Fat Mass Ratio in Brazilian HIV-infected Patients Under Antiretroviral Therapy and Its Relationship With Anthropometric Measurents

INTRODUCTION

Human immunodeficiency virus-related lipodystrophy is characterized by a variety of phenotypes and metabolic changes; however, consensus has not yet been reached on its diagnostic criteria. Different cutoff values for fat mass ratio have been proposed for this specific population as an objective diagnostic criterion for lipodystrophy. This study aimed to establish sex-specific reference values for fat mass ratio and to correlate them with anthropometric measurements for the diagnosis of human immunodeficiency virus-related lipodystrophy.

METHODOLOGY

A cross-sectional study was performed on 189 human immunodeficiency virus-infected patients under antiretroviral therapy. Anthropometric measurements were evaluated, and body composition was determined using dual-energy X-ray absorptiometry. Fat mass ratio was calculated as the ratio of the percentage of the trunk fat mass and the percentage of the lower limb fat mass.

RESULTS

One hundred and thirty-two patients (69%) presented lipodystrophy by objective criteria. In men, the cutoff for the fat mass ratio was 1.55 (area under the receiver operating characteristic curve: 0.73 [95% confidence interval: 0.62-0.83], p = 0.000008), with a sensitivity of 62.5%, a specificity of 70.5%, a positive predictive value of 77.8%, and a negative predictive value of 53.4%. In women, the cutoff for the fat mass ratio was 0.959 (area under the receiver operating characteristic curve: 0.70 [95% confidence interval: 0.56-0.85], p = 0.03), with a sensitivity of 83.60%, a specificity of 61.5%, a positive predictive value of 90.2%, and a negative predictive value of 47.1%. Fat mass ratio was positively correlated with waist circumference (men: r = 0.246, p = 0.019; women: r = 0.302, p = 0.014) and neck circumference (men: r = 0.304, p = 0.004; women: r = 0.366, p = 0.003) in both sexes; and body mass index (r = 0.288, p = 0.006) and waist-hip ratio (r = 0.288, p = 0.006) in men.

CONCLUSION

The fat mass ratio evaluated using dual-energy X-ray absorptiometry with the sex-specific cutoffs is an objective tool to define human immunodeficiency virus-related lipodystrophy.

CT Fat Density Accurately Reflects Histologic Fat Quality in Adults With HIV On and Off Antiretroviral Therapy

CONTEXT

Microscopic measurement of adipocyte size is the gold standard for determining adipose tissue (AT) quality. AT density on CT may also reflect adipocyte quality (lower density = poorer quality).

OBJECTIVE

We used abdominal subcutaneous AT (SAT) specimens and CT scans to validate CT SAT density as a marker of SAT quality in adults living with HIV.

SETTING AND DESIGN

Secondary data analysis from completed trial of antiretroviral therapy (ART) initiation (ACTG A5224s). CT abdominal SAT density was measured in HU. SAT specimens were digitally scanned for calculation of mean adipocyte area.

PARTICIPANTS

Participants had SAT biopsy and CT data at baseline (n = 54) and HIV-1 RNA <50 copies per milliliter on ART and biopsy or CT data at week 96 (n = 30).

OUTCOME MEASURES

Spearman correlations and linear regression models adjusting for participant characteristics examined associations between SAT density and adipocyte area.

RESULTS

Baseline median age was 40 years, CD4+ T lymphocyte count 219 cells per cubic millimeter, and body mass index 26.0 kg/m2; 89% were male and 67% white. Median SAT area and density were 199 cm2 and -100 HU. Over 96 weeks, SAT area increased (+18%) and SAT density decreased (-3%). Mean SAT adipocyte area correlated with SAT density (P < 0.01) off and on ART after adjustment for SAT area, age, race, sex, CD4+ T lymphocyte count, and HIV-1 RNA.

CONCLUSIONS

CT SAT density correlates with biopsy-quantified SAT adipocyte size in adults with HIV on and off ART, suggesting that CT is a useful tool for noninvasive assessment of SAT quality.

Can Biomarkers Advance HIV Research and Care in the Antiretroviral Therapy Era?

Despite achieving human immunodeficiency virus type 1 (HIV-1) RNA suppression below levels of detection and, for most, improved CD4+ T-cell counts, those aging with HIV experience excess low-level inflammation, hypercoagulability, and immune dysfunction (chronic inflammation), compared with demographically and behaviorally similar uninfected individuals. A host of biomarkers that are linked to chronic inflammation are also associated with HIV-associated non-AIDS-defining events, including cardiovascular disease, many forms of cancer, liver disease, renal disease, neurocognitive decline, and osteoporosis. Furthermore, chronic HIV infection may interact with long-term treatment toxicity and weight gain after ART initiation. These observations suggest that future biomarker-guided discovery and treatment may require attention to multiple biomarkers and, possibly, weighted indices. We are clinical trialists, epidemiologists, pragmatic trialists, and translational scientists. Together, we offer an operational definition of a biomarker and consider how biomarkers might facilitate progress along the translational pathway from therapeutic discovery to intervention trials and clinical management among people aging with or without HIV infection.

CROI 2016: Complications of HIV Infection and Antiretroviral Therapy

Noncommunicable conditions such as cardiovascular disease, hypertension, renal and bone diseases, and malignancies as well as infectious complications are an ongoing concern during the course of treated HIV disease. Research in this area continues to focus on the epidemiology and risk factors for these conditions, on identifying the contributions of HIV-related immunopathology to specific and collective end-organ diseases, and on evaluating interventions to prevent or reduce the morbidity associated with these conditions. Data presented at the 2016 Conference on Retroviruses and Opportunistic Infections provided new insights into all of these areas.

Dysfunctional Subcutaneous Fat With Reduced Dicer and Brown Adipose Tissue Gene Expression in HIV-Infected Patients

CONTEXT

HIV patients are at an increased risk for cardiometabolic disease secondary to depot-specific alterations in adipose function, but mechanisms remain poorly understood.

OBJECTIVE

The endoribonuclease Dicer has been linked to the modulation of brown and white adipocyte differentiation. We previously demonstrated that Dicer knockout mice undergo transformation of brown adipose tissue to white adipose tissue and develop a lipodystrophic phenotype. We hypothesized reduced Dicer and brown adipose tissue gene expression from nonlipomatous sc fat among HIV patients with a lipodystrophic phenotype.

DESIGN

Eighteen HIV (nine with and without lipodystrophic changes in fat distribution, characterized by excess dorsocervical adipose tissue [DCAT]) and nine non-HIV subjects underwent punch biopsy of abdominal sc fat to determine expression of Dicer and other adipose-related genes.

RESULTS

HIV subjects with long-duration antiretroviral use demonstrated excess DCAT vs non-HIV subjects (9.8 ± 1.0 vs 6.6 ± 0.8 cm(2), P = .02) with similar body mass index. Dicer expression was decreased in abdominal sc fat of HIV vs non-HIV (4.88 [1.91, 11.93] vs 17.69 [10.72, 47.91], P = .01), as were PPARα, ZIC1, PRDM16, DIO2, and HSP60 (all P ≤ .03). Moreover, the expression of Dicer (2.49 [0.02, 4.88] vs 11.20 [4.83, 21.45], P = .006), brown fat (PPARα [P = .002], ZIC1 [P = .004], LHX8 [P = .03], PRDM16 [P = .0008], PAT2 [P = .008], P2RX5 [P = .02]), beige fat (TMEM26 [P = .004], CD137 [P = .008]), and other genes (DIO2 [P = .002], leptin [P = .003], HSP60 [P = .0004]) was further decreased in abdominal sc fat comparing HIV subjects with vs without excess DCAT. Down-regulation of Dicer in the abdominal sc fat correlated with the down-regulation of all brown and beige fat genes (all P ≤ .01).

CONCLUSION

Our results demonstrate dysfunctional sc adipose tissue marked by reduced Dicer in relationship to the down-regulation of brown and beige fat-related genes in lipodystrophic HIV patients and may provide a novel mechanism for metabolic dysregulation. A strategy to increase browning of white adipose tissue may improve cardiometabolic health in HIV.

HIV/antiretroviral therapy-related lipodystrophy syndrome (HALS) is associated with higher RBP4 and lower omentin in plasma

Very little information is available on the involvement of newly characterized adipokines in human immunodeficiency virus (HIV)/antiretroviral therapy (ART)-associated lipodystrophy syndrome (HALS). Our aim was to determine whether apelin, apelin receptor, omentin, RBP4, vaspin and visfatin genetic variants and plasma levels are associated with HALS. We performed a cross-sectional multicentre study that involved 558 HIV type 1-infected patients treated with a stable highly active ART regimen, 240 of which had overt HALS and 318 who did not have HALS. Epidemiologic and clinical variables were determined. Polymorphisms in the apelin, omentin, RBP4, vaspin and visfatin genes were assessed by genotyping. Plasma apelin, apelin receptor, omentin, RBP4, vaspin and visfatin levels were determined by enzyme-linked immunosorbent assay in 163 patients (81 with HALS and 82 without HALS) from whom stored plasma samples were available. Student's t test, one-way ANOVA, chi-square test, Pearson and Spearman correlations and linear regression analysis were used for statistical analyses. There were no associations between the different polymorphisms assessed and the HALS phenotype. Circulating RBP4 was significantly higher (p < 0.001) and plasma omentin was significantly lower (p 0.001) in patients with HALS compared to those without HALS; differences in plasma levels of the remaining adipokines were nonsignificant between groups. Circulating RBP4 concentration was predicted independently by the presence of HALS. Apelin and apelin receptor levels were independently predicted by body mass index. Visfatin concentration was predicted independently by the presence of acquired immunodeficiency syndrome. HALS is associated with higher RBP4 and lower omentin in plasma. These two adipokines, particularly RBP4, may be a link between HIV/ART and fat redistribution syndromes.

Progression of Lipodystrophy (LD) with Continued Thymidine Analogue Usage: Long-Term Follow-Up from a Randomized Clinical Trial (The PIILR Study)

PURPOSE

During the 24-week PIILR study of protease inhibitor (PI) withdrawal, improved lipids and reduction in intraabdominal visceral fat was seen, however, there was also a loss of subcutaneous limb fat in patients with HIV-lipodystrophy (LD). It was hypothesized that overall improvement in LD may require a longer period of time off PIs.

METHOD

Follow-up of patients randomized to stop or continue PI-based therapy for 24 weeks, in a multicenter study, was continued for up to 120 weeks. Biochemistry and lipid parameters were assessed every 3 months. DEXA and CT scans were performed annually. Limb fat, visceral adipose tissue, and the lipodystrophy case definition score (LCDS) were used as indicators of LD severity.

RESULTS

Forty-five male patients with baseline and week 120 body composition data were assessed. There were no significant changes in the limb fat or visceral adipose tissue (VAT) components of LD, with the exception of the LCDS (change from baseline +5.79, p < .001). Control of viral replication was maintained and lipid and glycemic parameters were unchanged over the 120-week follow-up. Linear regression analysis showed on-study usage of stavudine was independently and significantly correlated with both decreased limb fat mass and a higher LCDS.

CONCLUSION

Body composition or metabolic features of LD did not improve over 2 years of observation in patients remaining on predominantly PI-sparing therapy. LD was adversely influenced by continued stavudine use.

Changes in Body Fat Measured by DEXA in Patients Taking Different Formulations of Stavudine

BACKGROUND

Lipoatrophy is a frequent complication of chronic stavudine therapy. Stavudine extended release formulation (stavudine ER) gives lower peak and higher trough levels than the immediate release formulation (stavudine IR), and we hypothesized that the lower peak might result in less lipoatrophy.

OBJECTIVE

To compare the rate of peripheral lipoatrophy between patients taking stavudine ER and stavudine IR.

METHOD

Body composition was measured by dual energy X-ray absorptiometry (DEXA) every 6 months for 18 months in 29 patients taking either stavudine ER or IR as part of a randomized controlled clinical trial.

RESULTS

DEXA fat measurements did not differ between the ER and IR groups at baseline, after a median of 32 months on stavudine-containing treatment. Over the 18 months of follow-up in the whole cohort limb fat decreased by a mean of 0.29 +/- 0.50 kg (p = .01) and leg fat percent decreased by a mean of 1.23% +/- 1.92% (p = .001), whereas trunk fat and trunk-to-limb fat percent ratio did not change significantly. There was no significant difference between the ER and IR groups in the rate of change of any of the fat parameters. At study completion, the proportion of patients with clinical lipodystrophy was similar in the stavudine ER and stavudine IR groups (67% and 64%, respectively; p = .893).

CONCLUSION

Stavudine ER does not appear to cause less peripheral lipoatrophy.

Changes in Facial Fat in HIV-Related Lipoatrophy, Wasting, and Weight Gain Measured by Magnetic Resonance Imaging

BACKGROUND

Changes in facial fat occurring over time in patients with HIV-related lipoatrophy have not been properly quantified. We aimed to define the longitudinal changes in facial fat compartments in patients with lipoatrophy and to compare these with changes accompanying wasting or weight gain.

METHOD

Facial MRI scans were performed at baseline and repeated after a median of 10 months in 24 patients, of whom 12 had moderate to severe lipodystrophy continuing antiretroviral therapy, 5 lost weight, and 7 gained weight (more than 10% weight change).

RESULTS

Superficial facial fat decreased by a median of 5.2 mL (p = .03) in patients with lipoatrophy, and 8 of 12 individuals showed more than 15% decrease (all of whom were taking stavudine). The decrease was mainly cheek fat. Superficial facial fat decreased by 6.0 mL in patients with weight loss (p = .04) and increased by 20.2 mL (p = .02) in patients with weight gain, and changes occurred in cheek fat, temporal fat, and masseter muscle and temporalis muscle compartments.

CONCLUSION

MRI can detect substantial ongoing changes in facial fat in patients with facial lipoatrophy. A characteristic pattern of compartmental change distinguishes lipoatrophy from wasting and weight recovery. MRI should be considered for use in clinical trials of interventions to prevent or treat lipoatrophy and may be useful for documenting changes in individual patients during clinical follow-up.

An adipocitolitic aqueous micro-gelatinous solution for buffalo hump deformity reduction

Buffalo hump is a manifestation of HIV related lipodistrophy, it is characterized by an enlargment of dorsocervical fat pad and is distressing for patients. Surgical correction until a few years ago was the only option for treatment, however in last years non surgical corrections was carried out with minimally invasive techniques. Authors report this case that describe a longer follow up of an already published study were this deformity was treated with the injection of an adipocitolitic aqueous micro-gelatinous solution and during all the follow up no relapse was observed.

Kager's fat pad inflammation associated with HIV infection and AIDS: MRI findings

OBJECTIVE

To describe magnetic resonance imaging (MRI) features of Kager's fat pad inflammation in HIV-positive patients with lipodystrophy due to protease inhibitor treatment and posterior ankle pain.

METHODS

A case-control, cross-sectional study; group 1 included 14 HIV-positive patients using protease inhibitors, presenting lipodystrophy syndrome and having posterior ankle pain; group 2 (CGHIV-) included 112 HIV-negative patients without lipodystrophy syndrome who were being evaluated for posterior ankle pain; group 3 (CGHIV + 1) included 23 HIV-positive patients not using a protease inhibitor, without lipodystrophy syndrome and with posterior ankle pain; group 4 (CGHIV + 2) comprised 18 HIV-positive patients who were being treated with a protease inhibitor and had lipodystrophy syndrome but did not have posterior ankle pain. Images were evaluated for the presence of edema by two radiologists who were blinded to clinical features. Fisher's exact test was used to evaluate differences among the groups. Interobserver variation was tested using Cohen's kappa (κ) statistic.

RESULTS

The presence of edema within Kager's fat pad was strongly associated with symptoms in HIV-positive patients who had lipodystrophy (p ≤ 0.0001). Concordance between observers was excellent (κ > 0.9).

CONCLUSION

MRI findings of Kager's fat pad inflammation related to HIV/AIDS is a source of symptoms in HIV patients with posterior ankle pain using protease inhibitors and having lipodystrophy syndrome.

Altered miRNA processing disrupts brown/white adipocyte determination and associates with lipodystrophy

miRNAs are important regulators of biological processes in many tissues, including the differentiation and function of brown and white adipocytes. The endoribonuclease dicer is a major component of the miRNA-processing pathway, and in adipose tissue, levels of dicer have been shown to decrease with age, increase with caloric restriction, and influence stress resistance. Here, we demonstrated that mice with a fat-specific KO of dicer develop a form of lipodystrophy that is characterized by loss of intra-abdominal and subcutaneous white fat, severe insulin resistance, and enlargement and "whitening" of interscapular brown fat. Additionally, KO of dicer in cultured brown preadipocytes promoted a white adipocyte-like phenotype and reduced expression of several miRNAs. Brown preadipocyte whitening was partially reversed by expression of miR-365, a miRNA known to promote brown fat differentiation; however, introduction of other miRNAs, including miR-346 and miR-362, also contributed to reversal of the loss of the dicer phenotype. Interestingly, fat samples from patients with HIV-related lipodystrophy exhibited a substantial downregulation of dicer mRNA expression. Together, these findings indicate the importance of miRNA processing in white and brown adipose tissue determination and provide a potential link between this process and HIV-related lipodystrophy.

Carotid intima media thickness is associated with body fat abnormalities in HIV-infected patients

BACKGROUND

HIV-infected patients may be at increased risk of cardiovascular (CV) events, and lipodystrophy is generally associated with proatherogenic metabolic disturbances. Carotid intima-media thickness (cIMT) has been used as a surrogate marker for atherosclerosis and it has been shown to be an independent risk factor for CV disease. Our objective was to evaluate cIMT in HIV-infected patients on combined anti-retroviral therapy (cART) with and without lipodystrophy defined by fat mass ratio (L-FMR), and to determine the association of lipodystrophy and visceral obesity [(visceral (VAT), subcutaneous adipose tissue (SAT) volume and VAT/SAT ratio, objectively evaluated by CT scan] with cIMT.

METHODS

Cross-sectional study of 199 HIV-infected patients. Body composition by DXA and abdominal CT, lipids, blood pressure, inflammatory markers, and cIMT by ultrasonography were performed. L-FMR was defined as the ratio of the percentage of trunk fat mass to the percentage of lower limb fat mass by DXA. Categorical variables were compared using the chi-square or Fisher's exact test. Spearman correlation coefficients were estimated to study the association between cIMT and clinical and metabolic characteristics. Means of cIMT, adjusted for age, were calculated, using generalized linear models.

RESULTS

L-FMR was present in 41.2% of patients and cIMT was higher in these patients [0.81 (0.24) vs. 0.76 (0.25); p=0.037)]. Lipodystrophic patients had higher VAT and VAT/SAT ratio and lower SAT. cIMT was associated with lipodystrophy evaluated by FMR, trunk fat, total abdominal fat, VAT and VAT/SAT ratio. No association was observed between cIMT and leg fat mass. Using generalized linear models, cIMT means were adjusted for age and no significant differences remained after this adjustment. The adjusted mean of cIMT was 0.787 (95%CI: 0.751-0.823) in patients without lipodystrophy, and 0.775 (95%CI: 0.732-0.817) in those with lipodystrophy (p=0.671).

CONCLUSIONS

HIV-infected patients on cART with lipodystrophy defined by FMR, had a significantly higher cIMT. Carotid IMT was also associated with classical cardiovascular risk factors. In these patients, visceral adipose tissue had a significant impact on cIMT, although age was the strongest associated factor.

Gender differences in GH response to GHRH+ARG in lipodystrophic patients with HIV: a key role for body fat distribution

OBJECTIVE

Gender influence on GH secretion in human immunodeficiency virus (HIV)-infected patients is poorly known.

DESIGN AND METHODS

To determine the effect of gender, we compared GH response to GH-releasing hormone plus arginine (GHRH+Arg), and body composition in 103 men and 97 women with HIV and lipodystrophy. The main outcomes were IGF1, basal GH, GH peak and area under the curve (AUC) after GHRH+Arg, body composition, visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT).

RESULTS

Men had lower GH peak and AUC than women (P<0.001). Of the study population, 21% of women and 37% of men had biochemical GH deficiency (GHD; GH peak <7.5 μg/l). VAT-to-SAT ratio was higher in men than in women with GHD (P<0.05). Unlike women, VAT, SAT, and trunk fat were greater in men with GHD than in men without GHD. IGF1 was significantly lower in women with GHD than in women without GHD, but not in men. At univariate analysis, BMI, trunk fat mass, VAT, and total adipose tissue were associated with GH peak and AUC in both sexes (P<0.05). BMI was the most significant predictive factor of GH peak, and AUC at multiregression analysis. Overall, abdominal fat had a less pronounced effect on GH in females than in males.

CONCLUSIONS

These data demonstrate that GH response to GHRH+Arg is significantly lower in HIV-infected males than females, resulting in a higher percentage of GHD in men. Adipose tissue distribution more than fat mass per se seems to account for GH gender differences and for the alteration of GH-IGF1 status in these patients.

The "smile-and-fill" injection technique: a dynamic approach to midface volumization

Injectable poly-L-lactic acid (PLLA) is a biodegradable, biocompatible, synthetic polymer that acts as a scaffold to promote collagen formation and is FDA-approved for the correction of facial lipoatrophy in patients with human immunodeficiency virus (HIV) infection. The safety and efficacy of injectable PLLA for the treatment of HIV-associated facial lipoatrophy has been demonstrated in clinical studies and is accompanied by improvement in patient quality of life. Volumization of the mid-face is regarded as complex. The importance of respecting patient mid-face differences at rest and in motion was highlighted in a study that demonstrated effectiveness of silicone microdroplets (0.01 mL) in a depot manner to treat HIV patients with facial lipoatrophy. One of the challenges of facial volume rejuvenation with these techniques is preserving and enhancing dynamic facial movements after treatment. To address this challenge, we developed an injection technique termed "smile-and-fill." In this case series, we describe three patients treated by this technique to restore the malar aspect of the mid-face with improvement several months post-treatment.

Biomedical consequences of alcohol use disorders in the HIV-infected host

Alcohol abuse is the most common and costly form of drug abuse in the United States. It is well known that alcohol abuse contributes to risky behaviors associated with greater incidence of human immunodeficiency virus (HIV) infections. As HIV has become a more chronic disease since the introduction of antiretroviral therapy, it is expected that alcohol use disorders will have an adverse effect on the health of HIV-infected patients. The biomedical consequences of acute and chronic alcohol abuse are multisystemic. Based on what is currently known of the comorbid and pathophysiological conditions resulting from HIV infection in people with alcohol use disorders, chronic alcohol abuse appears to alter the virus infectivity, the immune response of the host, and the progression of disease and tissue injury, with specific impact on disease progression. The combined insult of alcohol abuse and HIV affects organ systems, including the central nervous system, the immune system, the liver, heart, and lungs, and the musculoskeletal system. Here we outline the major pathological consequences of alcohol abuse in the HIV-infected individual, emphasizing its impact on immunomodulation, erosion of lean body mass associated with AIDS wasting, and lipodystrophy. We conclude that interventions focused on reducing or avoiding alcohol abuse are likely to be important in decreasing morbidity and improving outcomes in people living with HIV/AIDS.

Deiodinase 2 expression is increased in dorsocervical fat of patients with HIV-associated lipohypertrophy syndrome

CONTEXT

The pathogenesis and function of dorsocervical sc adipose tissue (DSAT) accumulation in HIV-infected patients is not known. Previous investigations using either UCP-1 expression or positron emission tomography have been inconclusive as to whether this depot represents brown adipose tissue (BAT). We investigated DSAT gene expression, including DIO2, a deiodinase that contributes to increased thermogenesis in brown fat, and simultaneously determined [¹⁸F]fluorodeoxyglucose ([¹⁸F]FDG) uptake in lipodystrophic HIV and healthy control subjects.

DESIGN

Thirteen HIV-infected and three non-HIV-infected men were recruited. HIV-infected subjects had evidence of significant lipodystrophy, including fat atrophy of the face, arms, and legs, and/or fat accumulation of the neck and abdomen. Subjects were cooled, followed by [¹⁸F]FDG positron emission tomography/computed tomography, fat biopsy of DSAT, and measurement of resting energy expenditure (REE). HIV-infected subjects were characterized as lipohypertrophic and lipoatrophic and compared.

RESULTS

Mean standardized uptake value of [¹⁸F]FDG and UCP-1 expression were not significantly different in DSAT among the groups. However, lipohypertrophic subjects demonstrated increased expression of DIO2 in DSAT compared with lipoatrophic subjects (P = 0.03). Among HIV-infected patients, DIO2 expression was strongly related to REE (r = 0.78, P = 0.002) and was a predictor of REE in multivariate modeling controlling for age, TSH, and lean body mass (r² = 0.79, P = 0.008). One control subject demonstrated typical BAT in the supraclavicular area.

CONCLUSIONS

Adipose tissue accumulating in the dorsocervical area in HIV lipodystrophy does not appear to be classical BAT. However, DIO2 expression is increased in DSAT among patients with HIV lipodystrophy, particularly those with increased visceral adiposity, and is positively associated with energy expenditure.

Suppression of pre adipocyte differentiation and promotion of adipocyte death by anti-HIV drugs

In the present study, we investigated the ability of anti-HIV drugs to interfere with normal cell cycle progression and to induce oxidative stress by perturbing the redox environment. Our results provide evidence that anti-HIV drugs have a differential effect on adipocyte cell cycle and differentiation, being able to modify the response to oxidative stress through an increase of reactive oxygen species (ROS) that compromises the induction of phase-2 and antioxidant enzymes. In detail, saquinavir, efavirenz, and stavudine exert antiadipogenic influences on the model 3T3-L1 cell line, perturbing the oxidative response and inducing of apoptosis. When considered together, the effects of anti-HIV drugs on 3T3-L1 pre adipocytes are distinct but commonly antiadipogenic, thus suggesting another additional possible mechanism by which antiretroviral therapies could contribute to lipoatrophy.

Assessment of body fat composition disturbances by bioimpedance analysis in HIV-infected adults

HIV-lipodystrophy syndrome is characterized by different patterns of body fat distribution (BFD) which are identified by clinical and body composition (BC) assessment, including bioimpedance analysis (BIA). Our aim was to compare BC in HIV-infected patients on combination antiretroviral therapy (cART) according to 4 distinct phenotypes of BFD (G1-no lipodystrophy, G2-isolated central fat accumulation, G3-lipoatrophy, G4-mixed forms of lipodystrophy) and assessed factors associated with them. Anthropometry and BIA were performed in 344 HIV-1 patients. G2 and G4 phenotype patients had significantly higher fat mass (FM) but no differences were observed in fat-free mass (FFM) and total body water among the 4 phenotypes. Significant negative associations were found between the presence of lipoatrophy and female gender, body mass index (BMI), waist (WC), hip (HC) and thigh circumferences, and total body FM estimated by BIA. After adjustment for gender, cART duration and BMI, G3 had significant lower WC [odds ratio (OR)=0.84; 0.78- 0.90] and HC (OR=0.88; 0.81-0.96) mean. Independently of gender, cART duration and BMI, G2 remained significantly associated with higher WC (OR=1.11; 1.05-1.18) and HC (OR=1.15; 1.07-1.23) mean, and with FM estimated by BIA [FM as %, OR=1.17 (1.09-1.26); and FM as kg, OR=1.15 (1.06- 1.25)]. There was a significant positive association between G4 and female gender (OR=1.66; 1.01-2.75), BMI (OR=1.10; 1.04-1.17) and WC (OR=1.15; 1.09-1.21). The similar FFM along the BFD spectrum describes the actual BC of these patients without sarcopenia. In a clinical setting, BIA is an easy and useful tool to evaluate fat mass and FFM and gives us a picture of BC that was not possible with anthropometry.

Comparison of dorsocervical with abdominal subcutaneous adipose tissue in patients with and without antiretroviral therapy-associated lipodystrophy

OBJECTIVE

Combination antiretroviral therapy (cART) is associated with lipodystrophy, i.e., loss of subcutaneous adipose tissue in the abdomen, limbs, and face and its accumulation intra-abdominally. No fat is lost dorsocervically and it can even accumulate in this region (buffalo hump). It is unknown how preserved dorsocervical fat differs from abdominal subcutaneous fat in HIV-1-infected cART-treated patients with (cART+LD+) and without (cART+LD-) lipodystrophy.

RESEARCH DESIGN AND METHODS

We used histology, microarray, PCR, and magnetic resonance imaging to compare dorsocervical and abdominal subcutaneous adipose tissue in cART+LD+ (n=21) and cART+LD- (n=11).

RESULTS

Albeit dorsocervical adipose tissue in cART+LD+ seems spared from lipoatrophy, its mitochondrial DNA (mtDNA; copies/cell) content was significantly lower (by 62%) than that of the corresponding tissue in cART+LD-. Expression of CD68 mRNA, a marker of macrophages, and numerous inflammatory genes in microarray were significantly lower in dorsocervical versus abdominal subcutaneous adipose tissue. Genes with the greatest difference in expression between the two depots were those involved in regulation of transcription and regionalization (homeobox genes), irrespective of lipodystrophy status. There was negligible mRNA expression of uncoupling protein 1, a gene characteristic of brown adipose tissue, in either depot.

CONCLUSIONS

Because mtDNA is depleted even in the nonatrophic dorsocervical adipose tissue, it is unlikely that the cause of lipoatrophy is loss of mtDNA. Dorsocervical adipose tissue is less inflamed than lipoatrophic adipose tissue. It does not resemble brown adipose tissue. The greatest difference in gene expression between dorsocervical and abdominal subcutaneous adipose tissue is in expression of homeobox genes.

Disorders of fat partitioning in treated HIV-infection

HIV-associated lipodystrophy is clinically characterized by body fat changes including subcutaneous fat loss (lipoatrophy) with or without truncal fat accumulation (lipohypertrophy). Thymidine nucleoside reverse transcriptase inhibitors, stavudine and to a lesser extent zidovudine, are major contributors for lipoatrophy. Drug factors are not clear for lipohypertrophy. Restoration to health with effective viral suppression and weight gain may be factors playing significant roles in lipohypertrophy. Mitochondrial dysfunction and inflammation in subcutaneous adipose tissue are key factors in the pathogenesis of HIV-associated lipoatrophy. The pathogenesis of lipohypertrophy is less well understood. Switching from thymidine nucleoside reverse transcriptase inhibitors restores subcutaneous fat in patients with HIV-associated lipoatrophy, but improvement is slow and limited. Surgical filling cosmetically improves facial lipoatrophy. Exercise and diet may reduce increased visceral adipose tissue. Liposuction may be useful to remove superficial, localized fat accumuli.

Regional adipose tissue measured by MRI over 5 years in HIV-infected and control participants indicates persistence of HIV-associated lipoatrophy

OBJECTIVE

Peripheral fat loss and visceral fat gain have been reported in HIV infection. There are limited data on long-term change in adipose tissue in HIV-infected patients vs. controls. Therefore, we determined change in regional adipose tissue from baseline examination to 5 years later among participants in the study of Fat Redistribution and Metabolic Change in HIV Infection.

METHODS

Regional adipose tissue volume was measured using MRI at both examinations in 477 HIV-infected and 214 control men and women. Lipoatrophy was defined as leg subcutaneous adipose tissue (SAT) below the cutoff point marking the lowest decile (10%) of controls at each examination.

RESULTS

HIV-infected and control participants showed similar adipose tissue gains. In men, all SAT depots and visceral adipose tissue started lower and remained lower on average in HIV-infected vs. controls. In women, leg and arm SAT also started lower and remained lower in HIV-infected vs. controls. Mean leg SAT of HIV-infected men was 67% of control men at baseline and 65% at follow-up; for women 83% and 77%. At baseline, 48% of HIV-infected participants had lipoatrophy; on average those with baseline lipoatrophy gained 0.96L of leg SAT compared with 1.23L gain for controls in the lowest decile (P = 0.16). At follow-up, 53% of HIV-infected participants had lipoatrophy. In multivariable models, discontinuation of stavudine appeared to produce little gain in leg SAT ( approximately 1.1%/year).

CONCLUSION

HIV-infected participants did not substantially recover SAT compared with controls, although both showed average gains. HIV-associated lipoatrophy persisted after 5 years of follow-up.

Patient satisfaction and duration of effect with PLLA: a review of the literature

Poly-L-lactic acid (PLLA) has been available to the European medical community as a treatment for Human Immunodeficiency Virus (HIV)-associated facial lipoatrophy for nearly a decade, gaining U.S. Food and Drug Administration (FDA) approval for this indication in 2004. PLLA has been utilized in an off-label manner in the U.S. to treat lipoatrophy of aging in the non-HIV population. The literature regarding safety and efficacy of PLLA is well-documented, while studies regarding patient satisfaction and duration are more limited. The following review article discusses the currently available literature pertaining to the durability and patient satisfaction after PLLA treatment. Patients treated for HIV-related facial lipoatrophy and cosmetic use of PLLA for lipoatrophy of aging are discussed separately.

Longitudinal changes in regional fat content in HIV-infected children and adolescents

BACKGROUND

Alterations in regional fat are often reported in HIV infection. Prior studies have not distinguished between normal changes in regional fat related to sexual maturation and those due to HIV. The study aim was to compare changes in regional fat distribution in HIV-infected (HIV+) and healthy (HIV-) children and adolescents living in the United States.

METHODS

Serial dual energy X-ray absorptiometry was performed at baseline and two annual follow-up visits in 64 HIV+ and 147 HIV--participants aged 6-16 years. Total, leg, arm, and trunk fat masses (kg) and regional fat distribution as the percentage of total body fat (%) were compared.

RESULTS

HIV+ and HIV--participants did not differ in total fat mass, but the HIV+ group had significantly lower leg and greater arm fat and trunk fat percentage at all time points. Over time, decreases in leg fat percentage and increases in arm fat percentage were more marked among the HIV+ group. Differences between HIV+ and HIV--groups in arm and leg fat percentage remained significant when age, sex, race, height, and pubertal stage were accounted for by mixed effect modeling. Apart from prior treatment with stavudine, no differences in fat distribution were observed according to treatment or degree of immunodeficiency or viremia.

CONCLUSION

Although no single pattern of change in regional fat distribution was uniquely associated with HIV, perinatally HIV-infected youth manifest significantly decreased leg fat and increased arm and trunk fat. These differences increase over time and may contribute to cardiovascular disease risk.

Disorders of body fat distribution in HIV-1-infected patients

Body fat disorders are a common and relevant problem in HIV-1-infected patients that can be associated with metabolic alterations. Many controversies in their definition, pathogenesis, measurement, and management remain unclear. Several factors including HIV-1 infection itself and antiretroviral therapy have been associated with the development of these alterations. Most studies show that the action of drugs on the pathogenesis of lipoatrophy is undeniable. However, they also show that there are considerable differences not only between the different families of antiretroviral drugs, but also between the individual members of these families. The diagnosis of lipodystrophy is limited by the absence of an agreed definition and a reference for normality. Accurate diagnosis, especially in mild-moderate cases, is difficult, almost always subjective, not standardized, and cannot be carried out by a single method. In general, subjective evaluation by the physician and patient, together with simple techniques such as anthropometry, can provide highly valuable information, especially when used over time. Although there is no known therapy to completely reverse lipodystrophy once it becomes established, there is evidence that lipoatrophy can be partially improved by replacing thymidine analogs in certain cases. In addition, reparative surgery may prove useful in moderate or severe cases. Neither the interruption of antiretroviral therapy nor the use of metformin, glitazones or growth hormone analogs can be recommended due to their limited efficacy or associated complications.

Depot-specific adipocyte cell lines reveal differential drug-induced responses of white adipocytes--relevance for partial lipodystrophy

Intra-abdominal (IA) fat functionally differs from subcutaneous (SC) adipose tissue, likely contributing to its stronger association with obesity-induced morbidity and to differential response to medications. Drug-induced partial lipodystrophy, like in response to antiretroviral agents, is an extreme manifestation of the different response of different fat depots, with loss of SC but not IA. Investigating depot-specific adipocyte differences is limited by the low accessibility to IA fat and by the heterogenous cell population comprising adipose tissue. Here, we aimed at utilizing immortalized preadipocyte cell lines from IA (epididymal) or SC (inguinal) fat to investigate whether they differentially respond to the HIV protease inhibitor nelfinavir. Preadipocytes were readily amenable to adipogenesis, as evidenced by lipid accumulation, expression of adipose-specific genes, measurable lipolysis, and insulin responsiveness. Leptin secretion was higher by the SC line, consistent with known differences between IA and SC fat. As previously reported, nelfinavir inhibited adipogenesis downstream of C/EBPbeta, but similarly in both cell lines. In contrast, nelfinavir's capacity to diminish insulin signaling, decrease leptin secretion, enhance basal lipolysis, and decrease expression of the lipid droplet-associated protein perilipin occurred more robustly and/or at lower nelfinavir concentrations in the SC line. This was despite similar intracellular concentrations of nelfinavir (23.8 +/- 5.6 and 33.6 +/- 12.2 microg/mg protein for inguinal and epididymal adipocytes, respectively, P = 0.46). The cell lines recapitulated depot-differential effects of nelfinavir observed in differentiated primary preadipocytes and with whole tissue explants. Thus, we report the use of fat depot-specific adipocyte cell lines for unraveling depot-differential responses to a drug causing partial lipodystrophy.

Comparability of echographic and tomographic assessments of body fat changes related to the HIV associated adipose redistribution syndrome (HARS) in antiretroviral treated patients

To assess the comparability of ultrasonographic (US) subcutaneous fat thickness (SFT) measurements in comparison with computed tomography (CT) at reference points (RPs) representative of HIV related adipose redistribution syndrome (HARS) in patients treated with antiretrovirals. US and CT measurements were compared in nine patients with clinical reports of HARS. We obtained the best resolution of facial (at deepest point of Bichat pad), brachial (in the dorsal face of arm) and crural SFT (at mid thigh) by means of minimal transducer pressures avoiding potential biases such as stand off pads pressure on the skin and artefacts due to too abundant quantity of gel. CT scans were obtained in the same RP where US measurements were performed such as identified by means of metallic skin markers. Median US measurement of facial SFT was 8.8 mm (95% CI: 3.1 to 13.4), 3.95 mm (95% CI: 2.62 to 5.84) for brachial SFT and 4 mm (95% CI: 3.4 to 9.4) for crural SFT. Median CT assessments of facial SFT was 8.7 mm (95% CI: 3.5 to 13.5), 4.2 mm (95% CI: 2.6 to 5.88) for brachial SFT and 5 mm (95% CI: 3.9 to 10.3) for crural SFT, with no significant difference at each RP. A linear regression showed good CT/US comparability at each RP, with no significant deviation from linearity (p > 0.10). US shows to be highly comparable with CT, excluding invaliding biases as the transducer pressure on the skin. Given the proven efficacy on the HARS assessments, if well standardized, US could be a reliable method, simpler than CT in the management of body fat changes related to HARS.

Adipose tissue inflammation and liver fat in patients with highly active antiretroviral therapy-associated lipodystrophy

In this cross-sectional study, we sought to determine whether gene expression of macrophage markers and inflammatory chemokines in lipoatrophic subcutaneous abdominal adipose tissue and liver fat content are increased and interrelated in human immunodeficiency virus (HIV)-1-positive, highly active antiretroviral therapy (HAART)-treated patients with lipodystrophy (HAART+LD+; n = 27) compared with those without (HAART+LD-; n = 13). The study groups were comparable with respect to age, gender, and body mass index. The HAART+LD+ group had twofold more intra-abdominal (P = 0.01) and 1.5-fold less subcutaneous (P = 0.091) fat than the HAART+LD- group. As we have reported previously, liver fat was 10-fold higher in the HAART+LD+ compared with the HAART+LD- group (P = 0.00003). Inflammatory gene expression was increased in HAART-lipodystrophy: CD68 4.5-fold (P = 0.000013), tumor necrosis factor (TNF)-alpha 2-fold (P = 0.0094), chemokine (C-C motif) ligand (CCL) 2 2.5-fold (P = 0.0024), CCL3 7-fold (P = 0.0000017), integrin alphaM (ITGAM) 3-fold (P = 0.00067), epidermal growth factor-like module containing, mucin-like, hormone receptor-like (EMR)1 2.5-fold (P = 0.0038), and a disintegrin and metalloproteinase domain (ADAM)8 3.5-fold (P = 0.00057) higher in the HAART+LD+ compared with the HAART+LD- group. mRNA concentration of CD68 (r = 0.37, P = 0.019), ITGAM (r = 0.35, P = 0.025), CCL2 (r = 0.39, P = 0.012), and CCL3 (r = 0.54, P = 0.0003) correlated with liver fat content. In conclusion, gene expression of markers of macrophage infiltration and adipose tissue inflammation is increased in lipoatrophic subcutaneous abdominal adipose tissue of patients with HAART-associated lipodystrophy compared with those without. CD68, ITGAM, CCL2, and CCL3 expression is significantly associated with accumulation of liver fat.

A standardized, comprehensive magnetic resonance imaging protocol for rapid and precise quantification of HIV-1-associated lipodystrophy

OBJECTIVES

Although multiple methods have been proposed, there is no current gold standard for assessing HIV-1-associated lipodystrophy.

METHODS

HIV-1-infected participants were randomly enrolled and surveyed about changes in the abdomen, thigh, cheek and neck areas. Magnetic resonance imaging (MRI) sequences of these sites were obtained. Participants were grouped according to survey results, and the MRI measurements were compared between groups.

RESULTS

One hundred participants were included in the study, of whom 79% reported any body fat changes. Persons reporting increased abdominal girth had higher visceral ([mean+/-standard deviation] 142+/-75 vs. 59+/-48 cm2; P<0.0001) and total abdominal adipose tissue than those reporting no change (344+/-119 vs. 201+/-95 cm2; P<0.0001). The amount of localized fat was less for persons reporting sunken cheeks and reduced diameter of the legs compared with those who noted no changes (5.9+/-3.6 vs. 9.3+/-3.8 cm2; P<0.0001, and 35+/-28 vs. 112+/-56 cm2; P<0.0001). Participants reporting increased neck girth had a thicker fat layer in the dorsocervical region compared with those reporting no change (4.0+/-1.8 vs. 2.3+/-1.4 cm; P<0.0002).

CONCLUSIONS

MRI is a precise method for rapidly surveying body regions affected by HIV-1-associated lipodystrophy. Our proposed protocol provides a rapid, comprehensive survey of these areas, without the need to combine multiple modalities or to expose subjects to radiation.

Mitochondrial RNA and DNA alterations in HIV lipoatrophy are linked to antiretroviral therapy and not to HIV infection

BACKGROUND

The aim of this study was to assess the effect of antiretroviral therapy (ART) versus HIV on mitochondria in fat.

METHODS

Subcutaneous fat was collected from 45 HIV-infected patients on ART with lipoatrophy, 11 HIV-infected ART-naive patients and nine healthy controls. Three mitochondrial transcripts: NADH dehydrogenase subunit 1 (ND1), cytochrome B (CYTB) and NADH dehydrogenase subunit 6 (ND6) genes were quantitated using TaqMan probes and normalized to nuclear-encoded ribosomal L13.

RESULTS

ND1/L13 and CYTB/L13 were lower in HIV-positive patients on ART with lipoatrophy versus ART-naive patients (3.4 versus 7.2 [P=0.017] and 2.5 versus 4.6 [P=0.006], respectively). No difference was found between ART-naive patients and controls (P>0.70). ND6/L13 was similar between all groups. Dual-energy X-ray absorptiometry-measured limb fat and mitochondrial DNA in fat were also lower in HIV-positive patients on ART with lipoatrophy versus HIV-infected, ART-naive patients (4,382 versus 7,662 g [P=0.02] and 726 versus 1,372 copies/cell [P=0.03], respectively), but no difference was found between ART-naive and controls. In a multiple regression analysis, limb fat correlated with all three mitochrondrial RNA, whereas mitochondrial DNA did not correlate with mitochondrial RNA or limb fat.

CONCLUSIONS

In contrast to ART-naive patients, HIV-positive patients on ART with lipoatrophy had significant depletion in mitochondrial DNA in fat and mitochondrial RNAs. This suggests that mitochondrial toxicity in lipoatrophy could be driven by ART and not by HIV itself. In addition, mitochondrial RNA abnormalities, and not mitochondrial DNA depletion, could be a key driving force behind lipoatrophy.

Long-term body fat outcomes in antiretroviral-naive participants randomized to nelfinavir or efavirenz or both plus dual nucleosides. Dual X-ray absorptiometry results from A5005s, a substudy of Adult Clinical Trials Group 384

BACKGROUND

Long-term regional body fat outcomes have not been well described in randomized antiretroviral drug trials.

METHODS

Dual x-ray absorptiometry (DXA) scans were performed every 16 weeks on a subset of 157 antiretroviral-naive participants who were randomized to receive nelfinavir, efavirenz, or both, combined with zidovudine and lamivudine or stavudine and didanosine, in a multicenter trial. Participants with any available data after baseline up to week 144 contributed to this as-treated analysis.

RESULTS

Limb fat increased similarly in all groups during the first 32 weeks. After week 32, limb fat changed by - 1.7% per year for zidovudine-lamivudine and by -19.0% per year for didanosine-stavudine (mixed model analysis of variance [MMANOVA], P < 0.0001). Adjusting for nucleoside backbone, there was an additional decrease in limb fat of -8.7% per year for the combined nelfinavir and nelfinavir + efavirenz group compared with the efavirenz group (MMANOVA, P = 0.03). Among participants receiving zidovudine-lamivudine, after week 32, limb fat changed by +2.7% per year with efavirenz and by -7.9% per year for the combined nelfinavir and nelfinavir + efavirenz group (MMANOVA, P = 0.03).

CONCLUSIONS

Over 144 weeks, zidovudine-lamivudine was superior to didanosine-stavudine with regard to limb fat loss. The combination of zidovudine, lamivudine, and efavirenz showed no overall pattern suggesting limb fat loss over time and was significantly superior to the pooled zidovudine-lamivudine-nelfinavir (with and without efavirenz) arms.

Longitudinal increases in waist circumference are associated with HIV-serostatus, independent of antiretroviral therapy

BACKGROUND

The relative contributions of the different classes of antiretroviral therapy (ART), HIV infection per se, and aging to body shape changes in HIV-infected patients have not been clearly defined in longitudinal studies.

METHODS

Since September 1999, men enrolled in the Multicenter AIDS Cohort Study have undergone measurements of body mass index (BMI) and body circumferences at each semi-annual visit. The effect of HIV-serostatus and cumulative exposure to the three major ART classes on changes in anthropomorphic measurements occurring between 1999 and 2004 among HIV-infected and HIV-uninfected men were determined using linear mixed effects regression models.

RESULTS

At baseline, average BMI and circumference measurements were greater in HIV-uninfected men (n = 392) than HIV-infected men (n = 661) (BMI, 27.3 versus 25.3 kg/m; waist, 96.4 versus 90.2 cm; hip 101.3 versus 95 cm, thigh 54.1 versus 50.8 cm; arm 33.3 versus 31.7 cm, P < 0.001 for each comparison). Cumulative nucleoside reverse transcriptase inhibitor (NRTI) exposure, but not protease inhibitor or non-nucleoside reverse transcriptase inhibitor exposure, was associated with statistically significant changes in BMI (-0.11 +/- 0.04 kg/m per year) and in circumferences of waist (-0.27 +/- 0.07 cm/year), hip (-0.24 +/- 0.05 cm/year), and thigh (-0.16 +/- 0.03 cm/year) over the 5 years of follow-up. Independent of ART exposure, HIV-infected men had a more rapid increase in waist circumference over the study interval than did the HIV-uninfected men (difference 0.33 +/- 0.15 cm/year, P = 0.02).

CONCLUSION

Cumulative NRTI therapy was associated with longitudinal decreases in body circumference measurements, whereas HIV-serostatus was associated with increases in waist circumference independent of ART.

Inhibition of lipolysis stimulates peripheral glucose uptake but has no effect on endogenous glucose production in HIV lipodystrophy

HIV-infected patients with lipodystrophy (HIV lipodystrophy) are insulin resistant and have elevated plasma free fatty acid (FFA) concentrations. We aimed to explore the mechanisms underlying FFA-induced insulin resistance in patients with HIV lipodystrophy. Using a randomized, placebo-controlled, cross-over design, we studied the effects of an overnight acipimox-induced suppression of FFAs on glucose and FFA metabolism by using stable isotope-labeled tracer techniques during basal conditions and a two-stage euglycemic-hyperinsulinemic clamp (20 and 50 mU insulin/m(2) per min, respectively) in nine patients with nondiabetic HIV lipodystrophy. All patients received antiretroviral therapy. Biopsies from the vastus lateralis muscle were obtained during each stage of the clamp. Acipimox treatment reduced basal FFA rate of appearance by 68.9% (95% CI 52.6-79.5) and decreased plasma FFA concentration by 51.6% (42.0-58.9) (both, P < 0.0001). Endogenous glucose production was not influenced by acipimox. During the clamp, the increase in glucose uptake was significantly greater after acipimox treatment compared with placebo (acipimox: 26.85 micromol x kg(-1) x min(-1) [18.09-39.86] vs. placebo: 20.30 micromol x kg(-1) x min(-1) [13.67-30.13]; P < 0.01). Insulin increased phosphorylation of Akt Thr(308) and glycogen synthase kinase-3beta Ser(9), decreased phosphorylation of glycogen synthase (GS) site 3a + b, and increased GS activity (percent I-form) in skeletal muscle (P < 0.01). Acipimox decreased phosphorylation of GS (site 3a + b) (P < 0.02) and increased GS activity (P < 0.01) in muscle. The present study provides direct evidence that suppression of lipolysis in patients with HIV lipodystrophy improves insulin-stimulated peripheral glucose uptake. The increased glucose uptake may in part be explained by increased dephosphorylation of GS (site 3a + b), resulting in increased GS activity.

Visceral and subcutaneous adiposity measurements in adults: influence of measurement site

OBJECTIVE

Excess abdominal adiposity is a known risk factor for cardiovascular diseases. Computed tomography can be used to examine the visceral (VAT) and subcutaneous (SAT) components of abdominal adiposity, but it is unresolved whether single-slice or multi-slice protocols are needed.

RESEARCH METHOD AND PROCEDURES

Nine computed tomography scans were obtained in the lumbar spine region of 24 adults. The nine slices were obtained at three intervertebral positions (L2-L3, L3-L4, and L4-L5) and at 7 mm above and below these locations. Intra-site and inter-site differences in SAT, VAT, total adipose tissue, and the VAT/SAT ratio were examined using ANOVA and confidence intervals for pairwise differences between means.

RESULTS

Intervertebral SAT values increased from 103.1 +/- 50.9 (standard deviation) cm(2) at L2-L3 to 153.3 +/- 68.8 cm(2) at L4-L5, whereas the corresponding VAT values decreased from 164.3 +/- 125.4 to 126.0 +/- 82.7 cm(2). The VAT/SAT ratio was not constant, decreasing from 1.8 +/- 1.4 to 0.9 +/- 0.7. Repeated-measures ANOVA indicated significant inter- and intra-site differences (p </= 0.02) for SAT, VAT, and the VAT/SAT ratio at L3-L4 and L4-L5 (p < 0.001).

DISCUSSION

These differences show the limitation of using a single-slice assessment of abdominal fat distribution, both for a subject and between subjects. Furthermore, the sizeable differences in the intra-site scans indicate that precise repositioning is needed for longitudinal studies. In summary, our findings suggest that a multi-site imaging protocol may provide a more complete assessment of abdominal fat stores and distribution than use of a single site.

Immediate versus delayed polyalkylimide gel injections to correct facial lipoatrophy in HIV-positive patients

OBJECTIVE

To evaluate the safety and efficacy of polyalkylimide gel (PAIG) in the treatment of HIV-associated facial lipoatrophy.

DESIGN

A randomized, open-label, single-centre study.

METHODS

HIV-positive individuals with facial lipoatrophy (based on physician assessment) were randomly assigned to immediate (weeks 0 and 6) or delayed (weeks 12 and 18) PAIG injections administered into the subcutaneous plane. Outcome measures included a change in facial lipoatrophy severity scores (five-point scale), adverse events, photographic assessment, and changes in quality of life (QoL), depression and anxiety using validated surveys.

RESULTS

Thirty-one patients (median age 48 years, 97% male) were enrolled and completed 48 weeks of follow-up. Overall, the median volume of product injected bilaterally was 16.0 ml. Adverse events, including swelling, redness, bruising and pain, were mild, and resolved after a median of 3 days. There were no cases of necrosis, nodules or infection. Compared with patients randomly assigned to delayed treatment, patients in the immediate therapy group had significantly lower physician-rated facial lipoatrophy scores (0 versus 2; P < 0.0001), improved QoL (P = 0.01), and lower anxiety (P = 0.02) at week 12. At week 48, median physician and patient facial lipoatrophy scores were 0 and 1, respectively, for the entire cohort, and were not significantly different between the groups. Significant improvements in patient anxiety (P = 0.001) and depression (P = 0.01) were observed from baseline to week 48.

CONCLUSION

Treatment with PAIG was effective and safe and led to improvements in facial lipoatrophy grading, QoL, anxiety and depression scores in HIV-infected patients with facial lipoatrophy.

Epicardial adipose tissue is related to carotid intima-media thickness and visceral adiposity in HIV-infected patients with highly active antiretroviral therapy-associated metabolic syndrome

BACKGROUND

High cardiovascular risk and accelerated atherosclerosis are associated with human immunodeficiency virus (HIV). Recently, the use of highly active antiretroviral therapy (HAART) for the treatment of HIV infection is correlated with the development of HAART-associated metabolic syndrome and lipodystrophy (LDS). Detection of epicardial fat thickness, new index of visceral adiposity in non HIV-infected patients, might be important as diagnostic tool in HIV-infected patients on HAART.

OBJECTIVE

Primary objective of this study was to evaluate whether echocardiographic epicardial adipose tissue is related to visceral adipose tissue (VAT) and Carotid Intima-Media Thickness (IMT), index of atherosclerosis in HIV-infected patients on HAART with LDS.

DESIGN

We studied 60 consecutive HIV-infected subjects with HAART-associated metabolic syndrome and LDS and 45 HIV-infected subjects on HAART without LDS.

MAIN OUTCOMES MEASURES

Epicardial fat thickness and IMT were measured by ultrasonography in both study and control groups. Magnetic resonance imaging (MRI) was used to calculate VAT in HIV-infected subjects on HAART with LDS.

RESULTS

Epicardial adipose tissue thickness showed an excellent correlation with MRI-VAT (r=0.85; P<0.001) and IMT (r=0.78;P<0.001) in HIV-infected patients on HAART-with LDS. Multiple regression analysis showed that epicardial fat thickness was best predicted by MRI-VAT and IMT (R2=0.57, p<0.001 and p<0.01, respectively). HIV-infected patients with HAART-associated metabolic syndrome and LDS showed higher epicardial fat thickness and IMT (8 vs 6.5 mm; 0.71 vs 0.66 mm, respectively, p<0.01 for both) than HIV-infected subjects on HAART without LDS.

CONCLUSION

Echocardiographic assessment of epicardial fat may have the potential to be a simple and reliable marker of visceral adiposity and increased cardiovascular risk in HIV-infected patients with HAART-associated metabolic syndrome and LDS.

Relation of stavudine discontinuation to anthropometric changes among HIV-infected women

OBJECTIVE

To characterize changes in regional anthropometry associated with stavudine exposure and discontinuation.

DESIGN

Seven hundred thirty-four HIV-infected participants who reported using stavudine (574 of whom later discontinued stavudine) and 698 HIV-uninfected participants from the Women's Interagency HIV Study provided anthropometrics at 8706 semiannual visits between July 1999 and March 2005.

METHODS

Changes in weight, waist, chest, upper arm, hip, and midthigh circumferences were evaluated using linear regression with generalized estimating equations.

RESULTS

HIV-uninfected women demonstrated increases in regional anthropometry at every body site, whereas HIV-infected women demonstrated decreases in weight and circumferences of the waist, chest, hip, and thigh. A smaller annual decrease in hip circumference was seen after discontinuing stavudine for >2.25 years compared with the decrease observed while on stavudine (P = 0.01). Discontinuing stavudine for >2.25 years was associated with smaller (P < 0.05) decreases in hip (-0.06 cm/y) and thigh (-0.005 cm/y) circumference compared with the decreases observed between 1 and 2.25 years (hip: -0.46 cm/y, thigh: -0.24 cm/y) or < or =1 year (hip: -0.64 cm/y, thigh: -0.27 cm/y) after stavudine discontinuation.

CONCLUSIONS

Regardless of continuing or discontinuing stavudine, HIV-infected women demonstrate decreases in weight and body circumference measurements over time. The lower limb seems to be most affected by stavudine exposure, with stabilization observed more than 2 years after discontinuation.

Balancing disfigurement and fear of disease progression: Patient perceptions of HIV body fat redistribution

This study was conducted to identify and describe the perceived morphologic changes of body fat redistribution and related distress among persons taking combination antiretroviral therapy. Six focus group interviews were conducted in four different US cities with men and women (n = 58) who reported antiretroviral-related symptoms of body fat loss and/or gain. Interview data were audiotaped, transcribed verbatim and systematically analysed using inductive techniques. Physical discomfort and impairment and psychological and social distress were reported across sex, sexual orientation and geographic subgroups. While participants acknowledged that antiretroviral drugs were keeping them alive, there was tension between the desire for life-sustaining treatment and optimal quality of life. Some participants engaged in harmful heath behaviours in an attempt to control bodily changes (e.g. non-adherence to antiretroviral regimen). Participants feared that fat loss represented disease progression and worried that visible changes would lead to unintentional disclosure of their HIV status. Although a potential source of support, healthcare providers were commonly perceived as ignoring and, in so doing, discrediting patient distress. Participants recognised the limitations of current lipodystrophy treatment options, yet a cure for the syndrome seemed less important to them in the short term than simply being listened to and the powerful, but oblique sources of distress addressed.

Changes in the peripheral blood mtDNA levels in naive patients treated by different nucleoside reverse transcriptase inhibitor combinations and their association with subsequent lipodystrophy

Nucleoside reverse transcriptase inhibitors (NRTIs) differ in the type and severity of adverse effects resulting from mitochondrial abnormalities. mtDNA in peripheral blood mononuclear cells (PBMCs) was measured during the first 12 months of different NRTIs combinations and its association with clinical lipodystrophy was estimated. Extended follow-up of a randomized trial, ALBI-ANRS 070, including antiretroviral naive patients was conducted. Total DNA was extracted from available cryopreserved PBMCs at baseline and months 6 and 12. Nuclear and mitochondrial genes were amplified using a real-time PCR assay. Clinical lipodystrophy was assessed 30 months after randomization using a standardized questionnaire. A logistic regression analysis assessed the value of mtDNA to predict lipodystrophy. Mean mtDNA level (copies/cell) significantly decreased from 5847 at baseline to 3176 at month 12 (p < 0.0001). In the zidovudine + lamivudine (ZDV + 3TC) arm (n = 37), the mean mtDNA was 6098, 6807, and 3725 copies/cell for baseline, month 6, and month 12, respectively. In the stavudine + didanosine (d4T + ddI) arm (n = 40), the mean values were 5616, 5731, and 2648 copies/cell, respectively. The proportion of patients in the lowest quartile of mtDNA (<1421 copies/cell) at month 12 was higher in 18 patients with lipodystrophy (44%) than in 28 without lipodystrophy (7%) (p = 0.008). At 12 months, a larger reduction of mtDNA from baseline was observed in those started on the d4T + ddI arm. Furthermore, a low mtDNA level at month 12 was associated with the subsequent development of lipodystrophy. This marker may be of value for the early prevention of lipodystrophy in treated HIV-infected patients.

Pathogenesis of lipodystrophy and lipid abnormalities in patients taking antiretroviral therapy

HIV-associated lipodystrophy, arising as a result of long-term therapy with antiretroviral medications, is a complex syndrome characterized by changes in regional fat mass, dyslipidemia, and insulin sensitivity that, once established, is difficult to reverse. The syndrome arises largely as a result of effects of nucleoside reverse transcriptase inhibitors and protease inhibitors on lipid metabolism. Many of these effects have their basis at a molecular level with nucleoside reverse transcriptase inhibitors linked to inhibition of mitochondrial RNA transcription, depletion of mitochondrial DNA and mitochondrial dysfunction and protease inhibitors linked with adipocyte toxicity through interference with the function of essential cellular transcription factors such as sterol regulatory element binding protein 1c. These molecular toxicities can affect non-adipose tissues, and together with secondary effects on lipid and glucose metabolism of changes in body fat mass, help to contribute to the dyslipidemia and insulin resistance characteristic of this syndrome. This review will summarize what is known of the molecular mechanisms underlying HIV-associated lipodystrophy. A greater understanding of these mechanisms is essential if effective therapeutic options are to be found.

Relationship of mitochondrial DNA depletion and respiratory chain activity in preadipocytes treated with nucleoside reverse transcriptase inhibitors

OBJECTIVE

To study the impact of adipocyte differentiation on nucleoside reverse transcriptase inhibitor (NRTI)-mediated mitochondrial DNA (mtDNA) depletion and to correlate mtDNA depletion with the activity of the respiratory chain complexes.

METHODS

We studied adipocyte phenotype, viability, differentiation (CCAAT/enhancer-binding protein [C/EBP]-alpha and peroxisome proliferator-activated receptor [PPAR]-gamma expression), adiponectin production, mtDNA content, activity of respiratory chain complexes and citrate synthase activity in 3T3-L1 adipocytes. Cells were exposed to zidovudine (6 microM or 180 microM), stavudine (3 microM or 90 microM), and zalcitabine (0.1 microM or 3 microM) at different developmental stages for up to 2 months.

RESULTS

Zidovudine and stavudine impaired adiponectin production in vitro at therapeutic Cmax concentrations, but none of the tested NRTIs had a negative impact on adipocyte differentiation or led to mtDNA depletion at these concentrations. Susceptibility of preadipocytes to mtDNA depletion was dependent on cell proliferation and differentiation, and mtDNA depletion occurred only after exposure to high drug concentrations. Under these conditions, stavudine led to up to 80% mtDNA depletion in both dividing and differentiating preadipocytes, whereas zidovudine affected mtDNA only in the differentiating cells. Despite mtDNA depletion by NRTIs, activity of the respiratory chain complexes was found to be unimpaired.

CONCLUSIONS

We found mtDNA depletion in adipocytes but proliferation and/or differentiation of the cells seems to be a prerequisite for this phenomenon. Depletion of mtDNA up to 80%, however, was not associated with impaired respiratory chain activity in 3T3-L1 preadipocytes.

Longitudinal anthropometric changes in HIV-infected and HIV-uninfected men

BACKGROUND

Although morphologic abnormalities are common among HIV-infected persons receiving highly active antiretroviral therapy (HAART), longitudinal comparative body shape changes among HAART-treated HIV-infected men versus HIV-seronegative men of similar age remain unclear.

METHODS

Since September 1999, men enrolled in the Multicenter AIDS Cohort Study underwent body mass index (BMI) and circumference measurements of the waist, hip, thigh, and arm at each semiannual visit. Changes in these measurements that occurred between 1999 and 2003 among HIV-infected men were compared with measurements of HIV-seronegative men using linear mixed effects regression models. The HIV-infected men were further stratified by treatment group (no antiretroviral therapy [ART], monotherapy or combination [mono/combo] ART, or HAART). Analyses were adjusted for age, nadir CD4 cell count, and BMI (for circumference measurements).

RESULTS

Over the 4-year observation period, mean BMI increased significantly among the 392 HIV-seronegative men (0.12 kg/m/y; P < 0.001) but did not change in the 3 HIV-infected groups (combined n = 661). Mean waist and hip circumferences increased significantly in all groups. Hip circumferences increased more slowly in the HIV-positive HAART-treated group (n = 488) than in the HIV-seronegative group (0.18 vs. 0.49 cm/y; P < 0.001), however, yielding a more rapid increase in the waist/hip ratio in the HIV-positive, HAART-treated group over time (0.005 per year; P < 0.001).

CONCLUSIONS

The increased rate of change in waist/hip ratio in HIV-infected men receiving HAART compared with HIV-seronegative men is attributable to slower increases in hip circumference rather than an increased rate of change in waist circumference. These findings underscore the importance of body fat composition changes in the peripheral compartment relative to the central compartment among HIV-infected men receiving HAART.

Safety and Efficacy of Poly-l-lactic Acid Injections in Persons with HIV-Associated Lipoatrophy: The US Experience

BACKGROUND

With the introduction of highly active antiretroviral therapy (HAART), HIV/AIDS has become a more chronic disease. This increase in survival, however, has been accompanied by the occurrence of metabolic and morphologic changes known collectively as HIV-associated lipodystrophy.

OBJECTIVE

The objective was to evaluate the quantifiable improvement in facial wasting (lipoatrophy) after serial injections of poly-L-lactic acid (PLLA) as well as the long-term safety and durability of this material.

METHODS AND MATERIALS

A single-site, open-label study in which patients received up to six treatment sessions of injectable PLLA. Patients were followed for 12 months after treatment. Patients were evaluated for increase in total cutaneous thickness by skin calipers. Serial photographs and patient satisfaction and patient well-being questionnaires were undertaken throughout the study period.

RESULTS

Patients at the end of treatment exhibited a mean increase in skin thickness of 65.1% compared with baseline values. This correction was maintained throughout the 12-month follow-up period (68.8% at 6 months and 73% at 12 months). On a one to five scale, patient satisfaction was 4.5 at the end of treatment and increased to 4.8 at 12-month follow-up. No serious adverse events were reported.

CONCLUSION

PLLA is a safe and well-tolerated treatment option for HIV-associated lipoatrophy.

A randomized comparative trial of tenofovir DF or abacavir as replacement for a thymidine analogue in persons with lipoatrophy

BACKGROUND

Long-term antiretroviral therapy, while dramatically reducing HIV-related morbidity and mortality, is associated with metabolic and morphological changes. Peripheral fat loss, lipoatrophy, appears most associated with prolonged therapy with thymidine nucleoside analogues.

METHODS

A randomized, open-label, comparative study of switching from a thymidine nucleoside analogue to either tenofovir disoproxil fumarate (DF) or abacavir in 105 individuals on successful antiretroviral therapy with clinically evident moderate to severe lipoatrophy.

RESULTS

Individuals were randomized to tenofovir DF (52) or abacavir (53). The switch was well tolerated and the majority of patients completed 48 weeks of study. One individual in the tenofovir DF group and three in the abacavir group discontinued due to drug-related adverse events. Both groups similarly maintained virological control. Limb fat mass increased similarly in both groups: mean increases by week 48 of 329 and 483 g in tenofovir DF and abacavir groups, respectively [mean 95% confidence interval for difference, -154.3 (range -492.8 to 184.3)]. This change from baseline was statistically significant in both groups (tenofovir DF, P = 0.01; abacavir, P = 0.0001). Mean total cholesterol, low density lipoprotein cholesterol and triglycerides improved modestly with switching to tenofovir DF but were unchanged with abacavir. The changes in these parameters were significantly greater in the tenofovir DF arm relative to abacavir.

CONCLUSIONS

Switching from a thymidine nucleoside analogue to either tenofovir DF or abacavir leads to significant improvement in limb fat mass over 48 weeks. Tenofovir DF may have modest advantages over abacavir for changes in lipids. Peripheral lipoatrophy, when clinically apparent, resolves slowly following treatment switching.

Prospective, Open-Label, 18-Month Trial of Calcium Hydroxylapatite (Radiesse) for Facial Soft-Tissue Augmentation in Patients with Human Immunodeficiency Virus-Associated Lipoatrophy: One-Year Durability

BACKGROUND

The objective was to evaluate the safety and effectiveness of soft-tissue augmentation of calcium hydroxylapatite (Radiesse) in patients with facial lipoatrophy secondary to human immunodeficiency virus disease.

METHODS

This 18-month, prospective, open-label, multicenter clinical trial of calcium hydroxylapatite for soft-tissue augmentation of patients with facial lipoatrophy enrolled 100 subjects (94 men and six women).

RESULTS

Correction of facial lipoatrophy was evaluated by comparing changes from baseline using the Global Aesthetic Improvement Scale, with confirmation using standardized photography. All 100 patients were determined to be improved or better at 3 months. Secondary effectiveness endpoints-improvement at 6 months on the scale and skin thickness measurements at 3 and 6 months-were also met. Twelve-month data and 18-month scale scores were also available. One hundred percent of assessable patients were rated as improved or better on the scale at every time point through 12 months; 91 percent were improved or better at 18 months. "Yes" responses to all patient satisfaction questions ranged from 97 percent to 100 percent at every evaluation through 12 months. In addition, skin thickness measurements at 12 months remained statistically better than those at baseline. Eighteen-month patient satisfaction and skin thickness measurements were not available at the time of submission. Adverse events reported through 12 months were generally mild (ecchymosis, edema, erythema, pain, and pruritus), not unexpected, and generally short in duration. Eighteen-month safety data were not available at the time of submission.

CONCLUSIONS

Radiesse is an appropriate and well-tolerated treatment for patients with facial lipoatrophy. It demonstrates an excellent safety profile, causes immediate augmentation of the soft tissues, and appears to provide relatively long-lasting improvement in appearance, with very high patient satisfaction.

[Pathogenic mechanisms for fat redistribution in patients with HIV disease]

Lipodystrophy syndrome is a common term in the literature traditionally used to describe several morphologic (lipoatrophy; lipohypertrophy; mixed syndrome) and metabolic (dyslipidemia, insulin resistance) disturbances found in patients with HIV disease, with or without treatment with highly active antiretroviral therapy (HAART). Increasing evidence suggests these disorders, though commonly clustering in a syndrome pattern, have distinct pathologic pathways and can occur independently of each other. The pathogenesis of these disorders is complex, but recent hypotheses and evidence suggest that impairment to adipocyte differentiation, in particular through alterations in the expression of the transcription factor sterol responsive element binding protein-lc (SREBP1c), impairment of adipokine regulation, unopposed production of proinflammatory cytokines, adipocyte apoptosis mediated by proinflammatory cytokines such as tumor necrosis factor (TNF-alpha) and IL-6, dysregulation of 1l-beta-hydroxysteroid dehydrogenase, and mitochondrial toxicity may play a role.

Carotid intima-media thickness is slightly increased over time in HIV-1-infected patients

OBJECTIVES

HIV-infected patients are at risk of atherosclerosis and cardiovascular diseases. In a 12-month follow-up study, we aimed to investigate changes in carotid intima-media thickness (IMT), a surrogate marker of atherosclerosis, and its determinants in HIV-1-infected patients.

METHODS

Our multicentre prospective longitudinal cohort study included 346 HIV-infected patients, for each of whom two IMT measurements were taken by B-mode ultrasonography at baseline (M0) and 1 year later (M12).

RESULTS

We observed a significant but moderate increase in the common carotid artery (CCA) median IMT, from 0.54 to 0.56 mm (P<10(-4)), i.e. an increase of 0.020 mm (95% confidence interval 0.012-0.029). There was a significant association between cross-sectional CCA IMT measures at M12 and conventional cardiovascular risk factors (higher CCA IMT with older age, P<10(-4); male gender, P=0.02; tobacco consumption, P=0.05), as well as higher CD4 cell count at M12 (>median 455 cells/microL, P=0.01). Only CD4 cell count at M0 was strongly and positively associated with the variation in IMT between M0 and M12 (P=4 x 10(-3)). IMT progression was +0.0020 mm for the lowest quartile of CD4 cell count distribution at M0, i.e. 3-253 cells/microL, +0.010 mm for 253-402 cells/microL, +0.043 mm for 402-590 cells/microL, and +0.028 mm for 590-2270 cells/microL. No association was found with type or duration of antiretroviral exposure.

CONCLUSIONS

Conventional cardiovascular risk factors are major determinants of IMT evolution. The link between immunological status and carotid IMT requires further study.

Treatment of human immunodeficiency virus-associated facial lipoatrophy with lipofilling and submalar silicone implants

In the absence of a current therapy to prevent facial lipoatrophy in HIV+ patients treated with HAART, surgical correction of the defect still remains the best option. We evaluate two different surgical techniques for facial contour enhancing and suggest the right choice related to the lipodystrophy severity. Twelve HIV+ patients underwent surgical submalar correction: eight were treated with lipofilling following Coleman's technique and four had bilateral malar silicone implants inserted after determining their positioning with the aid of a new software. Both techniques gave long lasting results in facial contour reshaping ranging from good to very good. No complication was observed. In the mean follow-up period of 2 years no patient felt uncomfortable with his/her image. Both techniques, lipofilling and silicone implant positioning, for managing facial lipoatrophy in HIV+ patients treated with HAART had good results, but the right choice has to be related to the severity of the lipodystrophy in the patient.