Combination antiretroviral therapy -associated lipodystrophy : insights into pathogenesis and treatment

Introduction: Combination antiretroviral therapy (cART) has decreased morbidity and mortality of individuals infected with human immunodeficiency virus type 1 (HIV-1). Its use, however, is associated with adverse effects which increase the patients risk of conditions such as diabetes and coronary heart disease. Perhaps the most stigmatizing side effect is lipodystrophy, i.e., the loss of subcutaneous adipose tissue (SAT) in the face, limbs and trunk while fat accumulates intra-abdominally and dorsocervically. The pathogenesis of cART-associated lipodystrophy is obscure. Nucleoside reverse transcriptase inhibitors (NRTI) have been implicated to cause lipoatrophy via mitochondrial toxicity. There is no known effective treatment for cART-associated lipodystrophy during unchanged antiretroviral regimen in humans, but in vitro data have shown uridine to abrogate NRTI-induced toxicity in adipocytes. Aims: To investigate whether i) cART or lipodystrophy associated with its use affect arterial stiffness; ii) lipoatrophic SAT is inflamed compared to non-lipoatrophic SAT; iii) abdominal SAT from patients with compared to those without cART-associated lipoatrophy differs with respect to mitochondrial DNA (mtDNA) content, adipose tissue inflammation and gene expression, and if NRTIs stavudine and zidovudine are associated with different degree of changes; iv) lipoatrophic abdominal SAT differs from preserved dorsocervical SAT with respect to mtDNA content, adipose tissue inflammation and gene expression in patients with cART-associated lipodystrophy and v) whether uridine can revert lipoatrophy and the associated metabolic disturbances in patients on stavudine or zidovudine based cART. Subjects and methods: 64 cART-treated patients with (n=45) and without lipodystrophy/-atrophy (n=19) were compared cross-sectionally. A marker of arterial stiffness, heart rate corrected augmentation index (AgIHR), was measured by pulse wave analysis. Body composition was measured by magnetic resonance imaging and dual-energy X-ray absorptiometry, and liver fat content by proton magnetic resonance spectroscopy. Gene expression and mtDNA content in SAT were assessed by real-time polymerase chain reaction and microarray. Adipose tissue composition and inflammation were assessed by histology and immunohistochemistry. Dorsocervical and abdominal SAT were studied. The efficacy and safety of uridine for the treatment of cART-associated lipoatrophy were evaluated in a randomized, double-blind, placebo-controlled 3-month trial in 20 lipoatrophic cART-treated patients. Results: Duration of antiretroviral treatment and cumulative exposure to NRTIs and protease inhibitors, but not the presence of cART-associated lipodystrophy, predicted AgIHR independent of age and blood pressure. Gene expression of inflammatory markers was increased in SAT of lipodystrophic as compared to non-lipodystrophic patients. Expression of genes involved in adipogenesis, triglyceride synthesis and glucose disposal was lower and of those involved in mitochondrial biogenesis, apoptosis and oxidative stress higher in SAT of patients with than without cART-associated lipoatrophy. Most changes were more pronounced in stavudine-treated than in zidovudine-treated individuals. Lipoatrophic SAT had lower mtDNA than SAT of non-lipoatrophic patients. Expression of inflammatory genes was lower in dorsocervical than in abdominal SAT. Neither depot had characteristics of brown adipose tissue. Despite being spared from lipoatrophy, dorsocervical SAT of lipodystrophic patients had lower mtDNA than the phenotypically similar corresponding depot of non-lipodystrophic patients. The greatest difference in gene expression between dorsocervical and abdominal SAT, irrespective of lipodystrophy status, was in expression of homeobox genes that regulate transcription and regionalization of organs during embryonal development. Uridine increased limb fat and its proportion of total fat, but had no effect on liver fat content and markers of insulin resistance. Conclusions: Long-term cART is associated with increased arterial stiffness and, thus, with higher cardiovascular risk. Lipoatrophic abdominal SAT is characterized by inflammation, apoptosis and mtDNA depletion. As mtDNA is depleted even in non-lipoatrophic dorsocervical SAT, lipoatrophy is unlikely to be caused directly by mtDNA depletion. Preserved dorsocervical SAT of patients with cART-associated lipodystrophy is less inflamed than their lipoatrophic abdominal SAT, and does not resemble brown adipose tissue. The greatest difference in gene expression between dorsocervical and abdominal SAT is in expression of transcriptional regulators, homeobox genes, which might explain the differential susceptibility of these adipose tissue depots to cART-induced toxicity. Uridine is able to increase peripheral SAT in lipoatrophic patients during unchanged cART.Johdanto: Ihmisen immuunikatoviruksen (HIV) hoitoon käytetyt lääkeyhdistelmät ovat vähentäneet HIV-positiivisten henkilöiden sairastuvuutta ja kuolleisuutta. Yhdistelmähoitoon liittyy kuitenkin vakavia sivuvaikutuksia, jotka lisäävät potilaiden riskiä sairastua mm. diabetekseen ja sepelvaltimotautiin. Yksi leimaavimpia sivuvaikutuksia on lipodystrofia eli ihonalaisen rasvakudoksen häviäminen (lipoatrofia) kasvoista, raajoista ja vatsalta samalla kun rasvaa kertyy ylen määrin vatsaonteloon ja niskaan. Ilmiön syyt ovat epäselvät. Useiden HIV:ta vastaan suunnattujen lääkeaineiden on epäilty aiheuttavan lipodystrofiaa mm. tuhoamalla mitokondrioita, solujen energiatehtaita . Lipodystrofiaan ei ole tehokasta hoitoa, ellei HIV-lääkitystä muuteta, mutta esim. uridiini on ollut lupaava apu solumallitutkimusten valossa. Tavoitteet: Tutkia liittyykö yhdistelmähoitoon tai sen käyttöön liittyvään lipodystrofiaan verisuonien jäykistymistä, onko lipoatrofinen rasvakudos tulehtunutta verrattuna ei-lipoatrofiseen rasvakudokseen, eroaako lipoatrofinen ei-lipoatrofisesta rasvakudoksesta mm. mitokondriomäärän ja aineenvaihduntaan vaikuttavien geenien ilmentymisen suhteen sekä poikkeaako lipodystrofiassa paremmin säilyvä niskan rasva häviävästä vatsan ihonalaisrasvasta ja onko se mahdollisesti ruskeata rasvaa. Lisäksi tutkimme, voiko ravintolisänä käytetty uridiini parantaa lipoatrofiaa ja siihen liittyviä aineenvaihduntahäiriöitä, kuten rasvamaksaa ja heikentynyttä insuliiniherkkyyttä. Menetelmät: Tutkimuksiin osallistui 64 HIV-positiivista yhdistelmähoidettua potilasta, joista 45:lla oli ja 19:lla ei ollut kehittynyt lääkitykseen liittyviä rasvakudoksen muutoksia. Verisuonijäykkyys tutkittiin pulssiaaltoanalyysilla, kehon koostumus mitattiin kaksienergisella röntgenabsorptiometria- sekä magneettikuvaantamisella ja maksan rasvapitoisuus protonispektroskopialla. Rasvakudosnäytteet otettiin potilaiden vatsan ja niskan ihoalaisrasvasta ja niistä mitattiin eri geenien ilmentymistä sekä mitokondrioiden ja tulehdussolujen määrää mm. DNA:n monistustekniikalla ja kudosleikevärjäyksin. Uridiinin tehoa lipoatrofian hoidossa arvioitiin 3kk satunnaistetussa lumelääkekontrolloidussa tutkimuksessa, johon osallistui 20 HIV-positiivista yhdistelmähoidettua lipoatrofista henkilöä. Tulokset: HIV-lääkityksen kesto, mutta ei lipodystrofia, altistaa verisuonien jäykistymiselle iästä ja verenpainetasosta riippumatta. Lipoatrofisessa rasvakudoksessa tulehdukseen liittyvien geenien ilmentyminen ja tulehdussolujen määrä ovat lisääntyneet, kun taas mitokondriomäärä sekä rasvasolujen muodostumiseen ja toimintaan liittyvien geenien ilmentyminen vähentyneet verrattuna ei-lipoatrofiseen rasvakudokseen. Lipodystrofiassa säilyvä/lisääntyvä niskan rasva on vähemmän tulehtunutta kuin herkemmin häviävä vatsan ihonalaisrasva eikä se ole ruskeata rasvaa. Lipodystrofisten henkilöiden niskan rasvassa on vähemmän mitokondrioita kuin ei-lipodystrofisten henkilöiden niskan rasvassa, vaikka kudokset ovat ulkoisesti samannäköisiä. Niskan ja vatsan alueen ihonalaisrasva eroaa eniten ns. homeobox-geenien ilmentymisessä eli sellaisten geenien, jotka määrittelevät kudosten sijainnin ja ominaisuudet sikiökehityksen varhaisvaiheessa. Uridiini lisää ihonalaisrasvan määrää lipoatrofisilla potilailla, mutta ei vaikuta maksan rasvapitoisuuteen tai insuliiniherkkyyteen. Johtopäätökset: HIV:n hoitoon käytettyjen lääkkeiden pitkäaikaiskäyttö lisää verisuonien jäykkyyttä ja siten potilaiden riskiä sairastua sydän- ja verisuonitauteihin. Lipoatrofinen rasva on tulehtunut ja sen mitokondriovarannot vähentyneet. Koska mitokondrioiden vähyys on todettavissa niskarasvassa myös sellaisilla lipodystrofisilla henkilöillä, joilla se on säilynyt atrofialta, mitokondriokatoa ei voida pitää lipoatrofiaa suoraan aiheuttavana tekijänä. Niskan ja vatsan ihonalaisrasvan merkittävin ero on elinkehitystä ohjaavissa geeneissä, mikä voi selittää kudosten erilaisen alttiuden lääkkeiden sivuvaikutuksille. Uridiini on tehokas hoito HIV-potilaiden lipodystrofiaan muuttumattoman yhdistelmähoidon aikana

Analysis of naturally occurring mutations in the human lipodystrophy protein seipin reveals multiple potential pathogenic mechanisms

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Berardinelli-Seip Syndrome

We have reported two cases of Berardinelli-syndrome in a family which is a rare autosomal recessive disorder of the adipose tissue, originally described by Berardinelli and Seip, has been reported in approximately 120 patients of various ethnic origins. Assuming that only 1 in 4 patients is reported.Patients present with acanthosis nigricans (dark velvety pigmentation of the skin) in the axilla, neck or groin, severe insulin resistance, high levels of serum insulin and serum triglycerides.The other clinical features consist of enlarged hands, feet and prominent mandible (acromegaloid features), increased sweating, umbilical hernia and lytic lesions (bone appear to be eaten-up on X-rays) in long bones of the upper and lower extremities (arms, forearm, hands, thigh, calf, legs and feet) such as humerus, femur, etc. Hepatomegaly from fatty liver is almost universal and may ultimately lead to cirrhosis. Splenomegaly is common. Nearly all patients have a prominent umbilicus or frank umbilical hernia. Females present with enlarged clitoris, increased body hair, absence of or irregular menstrual cycles, and polycystic ovaries (enlarged ovaries). Only a few affected women have had successful pregnancies, whereas affected men have normal fertilit

Seipin oligomers can interact directly with AGPAT2 and lipin 1, physically scaffolding critical regulators of adipogenesis

This work was supported by a Merit Scholarship from the Islamic Development Bank (to M.M.U.T.), The Agency for Science, Technology and Research, Singapore (A*STAR) (M.F.M.S), the Medical Research Council (MRC) [NIRG GO800203 and Research Grant MR/L002620/1 (to J.J.R.), Program GrantG09000554 (to S.O.R)], The Wellcome Trust [078986/Z/06/Z (to S.O.R.)], the MRC Centre for Obesity and Related Metabolic Disorders (MRC-CORD) [GO600717] and the NIHR Comprehensive Biomedical Research Centre [CG50826].Peer reviewedPublisher PD

Deep subcutaneous application of poly-L-lactic acid as a filler for facial lipoatrophy in HIV-infected patients

Introduction: Facial lipoatrophy is a crucial problem of HIV-infected patients undergoing highly active antiretroviral therapy (HAART). Poly-L-lactic acid (PLA), provided as New-Fill(R)/Sculptra(TM), is known as one possible treatment option. In 2004 PLA was approved by the FDA as Sculptra(TM) for the treatment of lipoatrophy of the face in HIV-infected patients. While the first trials demonstrated relevant efficacy, this was to some extent linked to unwanted effects. As the depth of injection was considered relevant in this context, the application modalities of the preparation were changed. The preparation was to be injected more deeply into subcutaneous tissue, after increased dilution. Material and Methods: To test this approach we performed a pilot study following the new recommendations in 14 patients. Results: While the efficacy turned out to be about the same, tolerability was markedly improved. The increase in facial dermal thickness was particularly obvious in those patients who had suffered from lipoatrophy for a comparatively small period of time. Conclusion: With the new recommendations to dilute PLA powder and to inject it into the deeper subcutaneous tissue nodule formation is a minor problem. However, good treatment results can only be achieved if lipoatrophy is not too intense; treatment intervals should be about 2 - 3 weeks. Copyright (C) 2005 S. Karger AG, Basel

Myristic acid potentiates palmitic acid-induced lipotoxicity and steatohepatitis associated with lipodystrophy by sustaning de novo ceramide synthesis.

Palmitic acid (PA) induces hepatocyte apoptosis and fuels de novo ceramide synthesis in the endoplasmic reticulum (ER). Myristic acid (MA), a free fatty acid highly abundant in copra/palmist oils, is a predictor of nonalcoholic steatohepatitis (NASH) and stimulates ceramide synthesis. Here we investigated the synergism between MA and PA in ceramide synthesis, ER stress, lipotoxicity and NASH. Unlike PA, MA is not lipotoxic but potentiated PA-mediated lipoapoptosis, ER stress, caspase-3 activation and cytochrome c release in primary mouse hepatocytes (PMH). Moreover, MA kinetically sustained PA-induced total ceramide content by stimulating dehydroceramide desaturase and switched the ceramide profile from decreased to increased ceramide 14:0/ceramide16:0, without changing medium and long-chain ceramide species. PMH were more sensitive to equimolar ceramide14:0/ceramide16:0 exposure, which mimics the outcome of PA plus MA treatment on ceramide homeostasis, than to either ceramide alone. Treatment with myriocin to inhibit ceramide synthesis and tauroursodeoxycholic acid to prevent ER stress ameliorated PA plus MA induced apoptosis, similar to the protection afforded by the antioxidant BHA, the pan-caspase inhibitor z-VAD-Fmk and JNK inhibition. Moreover, ruthenium red protected PMH against PA and MA-induced cell death. Recapitulating in vitro findings, mice fed a diet enriched in PA plus MA exhibited lipodystrophy, hepatosplenomegaly, increased liver ceramide content and cholesterol levels, ER stress, liver damage, inflammation and fibrosis compared to mice fed diets enriched in PA or MA alone. The deleterious effects of PA plus MA-enriched diet were largely prevented by in vivo myriocin treatment. These findings indicate a causal link between ceramide synthesis and ER stress in lipotoxicity, and imply that the consumption of diets enriched in MA and PA can cause NASH associated with lipodystrophy

Adherence to antiretroviral therapy in patients enrolled in a comprehensive care program in Cambodia: a 24-month follow-up assessment

BACKGROUND: The long-term maintenance of antiretroviral therapy (ART) remains an important issue, especially in limited-resource settings where additional barriers exist. A cross-sectional study was performed 24 months after ART initiation for patients treated in Cambodia in order to estimate the prevalence and identify determinants of non-adherence. METHODS: Adults receiving ART for 24 +/- 2 months were considered eligible for the study. Self-reported non-adherence was defined according to an algorithm based on six items. The questionnaire also assessed ART-related side effects and HIV disclosure. HIV-1 RNA plasma viral load was measured using real-time PCR. Multivariate rare events logistic regression analysis was used to identify independent factors associated with non-adherence. RESULTS: A total of 346 patients participated in the study. At 24 months, 95% of patients were adherent, 80% had HIV RNA <40 copies/ml and 75% had CD4+ T-cell counts >200 cells/mm3. Virological success was significantly higher in adherent patients than in non-adherent patients (81% versus 56%, P=0.021). Living in a rural area, limited HIV disclosure and perceived lipodystrophy were independently associated with non-adherence. CONCLUSIONS: At 24 months, adherence to ART was high and explained positive virological outcomes. In order to maintain adherence and long-term virological benefits, special attention should be given to patients living in rural areas, those with lipodystrophy-related symptoms and others who express difficulties disclosing their condition to close family members

Does counseling increase sustained benefit of HAART among prison inmates after release to the community?

The lack of sustained effectiveness of HAART after release to the community of HIV-infected inmates treated in prison was well demonstrated by Springer et al. in a recent article. This disappointing result occurred even though all of the patients scheduled for release were referred for transitional case management services to a community-based organization and were provided with a 2-week supply of medications, a medical appointment with an HIV care provider, emergency housing and food, and assistance with other identified unmet needs