Impact of switching to raltegravir and/or adding losartan in lymphoid tissue fibrosis and inflammation in people living with HIV. A randomized clinical trial

BACKGROUND

Persistent inflammation and immune activation are associated with lymph node fibrosis and end-organ diseases in treatment-suppressed people living with HIV (PLWH). We investigated the effect of switching to raltegravir and/or adding losartan on lymphoid tissue fibrosis and on the inflammatory/immune-activation mediators in treated HIV patients.

METHODS

Chronic HIV-infected patients treated with two nucleoside reverse transcriptase inhibitors (2NRTI) and one non-NRTI (NNRTI) or protease inhibitor (PI) during at least 48 weeks were randomized to four groups (n = 48): 2NRTI + efavirenz (EFV), 2NRTI + EFV + losartan, 2NRTI + raltegravir and 2NRTI + raltegravir + losartan for 48 weeks. Tonsillar biopsy and peripheral blood markers of CD4 and CD8 T-lymphocyte activation and senescence, monocyte activation and soluble markers of inflammation were determined at baseline and at week 48 and compared between groups.

RESULTS

No changes in lymphoid tissue architecture were observed. Adding losartan had no impact on lymphocyte subsets. Conversely, patients who switched to raltegravir showed a higher decrease in all activated [CD4+CD38+HLA-DR+, -0.3 vs. 0.48 (P = 0.033); CD8+CD38+ HLA-DR+, -1.6 vs. 1.3 (P = 0.02)] and senescent [CD4+CD28-CD57+, -0.3 vs. 0.26 (P = 0.04); CD8+CD28-CD57+, -6.1 vs. 3.8 (P = 0.002)] T lymphocytes. In addition, the median CD4/CD8 ratio increased by 0.35 in patients in the raltegravir group vs. 0.03 in the other arms (P = 0.002). Differences between groups in monocyte subpopulations or soluble inflammation markers were not observed.

CONCLUSIONS

Losartan had no effect on lymphoid fibrosis or immune activation/inflammation. Conversely, switching to a regimen with raltegravir significantly decreased activated and senescent T-lymphocyte subpopulations and increased CD4/CD8 ratio in successfully treated PLWH.

Exercise test in detecting anomalous behaviour of blood pressure in patients successfully operated on for coarctation of the aorta

Twenty-eight patients operated with success for isolated coarctation of the aorta (i.e. with normal blood pressure and upper/lower limb gradient < or = 20 mmHg at rest) underwent exercise testing to evaluate blood pressure and upper/lower limb pressure gradient during exercise. At maximum effort: 57% (16/28) of the patients were hypertensive and 43% (12/28) of patients increased upper/lower limb gradient over 35 mmHg. No significant correlation was found between the age at surgery (before or after 3 years of age) and maximal systolic blood pressure on exercise and maximal pressure gradient on exercise. The 12 patients with an exercise pressure gradient > 35 mmHg underwent digital angiography or magnetic resonance of the aorta. In 7 cases a mild residual narrowing was found (5 with mild transverse aortic arch hypoplasia, 2 with a mild residual coarctation). In 5 cases no residual narrowing was present. Many factors are thought to be involved in the anomalous behaviour of blood pressure during effort: in some cases anatomic factors, as residual narrowings of the aorta, in other cases functional factors, as increased forearm vascular reactivity, altered baroceptor function, different reactivity and structure of the pre- and post-stenotic aorta, etc., in other cases finally, both factors, anatomic and functional. We conclude that the exercise testing provides the best information on blood pressure modifications during activity and it allows to us to identify those patients which, because of exercise-induced hypertension, remain at risk of premature cardiovascular disease, also after a successful operation. However, when hypertension is found during effort, a strenous physical activity should be avoided and antihypertensive treatment may be required. So the cardiovascular risk due to hypertension can be reduced in the long term follow-up. Corrective surgery for coarctation of the aorta, introduced in 1944, has completely modified the natural history of the disease. Nowadays the operative risk is very low for isolated coarctation and the great majority of the patients is asymptomatic after surgical repair. Nevertheless, their life expectancy is substantially shortened, if compared with the survival curve of a normal population. The vascular and cardiovascular accidents, usually related to residual systemic hypertension, are the most common cause of this. Some studies in the literature have shown that many patients with normal blood pressure and no or little residual upper/lower limb pressure gradient at rest, may develop an anomalous blood pressure response e and/or a high upper/lower limb pressure gradient during exercise. We have studied by exercise test a group of patients successfully operated on for isolated coarctation of the aorta to evaluate the behaviour of the systolic blood pressure and the upper/lower limb pressure gradient during exercise. The aim was to recognize the patients who, inspite of very good operative result, remain at cardiovascular risk in the long-term follow-up.

[Transcatheter closing of patent ductus arteriosus using detachable coils]

Various devices have been developed for the percutaneous closure of persistent patent ductus arteriosus (PDA). In recent years Gianturco coils have become increasingly widespread for this purpose. Poor control during positioning is a major disadvantage of Gianturco coils, with resultant embolization of coils and residual shunts. Modifications to improve the positioning of coils have been developed. Very recently a new screwing detachable coil is available (Cook Cardiology, Europe). Between January 1996 and March 1999, 24 consecutive patients with PDA underwent cardiac catheterization. Twenty cases were judged suitable for this procedure, on the base of diameter and morphology of the ductus. Three cases were excluded because of the ductal diameter was too large (> 4.2 mm) and one because of its morphology (type B). In 19 patients a single coil was positioned, while in 1 case 2 coils were simultaneously used. In 19 cases (95%) complete closure was obtained (in 15 cases immediately, in 2 after 24 hours, in 2 after 1 month). One case showed a residual shunt and a second coil was applied eighteen months later with complete closure. So, considering also this last case, the closure was achieved in 100%. There were neither embolization or other complications. In conclusion, screwing detachable coil for PDA closure is a safe, very effective and at low cost technique. Therefore nowadays this procedure represents the method of choice for occlusion of small PDA (minimal diameter < or = 4 mm).