Terapias de simplificación en pacientes con infección por el virus de la inmunodeficiencia humana y su impacto metabólico

Consultable des del TDXTítol obtingut de la portada digitalitzadaEl tratamiento antirretroviral de alta eficacia ha reducido drásticamente la morbi-mortalidad de los pacientes con infección por el VIH al conseguir una supresión mantenida del virus. Sin embargo, la erradicación de éste es aún un objetivo a alcanzar y por tanto, por el momento, la terapia antirretroviral debe mantenerse de forma indefinida. Esto lleva a la aparición de un gran número de efectos adversos asociados al tratamiento antiviral, que en muchos casos son el motivo principal de un mal cumplimiento y del rechazo a la medicación antiviral o de interrupciones de la misma. Así pues, es necesario investigar sobre los mecanismos de producción de estos efectos secundarios, así como investigar nuevas estrategias terapéuticas para su prevención y nuevas combinaciones menos complejas para asegurar un correcto cumplimiento del tratamiento a largo plazo. Entre los efectos secundarios que en la actualidad están motivando más estudios destacan los cambios en la redistribución de la grasa corporal, las alteraciones del metabolismo lipídico y la resistencia a la insulina. En la primera parte de nuestro proyecto presentamos una revisión exhaustiva de estos trastornos, sus características clínico-analíticas, su prevalencia, así como sus posibles causas y mecanismos etiopatogénicos. Posteriormente se describen los objetivos, el diseño y los resultados de nuestros propios trabajos de simplificación. Los dos primeros trabajos presentados estudian la eficacia virológica-inmunológica y la seguridad de pautas de simplificación cuando se sustituyen los inhibidores de la proteasa (IP) por inhibidores de la transcriptasa inversa no análogos a nucleósidos (ITINAN). Ambos estudios, randomizados y prospectivos, demuestran una potencia antiviral similar entre las combinaciones que incluyen ITINANs y los que incluyen IPs. Sin embargo, las pautas basadas en ITINAN se asocian a una menor toxicidad metabólica y a una significativa mejoría de la calidad de vida por la mayor simplicidad de las combinaciones. Al mismo tiempo, el segundo de estos trabajos demuestra la equipotencia antiviral entre los dos ITINANs comercializados, nevirapina y efavirenz, al investigar la eficacia antiviral de ambos por primera vez en un mismo estudio y de forma randomizada, y a su vez comparándolos con los IPs. Finalmente, el tercer trabajo se diseñó para evaluar en detalle, por resonancia nuclear magnética, los cambios cualitativos y cuantitativos de los lípidos y lipoproteinas tras reemplazar los IPs por nevirapina. Los resultados obtenidos nos llevan a confirmar que la sustitución de los IPs por el ITINAN mejora el perfil lipídico al reducir las fracciones lipídicas más aterogénicas y al aumentar las protectoras. Todos estos cambios podrían influir favorablemente sobre el riesgo cardiovascular de los pacientes con infección por el VIH que siguen tratamiento antirretroviral. Así pues, concluimos diciendo que las terapias de simplificación basadas en los ITINAN, efavirenz o nevirapina, constituyen una estrategia antirretroviral eficaz por la potencia antiviral de dichos compuesto. Asimismo suponen combinaciones más sencillas puesto que representan un reducido número de comprimidos con respecto a las terapias con IPs, con la consecuente facilitación de la adherencia al tratamiento y proporcionan un efecto beneficioso sobre el metabolismo de los lípidos, que podría representar un menor riesgo de complicaciones cardiovasculares a medio-largo término.The eradication of HIV infection is unattainable at present in the clinical setting despite the initial expectations derived from the ability of highly active antiretroviral therapy (HAART) to profoundly suppress viral replication and to limit morbidity and mortality of HIV/AIDS disease. Consequently, antiretroviral treatment has to be maintained for life, once it is initiated. This derives in the occurrence of adverse events such as lipodystrophy syndrome and metabolic disturbances (dyslipemia and insuline resistance) that are often cumulative. Additionally, this toxicity often leads to a bad adherence or to treatment interruptions. For these reasons, it is necessary to assess the etiopathogenic mechanism of these abnormalities and to design strategies to prevent or to revert them. Likewise, simpler antiretroviral combinations should be provided to assure a properly long-term adherence. Metabolic HAART-related toxicity has been described in the first part of our project including its characteristics, prevalence, aetiology and its possible pathogenic mechanism. The second part summarizes the results of three different simplification studies conducted in our HIV Unit. Two of these trials find out the antiviral efficacy and safety of different simplification approaches where the protease inhibitors (PI) were replaced by a non-nucleoside reverse transcriptase inhibitor (NNRTI), nevirapine or efavirenz. These prospective randomised studies showed a similar antiviral potency between PIs and NNRTIs-containing regimens. Combinations including NNRTIs, mainly nevirapine, were associated with less metabolic toxicity and with an improvement in quality of life. In addition, a similar antiviral potency between both commercialised NNRTIs, nevirapine and efavirenz, was demonstrated in one of these studies for first time in a comparative randomised study. Finally, the third trial was designed to evaluate in detail the qualitative and quantitative changes on lipids and lipoproteins by nuclear magnetic resonance (NMR) after the nevirapine introduction. These data confirmed the improvement in lipid profile when the PI was replaced by nevirapine, showing a reduction in the more atherogenic lipid fractions and an increase in the protectors ones. These metabolic changes could reduce the cardiovascular risk of this population. In conclusion, simpler approaches based on NNRTIs, efavirenz or nevirapine, are a valid antiretroviral strategy due to its antiviral potency and simplicity. The improvement in lipid profile could consequently decrease the atherogenic index of these patients at long-term

Prospective study to assess progression of renal markers after interruption of tenofovir due to nephrotoxicity

Background. Prospective studies about the reversibility of tenofovir disoproxil fumarate- (TDF-) related renal impairment remain scarce. Methods. This is an observational prospective study including all patients that presented at our HIV Unit who interrupted TDF owing to nephrotoxicity. We assessed the evolution of renal parameters after discontinuation of this drug. Results. We included 59 patients, who were followed up for 72 weeks. Most were male (41, 69.5%), median (IQR) age was 53 (44; 58) years, and median time receiving TDF-containing regimens was 55.4 (28; 87.7) months. Most patients were receiving PI-based treatments (67%). At the final visit, most of the subjects showed complete recovery (35, 59.3%) or improvement (13 subjects, 22%). Significant improvements were observed in creatinine levels (from 84.9 [73.8; 97.5] to 78 [69.6; 91] mu mol/L, p = 0.013), estimated glomerular filtration rate (eGFR, CKD EPI equation, from 87.7 [67; 99] to 89.9 [73.6; 99.3] mL/min/1.73 m(2), p = 0.017), and number of patients with eGFR <60 mL/min/1.73 m(2) (from 9 [15.3%] to 1 [1.7%], p = 0.031). A trend toward significance was observed in abnormal urine proteinuria/creatinine ratio (from 22 [37%] to 8 [13.6%], p = 0.057). Conclusions. Our results corroborate the high frequency of complete or partial renal recovery in patients receiving TDF-containing regimens who discontinued therapy owing to nephrotoxicity.Peer ReviewedPostprint (published version

Prevalence, evolution, and related risk factors of kidney disease among Spanish HIV-infected individuals

Prevalence of kidney disease (KD) is increasing among human immunodeficiency virus (HIV)-infected population. Different factors have been related, varying on different published series. The objectives were to study prevalence of KD in those patients, its evolution, and associated risk factors. An observational cohort study of 1596 HIV-positive patients with cross-sectional data collection in 2008 and 2010 was conducted. We obtained clinical and laboratory markers, and registered previous or current treatment with tenofovir (TDF) and indinavir (IDV). The sample was divided according to estimated glomerular filtration rate (eGFR) by modification of diet in renal disease (MDRD) equation. Group 1: eGFR ≤60 mL/min/1.73 m 2 ; group 2: eGFR >60 mL/min/1.73 m 2. Among the patients, 76.4% were men, mean age (SD) 45 ± 9 years, time since diagnose of HIV 14 ± 7 years, and 47.2% of the patients received previous treatment with TDF and 39.1% with IDV. In 2008, eGFR ≤60: 4.9% (91.4% of them in chronic kidney disease [CKD] stage 3, eGFR 59-30 mL/min); this group was older, presented higher fibrinogen levels, and more patients were treated previously with TDF and IDV. In 2010, eGFR ≤60: 3.9% (87.1% stage 3 CKD). The 2.4% of cohort showed renal improvement and 1.3% decline of renal function over time. The absence of hypertension and treatment with TDF were associated with improvement in eGFR. Increased age, elevated fibrinogen, decreased albumin, diabetes mellitus, hyperTG, and worse virological control were risk factors for renal impairment. The HIV-positive patients in our area have a CKD prevalence of 4% to 5% (90% stage 3 CKD) associated with ageing, inflammation, worse immune control of HIV, TDF treatment, and metabolic syndrome

Estudio de los factores asociados a la pérdida de densidad mineral ósea en pacientes infectados con VIH

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Impact of protease inhibitors on the evolution of urinary markers: subanalyses from an observational cross-sectional study

Kidney injury (defined as the presence of albuminuria, proteinuria, glycosuria [without hyperglycemia], hematuria, and/or renal hypophosphatemia) is an emerging problem in human immunodeficiency virus (HIV)-infected patients, although few data are available on the role of protease inhibitors (PIs) in this condition. To determine the time to kidney injury in a cohort of HIV-infected patients receiving a PI-containing regimen. We report the results of a subanalysis of a published cross-sectional study. The subanalysis included only patients receiving PI-containing regimens for more than 6 months (377 of the overall 970 patients). We determined associated factors and constructed receiver operating characteristic curves to estimate time to kidney injury depending on the PI used. The percentage of patients with kidney injury was 27.7% for darunavir, 27.9% for lopinavir, and 30% for atazanavir. Time to kidney injury was as follows: 229 days for atazanavir/ritonavir (area under the curve [AUC], 0.639; sensitivity, 0.89; specificity, 0.41); 332 days for atazanavir/ritonavir plus tenofovir (AUC, 0.603; sensitivity, 0.75; and specificity, 0.29); 318 days for nonboosted atazanavir (AUC, 0.581; sensitivity, 0.89; and specificity, 0.29); 478 days for lopinavir/ritonavir (AUC, 0.566; sensitivity, 0.864; and specificity, 0.44); 1339 days for lopinavir/ritonavir plus tenofovir (AUC, 0.667; sensitivity, 0.86; and specificity, 0.77); 283 days for darunavir/ritonavir (AUC, 0.523; sensitivity, 0.80; and specificity, 0.261); and 286 days for darunavir/ritonavir plus tenofovir (AUC, 0.446; sensitivity, 0.789; and specificity, 0.245). The use of lopinavir/ritonavir without tenofovir was a protective factor (odds ratio = 1.772; 95% CI, 1.070-2.93; P = 0.026). For all PIs, the percentage of patients with kidney injury exceeded 27%, irrespective of tenofovir use. The longest time to kidney injury was recorded with lopinavir/ritonavir. These results demonstrate the need for renal monitoring, including urine samples, in patients receiving a PI-based regimen, even when tenofovir is not used concomitantly.Peer ReviewedPostprint (published version

High risk and probability of progression to osteoporosis at 10 years in HIV-infected individuals: the role of PIs

This is a pre-copyedited, author-produced PDF of an article accepted for publication in Journal of antimicrobial chemotherapy following peer review. The version of record Negredo, E., Langohr, K., Bonjoch, A., Perez, N., Estany, C., Puig, J., Echevarría, P., Clotet, B., Gómez Melis, G. High risk and probability of progression to osteoporosis at 10 years in HIV-infected individuals: the role of PIs. "Journal of antimicrobial chemotherapy", 1 Setembre 2018, vol. 73, núm. 9, p. 2452-2459 is available online at: https://academic.oup.com/jac/article-abstract/73/9/2452/5026321.Peer ReviewedPostprint (author's final draft

Clinical and Emotional Factors Related to Erectile Dysfunction in HIV-Infected Men

Altres ajuts: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a grant from Lluita contra la Sida Foundation.The prevalence and associated factors of erectile dysfunction (ED) in Human Immunodeficiency Virus (HIV)-infected men remain controversial. The authors evaluated ED, clinical, and emotional variables in a group of 501 HIV-infected men in a cross-sectional 4-month observational study. ED was assessed using the International Index of Erectile Function-5 and emotional status using the Hospital Anxiety and Depression (HAD) questionnaire. Median age (interquartile range) was 42 (35, 48) years. Time since HIV diagnosis was 6.3 (2.6, 17.1) years, 92% were taking antiretroviral treatment and 81.8% had an HIV-RNA viral load <50 copies. The prevalence of ED was 58.5%. ED was mild in 30.1%, mild to moderate in 19.5%, moderate in 6.1%, and severe in 2.5%. ED medications were used by 19% of men. In the univariate analysis, the variables associated with all degrees of ED were older age, longer time since HIV diagnosis, higher scores in HAD, not taking efavirenz, taking etravirine, taking ritonavir, HIV/Hepatitis C Virus coinfection, and taking a protease inhibitor-containing regimen. For mild to moderate, moderate, and severe ED, the same variables were significant, as were lower nadir CD4 cell count, lower social support, taking atazanavir, concomitant conditions, and concomitant treatments. The variables that remained significant in the multivariate analyses, considering all degrees of ED or excluding mild ED were the following: older age and higher scores in HAD total. In summary, ED affected more than half of this cohort of well controlled HIV-infected men. Age and emotional status seemed to play a fundamental role in its presence

High Prevalence of Sarcopenia in HIV-Infected Individuals

Sarcopenia is a geriatric syndrome that leads to a loss of functionality and mortality. We assessed the prevalence of sarcopenia in HIV-infected patients attended in our HIV Unit who had at least two DXA scans from 2000 to 2016 (1,720 DXA scans from 860 individuals). Sarcopenia was determinate according to appendicular skeletal muscle mass index (ASM) calculated as the ratio between skeletal muscle mass index (SMI) by DXA and height 2 (kg/m 2). We stratified patients by gender and age (50 years) and according to the interval between DXAs (≤3, 3-7, 7-10, >10 years). The statistical analysis was performed using SPSS version 19. Median (IQR) age was 52 (47; 57) years, and 76% were male. The median (IQR) time with HIV infection was 8 (3; 15) years. The prevalence of sarcopenia was 25.7% (95% CI, 22.8-28.7), more prevalent in those aged >50 years (27.8%). Stratifying by gender, 43% of women aged >50 years presented sarcopenia compared with 8.8% of men. The frequency of sarcopenia increased from 37.6% to 49.4% when interval between DXA was 7-10 years (n=109), significantly higher in women than in men (p=0.016). In addition to the traditional risk factors, time with HIV infection was associated with sarcopenia [RR 1.780 (95% CI, 1.314-2.411), p=0.001]. The prevalence and progression of sarcopenia in HIV-infected patients were high, mainly among women. Further studies are necessary to assess the best approaches to prevent this condition and its consequences

Classification Models for Neurocognitive Impairment in HIV Infection Based on Demographic and Clinical Variables

Objective: We used demographic and clinical data to design practical classification models for prediction of neurocognitive impairment (NCI) in people with HIV infection. Methods: The study population comprised 331 HIV-infected patients with available demographic, clinical, and neurocognitive data collected using a comprehensive battery of neuropsychological tests. Classification and regression trees (CART) were developed to obtain detailed and reliable models to predict NCI. Following a practical clinical approach, NCI was considered the main variable for study outcomes, and analyses were performed separately in treatment-naı¨ve and treatment-experienced patients. Results: The study sample comprised 52 treatment-naı¨ve and 279 experienced patients. In the first group, the variables identified as better predictors of NCI were CD4 cell count and age (correct classification [CC]: 79.6%, 3 final nodes). In treatment-experienced patients, the variables most closely related to NCI were years of education, nadir CD4 cell count, central nervous system penetration-effectiveness score, age, employment status, and confounding comorbidities (CC: 82.1%, 7 final nodes). In patients with an undetectable viral load and no comorbidities, we obtained a fairly accurate model in which the main variables were nadir CD4 cell count, current CD4 cell count, time on current treatment, and past highest viral load (CC: 88%, 6 final nodes). Conclusion: Practical classification models to predict NCI in HIV infection can be obtained using demographic and clinical variables. An approach based on CART analyses may facilitate screening for HIV-associated neurocognitive disorders and complement clinical information about risk and protective factors for NCI in HIV-infected patients