precursors for osteoclast differentiation. These precursors were infected with HIV, and the effects of different inoculum sizes and kinetics of viral replication were analyzed. Subsequently, osteoclastogenesis was evaluated by measuring cellular adhesion, cathepsin K expression, and resorptive activity. Furthermore, cytokine production was assessed by monitoring the production of IL-1β, RANK-L, and osteoclasts. The expression levels of co-receptors CCR5, CD9, and CD81 were measured before and after infection with HIV. The transcriptional levels of key factors for osteoclastogenesis (RANK, NFATc1, and DC-STAMP) were examined following HIV infection. Results Rapid, massive, and productive HIV infection severely impaired osteoclast differentiation, leading to compromised cellular adhesion, cathepsin K expression, and resorptive activity. HIV infection resulted in an earlier production of IL-1β concurrent with RANK-L, thereby suppressing osteoclast production. Infection with a high inoculum of HIV increased the expression of the co-receptor CCR5, as well as the tetraspanins CD9 and CD81, which correlated with deficient osteoclastogenesis. Massive HIV infection of osteoclast precursors affected the transcriptional levels of key factors involved in osteoclastogenesis, including RANK, NFATc1, and DC-STAMP. Conclusions The effects of HIV infection on osteoclast precursors were found to be dependent on the size of the inoculum and the kinetics of viral replication. These findings underscore the importance of understanding the underlying mechanisms to develop novel strategies for the prevention and treatment of bone disorders in individuals with HIV.
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Pezzaioli LC, Porcelli T, Delbarba A, Maffezzoni F, Focà E, Castelli F, Cappelli C, Ferlin A, Quiros-Roldan ME. Impact of hypogonadism on bone mineral density and vertebral fractures in HIV-infected men. J Endocrinol Invest 2022; 45:433-443. [PMID: 34460073 PMCID: PMC8783890 DOI: 10.1007/s40618-021-01665-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/20/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE Hypogonadism and osteoporosis are frequently reported in HIV-infected men and, besides multifactorial pathogenesis, they might be directly linked because of testicular involvement in bone health. We evaluated the prevalence of osteoporosis and vertebral fractures (VFs) in HIV-infected men, and assessed their relationship with gonadal function. METHODS We enrolled 168 HIV-infected men (median age 53). Osteoporosis and osteopenia were defined with T-score ≤ - 2.5SD and T-score between - 1 and - 2.5SD, respectively. VFs were assessed by quantitative morphometric analysis. Total testosterone (TT), calculated free testosterone (cFT), Sex Hormone Binding Globulin (SHBG), Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH) were obtained; overt hypogonadism was defined on symptoms and low TT or cFT, and classified into primary and secondary according to gonadotropins; compensated hypogonadism was defined as normal TT and cFT with high LH levels. RESULTS Overall, osteoporosis and osteopenia were found in 87.5% of patients, and VFs were detected in 25% of them; hypogonadism was identified in 26.2% of cases. Osteoporotic patients had higher SHBG vs those with normal bone mineral density (BMD). Fractured patients were more frequently hypogonadal and with higher SHBG. SHBG showed negative correlation with both spine and femoral BMD, and positive correlation with VFs. In multivariate models, FSH showed negative impact only on femoral BMD, whereas older age and higher SHBG predicted VFs. CONCLUSION We found a high burden of bone disease and hypogonadism in HIV-infected men, and we showed that the impact of gonadal function on bone health is more evident on VFs than on BMD.
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Affiliation(s)
- L C Pezzaioli
- Department of Clinical and Experimental Sciences, Unit of Endocrinology and Metabolism, University of Brescia and ASST Spedali Civili Brescia, Viale Europa 11, 25123, Brescia, Italy
| | - T Porcelli
- Endocrinology, Montichiari Hospital, ASST Spedali Civili Brescia, Montichiari (Brescia), Italy
| | - A Delbarba
- Department of Clinical and Experimental Sciences, Unit of Endocrinology and Metabolism, University of Brescia and ASST Spedali Civili Brescia, Viale Europa 11, 25123, Brescia, Italy
| | - F Maffezzoni
- Department of Clinical and Experimental Sciences, Unit of Endocrinology and Metabolism, University of Brescia and ASST Spedali Civili Brescia, Viale Europa 11, 25123, Brescia, Italy
| | - E Focà
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili Hospital, Brescia, Italy
| | - F Castelli
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili Hospital, Brescia, Italy
| | - C Cappelli
- Department of Clinical and Experimental Sciences, Unit of Endocrinology and Metabolism, University of Brescia and ASST Spedali Civili Brescia, Viale Europa 11, 25123, Brescia, Italy
| | - A Ferlin
- Department of Clinical and Experimental Sciences, Unit of Endocrinology and Metabolism, University of Brescia and ASST Spedali Civili Brescia, Viale Europa 11, 25123, Brescia, Italy.
| | - M E Quiros-Roldan
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili Hospital, Brescia, Italy
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Ozcan SN, Sevgi DY, Oncul A, Gunduz A, Pehlivan O, Terlemez R, Kuran B, Dokmetas L. The prevalence and associated factors of reduced bone mineral density (BMD) among men with suppressed viral load taking antiretroviral therapy. Curr HIV Res 2021; 20:74-81. [PMID: 34856908 DOI: 10.2174/1570162x19666211202100308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/02/2021] [Accepted: 10/21/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Reduced bone mineral density (BMD) is a frequent comorbidity observed in people living with HIV (PLHIV). OBJECTIVE The aim of the study is to determine the prevalence and associated factors of reduced bone mineral density (BMD) among men with suppressed viral load taking antiretroviral therapy. METHOD The study was conducted as a cross-sectional study design between January to April 2019. 211 patients were included in the study. Z-score at either body site between -1.0 and -2.0 or -2 or less were defined as osteopenia or osteoporosis, respectively. Multivariate logistic regression analysis was used to evaluate the factors affecting the development of reduced BMD. RESULTS The mean age of the patients involved in the study was 34.8 ± 7.6. Osteoporosis was detected in 21.4% and osteopenia in 44.5% of the patients. There was a significant relationship between HIV diagnosis time, ART usage duration, tenofovir disoproxil fumarate (TDF) use, TDF use in the past, total TDF usage time and decreased BMD. Multivariate logistic regression analysis showed that the likelihood of reduced bone marrow density was 67% lower among those with regular milk or dairy product intake compared to those without (OR=0.330; 95% CI = 0.12-0.92, p=0.033 ) Conclusion: There is a high prevalence of reduced BMD among PLHIV aged under 50 which is mainly confounded by HIV diagnosis time, ART usage duration and TDF usage. Although virological control has been achieved, these patients should be followed up, considering that they may have decreased BMD.
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Affiliation(s)
- Safiye Nur Ozcan
- University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital, İnfectious Diseases and Clinical Microbiology, Istanbul. Turkey
| | - Dilek Yıldız Sevgi
- University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital, İnfectious Diseases and Clinical Microbiology, Istanbul. Turkey
| | - Ahsen Oncul
- University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital, İnfectious Diseases and Clinical Microbiology, Istanbul. Turkey
| | - Alper Gunduz
- University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital, İnfectious Diseases and Clinical Microbiology, Istanbul. Turkey
| | - Ozgun Pehlivan
- University of Abant Izzet Baysal , Department of Public Health, Bolu. Turkey
| | - Rana Terlemez
- Department of Physical Medicine and Rehabilitation, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul. Turkey
| | - Banu Kuran
- Department of Physical Medicine and Rehabilitation, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul. Turkey
| | - Llyas Dokmetas
- University of Health Sciences Sisli Hamidiye Etfal Training and Research Hospital, İnfectious Diseases and Clinical Microbiology, Istanbul. Turkey
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Oster Y, Cohen MJ, Dresner-Pollak R, Szalat A, Elinav H. Increase in bone turnover markers in HIV patients treated with tenofovir disoproxil fumarate combined with raltegravir or efavirenz. Bone Rep 2020; 13:100727. [PMID: 33163587 PMCID: PMC7607241 DOI: 10.1016/j.bonr.2020.100727] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 09/30/2020] [Accepted: 10/12/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction Accelerated bone loss and osteoporosis are multifactorial comorbidities related to HIV and its treatments; however, their mechanisms remain elusive. Identifying HIV treatments that are differentially linked to osteoporosis risk, and clinical factors associated with HIV-related osteoporosis may enable optimizing anti-retroviral treatment (ART) and anti-osteoporosis therapy in preventing or treating this debilitating complication. This study aims to evaluate the dynamics of bone turnover markers after initiation of two commonly used antiretroviral regimens. Methods A prospective matched cohort study. Thirty treatment-naïve male patients (mean age 40 ± 10y) who initiated treatment with truvada (tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC)) + raltegravir or TDF/FTC + efavirenz were included in the study. Control group included 15 treatment-naive HIV patients. Serum morning fasting level of P1NP and CTX were measured 0, 1, 6, and 12 months after treatment initiation in the two study groups, and at 0, 6 and 12 months in the control group. Results In both treatment groups, but not in the control group, both markers increased significantly over time with no difference in BTM between patients treated with raltegravir or efavirenz. Levels of P1NP were statistically higher at 6 and 12 months after treatment initiation in both treatment groups compared to the controls, while CTX during treatment increased in both treatment groups but was significantly higher only in the raltegravir treatment group after 12 months. The ratio of area under the curve of P1NP/CTX correlated with CD4 increment. Conclusions Treatment initiation with raltegravir or efavirenz combined with TDF/FTC is associated with increased bone turnover. Thus, therapy that optimize bone turnover is needed to reduce bone loss at this vulnerable period and improve long-term bone health.
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Affiliation(s)
- Yonatan Oster
- Hadassah AIDS Center, Department of Clinical Microbiology and Infectious Diseases, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Matan J Cohen
- Clalit Health Services, Jerusalem District, affiliated with the School of Medicine, Hebrew University, Jerusalem, Israel
| | - Rivka Dresner-Pollak
- The Department of Endocrinology and Metabolism, Division of Internal Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Auryan Szalat
- Department of Medicine, Endocrinology and Metabolism Service, Hadassah Hebrew, University Medical Center, Jerusalem, Israel
| | - Hila Elinav
- Hadassah AIDS Center, Department of Clinical Microbiology and Infectious Diseases, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Mascarau R, Bertrand F, Labrousse A, Gennero I, Poincloux R, Maridonneau-Parini I, Raynaud-Messina B, Vérollet C. HIV-1-Infected Human Macrophages, by Secreting RANK-L, Contribute to Enhanced Osteoclast Recruitment. Int J Mol Sci 2020; 21:ijms21093154. [PMID: 32365752 PMCID: PMC7246503 DOI: 10.3390/ijms21093154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 12/16/2022] Open
Abstract
HIV-1 infection is frequently associated with low bone density, which can progress to osteoporosis leading to a high risk of fractures. Only a few mechanisms have been proposed to explain the enhanced osteolysis in the context of HIV-1 infection. As macrophages are involved in bone homeostasis and are critical host cells for HIV-1, we asked whether HIV-1-infected macrophages could participate in bone degradation. Upon infection, human macrophages acquired some osteoclast features: they became multinucleated, upregulated the osteoclast markers RhoE and β3 integrin, and organized their podosomes as ring superstructures resembling osteoclast sealing zones. However, HIV-1-infected macrophages were not fully differentiated in osteoclasts as they did not upregulate NFATc-1 transcription factor and were unable to degrade bone. Investigating whether infected macrophages participate indirectly to virus-induced osteolysis, we showed that they produce RANK-L, the key osteoclastogenic cytokine. RANK-L secreted by HIV-1-infected macrophages was not sufficient to stimulate multinucleation, but promoted the protease-dependent migration of osteoclast precursors. In conclusion, we propose that, by stimulating RANK-L secretion, HIV-1-infected macrophages contribute to create a microenvironment that favors the recruitment of osteoclasts, participating in bone disorders observed in HIV-1 infected patients.
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Affiliation(s)
- Rémi Mascarau
- Institut de Pharmacologie et Biologie Structurale, Université de Toulouse, CNRS UMR 5089, Université Toulouse III Paul Sabatier, CEDEX 04, 31077 Toulouse, France; (R.M.); (F.B.); (A.L.); (R.P.); (I.M.-P.)
| | - Florent Bertrand
- Institut de Pharmacologie et Biologie Structurale, Université de Toulouse, CNRS UMR 5089, Université Toulouse III Paul Sabatier, CEDEX 04, 31077 Toulouse, France; (R.M.); (F.B.); (A.L.); (R.P.); (I.M.-P.)
| | - Arnaud Labrousse
- Institut de Pharmacologie et Biologie Structurale, Université de Toulouse, CNRS UMR 5089, Université Toulouse III Paul Sabatier, CEDEX 04, 31077 Toulouse, France; (R.M.); (F.B.); (A.L.); (R.P.); (I.M.-P.)
| | - Isabelle Gennero
- Centre de Physiopathologie de Toulouse-Purpan, INSERM-CNRS UMR 1043, Université Toulouse III Paul Sabatier, 31024 Toulouse, France;
- Institut Fédératif de Biologie, Centre Hospitalier Universitaire Toulouse, 31059 Toulouse, France
| | - Renaud Poincloux
- Institut de Pharmacologie et Biologie Structurale, Université de Toulouse, CNRS UMR 5089, Université Toulouse III Paul Sabatier, CEDEX 04, 31077 Toulouse, France; (R.M.); (F.B.); (A.L.); (R.P.); (I.M.-P.)
- International Associated Laboratory (LIA) CNRS “IM-TB/HIV” (1167), 31077 Toulouse, France
- International Associated Laboratory (LIA) CNRS “IM-TB/HIV” (1167), Buenos Aires C1425AUM, Argentina
| | - Isabelle Maridonneau-Parini
- Institut de Pharmacologie et Biologie Structurale, Université de Toulouse, CNRS UMR 5089, Université Toulouse III Paul Sabatier, CEDEX 04, 31077 Toulouse, France; (R.M.); (F.B.); (A.L.); (R.P.); (I.M.-P.)
- International Associated Laboratory (LIA) CNRS “IM-TB/HIV” (1167), 31077 Toulouse, France
- International Associated Laboratory (LIA) CNRS “IM-TB/HIV” (1167), Buenos Aires C1425AUM, Argentina
| | - Brigitte Raynaud-Messina
- Institut de Pharmacologie et Biologie Structurale, Université de Toulouse, CNRS UMR 5089, Université Toulouse III Paul Sabatier, CEDEX 04, 31077 Toulouse, France; (R.M.); (F.B.); (A.L.); (R.P.); (I.M.-P.)
- International Associated Laboratory (LIA) CNRS “IM-TB/HIV” (1167), 31077 Toulouse, France
- International Associated Laboratory (LIA) CNRS “IM-TB/HIV” (1167), Buenos Aires C1425AUM, Argentina
- Correspondence: (B.R.-M.); (C.V.)
| | - Christel Vérollet
- Institut de Pharmacologie et Biologie Structurale, Université de Toulouse, CNRS UMR 5089, Université Toulouse III Paul Sabatier, CEDEX 04, 31077 Toulouse, France; (R.M.); (F.B.); (A.L.); (R.P.); (I.M.-P.)
- International Associated Laboratory (LIA) CNRS “IM-TB/HIV” (1167), 31077 Toulouse, France
- International Associated Laboratory (LIA) CNRS “IM-TB/HIV” (1167), Buenos Aires C1425AUM, Argentina
- Correspondence: (B.R.-M.); (C.V.)
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Delpino MV, Quarleri J. Influence of HIV Infection and Antiretroviral Therapy on Bone Homeostasis. Front Endocrinol (Lausanne) 2020; 11:502. [PMID: 32982960 PMCID: PMC7493215 DOI: 10.3389/fendo.2020.00502] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/23/2020] [Indexed: 01/18/2023] Open
Abstract
The human immunodeficiency virus type 1 (HIV)/AIDS pandemic represents the most significant global health challenge in modern history. This infection leads toward an inflammatory state associated with chronic immune dysregulation activation that tilts the immune-skeletal interface and its deep integration between cell types and cytokines with a strong influence on skeletal renewal and exacerbated bone loss. Hence, reduced bone mineral density is a complication among HIV-infected individuals that may progress to osteoporosis, thus increasing their prevalence of fractures. Highly active antiretroviral therapy (HAART) can effectively control HIV replication but the regimens, that include tenofovir disoproxil fumarate (TDF), may accelerate bone mass density loss. Molecular mechanisms of HIV-associated bone disease include the OPG/RANKL/RANK system dysregulation. Thereby, osteoclastogenesis and osteolytic activity are promoted after the osteoclast precursor infection, accompanied by a deleterious effect on osteoblast and its precursor cells, with exacerbated senescence of mesenchymal stem cells (MSCs). This review summarizes recent basic research data on HIV pathogenesis and its relation to bone quality. It also sheds light on HAART-related detrimental effects on bone metabolism, providing a better understanding of the molecular mechanisms involved in bone dysfunction and damage as well as how the HIV-associated imbalance on the gut microbiome may contribute to bone disease.
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Affiliation(s)
- María Victoria Delpino
- Instituto de Inmunología, Genética y Metabolismo (INIGEM), Universidad de Buenos Aires, CONICET, Buenos Aires, Argentina
- *Correspondence: María Victoria Delpino
| | - Jorge Quarleri
- Instituto de Investigaciones Biomédicas en Retrovirus y Sida (INBIRS), Universidad de Buenos Aires, CONICET, Buenos Aires, Argentina
- Jorge Quarleri
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Kim-Chang JJ, Wilson L, Chan C, Fischer B, Venturi G, Goodenow MM, Aldrovandi G, Weber TJ, Sleasman JW, Emmanuel, Lujan-Zilberman, Julian, Belzer, Flores, Tucker, Kovacs, Homans, Lozano, D'Angelo, Hagler, Trexler, Douglas, Tanney, DiBenedetto, Martinez, Bojan, Jackson, Febo, Ayala-Flores, Fuentes-Gomez, Futterman, Enriquez-Bruce, Campos, Steever, Geiger, Moscicki, Auerswald, Irish, Abdalian, Kozina, Baker, Peralta, Gorle, Friedman, Maturo, Major-Wilson, Puga, Leonard, Inman, Flynn, Dillard, Garofalo, Brennan, Flanagan. Tenofovir Has Minimal Effect on Biomarkers of Bone Health in Youth with HIV Receiving Initial Antiretroviral Therapy. AIDS Res Hum Retroviruses 2019; 35:746-754. [PMID: 31115244 DOI: 10.1089/aid.2018.0270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Both HIV infection and tenofovir disoproxil fumarate (TDF) treatment adversely impact bone metabolism and may lead to osteopenia, which has critical implications for youth with HIV (YWH). This study evaluates changes in the biomarkers of bone metabolism and inflammation among YWH receiving initial treatment with TDF- and non-TDF-containing antiretroviral therapies (ARTs). YWH [n = 23, median age 21 years (range 18-24), 87% male, 61% African American] were assessed for inflammatory and bone metabolism biomarkers at enrollment, after 48 weeks of TDF-containing ART, and 96 weeks of ART without TDF with continued viral suppression. Spearman's rank correlation evaluated biomarker associations. Bone alkaline phosphatase, parathyroid hormone, and osteopontin increased after TDF treatment. All fell after TDF was discontinued. Levels of RANKL and osteoprotegerin did not change throughout the study. There was little correlation between biomarkers of bone metabolism and either macrophage or lymphocyte activation at any time point. Our results establish baseline associations between bone metabolism and immune biomarkers for this population, and find that before CD4 T cell decline chronic inflammation does not perturb biomarkers of bone metabolism among YWH. The adverse effects of TDF on bone health may be marginal for YWH at the early stages of disease.
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Affiliation(s)
- Julie J. Kim-Chang
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Lorena Wilson
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Cliburn Chan
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Bernard Fischer
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Guglielmo Venturi
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Maureen M. Goodenow
- Molecular HIV Host Interaction Section, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Grace Aldrovandi
- Division of Infectious Diseases, Department of Pediatrics, University of California, Los Angeles, California
| | - Thomas J. Weber
- Division of Endocrinology, Metabolism and Nutrition, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - John W. Sleasman
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
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Evaluation of initial results of naïve HIV-infected patients regarding bone health. JOURNAL OF SURGERY AND MEDICINE 2019. [DOI: 10.28982/josam.566996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Older HIV-infected adults: complex patients-comorbidity (I). Eur Geriatr Med 2019; 10:189-197. [PMID: 34652750 DOI: 10.1007/s41999-018-0152-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/04/2018] [Indexed: 12/16/2022]
Abstract
Life expectancy in people living with HIV has increased in the past decades, since the introduction of highly active antiretroviral treatment. Increased survival comes along with new challenges for the HIV physician, as these patients will present comorbidities inherent to ageing that can appear more frequently and at younger age than the general population. The older HIV patient poses a unique challenge, as management should take into account different factors, some related to global ageing such as geriatric syndromes, traditional risk factors, social vulnerability, and age-related diseases, and others related to HIV infection like ART toxicity, drug-drug interactions, immune dysregulation and chronic inflammation. All the above can amount to great polypharmacy and multimorbidity that physician have to be aware of. Little is known about the best screening, management and treatment strategies to improve long-term health outcomes in this ageing population. The following article briefly reviews the main comorbidities that can affect the ageing HIV patient.
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Chen KY, Wang CH, Lin TY, Chang CY, Liu CL, Hsiao YC, Hung CC, Wang NC. Monitoring early developed low bone mineral density in HIV-infected patients by intact parathyroid hormone and circulating fibroblast growth factor 23. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2018; 52:693-699. [PMID: 30293926 DOI: 10.1016/j.jmii.2018.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/30/2018] [Accepted: 08/31/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE HIV-infected patients have a high prevalence of low bone mineral density (BMD), but BMD changes remain unclear. This cross-sectional retrospective observational study aimed to characterize the prevalence and associated factors of low BMD in HIV patients. METHODS Between 1 January 2015 and 31 December 2016, all patients aged 20 years or greater who sought for HIV care were included. BMD was measured by dual-energy X-ray absorptiometry. Multivariable analyses of the association with HIV disease status, treatment and anthropometric parameters were performed. Circulating fibroblast growth factor 23 and intact parathyroid hormone were measured. RESULTS A total of 137 patients was included; their median age was 39 years old; 97.8% were treated with combination antiretroviral therapy (cART); Body mass index (BMI) was 21.97 kg/m2. Sixty-one patients (44.5%) showed low BMD (osteopenia and osteoporosis) based on the WHO criteria. The median BMD was -0.80 g/cm2 (IQR, -1.5 to -0.2). The prevalence rate of low BMD was 37% in those who were aged 20-29 years, 45.2% in those who were aged 30-39 years, 45.2% in those who were aged 40-49 years, 45.8% in those who were aged 50-59 years, and 53.8% in those who were aged ≧60 years. More than half of patients (50.4%, 69/137) were younger than 40 years. Compared with normal BMD group, the low BMD group has a higher proportion of secondary hyperparathyroidism (18.0% vs 5.3%, p: 0.026) and a lower median C-terminal FGF23 level (48.92 vs 62.61 pg/ml, p: 0.008). Univariate and multivariate analyses of the factors associated with low BMD. We found that only serum intact-parathyroid hormone (iPTH) > 69 pg/ml (OR, 3.86; 95% CI, 1.14-13.09) was statistically significant associated with low BMD in multivariate analysis. CONCLUSIONS This cohort-based survey showed a high prevalence of low BMD among HIV-infected adults which included young-age patient in an university hospital. Secondary hyperparathyroidism was significantly associated with low BMD. There was no association between FGF23 and low BMD.
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Affiliation(s)
- Kuan-Yu Chen
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ching-Hsun Wang
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Te-Yu Lin
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chan-Yuan Chang
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chang-Lin Liu
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Chun Hsiao
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ching-Ching Hung
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ning-Chi Wang
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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Churchill D, Waters L, Ahmed N, Angus B, Boffito M, Bower M, Dunn D, Edwards S, Emerson C, Fidler S, Fisher M, Horne R, Khoo S, Leen C, Mackie N, Marshall N, Monteiro F, Nelson M, Orkin C, Palfreeman A, Pett S, Phillips A, Post F, Pozniak A, Reeves I, Sabin C, Trevelion R, Walsh J, Wilkins E, Williams I, Winston A. British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2015. HIV Med 2018; 17 Suppl 4:s2-s104. [PMID: 27568911 DOI: 10.1111/hiv.12426] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | | | | | - Mark Bower
- Chelsea and Westminster Hospital, London, UK
| | | | - Simon Edwards
- Central and North West London NHS Foundation Trust, UK
| | | | - Sarah Fidler
- Imperial College School of Medicine at St Mary's, London, UK
| | | | | | | | | | | | | | | | - Mark Nelson
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | | | | | | | | | - Anton Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Caroline Sabin
- Royal Free and University College Medical School, London, UK
| | | | - John Walsh
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Ian Williams
- Royal Free and University College Medical School, London, UK
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Paccou J, Viget N, Drumez E, Cortet B, Robineau O. Prevalence and risk factors for low bone mineral density in antiretroviral therapy-naive HIV-infected young men. Med Mal Infect 2018; 48:442-448. [PMID: 29699830 DOI: 10.1016/j.medmal.2018.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/01/2017] [Accepted: 02/27/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE We aimed to investigate the prevalence of low bone mineral density (BMD) and associated factors in antiretroviral therapy (ART)-naive HIV-infected young men. METHODS In this cross-sectional study, dual-energy X-ray absorptiometry (DXA) was used to measure BMD. BMD at the lumbar spine, total hip and femoral neck sites was expressed as a Z-score (number of standard deviations away from the mean in an age, race and sex-matched reference population). Low BMD was defined as Z-scores≤-2 at any of the three sites. The prevalence of low BMD was evaluated at the lumbar spine, total hip and femoral neck sites, as were risk factors associated with Z-scores. RESULTS The study cohort comprised 49 men, of whom 87.8% were white. Mean age was 31.6 (±7.7) years and mean BMI was 22.7 (±4.0)kg/m2. Half of patients (51.0%) were current smokers. The prevalence of low BMD was 24.5% [95% CI, 13.3-38.9]. Low estradiol levels and low BMI were associated with low Z-scores at each skeletal site, whereas current smoking and high IGF1 levels were associated with low Z-scores at the lumbar spine site. Among the HIV-related factors, low CD4+ cell count was associated with low Z-scores at the lumbar spine site. CONCLUSIONS We observed a high prevalence of low BMD in our ART-naive cohort of young men. Risk factors associated with low Z-scores were those usually observed in HIV-infected individuals (low BMI, current smoking and CD4+ cell count) or linked to endocrine hormone levels (estradiol, IGF-1).
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Affiliation(s)
- J Paccou
- Service de rhumatologie, CHU Lille, 59000 Lille, France; Université de Lille, université Littoral Côte d'Opale, PMOI EA 4490 faculté de chirurgie dentaire, place de Verdun, 59000 Lille, France.
| | - N Viget
- Service des maladies infectieuses, centre hospitalier Tourcoing, CHU Lille, 59000 Lille, France.
| | - E Drumez
- Département de biostatistiques - Santé publique, épidémiologie et qualité des soins, université de Lille, EA 2694, CHU Lille, 59000 Lille, France.
| | - B Cortet
- Service de rhumatologie, CHU Lille, 59000 Lille, France; Université de Lille, université Littoral Côte d'Opale, PMOI EA 4490 faculté de chirurgie dentaire, place de Verdun, 59000 Lille, France.
| | - O Robineau
- Service des maladies infectieuses, centre hospitalier Tourcoing, CHU Lille, 59000 Lille, France.
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Vlot MC, Grijsen ML, Prins JM, de Jongh RT, de Jonge R, den Heijer M, Heijboer AC. Effect of antiretroviral therapy on bone turnover and bone mineral density in men with primary HIV-1 infection. PLoS One 2018. [PMID: 29522570 PMCID: PMC5844537 DOI: 10.1371/journal.pone.0193679] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Introduction Previous studies indicate that human immunodeficiency virus (HIV)-infection and combination antiretroviral therapy (cART) can affect bone turnover. Furthermore, HIV-infected patients have lower bone mineral density (BMD) compared to a healthy reference population. Objective To evaluate the longitudinal effect of HIV-infection and cART on bone turnover markers (BTMs) and BMD in men with primary HIV-infection (PHI). Design, methods Thirty-five PHI-men were divided into two groups, those that received cART for the first time (n = 26) versus no-cART (n = 9). Dual-energy X-ray absorptiometry (DXA) was performed on femoral neck (FN), total hip (TH) and lumbar spine (LS) and BTMs (P1NP, alkaline phosphatase, osteocalcin, ICTP and CTX) were measured at baseline and follow-up. Results At baseline, the median CD4+ T-cell count was 455 cells/mm3 (IQR 320–620) and plasma viral load 5.4 log10 copies/mL (IQR 4.7–6.0) in the cART treated group, compared to 630 (IQR 590–910) and 4.8 (IQR 4.2–5.1) in the untreated group. The median follow-up time was 60.7 weeks (IQR 24.7–96.0). All BTMs, except ICTP, showed a significant increase during cART versus no changes of BTMs in the untreated group. FN and TH BMD showed a significant decrease in both groups. LS BMD did not change in both groups. Conclusion Bone turnover increased in PHI-men treated with cART which was accompanied by a decrease in FN and TH BMD. No increase of bone turnover was seen in untreated PHI-men. Our study suggests that cART results in increased bone turnover and decreased BMD of the hip in PHI-men.
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Affiliation(s)
- Mariska C. Vlot
- Department of Clinical Chemistry, Endocrine Laboratory, VU University Medical Center, Amsterdam, the Netherlands
- Department of Internal Medicine, Endocrinology, VU University Medical Center, Amsterdam, the Netherlands
| | - Marlous L. Grijsen
- Department of Internal Medicine, Infectious Diseases, Center for Infection and Immunity, Academic Medical Center, Amsterdam, the Netherlands
- Department of Dermatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan M. Prins
- Department of Internal Medicine, Infectious Diseases, Center for Infection and Immunity, Academic Medical Center, Amsterdam, the Netherlands
| | - Renate T. de Jongh
- Department of Internal Medicine, Endocrinology, VU University Medical Center, Amsterdam, the Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, Endocrine Laboratory, VU University Medical Center, Amsterdam, the Netherlands
| | - Martin den Heijer
- Department of Internal Medicine, Endocrinology, VU University Medical Center, Amsterdam, the Netherlands
| | - Annemieke C. Heijboer
- Department of Clinical Chemistry, Endocrine Laboratory, VU University Medical Center, Amsterdam, the Netherlands
- Department of Clinical Chemistry, Endocrine laboratory, Academic Medical Center, Amsterdam, the Netherlands
- * E-mail:
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Bone degradation machinery of osteoclasts: An HIV-1 target that contributes to bone loss. Proc Natl Acad Sci U S A 2018; 115:E2556-E2565. [PMID: 29463701 DOI: 10.1073/pnas.1713370115] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Bone deficits are frequent in HIV-1-infected patients. We report here that osteoclasts, the cells specialized in bone resorption, are infected by HIV-1 in vivo in humanized mice and ex vivo in human joint biopsies. In vitro, infection of human osteoclasts occurs at different stages of osteoclastogenesis via cell-free viruses and, more efficiently, by transfer from infected T cells. HIV-1 infection markedly enhances adhesion and osteolytic activity of human osteoclasts by modifying the structure and function of the sealing zone, the osteoclast-specific bone degradation machinery. Indeed, the sealing zone is broader due to F-actin enrichment of its basal units (i.e., the podosomes). The viral protein Nef is involved in all HIV-1-induced effects partly through the activation of Src, a regulator of podosomes and of their assembly as a sealing zone. Supporting these results, Nef-transgenic mice exhibit an increased osteoclast density and bone defects, and osteoclasts derived from these animals display high osteolytic activity. Altogether, our study evidences osteoclasts as host cells for HIV-1 and their pathological contribution to bone disorders induced by this virus, in part via Nef.
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Abstract
OBJECTIVES To determine the incidence of fracture among aging HIV-infected (HIV+) and uninfected men (HIV-). To evaluate factors independently associated with fracture risk. DESIGN Prospective, multicenter cohort study of men with or at risk for HIV. METHODS Outcome measures: all fractures (excluding skull, face and digits) and fragility fractures (vertebral column, femur, wrist and humerus) were collected semiannually in 1221 HIV+ and 1408 HIV- men aged at least 40. Adjusted incident rate ratios (aIRR) with an interaction term for age (40-49, 50-59 and ≥60 years) and HIV serostatus were estimated with Poisson regression models accounting for additional risk factors. RESULTS Fracture incidence increased with age among both HIV+ and HIV- men. Although there was no significant difference in fracture incidence by HIV serostatus among men aged 40-49 years, the HIV+ men aged 50-59 years had a significantly higher incidence of all fractures [aIRR: 2.06 (1.49, 2.84)] and fragility fractures [aIRR: 2.06 (1.21, 3.50)] compared with HIV- participants of similar age. HIV modified the effect of age on all fractures (P = 0.002) but did not significantly modify the effect for fragility fractures (P = 0.135). Hypertension increased the rate of all fractures by 32% after adjustment for covariates [aIRR: 1.32 (1.04, 1.69)]. CONCLUSION Fracture incidence increased with age among HIV+ and HIV- men but was higher among HIV+ men. A significant increase in fracture incidence was found among 50-59-year-old HIV+ men, highlighting the importance of osteoporosis screening for HIV-infected men above the age of 50.
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Gallego-Escuredo JM, Lamarca MK, Villarroya J, Domingo JC, Mateo MG, Gutierrez MDM, Vidal F, Villarroya F, Domingo P, Giralt M. High FGF21 levels are associated with altered bone homeostasis in HIV-1-infected patients. Metabolism 2017; 71:163-170. [PMID: 28521869 DOI: 10.1016/j.metabol.2017.03.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 03/23/2017] [Accepted: 03/27/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Fibroblast growth factor-21 (FGF21) has emerged as an important regulator of glucose, lipid, and body weight homeostasis. However, recent experimental studies have reported that increased FGF21 levels may lead to bone loss. OBJECTIVE To assess the relationship of serum FGF21 levels and altered bone homeostasis in HIV-1-infected patients. DESIGN Cross-sectional study of 137 HIV-1-infected patients and 35 healthy controls conducted at the Hospital de la Santa Creu i Sant Pau, Barcelona. Among HIV-1-infected patients, 35 were untreated (naïve), 43 were treated with antiretrovirals (HIV-1/ART) with no lipodystrophy, and 59 patients were HIV-1/ART and experienced lipodystrophy. Bone mineral density (BMD) and content (BMC) were assessed using dual-energy X-ray absorptiometry. Serum levels of FGF21, receptor activator of nuclear factor (NF)-KB ligand (RANKL), and C-telopeptide of type-I collagen (CTX-1) were measured by enzyme-linked immunosorbent assays. Serum levels of osteocalcin, osteoprotegerin, leptin, tumor necrosis factor-α, interleukin-6, interleukin-8, and monocyte chemoattractant protein-1 were determined using an antibody-linked, fluorescently labeled microsphere bead-based multiplex analysis system. RESULTS Alterations in bone parameters and bone homeostasis marker levels were consistent with higher turnover and bone loss in HIV-1 infected patients. FGF21 correlated negatively with BMD and BMC. FGF21 correlated positively with serum levels of osteoprotegerin and CTX-1, as well as with the CTX-1/osteocalcin ratio. CONCLUSIONS Elevated FGF21 levels are associated with poor bone homeostasis in HIV-1-infected patients. Increases in FGF21 serum level may be an indicator not only of metabolic derangement but it may also serve as a biomarker of altered bone homeostasis in HIV-1 infected patients.
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Affiliation(s)
- José M Gallego-Escuredo
- Institut de Recerca Biomèdica (IRB) de Lleida, Lleida, Spain; Departament de Bioquímica i Biomedicina Molecular and Institut de Biomedicina (IBUB), Universitat de Barcelona, and CIBER Fisiopatología de la Obesidad y Nutrición, Barcelona, Spain
| | - Maria Karuna Lamarca
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Villarroya
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Departament de Bioquímica i Biomedicina Molecular and Institut de Biomedicina (IBUB), Universitat de Barcelona, and CIBER Fisiopatología de la Obesidad y Nutrición, Barcelona, Spain
| | - Joan C Domingo
- Departament de Bioquímica i Biomedicina Molecular and Institut de Biomedicina (IBUB), Universitat de Barcelona, and CIBER Fisiopatología de la Obesidad y Nutrición, Barcelona, Spain
| | - Ma Gracia Mateo
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ma Del Mar Gutierrez
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francesc Vidal
- Infectious Diseases Unit, Department of Internal Medicine, Hospital Universitari Joan XXIII. IISPV. Universitat Rovira i Virgili, Tarragona, Spain
| | - Francesc Villarroya
- Departament de Bioquímica i Biomedicina Molecular and Institut de Biomedicina (IBUB), Universitat de Barcelona, and CIBER Fisiopatología de la Obesidad y Nutrición, Barcelona, Spain
| | - Pere Domingo
- Institut de Recerca Biomèdica (IRB) de Lleida, Lleida, Spain; Department of Infectious Diseases, Hospital Universitari Arnau de Vilanova, Lleida, Spain; Department of Infectious Diseases, Hospital Universitari de Santa María, Lleida, Spain; Universitat de Lleida, Lleida, Spain
| | - Marta Giralt
- Departament de Bioquímica i Biomedicina Molecular and Institut de Biomedicina (IBUB), Universitat de Barcelona, and CIBER Fisiopatología de la Obesidad y Nutrición, Barcelona, Spain.
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Noe S, Heldwein S, Pascucchi R, Oldenbüttel C, Wiese C, von Krosigk A, Jägel-Guedes E, Jäger H, Mayer W, Spinner CD, Wolf E. Cholecalciferol 20 000 IU Once Weekly in HIV-Positive Patients with Low Vitamin D Levels: Result from a Cohort Study. J Int Assoc Provid AIDS Care 2017; 16:315-320. [PMID: 28393662 DOI: 10.1177/2325957417702487] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
PURPOSE To evaluate efficacy and safety of 20 000 IU cholecalciferol weekly in HIV-infected patients. METHODS Longitudinal data for 243 HIV-infected patients with paired 25-OH-vitamin D3 values for the same month in 2 consecutive years were stratified by the initiation of supplementation in this retrospective study. RESULTS After 1 year of administration of cholecalciferol 20 000 IU weekly, about 78% of patients with initial vitamin D level <20 µg/L achieved vitamin D levels >20 µg/L and 42% achieved levels >30 µg/L. Supplemented patients with baseline vitamin D levels <20 µg/L showed a significant risk reduction for hypocalcemia ( P = .006; risk difference: 20.8%) and a significantly lower increase in alkaline phosphatase (AP) compared to those in the nonsubstituted group. CONCLUSION The dose of 20 000 IU of cholecalciferol once weekly was found to be safe and effective. Normalization of vitamin D levels within 1 year was observed in 42% to 75% of the patients.
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Affiliation(s)
- Sebastian Noe
- 1 MVZ Karlsplatz, HIV Clinical Care and Research Center, Munich, Germany
| | - Silke Heldwein
- 1 MVZ Karlsplatz, HIV Clinical Care and Research Center, Munich, Germany
| | - Rita Pascucchi
- 1 MVZ Karlsplatz, HIV Clinical Care and Research Center, Munich, Germany
| | - Celia Oldenbüttel
- 1 MVZ Karlsplatz, HIV Clinical Care and Research Center, Munich, Germany
| | - C Wiese
- 1 MVZ Karlsplatz, HIV Clinical Care and Research Center, Munich, Germany
| | - Ariane von Krosigk
- 1 MVZ Karlsplatz, HIV Clinical Care and Research Center, Munich, Germany
| | - Eva Jägel-Guedes
- 1 MVZ Karlsplatz, HIV Clinical Care and Research Center, Munich, Germany
| | - Hans Jäger
- 1 MVZ Karlsplatz, HIV Clinical Care and Research Center, Munich, Germany
| | | | - Christoph D Spinner
- 1 MVZ Karlsplatz, HIV Clinical Care and Research Center, Munich, Germany.,3 Department of Medicine II, University Hospital Klinikum rechts der Isar, Munich, Germany.,4 German Center for Infection Research (DZIF), Braunschweig, Germany.,5 MUC Research, Munich, Germany
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Ventura AS, Winter MR, Heeren TC, Sullivan MM, Walley AY, Holick MF, Patts GJ, Meli SM, Samet JH, Saitz R. Lifetime and recent alcohol use and bone mineral density in adults with HIV infection and substance dependence. Medicine (Baltimore) 2017; 96:e6759. [PMID: 28445303 PMCID: PMC5413268 DOI: 10.1097/md.0000000000006759] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/29/2017] [Accepted: 03/31/2017] [Indexed: 11/26/2022] Open
Abstract
Low bone mineral density (BMD) is common in people living with HIV infection (PLWH), increasing fracture risk. Alcohol use is also common in PLWH and is a modifiable risk factor for both HIV disease progression and low BMD. In PLWH, alcohol's effect on BMD is not well understood.We studied adult PLWH with substance dependence. We measured lifetime alcohol use (kg) and recent (i.e., past 30-day) alcohol use (categorized as: abstinent, low risk, or high risk). In adjusted multivariable regression analyses, we tested associations between lifetime and recent alcohol use and (i) mean BMD (g/cm) at the femoral neck, total hip, and lumbar spine and (ii) low BMD diagnosis (i.e., osteopenia or osteoporosis). We also examined associations between 2 measures of past alcohol use (i.e., total consumption [kg] and drinking intensity [kg/year]) and BMD outcome measures during 3 periods of the HIV care continuum: (i) period before first positive HIV test, (ii) period from first positive HIV test to antiretroviral therapy (ART) initiation, and (iii) period following ART initiation.We found no significant associations between lifetime alcohol use and mean femoral neck (β -0.000, P = .62), total hip (β -0.000, P = .83) or lumbar spine (β 0.001, P = .65) BMD (g/cm), or low BMD diagnosis (adjusted odds ratio [aOR] = 0.98, 95% Confidence Interval [CI]: 0.95-1.01). There was no significant correlation between past 30-day alcohol use and mean BMD (g/cm). Past 30-day alcohol use was associated with low BMD diagnosis (P = .04); compared to abstainers, the aOR for high risk alcohol use was 1.94 (95% CI: 0.91-4.12), the aOR for low risk alcohol use was 4.32 (95% CI: 1.30-14.33). Drinking intensity (kg/year) between first positive HIV test and ART initiation was associated with lower mean BMD (g/cm) at the femoral neck (β -0.006, P = .04) and total hip (β -0.007, P = .02) and increased odds of low BMD (aOR = 1.18, 95% CI = 1.03-1.36).In this sample of PLWH, we detected no association between lifetime alcohol use and BMD. However, recent drinking was associated with low BMD diagnosis, as was drinking intensity between first positive HIV test and ART initiation. Longitudinal studies should confirm these associations.
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Affiliation(s)
- Alicia S. Ventura
- Clinical Addiction Research and Education Unit, General Internal Medicine, Boston University School of Medicine and Boston Medical Center
- Department of Community Health Sciences, Boston University School of Public Health
| | | | - Timothy C. Heeren
- Department of Biostatistics, Boston University School of Public Health
| | | | - Alexander Y. Walley
- Clinical Addiction Research and Education Unit, General Internal Medicine, Boston University School of Medicine and Boston Medical Center
| | - Michael F. Holick
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA
| | | | - Seville M. Meli
- Department of Community Health Sciences, Boston University School of Public Health
| | - Jeffrey H. Samet
- Clinical Addiction Research and Education Unit, General Internal Medicine, Boston University School of Medicine and Boston Medical Center
- Department of Community Health Sciences, Boston University School of Public Health
| | - Richard Saitz
- Clinical Addiction Research and Education Unit, General Internal Medicine, Boston University School of Medicine and Boston Medical Center
- Department of Community Health Sciences, Boston University School of Public Health
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Abstract
Human immunodeficiency virus (HIV) infection is an established risk factor for low bone mineral density (BMD) and subsequent fracture, and treatment with combination antiretroviral therapy (cART) leads to additional BMD loss, particularly in the first 1-2 years of therapy. The prevalence of low BMD and fragility fracture is expected to increase as the HIV-infected population ages with successful treatment with cART. Mechanisms of bone loss in the setting of HIV infection are likely multifactorial, and include viral, host, and immune effects, as well as direct and indirect effects of cART, particularly tenofovir disoproxil fumarate (TDF) and the protease inhibitors (PIs). Emerging data indicate that BMD loss following cART initiation can be mitigated by prophylaxis with either long-acting bisphosphonates or vitamin D and calcium supplementation. In addition, newer antiretrovirals, particularly the integrase strand transfer inhibitors and tenofovir alafenamide (TAF), are associated with less intense bone loss than PIs and TDF. However, further studies are needed to establish optimal bone sparing cART regimens, appropriate screening intervals, and preventive measures to address the rising prevalence of fragility bone disease in the HIV population.
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21
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Biver E, Calmy A, Rizzoli R. Bone health in HIV and hepatitis B or C infections. Ther Adv Musculoskelet Dis 2017; 9:22-34. [PMID: 28101146 PMCID: PMC5228639 DOI: 10.1177/1759720x16671927] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Chronic infections with human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) add to age-dependent bone loss and may contribute to lower bone strength in the elderly. In this review, we report recent highlights on the epidemiology of bone fragility in chronic viral infections with HIV, HCV and HBV, its physiopathology and discuss the interference of antiviral therapies with bone metabolism. Chronic infections influence bone through the interactions between risk factors for bone fragility and falls (which are highly prevalent in infected patients), virus activity and antiviral drugs. HIV-infected patients are at increased risk of fracture and the risk is higher in cases of co-infection with HIV and untreated chronic viral hepatitis. In HIV patients, the majority of bone loss occurs during virus activity and at initiation of antiretroviral therapy (ART). However, long-term elderly HIV-infected patients on successful ART display bone microstructure alterations only partially captured by dual energy X-ray absorptiometry (DXA). Bone loss is associated with an increase of bone resorption, reflecting the upregulation of the receptor activator of nuclear factor-kappaB ligand (RANKL) and osteoprotegerin (OPG) pathways via a crosstalk between virus activity, inflammation and the immune system. The use of some antiviral drugs, such as tenofovir (controlling both HBV and HIV infections) or protease inhibitors, may be associated with higher bone toxicity. The reduction of tenofovir plasma concentrations with the implementation of tenofovir alafenamide (TAF) attenuates bone mineral density (BMD) loss but it remains unknown whether it will contribute to reducing fracture risk in long-term HIV-treated patients. Moreover, to what extent the new direct-acting agents for treatment of HCV, including nucleotide inhibitors and protease inhibitors, may affect bone health similarly as ART in HIV should be investigated.
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Affiliation(s)
- Emmanuel Biver
- Division of Bone Diseases, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases, HIV Unit, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - René Rizzoli
- Division of Bone Diseases, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Chiţu-Tișu CE, Barbu EC, Lazăr M, Ion DA, Bădărău IA. Low bone mineral density and associated risk factors in HIV-infected patients. Germs 2016; 6:50-9. [PMID: 27482514 DOI: 10.11599/germs.2016.1089] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 09/25/2015] [Accepted: 09/29/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Aging of persons with human immunodeficiency virus (HIV) resulted in high rates of osteopenia and osteoporosis. Multiple cohort studies have reported an increased prevalence of bone demineralization among HIV-infected individuals. The aim of this study was to evaluate bone mineral density (BMD) and risk factors for osteopenia/osteoporosis among HIV-positive patients attending the National Institute for Infectious Diseases "Prof.Dr. Matei Balș", Bucharest, Romania. METHODS We performed a cross-sectional study that enrolled 60 patients with HIV. The association between BMD and lifestyle habits (smoking), body mass index (BMI), nadir cluster of differentiation 4 (CD4) cell count, current CD4 cell count, HIV viral load and history of combination antiretroviral therapy (cART) were investigated. The BMD was measured at the lumbar spine, hips and total body using dual-energy X-ray absorptiometry (DEXA). RESULTS In the present study, DEXA evaluation showed an overall prevalence of osteoporosis of 16.66% (ten patients) and a prevalence of osteopenia of 48.33% (29 patients). In men, low BMI and cigarette smoking showed significant association with the diagnosis of lumbar spine demineralization (p=0.034 and p=0.041, respectively). Duration of exposure to cART classes in relation to BMD was also evaluated. The use of non-nucleoside reverse-transcriptase inhibitors (NNRTIs) was associated with low lumbar spine BMD in all patients (p=0.015). Reduced BMD was significantly associated with protease inhibitors (PIs)-containing treatment (p=0.043) in women. CONCLUSION At lumbar spine DEXA, male gender was statistically associated with reduced BMD. At the left hip Ward's area, decreased BMD T scores were significantly associated with aging. The reduced BMD was higher in patients receiving PI- or NNRTI-containing regimens.
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Affiliation(s)
- Cristina-Emilia Chiţu-Tișu
- MD, PhD student, Carol Davila University of Medicine and Pharmacy, Dr I. Cantacuzino Clinical Hospital, Bucharest, Romania
| | - Ecaterina-Constanţa Barbu
- MD, PhD student, Carol Davila University of Medicine and Pharmacy, Dr I. Cantacuzino Clinical Hospital, Bucharest, Romania
| | - Mihai Lazăr
- MD, PhD, Lecturer, Department of Physiopathology II, Carol Davila University of Medicine and Pharmacy, National Institute for Infectious Diseases "Prof. Dr. Matei Balş", Bucharest, Romania
| | - Daniela Adriana Ion
- MD, PhD, Professor, Department of Physiopathology II, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Ioana Anca Bădărău
- MD, PhD, Professor, Department of Physiology I, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Santi D, Madeo B, Carli F, Zona S, Brigante G, Vescini F, Guaraldi G, Rochira V. Serum total estradiol, but not testosterone is associated with reduced bone mineral density (BMD) in HIV-infected men: a cross-sectional, observational study. Osteoporos Int 2016; 27:1103-1114. [PMID: 26510848 DOI: 10.1007/s00198-015-3383-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 10/21/2015] [Indexed: 01/24/2023]
Abstract
SUMMARY By investigating the relationship between serum testosterone, estradiol, and bone mineral density (BMD) in a large cohort of HIV-infected men, estradiol was associated with BMD, relative estrogen deficiency being involved in bone loss in men with hypogonadism, in addition to all HIV-related factors. Increased aromatization in adipose tissue does not counteract HIV-related bone loss. INTRODUCTION The purpose of this study is to evaluate the relationship between serum testosterone, estradiol, and BMD in a large cohort of HIV-infected men. METHODS We investigated biochemical, hormonal parameters, and BMD in 1204 HIV-infected men (age 45.64 ± 7.33 years) participating in a cross-sectional, observational study. Among other parameters, the main outcome measures were serum total testosterone and estradiol, gonadotropins, 25-hydroxyvitamin D [25(OH)D], parathormone (PTH), calcium, phosphorous, femoral, and lumbar BMD. RESULTS In men with HIV, the prevalence of osteoporosis and osteopenia is 15.1 and 63.2% with 25(OH)D insufficiency being very common (60.1%). After age adjustment, BMD is positively associated with estradiol, but not testosterone, at linear (p < 0.001) and stepwise (p < 0.05) multiple regression. Lumbar BMD significantly increases across the estradiol quartiles but not among testosterone quartiles. Femoral and lumbar BMD are significantly higher in men with estradiol ≥ 27 pg/mL than in those with estradiol <27 pg/mL. Apart from estradiol, only age, calcium, and BMI predict BMD at stepwise linear multiple regression, but the strength of this association is weak. CONCLUSIONS Estradiol, but not testosterone, is associated with BMD in HIV-infected men and exerts a protective role on bone especially when it is above 27 pg/mL. Relative estrogen deficiency is a potential mechanism involved in bone loss in hypogonadal HIV-infected men, in addition to all HIV-related factors. Increased aromatization in adipose tissue does not counteract HIV-related bone loss. Finally, reduced BMD in young-to-middle-aged HIV-infected men might be considered a peculiar hallmark of HIV infection due to its relevant prevalence, representing one of the several pieces composing the complicated puzzle of premature aging related to HIV infection.
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Affiliation(s)
- D Santi
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via P. Giardini 1355, 41126, Modena, Italy
- Azienda USL of Modena, NOCSAE, Via P. Giardini 1355, 41126, Modena, Italy
| | - B Madeo
- Azienda USL of Modena, NOCSAE, Via P. Giardini 1355, 41126, Modena, Italy
| | - F Carli
- Metabolic Clinic, Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences for Adults and Children, Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - S Zona
- Metabolic Clinic, Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences for Adults and Children, Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - G Brigante
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via P. Giardini 1355, 41126, Modena, Italy
| | - F Vescini
- Endocrinology and Metabolism Unit, University-Hospital S. Maria della Misericordia of Udine, P.za S. Maria della Misericordia 15, 33100, Udine, Italy
| | - G Guaraldi
- Metabolic Clinic, Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences for Adults and Children, Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, Italy
| | - V Rochira
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via P. Giardini 1355, 41126, Modena, Italy.
- Azienda USL of Modena, NOCSAE, Via P. Giardini 1355, 41126, Modena, Italy.
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24
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Carr A, Grund B, Neuhaus J, Schwartz A, Bernardino JI, White D, Badel-Faesen S, Avihingsanon A, Ensrud K, Hoy J. Prevalence of and risk factors for low bone mineral density in untreated HIV infection: a substudy of the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial. HIV Med 2015; 16 Suppl 1:137-46. [PMID: 25711332 DOI: 10.1111/hiv.12242] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVES HIV infection is associated with a higher prevalence of low bone mineral density (BMD) and fractures than that found in the general population. There are limited data in HIV-positive adults, naïve to antiretroviral therapy (ART), with which to estimate the relative contribution of untreated HIV infection to bone loss. METHODS The primary objective of the Strategic Timing of AntiRetroviral Treatment (START) Bone Mineral Density Substudy is to compare the effect of immediate versus deferred initial ART on bone. We evaluated traditional, demographic, HIV-related and immunological factors for their associations with baseline hip and lumbar spine BMD, measured by dual-energy X-ray absorptiometry, using multiple regression. RESULTS A total of 424 ART-naïve participants were enrolled at 33 sites on six continents; the mean age was 34 years [standard deviation (SD) 10.1 years], 79.0% were nonwhite, 26.0% were women, and 12.5% had a body mass index (BMI) < 20 kg/m(2) . Mean (SD) Z-scores were -0.41 (0.94) at the spine and -0.36 (0.88) for total hip; 1.9% had osteoporosis and 35.1% had low BMD (hip or spine T-score < -1.0). Factors independently associated with lower BMD at the hip and spine were female sex, Latino/Hispanic ethnicity, lower BMI and higher estimated glomerular filtration rate. Longer time since HIV diagnosis was associated with lower hip BMD. Current or nadir CD4 cell count and HIV viral load were not associated with BMD. CONCLUSIONS In this geographically and racially diverse population of ART-naïve adults with normal CD4 cell counts, low BMD was common, but osteoporosis was rare. Lower BMD was significantly associated with traditional risk factors but not with CD4 cell count or viral load.
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Affiliation(s)
- A Carr
- Centre for Applied Medical Research, St Vincent's Hospital, Sydney, Australia
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25
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Byrne DD, Newcomb CW, Carbonari DM, Nezamzadeh MS, Leidl KBF, Herlim M, Yang YX, Hennessy S, Kostman JR, Leonard MB, Localio AR, Re VL. Increased risk of hip fracture associated with dually treated HIV/hepatitis B virus coinfection. J Viral Hepat 2015; 22:936-47. [PMID: 25754215 PMCID: PMC4561220 DOI: 10.1111/jvh.12398] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 01/07/2015] [Indexed: 01/14/2023]
Abstract
HIV and hepatitis B virus (HBV) infections are each associated with reduced bone mineral density, but it is unclear whether HIV/HBV coinfection is associated with an increased risk of fracture. We determined whether dually treated HIV/HBV patients had a higher incidence of hip fracture compared to treated HBV-monoinfected, antiretroviral therapy (ART)-treated HIV-monoinfected and HIV/HBV-uninfected patients. We conducted a cohort study among 4156 dually treated HIV/HBV-coinfected, 2053 treated HBV-monoinfected, 96,253 ART-treated HIV-monoinfected, and 746,794 randomly sampled uninfected persons within the US Medicaid populations of California, Florida, New York, Ohio and Pennsylvania (1999-2007). Coinfected patients were matched on propensity score to persons in each comparator cohort. Weighted survival models accounting for competing risks were used to estimate cumulative incidences and hazard ratios (HRs) with 95% confidence intervals (CIs) of incident hip fracture for dually treated coinfected patients compared to (i) HBV-monoinfected receiving nucleos(t)ide analogue or interferon alfa therapy, (ii) HIV-monoinfected on ART and (iii) uninfected persons. Dually treated coinfected patients had a higher cumulative incidence of hip fracture compared to ART-treated HIV-monoinfected (at 5 years: 1.70% vs 1.24%; adjusted HR, 1.37 [95% CI, 1.03-1.83]) and uninfected (at 5 years: 1.64% vs 1.22%; adjusted HR, 1.35 [95% CI, 1.03-1.84]) persons. The cumulative incidence of hip fracture was higher among coinfected than treated HBV-monoinfected patients (at 5 years: 0.70% vs 0.27%), but this difference was not statistically significant in competing risk analysis (adjusted HR, 2.62 [95% CI, 0.92-7.51]). Among Medicaid enrollees, the risk of hip fracture was higher among dually treated HIV/HBV-coinfected patients than ART-treated HIV-monoinfected and uninfected persons.
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Affiliation(s)
- Dana D. Byrne
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Craig W. Newcomb
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Dena M. Carbonari
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Melissa S. Nezamzadeh
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kimberly B. F. Leidl
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Maximilian Herlim
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Yu-Xiao Yang
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sean Hennessy
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jay R. Kostman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for AIDS Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary B. Leonard
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for AIDS Research, University of Pennsylvania, Philadelphia, PA, USA,Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - A. Russell Localio
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vincent Lo Re
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Penn Center for AIDS Research, University of Pennsylvania, Philadelphia, PA, USA
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26
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Wang Q, Liu J, Ding H, Geng W, Xu J, Guo X, Sun A, Kang J, Li X, Li Y, Jiang Y, Shang H. Reduced bone mineral density among ART-naive male patients with HIV in China. Future Virol 2015. [DOI: 10.2217/fvl.15.51] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aims: To evaluate the prevalence and associated factors of reduced bone mineral density (BMD) among antiretroviral therapy (ART) naive HIV-infected male patients in China. Methods: We compared BMD between HIV-infected male patients and healthy controls. Risk factors of reduced BMD were studied using multivariable linear regression. Results: Reduced BMD rate of chronic HIV infection patients was higher. HIV infection was independently associated with decreased BMD after adjusting for demographic factors. Older age, lower BMI and men who have sex with men (MSM) were revealed as the risk factors of lower BMD in HIV-infected male patients. Conclusion: Reduced BMD rate of HIV-infected patients was high. Policies are needed for prevention and treatment.
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Affiliation(s)
- Qi Wang
- Key Laboratory of AIDS Immunology of National Health & Family Planning Commission, Department of Laboratory Medicine, The First Affiliated Hospital, China Medical University, Shenyang, P. R. China
- Collaborative Innovation Center for Diagnosis & Treatment of Infectious Diseases, Hangzhou, China
| | - Jing Liu
- Key Laboratory of AIDS Immunology of National Health & Family Planning Commission, Department of Laboratory Medicine, The First Affiliated Hospital, China Medical University, Shenyang, P. R. China
- Collaborative Innovation Center for Diagnosis & Treatment of Infectious Diseases, Hangzhou, China
| | - Haibo Ding
- Key Laboratory of AIDS Immunology of National Health & Family Planning Commission, Department of Laboratory Medicine, The First Affiliated Hospital, China Medical University, Shenyang, P. R. China
- Collaborative Innovation Center for Diagnosis & Treatment of Infectious Diseases, Hangzhou, China
| | - Wenqing Geng
- Key Laboratory of AIDS Immunology of National Health & Family Planning Commission, Department of Laboratory Medicine, The First Affiliated Hospital, China Medical University, Shenyang, P. R. China
- Collaborative Innovation Center for Diagnosis & Treatment of Infectious Diseases, Hangzhou, China
| | - Junjie Xu
- Key Laboratory of AIDS Immunology of National Health & Family Planning Commission, Department of Laboratory Medicine, The First Affiliated Hospital, China Medical University, Shenyang, P. R. China
- Collaborative Innovation Center for Diagnosis & Treatment of Infectious Diseases, Hangzhou, China
| | - Xiaolin Guo
- Key Laboratory of AIDS Immunology of National Health & Family Planning Commission, Department of Laboratory Medicine, The First Affiliated Hospital, China Medical University, Shenyang, P. R. China
- Collaborative Innovation Center for Diagnosis & Treatment of Infectious Diseases, Hangzhou, China
| | - Amy Sun
- Key Laboratory of AIDS Immunology of National Health & Family Planning Commission, Department of Laboratory Medicine, The First Affiliated Hospital, China Medical University, Shenyang, P. R. China
- Collaborative Innovation Center for Diagnosis & Treatment of Infectious Diseases, Hangzhou, China
| | - Jing Kang
- Key Laboratory of AIDS Immunology of National Health & Family Planning Commission, Department of Laboratory Medicine, The First Affiliated Hospital, China Medical University, Shenyang, P. R. China
- Collaborative Innovation Center for Diagnosis & Treatment of Infectious Diseases, Hangzhou, China
| | - Xiaolin Li
- Key Laboratory of AIDS Immunology of National Health & Family Planning Commission, Department of Laboratory Medicine, The First Affiliated Hospital, China Medical University, Shenyang, P. R. China
- Collaborative Innovation Center for Diagnosis & Treatment of Infectious Diseases, Hangzhou, China
| | - Yushu Li
- Liaoning Provincial Key Laboratory of Endocrine Diseases, Department of Endocrinology & Metabolism, Institute of Endocrinology, The First Affiliated Hospital of China Medical University, Shenyang, P. R. China
| | - Yongjun Jiang
- Key Laboratory of AIDS Immunology of National Health & Family Planning Commission, Department of Laboratory Medicine, The First Affiliated Hospital, China Medical University, Shenyang, P. R. China
- Collaborative Innovation Center for Diagnosis & Treatment of Infectious Diseases, Hangzhou, China
| | - Hong Shang
- Key Laboratory of AIDS Immunology of National Health & Family Planning Commission, Department of Laboratory Medicine, The First Affiliated Hospital, China Medical University, Shenyang, P. R. China
- Collaborative Innovation Center for Diagnosis & Treatment of Infectious Diseases, Hangzhou, China
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Takeda K, Adhikari R, Yamada KM, Dhawan S. Hemin activation of innate cellular response blocks human immunodeficiency virus type-1-induced osteoclastogenesis. Biochem Biophys Res Commun 2015; 464:7-12. [PMID: 25998388 DOI: 10.1016/j.bbrc.2015.05.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 05/11/2015] [Indexed: 12/23/2022]
Abstract
The normal skeletal developmental and homeostatic process termed osteoclastogenesis is exacerbated in numerous pathological conditions and causes excess bone loss. In cancer and HIV-1-infected patients, this disruption of homeostasis results in osteopenia and eventual osteoporesis. Counteracting the factors responsible for these metabolic disorders remains a challenge for preventing or minimizing this co-morbidity associated with these diseases. In this report, we demonstrate that a hemin-induced host protection mechanism not only suppresses HIV-1 associated osteoclastogenesis, but it also exhibits anti-osteoclastogenic activity for non-infected cells. Since the mode of action of hemin is both physiological and pharmacological through induction of heme oxygenase-1 (HO-1), an endogenous host protective response to an FDA-licensed therapeutic used to treat another disease, our study suggests an approach to developing novel, safe and effective therapeutic strategies for treating bone disorders, because hemin administration in humans has previously met required FDA safety standards.
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Affiliation(s)
- Kazuyo Takeda
- Microscopy and Imaging Core Facility, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Rewati Adhikari
- Division of Transfusion Transmitted Diseases, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, MD, USA
| | - Kenneth M Yamada
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Subhash Dhawan
- Division of Transfusion Transmitted Diseases, Center for Biologics Evaluation and Research, Food and Drug Administration, Bethesda, MD, USA.
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Falutz J. Editorial Commentary: Unmasking the Bare Bones of HIV Preexposure Prophylaxis. Clin Infect Dis 2015; 61:581-3. [PMID: 25908681 DOI: 10.1093/cid/civ329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 03/24/2015] [Indexed: 12/16/2022] Open
Affiliation(s)
- Julian Falutz
- Chronic Viral Illness Service, Division of Geriatrics, McGill University Hospital Center, Montreal, Quebec, Canada
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29
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Blick G, Khera M, Bhattacharya RK, Kushner H, Miner MM. Testosterone Replacement Therapy in Men With Hypogonadism and HIV/AIDS: Results From the TRiUS Registry. Postgrad Med 2015; 125:19-29. [DOI: 10.3810/pgm.2013.03.2638] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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30
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Abstract
Concern has been raised that HIV infection, its treatment, or both adversely affect skeletal health. Cross-sectional studies show that bone mineral density (BMD) is 3-5% lower in patients infected with HIV than in uninfected controls, but patients with HIV infection are, on average, 5 kg lighter than uninfected people. After this weight difference is accounted for, BMD differences are smaller and not clinically relevant. Longitudinal studies show short-term BMD loss of 2-4% over 1-2 years when antiretroviral therapy is started, followed by longer periods of BMD increase or stability. Losses are greatest with treatment regimens that contain tenofovir. Patients infected with HIV have slightly higher fracture rates than controls, but the increased risk of fracture is substantially attenuated by adjustment for traditional risk factors for fracture. These reassuring findings suggest that management of skeletal health in HIV should follow guidelines for the general population. In general, effective antiretroviral treatment and avoidance of undernutrition are the two most important factors for maintenance of skeletal health in patients infected with HIV.
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Affiliation(s)
- Mark J Bolland
- Department of Medicine, University of Auckland, Auckland, New Zealand.
| | - Andrew Grey
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Ian R Reid
- Department of Medicine, University of Auckland, Auckland, New Zealand
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Rey D, Treger M, Sibilia J, Priester M, Bernard-Henry C, Cheneau C, Javier RM. Bone mineral density changes after 2 years of ARV treatment, compared to naive HIV-1-infected patients not on HAART. Infect Dis (Lond) 2014; 47:88-95. [PMID: 25426996 DOI: 10.3109/00365548.2014.968610] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The prevalence of osteopenia and osteoporosis is increased in human immunodeficiency virus (HIV)-infected patients. The pathogenesis of this low bone mineral density (BMD) is multifactorial. METHODS We conducted a prospective study over a 2-year period of the BMD in non-treated ARV-naïve HIV-infected-males, in comparison to HIV-infected males commencing a first ARV treatment, and analyzed the evolution of bone turnover markers. RESULTS A total of 39 caucasian males (median age 38.6 years) were enrolled, including 10 who started ARV treatment (group 1), and 29 without indications for ARV therapy (group 2). In the latter group, 11 subjects commenced ARV during the study; therefore the remainder of their follow-up was within group 1, which finally consisted of 21 patients. At baseline, 9 patients (19.5%) had osteoporosis at least at 1 site, while 28 (61%) showed osteopenia. Lower BMD was correlated with tobacco use. Lumbar spine and total hip BMD significantly decreased in group 1 patients after 6 months of treatment, then stabilized (2.4% and 4% loss, respectively, at 24 months), while no significant change in BMD was observed in group 2 subjects. At baseline, one patient had an increased CTX (C-terminal cross-linking telopeptide of type 1 collagen) and all BSAP (bone-specific alkaline phosphatase) results were normal. During follow-up, both CTX and BSAP increased in group 1 patients, while they did not change in group 2. CONCLUSION Osteoporosis and osteopenia are frequent in HIV-infected males. After ARV initiation, BMD decreased, and bone turnover markers increased, even though the BMD remained stable in non-treated patients. These results underline the impact of HIV treatment on BMD and bone metabolism.
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Affiliation(s)
- David Rey
- From the Le Trait d'Union, Hôpitaux Universitaires Strasbourg
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32
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Titanji K, Vunnava A, Sheth AN, Delille C, Lennox JL, Sanford SE, Foster A, Knezevic A, Easley KA, Weitzmann MN, Ofotokun I. Dysregulated B cell expression of RANKL and OPG correlates with loss of bone mineral density in HIV infection. PLoS Pathog 2014; 10:e1004497. [PMID: 25393853 PMCID: PMC4231117 DOI: 10.1371/journal.ppat.1004497] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 10/01/2014] [Indexed: 11/18/2022] Open
Abstract
HIV infection is associated with high rates of osteopenia and osteoporosis, but the mechanisms involved are unclear. We recently reported that bone loss in the HIV transgenic rat model was associated with upregulation of B cell expression of the key osteoclastogenic cytokine receptor-activator of NF-κB ligand (RANKL), compounded by a simultaneous decline in expression of its physiological moderator, osteoprotegerin (OPG). To clinically translate these findings we performed cross-sectional immuno-skeletal profiling of HIV-uninfected and antiretroviral therapy-naïve HIV-infected individuals. Bone resorption and osteopenia were significantly higher in HIV-infected individuals. B cell expression of RANKL was significantly increased, while B cell expression of OPG was significantly diminished, conditions favoring osteoclastic bone resorption. The B cell RANKL/OPG ratio correlated significantly with total hip and femoral neck bone mineral density (BMD), T- and/or Z-scores in HIV infected subjects, but revealed no association at the lumbar spine. B cell subset analyses revealed significant HIV-related increases in RANKL-expressing naïve, resting memory and exhausted tissue-like memory B cells. By contrast, the net B cell OPG decrease in HIV-infected individuals resulted from a significant decline in resting memory B cells, a population containing a high frequency of OPG-expressing cells, concurrent with a significant increase in exhausted tissue-like memory B cells, a population with a lower frequency of OPG-expressing cells. These data validate our pre-clinical findings of an immuno-centric mechanism for accelerated HIV-induced bone loss, aligned with B cell dysfunction. HIV infection causes significant bone loss and skeletal deterioration, leading to fractures that are often devastating and incur significant financial burden on patients and their families. HIV-infected individuals have up to a five-fold higher risk of bone fractures, and the increasing average age of people living with HIV/AIDS has triggered fears of an impending epidemic of bone fractures in this population. Antiretroviral therapy, used to manage HIV infection, fails to prevent, but rather paradoxically accelerates skeletal decline. The underlying mechanisms of HIV-induced bone loss are poorly understood. The aim of this study was to clarify the mechanisms of bone loss in HIV-infected patients, in an effort to better understand how bone loss and fractures occur, and consequently how it can be prevented in this population. The cytokine RANKL (Receptor Activator of Nuclear Factor kappa-B Ligand) helps induce bone loss. We show that RANKL expression was increased in immune cells in HIV-infected individuals. Another cytokine, osteoprotegerin (OPG), counteracts the activity of RANKL, and therefor helps prevent bone loss. OPG expression by the same immune cells was decreased in HIV-infected individuals. We conclude that disrupted immune cell expression of RANKL and OPG in HIV-infected patients contributes to bone loss.
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Affiliation(s)
- Kehmia Titanji
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Aswani Vunnava
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Anandi N. Sheth
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Cecile Delille
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Jeffrey L. Lennox
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Sara E. Sanford
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Antonina Foster
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Andrea Knezevic
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Kirk A. Easley
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - M. Neale Weitzmann
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Atlanta VA Medical Center, Decatur, Georgia, United States of America
- Winship Cancer Institute, Emory University, Atlanta, Georgia, United States of America
- * E-mail: (MNW); (IO)
| | - Ighovwerha Ofotokun
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
- * E-mail: (MNW); (IO)
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Abstract
INTRODUCTION Low bone mineral density (BMD) is common in HIV-positive patients, although the role played by HIV infection versus sociodemographic and metabolic factors remains unclear. METHODS Understanding the Pathology of Bone Disease in HIV-infected individuals (HIV UPBEAT) is a prospective cohort study, enrolled HIV-positive and HIV-negative participants from similar demographic backgrounds. Dual X-ray absorptiometry at femoral neck, total hip and lumbar spine and blood tests were performed. Associations between BMD and factors of interest were assessed using multivariable linear regression. RESULTS A total of 474 participants were recruited. Two hundred and ten were HIV-positive, of whom, 59% were male, 40% African and median (interquartile range) age was 39 (33, 46) years. HIV acquisition risks were heterosexual sex (46.9%), homosexual sex (25.4%) and intravenous drug use (18.7%). Of the HIV-negative participants, 44% were male, 25% were African and median (interquartile range) age was 42 (34-49) years. HIV infection was independently associated with a 0.062 (P < 0.0001), 0.078 (P < 0.0001) and 0.060 g/cm (P = 0.0002) lower BMD at femoral neck, total hip and lumbar spine, respectively, after adjustment for demographic/ lifestyle factors and BMI. After further adjustment for bone biomarkers, HIV remained independently associated with reduced BMD at each site, although effect sizes were reduced. The HIV-positive group had significantly higher bone turnover (all between-group P < 0.0001). Treatment variables and cumulative exposure to antiretroviral therapy were not associated with lower BMD at femoral neck or total hip, but acquisition of HIV infection via intravenous drug use and longer time since HIV diagnosis were independently associated with lower lumbar spine BMD. DISCUSSION HIV is independently associated with lower BMD, and its effect is likely mediated, in part, by alterations in bone metabolism.
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Abstract
PURPOSE OF REVIEW Low bone mineral density (BMD) is common in those with HIV, associated with higher bone turnover and a higher prevalence of fractures. This review explores low BMD in HIV, focusing on underlying mechanisms and relationships between low BMD and HIV infection, immune dysfunction, and antiretroviral therapy (ART). RECENT FINDINGS Greater reductions in BMD accompanying reductions in HIV viremia at initiation of first-line or second-line ART suggest an important role for immune- or viral-mediated mechanisms in its pathogenesis. SUMMARY As bone metabolism is part-regulated by T cells and B cells, we propose that earlier initiation of ART at higher CD4 T-cell counts may attenuate BMD loss by abrogating immune- and viral-mediated disturbances in bone metabolism that accompany ART initiation. Further pathogenesis-based research is required in this field, focusing on the complex interaction between virus, immune system, ART, and bone metabolism.
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Huang JS, Hughes MD, Riddler SA, Haubrich RH. Bone mineral density effects of randomized regimen and nucleoside reverse transcriptase inhibitor selection from ACTG A5142. HIV CLINICAL TRIALS 2014; 14:224-34. [PMID: 24144899 DOI: 10.1310/hct1405-224] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare the longitudinal changes in total bone mineral density (TBMD) across antiretroviral (ARV) regimens. METHODS A5142 was an open-label study comparing 3 ARV regimens for the initial treatment of HIV-1. Subjects were randomized equally to efavirenz (EFV) plus 2 nucleoside reverse transcriptase inhibitors (NRTIs), lopinavir/ritonavir (LPV/r) plus 2 NRTIs, or LPV/r plus EFV without NRTI. The NRTI regimen (lamivudine [3TC] plus zidovudine [ZDV], stavudine [d4T], or tenofovir [TDF]) was selected prior to randomization. TBMD was assessed via whole-body dual-energy X-ray absorptiometry (DXA) at baseline and 48 and 96 weeks. Analysis was modified intent-to-treat (ITT) ignoring regimen changes using all evaluations. RESULTS Significant mean declines in TBMD at week 48 were observed among subjects. In repeated-measures analysis of changes (including randomized regimen, NRTI used, and time), there was a significant difference in the NRTI-containing arms in mean percentage change in TBMD at week 48 according to NRTI used (P < .001). Subjects taking ZDV had similar changes to those taking d4T (P = .970), whereas those taking TDF had larger declines (P < .001). There was a nonsignificant trend toward greater mean declines among subjects taking LPV/r versus EFV (P = .080). Overall, TDF-containing regimens demonstrated the greatest losses in TBMD, while EFV regimens without TDF had lesser TBMD reductions even compared to the NRTI-sparing arm. From week 48 to 96, all treatment groups continued to lose TBMD at similar rates. CONCLUSIONS Among NRTI-containing arms, NRTI selection, especially use of TDF, had a greater effect on TBMD change than randomized regimen. The long-term clinical significance remains to be demonstrated.
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Affiliation(s)
- Jeannie S Huang
- Department of Pediatrics, University of California San Diego, La Jolla, California
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Blick G. Optimal diagnostic measures and thresholds for hypogonadism in men with HIV/AIDS: comparison between 2 transdermal testosterone replacement therapy gels. Postgrad Med 2013; 125:30-9. [PMID: 23816769 DOI: 10.3810/pgm.2013.03.2639] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To determine the incidence of hypogonadism in men with human immunodeficiency virus (HIV)/acquired immunodeficiency virus (AIDS), the most useful serum testosterone measurement and threshold for diagnosing hypogonadism, and the comparative efficacy of 2 testosterone replacement therapy (TRT) 1% gels (AndroGel® [Abbott Laboratories] and Testim® [Auxilium Pharmaceuticals, Inc.]). DESIGN AND SUBJECTS This was a 2-stage observational study. In stage 1, patient records from 2 medical practices specializing in HIV/AIDS were reviewed. Eligible patients were aged ≥ 18 years; had HIV-seropositive status confirmed by enzyme-linked immunosorbent assay and western blot test or HIV-1 viremia confirmed by HIV-1 RNA polymerase chain reaction; and had prior baseline testosterone assessments for hypogonadism (ie, presence of signs/symptoms of hypogonadism as well as total testosterone [TT] and free testosterone [FT] level measurements). Stage 2 included the evaluation of patients from stage 1 who were treated with 5 to 10 g/day of TRT. The stage 2 inclusion criteria were a diagnosis of low testosterone (defined as TT level < 300 ng/dL and/or FT level < 50 pg/mL, as per The Endocrine Society guidelines and presence/absence of hypogonadal signs and symptoms); ≥ 12 months of evaluable sign and symptom assessments and TT/FT level measurements while on TRT with either Testim® or AndroGel®; and ≥ 4 weeks on initial TRT if the initial TRT was switched or discontinued. RESULTS Four hundred one of 422 patients met the stage 1 inclusion criteria and 167 of 401 patients (AndroGel®, n = 92; Testim®, n = 75) met the stage 2 inclusion criteria. Total testosterone level < 300 ng/dL alone identified 24% (94 of 390) of patients as hypogonadal, but failed to diagnose an additional 111 patients (67.7%) with FT levels < 100 pg/mL and hypogonadal symptoms. Through month 12, AndroGel® increased mean TT levels by +42.8% and FT levels by +66.9%, compared with +178.7% (P = 0.017) and +191% (P = 0.039), respectively, for Testim®. Patients treated with Testim® showed significantly greater improvements in libido, sexual performance, nighttime energy, focus/concentration, and abdominal girth, and trends for greater improvement in fatigue and erectile dysfunction than patients treated with AndroGel®. No patients discontinued therapy due to adverse events. CONCLUSION The most useful serum testosterone measurement and threshold for diagnosing hypogonadism in men with HIV/AIDS was FT level < 100 pg/mL, which identified 64% of men as hypogonadal with the presence of ≥ 1 hypogonadal symptom. This is above currently accepted thresholds. Criteria using TT level < 300 ng/dL and FT level < 50 pg/mL only diagnosed 24% and 19% of patients, respectively, as having hypogonadism. Testim® was more effective than AndroGel® in increasing TT and FT levels and improving hypogonadal symptoms.
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Affiliation(s)
- Gary Blick
- Circle Care Center, Norwalk, CT 06850, USA.
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Grijsen ML, Vrouenraets SME, Wit FWNM, Stolte IG, Prins M, Lips P, Reiss P, Prins JM. Low Bone Mineral Density, Regardless of HIV Status, in Men Who Have Sex With Men. J Infect Dis 2012; 207:386-91. [DOI: 10.1093/infdis/jis687] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Negredo E, Bonjoch A, Gómez-Mateu M, Estany C, Puig J, Perez-Alvarez N, Rosales J, di Gregorio S, del Rio L, Gómez G, Clotet B. Time of progression to osteopenia/osteoporosis in chronically HIV-infected patients: screening DXA scan. PLoS One 2012; 7:e46031. [PMID: 23056229 PMCID: PMC3466220 DOI: 10.1371/journal.pone.0046031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 08/28/2012] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Algorithms for bone mineral density (BMD) management in HIV-infected patients are lacking. Our objective was to assess how often a dual-energy x-ray absorptiometry (DXA) scan should be performed by assessing time of progression to osteopenia/osteoporosis. METHODS All DXA scans performed between 2000 and 2009 from HIV-infected patients with at least two DXA were included. Time to an event (osteopenia and osteoporosis) was assessed using the Kaplan-Meier method. Strata (tertiles) were defined using baseline minimum T scores. Differences between strata in time to an event were compared with the log-rank test. RESULTS Of 391 patients (1,639 DXAs), 49.6% had osteopenia and 21.7% osteoporosis at their first DXA scan. Of the 112 (28.6%) with normal BMD, 35.7% progressed to osteopenia; median progression time was 6.7 years. These patients were stratified: "low-risk" (baseline minimum T score >-0.2 SD), "middle-risk" (between -0.2 and -0.6 SD), and "high-risk" (from -0.6 to -1 SD); median progression time to osteopenia was 8.7, >7.2, and 1.7 years, respectively (p<0.0001). Of patients with osteopenia, 23.7% progressed to osteoporosis; median progression time was >8.5 years. Progression time was >8.2 years in "low-risk" tertile (T score between -1.1 and -1.6 SD), >8.5 years in "middle-risk" (between -1.6 and -2), and 3.2 years in "high-risk" (from -2 to -2.4) (p<0.0001). CONCLUSIONS Our results may help to define the BMD testing interval. The lowest T score tertiles would suggest recommending a subsequent DXA in 1-2 years; in the highest tertiles, ≥6 years. Early intervention in patients with bone demineralization could reduce fracture-related morbidity/mortality.
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Affiliation(s)
- Eugenia Negredo
- Lluita contra la SIDA Foundation, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Mulligan K, Harris DR, Emmanuel P, Fielding RA, Worrell C, Kapogiannis BG, Monte D, Sleasman J, Wilson CM, Aldrovandi GM. Low bone mass in behaviorally HIV-infected young men on antiretroviral therapy: Adolescent Trials Network Study 021B. Clin Infect Dis 2012; 55:461-8. [PMID: 22573848 PMCID: PMC3491777 DOI: 10.1093/cid/cis455] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 04/10/2012] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Peak bone mass is achieved in adolescence/early adulthood and is the key determinant of bone mass in adulthood. We evaluated the association of bone mass with human immunodeficiency virus (HIV) infection and antiretroviral therapy (ART) during this critical period among behaviorally HIV-infected young men and seronegative controls. METHODS HIV-positive men (N = 199) and HIV-negative controls (N = 53), ages 14-25 years, were studied at 15 Adolescent Trials Network for HIV/AIDS Interventions sites. HIV-positive participants were recruited on the basis of ART status: ART-naive (N = 105) or on a regimen containing a nonnucleoside reverse transcriptase inhibitor (NNRTI; N = 52) or protease inhibitor (PI; N = 42). Bone mineral density (BMD) and content (BMC) and body composition were measured by dual-energy X-ray absorptiometry (DXA). Results were compared across groups by linear modeling. Bone results were adjusted for race, body mass index (BMI), and type of DXA (Hologic/Lunar). RESULTS The HIV-positive and HIV-negative groups had comparable median age (21 years) and racial/ethnic distribution. Median times since HIV diagnosis were 1.3, 1.9, and 2.2 years in the ART-naive, NNRTI, and PI groups, respectively (P = .01). Total and regional fat were significantly lower in the ART-naive group compared with seronegative controls. Mean BMD and Z scores were generally lower among HIV-positive participants on ART, particularly in the PI group. Average Z scores for the spine were below zero in all 4 groups, including controls. CONCLUSIONS Young men on ART with a relatively recent diagnosis of HIV infection have lower bone mass than controls. Longitudinal studies are required to determine the impact of impaired accrual or actual loss of bone during adolescence on subsequent fracture risk.
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Dickinson SA, Fantry LE. Use of dual-energy x-ray absorptiometry (DXA) scans in HIV-infected patients. ACTA ACUST UNITED AC 2012; 11:239-44. [PMID: 22511611 DOI: 10.1177/1545109712438751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Multiple studies have demonstrated increased rates of osteopenia and osteoporosis in HIV-infected patients but there have been no published studies on current screening practices. We conducted a retrospective chart review of 2924 patients attending an urban HIV clinic. Thirty patients (1%) had dual-energy x-ray absorptiometry (DXA) scans. Patients undergoing DXA scans were more likely to be older, women, and have nondetectable HIV viral load and CD4 count ≥200. The most frequently cited indications for screening were perimenopausal or postmenopausal status and HIV infection. Of the patients screened, 96% had osteopenia or osteoporosis with a median T-score of -1.9 and a median of 3.8 osteoporosis risk factors in addition to HIV. Of the 20 practitioners in the clinic, only 7 had patients with screening DXA scans. DXA scans are underutilized in the HIV population given the high rate of osteopenia and osteoporosis detected in this study.
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Affiliation(s)
- S A Dickinson
- 1University of Maryland Medical Center, Internal Medicine, Baltimore, MD, USA
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Bander D, Parczewski M. Osteoporosis and vitamin D deficiency in HIV-infected patients: Genetic and classical factors compared to the HIV-associated ones – Review. HIV & AIDS REVIEW 2012. [DOI: 10.1016/j.hivar.2011.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Incidence of low and high-energy fractures in persons with and without HIV infection: a Danish population-based cohort study. AIDS 2012; 26:285-93. [PMID: 22095195 DOI: 10.1097/qad.0b013e32834ed8a7] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare fracture risk in persons with and without HIV infection and to examine the influence of highly active antiretroviral therapy (HAART) initiation on risk of fracture. DESIGN Population-based nationwide cohort study using Danish registries. METHODS Outcome measures were time to first fracture at any site, time to first low-energy and high-energy fracture in HIV-infected patients (n = 5306) compared with a general population control cohort (n = 26 530) matched by sex and age during the study period 1995-2009. Cox regression analyses were used to estimate incidence rate ratios (IRRs). RESULTS HIV-infected patients had increased risk of fracture [IRR 1.5, 95% confidence interval (CI) 1.4-1.7] compared with population controls. The relative risk was lower in HIV-monoinfected patients (IRR 1.3, 95% CI 1.2-1.4) than in HIV/hepatitis C virus (HCV)-coinfected patients (IRR 2.9, 95% CI 2.5-3.4).Both HIV-monoinfected and HIV/HCV-coinfected patients had increased risk of low-energy fracture, IRR of 1.6 (95% CI 1.4-1.8) and 3.8 (95% CI 3.0-4.9). However, only HIV/HCV-coinfected patients had increased risk of high-energy fracture, IRR of 2.4 (95% CI 2.0-2.9). Among HIV-monoinfected patients the risk of low-energy fracture was only significantly increased after HAART exposure, IRR of 1.8 (95% CI 1.5-2.1). The increased risk in HAART-exposed patients was not associated with CD4 cell count, prior AIDS, tenofovir or efavirenz exposure, but with comorbidity and smoking. CONCLUSION HIV-infected patients had increased risk of fracture compared with population controls. Among HIV-monoinfected patients the increased risk was observed for low-energy but not for high-energy fractures, and the increased risk of low-energy fracture was only observed in HAART-exposed patients.
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Lima ALLM, de Oliveira PRD, Plapler PG, Marcolino FMDA, de Souza Meirelles E, Sugawara A, Gobbi RG, dos Santos ALG, Camanho GL. Osteopenia and osteoporosis in people living with HIV: multiprofessional approach. HIV AIDS (Auckl) 2011; 3:117-24. [PMID: 22267944 PMCID: PMC3257973 DOI: 10.2147/hiv.s6617] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Increasing bone mineralization abnormalities observed among people living with HIV (PLWHIV) result from various factors relating to the host, the virus, and the antiretrovirals used. Today, HIV infection is considered to be a risk factor for bone mineralization disorders. The test most recommended for diagnosing osteoporosis is measurement of bone mineral density by means of dual energy X-ray absorptiometry at two sites. Osteoporosis treatment has the aims of bone mass improvement and fracture control. A combination of calcium and vitamin D supplementation may reduce the risk of fractures. Antiresorptive drugs act by blocking osteoclastic activity and reducing bone remodeling. On the other hand, bone-forming drugs stimulate osteoblastogenesis, thereby stimulating the formation of bone matrix. Mixed-action medications are those that are capable of both stimulating bone formation and inhibiting reabsorption. Antiresorptive drugs form the group of medications with the greatest quantity of scientific evidence confirming their efficacy in osteoporosis treatment. Physical activity is a health promotion strategy for the general population, but only preliminary data on its real value and benefit among PLWHIV are available, especially in relation to osteoporosis.
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Affiliation(s)
- Ana Lucia Lei Munhoz Lima
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Priscila Rosalba D de Oliveira
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Perola Grimberg Plapler
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Flora Maria D Andrea Marcolino
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Eduardo de Souza Meirelles
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - André Sugawara
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Riccardo Gomes Gobbi
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Alexandre Leme Godoy dos Santos
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Gilberto Luis Camanho
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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Liu AY, Vittinghoff E, Sellmeyer DE, Irvin R, Mulligan K, Mayer K, Thompson M, Grant R, Pathak S, O'Hara B, Gvetadze R, Chillag K, Grohskopf L, Buchbinder SP. Bone mineral density in HIV-negative men participating in a tenofovir pre-exposure prophylaxis randomized clinical trial in San Francisco. PLoS One 2011; 6:e23688. [PMID: 21897852 PMCID: PMC3163584 DOI: 10.1371/journal.pone.0023688] [Citation(s) in RCA: 133] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2011] [Accepted: 07/22/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pre-exposure prophylaxis (PrEP) trials are evaluating regimens containing tenofovir-disoproxil fumarate (TDF) for HIV prevention. We determined the baseline prevalence of low bone mineral density (BMD) and the effect of TDF on BMD in men who have sex with men (MSM) in a PrEP trial in San Francisco. METHODS/FINDINGS We evaluated 1) the prevalence of low BMD using Dual Energy X-ray Absorptiometry (DEXA) in a baseline cohort of 210 HIV-uninfected MSM who screened for a randomized clinical trial of daily TDF vs. placebo, and 2) the effects of TDF on BMD in a longitudinal cohort of 184 enrolled men. Half began study drug after a 9-month delay to evaluate changes in risk behavior associated with pill-use. At baseline, 20 participants (10%) had low BMD (Z score≤-2.0 at the L2-L4 spine, total hip, or femoral neck). Low BMD was associated with amphetamine (OR = 5.86, 95% CI 1.70-20.20) and inhalant (OR = 4.57, 95% CI 1.32-15.81) use; men taking multivitamins, calcium, or vitamin D were less likely to have low BMD at baseline (OR = 0.26, 95% CI 0.10-0.71). In the longitudinal analysis, there was a 1.1% net decrease in mean BMD in the TDF vs. the pre-treatment/placebo group at the femoral neck (95% CI 0.4-1.9%), 0.8% net decline at the total hip (95% CI 0.3-1.3%), and 0.7% at the L2-L4 spine (95% CI -0.1-1.5%). At 24 months, 13% vs. 6% of participants experienced >5% BMD loss at the femoral neck in the TDF vs. placebo groups (p = 0.13). CONCLUSIONS Ten percent of HIV-negative MSM had low BMD at baseline. TDF use resulted in a small but statistically significant decline in BMD at the total hip and femoral neck. Larger studies with longer follow-up are needed to determine the trajectory of BMD changes and any association with clinical fractures. TRIAL REGISTRATION ClinicalTrials.gov: NCT00131677.
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Affiliation(s)
- Albert Y Liu
- San Francisco Department of Public Health, San Francisco, California, United States of America.
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Kowalski J, Cholewińska G. An increased risk of osteoporosis in a HIV-infected patient in the era of HAART. Case report analysis. HIV & AIDS REVIEW 2011. [DOI: 10.1016/j.hivar.2011.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Barkhordarian A, Ajaj R, Ramchandani MH, Demerjian G, Cayabyab R, Danaie S, Ghodousi N, Iyer N, Mahanian N, Phi L, Giroux A, Manfrini E, Neagos N, Siddiqui M, Cajulis OS, Brant XMC, Shapshak P, Chiappelli F. Osteoimmunopathology in HIV/AIDS: A Translational Evidence-Based Perspective. PATHOLOGY RESEARCH INTERNATIONAL 2011; 2011:359242. [PMID: 21660263 PMCID: PMC3108376 DOI: 10.4061/2011/359242] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Revised: 02/24/2011] [Accepted: 03/02/2011] [Indexed: 01/21/2023]
Abstract
Infection with the human immunodeficiency virus-1 (HIV) and the resulting acquired immune deficiency syndrome (AIDS) alter not only cellular immune regulation but also the bone metabolism. Since cellular immunity and bone metabolism are intimately intertwined in the osteoimmune network, it is to be expected that bone metabolism is also affected in patients with HIV/AIDS. The concerted evidence points convincingly toward impaired activity of osteoblasts and increased activity of osteoclasts in patients with HIV/AIDS, leading to a significant increase in the prevalence of osteoporosis. Research attributes these outcomes in part at least to the ART, PI, and HAART therapies endured by these patients. We review and discuss these lines of evidence from the perspective of translational clinically relevant complex systematic reviews for comparative effectiveness analysis and evidence-based intervention on a global scale.
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Affiliation(s)
- André Barkhordarian
- Section of Oral Biology, Division of Oral Biology & Medicine, UCLA School of Dentistry, Los Angeles, CA 90095, USA
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Algorithm for the Management of Osteoporosis. South Med J 2011; 104:247. [DOI: 10.1097/smj.0b013e31820c02fc] [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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Nonsurgical Management of Severe Osteonecrosis of the Knee in an HIV-Positive Patient: A Case Report. Case Rep Infect Dis 2011; 2011:935041. [PMID: 22570802 PMCID: PMC3336249 DOI: 10.1155/2011/935041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 06/07/2011] [Indexed: 11/17/2022] Open
Abstract
Due to the life-prolonging effects of combination antiretroviral therapy, many people with HIV are living longer. However, this enhanced longevity is often mirrored by increased disability resulting from HIV and/or the adverse effects of medication. Management of HIV-positive patients is further complicated by comorbidities related to aging, including bone and joint disorders. In this paper, we describe the nonsurgical management of an HIV-positive patient with premature onset of severe osteonecrosis of the knee. A 50-year-old man who had been HIV-positive for 16 years and on combination antiretroviral therapy for 11 years presented to his family physician with extreme discomfort in his right knee. He was diagnosed with osteonecrosis of the right knee, but resisted total knee arthroplasty because of potential complications under anesthesia related to comorbid advanced liver disease. Instead, a successful combination of non-surgical management strategies was employed by the patient and his health care team.
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