PERCENTAGE OF CD8/38 T CELLS PRE AND POST ANTI RETROVIRAL THERAPY AMONG HIV INFECTED PATIENTS

Transcription

1 PERCENTAGE OF CD8/38 T CELLS PRE AND POST ANTI RETROVIRAL THERAPY AMONG HIV INFECTED PATIENTS PUBLICATION ARTICLE To meet requirements To achieve the Degree of Clinical Pathology Specialist Prepared by: Yunika Puspa Dewi 11/326437/PKU/12910 PRESENTED TO CLINICAL PATHOLOGY SPECIALIST PROGRAMME UNIVERSITY OF GADJAH MADA YOGYAKARTA 2016 i

2 PERCENTAGE OF CD8/38 T CELLS PRE AND POST ANTI RETROVIRAL THERAPY AMONG HIV INFECTED PATIENTS PUBLICATION ARTICLE To meet requirements To achieve the Degree of Clinical Pathology Specialist Prepared by: Yunika Puspa Dewi 11/326437/PKU/12910 Has been approved on February 2 nd 2016 by Advisor, Advisor, dr. Umi S. Intansari, M.Kes, Sp.PK(K) NIP dr. Usi Sukorini, M.Kes, Sp.PK(K) NIP ii

3 ABSTRACT Background: Human immunodeficiency virus infection still being a major health problem worldwide. The success of ART depends not only on the efficacy of drugs to lower VL but also immune system's ability to control the virus replication. Lymphocyte activation profiles especially CD8 + T cell activation have been in a spotlight to monitor patient with ART. On a Multicenter AIDS Cohort Study, CD38 expression is a predictor for disease progression better than other immune activation markers. Aims of this study was to know is there any significant different of CD8/38 T cells percentages between pre and 6 months post ART in HIV infected patients. Methods: This was a prospective longitudinal study with quasi-experimental without control design (One-Group Pretest-Posttest Design). Subjects of this study were newly diagnosed HIV-infected adult patients who had not received ART before and were treated at the clinic of Edelweis dr. Sardjito general hospital and clinics of Tropical Infectious Diseases dr. Kariadi general hospital. All clinical and laboratory information were collected before (pre-art) and after ART (post- ART). Laboratory tests performed were complete blood count, CD4 T cell count, the percentage of CD8/38 T cells and VL. Statistical analysis was performed to know is there any significant difference in the percentage of CD8/38 T cells between pre-art and 6 months post ART using paired t test. Results: Total study s subjects were 45 people, mostly were men 39 (86.7%) with median age was 28 (19-51) years. Risk factors for HIV transmission mostly were homosexuals 30 (66.7%). Most of the study subjects were still in clinical stage 1 and 2, (53.3%) and 16 (35.6%) respectivey. The percentage of CD8/38 T cells pre ART were 45.3 ± 15.63%. At the end of the observation period which was 6 months after ART, there was a significant decrease in the percentage of CD8/38 T cells which reached ± 11.05% (p <0.0001). Conclusion: The percentage of CD8/38 T cells pre and post ART differed significantly. The percentage of CD8/38 T cells examination may be useful in monitoring ART responses, especially in the first year of antiretroviral therapy. Keywords: HIV, percentage of CD8/38 T cells, immune activation, ART 1

4 BACKGROUND Human immunodeficiency virus (HIV) infection is still a major public health problem in the world. Report from acquired immune deficiency syndrome (AIDS) epidemic, number of people living with HIV/AIDS (PLWHA) in the world reached 36.9 million (34.3 to 41.4 million) in 2014, with 34.3 million of them were adult. Access to antiretroviral therapy (ART) has been increasingly widespread, with 12.9 million people receive ART in the world in In Indonesia until September 2014, the cumulative number of HIV/AIDS cases was , with of them had died. Special Region of Yogyakarta with the AIDS cases prevalence amounted to cases per was the province with the 8 th highest prevalence in Indonesia. 2,3 CD8/38 T cells roles in the pathogenesis of HIV is still unclear. CD38 is a transmembrane glycoprotein molecules, single chain expressed by a variety of cells and at different stages of maturation or differentiation. In CD8 T-cells, in has been shown that the CD38 subpopulation is in the pre G0-G1 phases, suggestive of preapoptotic state, but other study showed that the expression of CD38 protects HIV-infected cells from apoptosis. 4,5 CD8 T cells that express CD38 also has polyfunctional profile defined by the capacity to secrete multiple cytokines and chemokines to control viral replication in chronic HIV infection. 6 The three main pathogenic events of HIV infection are CD4 T cells depletion, immune activation and immune exhaustion. In untreated HIV patients, there is an increased expression of activation markers on almost all immune cells particularly CD38 surface marker expression on T cells. ART led to VL decreased and followed by immune reconstitution gradually. Changes in the immune and viral dynamics during therapy led to a decreased immune activation. 7,8 Examination of CD8/38 T cells may be useful for ART monitoring especially in the first year. On one hand, this test for relentlessly decreasing CD8/38 T cells is informative to demonstrate a continued improvement with meager if any CD4 count gains. On the other hand, CD38 reactivation seems to detect early signs of noncompliance ( nonadherence ) 2

5 and/or developing drug resistance. 9 CD38 expression on CD8 T cells continues to decline but did not reach the normal values despite undetectable VL on successful ART indicates the role of CD38 as a marker of residual HIV replication. 10,11 Aims of this study was to know is there any significant different of CD8/38 T cells percentages between pre and 6 months post ART in HIV infected patients. METHODS This was a prospective longitudinal study with quasi-experimental without control design (One-Group Pretest-Posttest Design). Subjects of this study were newly diagnosed HIV-infected adult patients who had not received ART before and were treated at the clinic of Edelweis dr. Sardjito general hospital and clinics of Tropical Infectious Diseases dr. Kariadi general hospital. Inclusion criteria were adult HIV infected patients, male or female, with or without co-infection, understood and signed the informed consent form. The exclusion criteria were Abs CD4 T cells <50 cells/ul, didn t get or refuse to undergo ART, didn t comply ART and incomplete data. Patients who came to the clinic for pra ART consultation were offered to join this study by the research assistant. The clinical research form (CRF) was filled by the clinicians who treated the patients. The CRF consisted of identity, risk factor, clinical stadium, ARV regimen, and laboratory test results. Whole blood was collected by venipuncture in vacutainer tubes containing EDTA (ethylene diamine tetraacetic acid). The complete blood count were determined with automatic hematology analyzer. The absolute numbers of CD4 T cells and percentages of CD8/38 T cells were determined using BD FACSCalibur with monoclonal antibody CD3FITC/CD4PE/CD45PerCP and CD8FITC/CD38PE/CD45PerCP, respectively. Viral load were measured using COBAS AmpliPrep/COBAS TaqMan HIV-1 Test, version 2.0 (TaqMan 48), manufactured by Roche Molecular Systems, Inc., with low detection limit was 20 copies/ml. The data were collected serially, before ART initiation (Pre ART), and 6 months after (Post ART). 3

6 Gating strategy for CD8/38 T cells percentage analysis (Fig. 1). a) Cells gating was based on forward scatter (FSC) and side scatter (SSC) with leucocytes were at R1. b) Lymphocytes gating was based on CD45PerCP and SSC with lymphocytes was at R2. c) CD8 T cells gating was based on CD38PE and CD8FITC with CD8 T cells were at R3. d) CD8/38 T cells gating was from R3 with CD8/38 T cells were at M1. We used a CD38 side-scatter dot plot in healthy controls to select the monocyte population as a positive control for CD8 T cells that strongly expressed CD38. The gate was set between the CD38-bright monocytes and CD38- positive granulocytes. Figure 1. Gating strategy for CD8/38 T cells percentage analysis. The number of adult patients who are recently diagnosed with HIV who had successfully recruited were 80 patients. Patients with Abs CD4 T cells <50 cells/ul were 8 and patients that had never undergone HAART were 2. Thus the total number of patients that were monitored of its response toward the therapy were 70. Within 6 months of monitoring, 22 patients were not compliant with the drug 4

7 regimen which resulted in the decrease number of patients with a total of 48 remaining patients by the end of the 6th month post-haart. Three blood samples could not be analyzed, making the total number of subjects that could be analyzed were 45 subjects (Fig 2). Figure 2. Research subject recruitment flowchart. This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethical Committee of Faculty of Medicine, Gadjah Mada University, and was granted permission by the Director of Dr. Sardjito hospital, Yogyakarta and Dr. Kariadi hospital, Semarang. Data collected were checked for authenticity and accuracy, then were coded, tabulated and entered into the computer. For continuous data, data were presented in mean ± SD if the data distribution were normal or median (min-max) if the data distribution were abnormal, while for categorical data were presented in frequency and proportion. Statistical analysis was done using paired t test. RESULTS AND DISCUSSIONS Total subjects who meet the inclusion and exclusion criteria in this study were 45 people with mostly were men 39 (86.7%) with median age was 28 years 5

8 old. Risk factors for HIV infection mostly were homosexuals 30 (66.7%). Most of the study subjects were still in clinical stage 1 and 2 which were 24 (53.3%) and 16 (35.6%) respectively. Data presented in table 1. Table 1. Baseline characteristic of the study subjects. Variables n % Mean ± SD* Med (Min-Max)** Ages (years) 28 (19-51) Sex Male 39 86,7 Female 6 13,3 Routes of transmissions Heterosexual 17 37,8 Homosexual 30 66,7 IDU s 4 8,9 Clinical stadium , , , *Normally distributed data; **Abnormally distributed data HIV transmission patterns based of this study was consistent with Ministry of Health, 2014 reports that HIV infection was most prevalent in the productive age group of years old followed by years old age group and mostly were men. 2 Transmission patterns based on risk factors in this study mostly were homosexual in contrast from Ministry of Health, 2014 reports which the pattern of transmission based on the risk factors mostly were heterosexual, but similar with results study conducted in 10 countries including Canada, Australia and countries in Europe where the pattern of transmission based on risk factors were homosexuals (71.9%). 12 Almost of the study subjects were in clinical stage 1 and 2. It was due to the recruitment procedures which were from outpatient clinic so almost of all the study subjects were in good condition. There are three main types of immunovirologic responders in clinical practice: concordant responders (40-60%), concordant non-responders ( %), 6

9 and discordant responders that include lack of CD4 increases despite viral suppression (7-48%), and optimal CD4 responses in the absence of viral suppression (5-23.8%). 13 We found an increase of abs CD4 T cells that was in line with viral load reduction as well as the percentage of CD8/38 T cells post ART which indicates the successful of ARV therapy in study subjects generally (Table 2). Table 2. Laboratory characteristic pre and post ART Tests Pre ART Mean ± SD* Med (Min-Max)** Post ART Mean ± SB* Med (Min-Max)** Abs CD4 T cells (cells/ul) 288 ± ± 152 Viral load (copies/ml) ( ) 27 ( ) CD8/38 T cells (%) 45,3 ± 15,63 30,76 ± 11,18 *Normally distributed data; **Abnormally distributed data The successful of ARV therapy depends not only on the efficacy of antiretroviral therapy in reducing VL but also in the ability of the immune system to recover and control the residual viral. Markers that can identify the function of immune cells might be able to add value in monitoring therapy. 4 In this study, the mean percentage of CD8/38 T cells pre ART was 45.3 ± 15.63%. There was a significant decreased that reached ± 11.05% at the end of the observation period. This result are in agreement with Jiao et al., 2011 that demonstrated the median percentage of CD8/38 T cells pre ART was more than 80%, and declined gradually up to 73.77% at week 12 of ART. 14 7

10 Figure 3. Percentage of CD8/38 T cells pre and post ART. The reduction in T-cell activation seen after HAART is a well-documented phenomenon, although there is controversy about the extent of this reduction and whether normalization is achievable. We found, although the percentage of CD8/38 T cells post ARV therapy declined but the level was still higher than in healthy subjects which was 7.49 ± 3.97 (3-19). The percentage of CD8/38 T cells in healthy subjects we used was based on study conducted in Thailand. The aim of this study was to determine the reference range of CD38 on South-East Asia population particularly Thailand. 15,16 We postulate that residual low-level HIV replication may account for our findings, and previous reports have demonstrated low levels of HIV replication in patients with long-term undetectable plasma viremia on ART. Other than that, the persistently high of immune activation may be due to co-infection by other viruses such as cytomegalovirus and Epstein-Barr virus and the consequences of the mucosal immune dysfunction due to CD4 T cells depletion in the acute phase and intestinal bacterial translocation into systemic circulation. 17,10 This study limitations were almost all of subject were in good clinical condition so limit the generalizability and the relatively short observation period. We also didn t analyze the effect of other drugs and type of ARV regimens on immune activation so the effects of other therapies and type of ARV regimens on 8

11 this results could not be ruled out. Activation was significantly increased in CD8 T cells of untreated patients. The increase was mainly caused by the CD45RO subset, because the level of CD38 in CD45RO cells was only slightly elevated in CD8 cells. Thus, when comparing the level of CD38 on CD45RO cells of patients with that in HIV-negative controls, the increase was occasionally as high as 20-fold. This finding highlights the importance of measuring CD38 selectively on CD45RO cells. 10 CONCLUSION The percentage of CD8/38 T cells post-therapy ARV declined significantly. The percentage of CD8/38 T cells test may be useful in monitoring the ART responses, especially in the first semester of ART. REFFERENCES 1. WHO. HIV Reporting: Global update on The Health Sector Response to HIV. Geneva: WHO Press; Ditjen PP & PL Kemenkes RI. Statistik Kasus HIV/AIDS di Indonesia. Jakarta; Komisi Penanggulangan AIDS DI. Yogyakarta. Data Kasus HIV & AIDS DIY. DI. Yogyakarta; Froebel KS, Raab GM, D Alessandro C, Armitage MP, Mackenzie KM, Struthers M, et al. A single measurement of CD38CD8 cells in HIV+, longterm surviving injecting drug users distinguishes those who will progress to AIDS from those who will remain stable. Clinical and Experimental Immunology. 2000;122(1): Sandoval-montes C, Santos-argumedo L. CD38 is expressed selectively during the activation of a subset of mature T cells with reduced proliferation but improved potential to produce cytokines membrane glycoprotein expressed by hematopoi-. Journal of Leukocyte Biology. 2005;77(April). 6. Streeck H, Brumme ZL, Anastario M, Cohen KW, Jolin JS, Meier A, et al. Antigen load and viral sequence diversification determine the functional profile of HIV-1-specific CD8+ T cells. PLoS Medicine. 2008;5(5): Lawn SD, Butera ST, Folks TM. Contribution of Immune Activation to the Pathogenesis and Transmission of Human Immunodeficiency Virus Type 1 Infection. Clinical Microbiology Reviews. 2001;14(4):

12 8. Ramana K V. Effect of Highly Active Antiretroviral Therapy ( HAART ) on Human Immunodeficiency Virus Disease Pathogenesis and Progression. American Journal of Public Health Research. 2014;2(3): Glencross DK, Janossy G, Coetzee LM, Lawrie D, Scott LE, Sanne I, et al. CD8/CD38 activation yields important clinical information of effective antiretroviral therapy: findings from the first year of the CIPRA-SA cohort. Cytometry Part B (Clinical cytometry) Jan;74B(Suppl. 1):S Benito JM, López M, Lozano S, Ballesteros C, Martinez P, González-Lahoz J, et al. Differential upregulation of CD38 on different T-cell subsets may influence the ability to reconstitute CD4+ T cells under successful highly active antiretroviral therapy. Journal of acquired immune deficiency syndromes. 2005;38(4): Almeida M, Cordero M, Almeida J, Orfao A. Relationship Between CD38 Expression on Peripheral Blood T-Cells and Monocytes, and Response to Antiretroviral Therapy : A One-Year Longitudinal Study of a Cohort of Chronically Infected ART-Naive HIV-1 1 Patients. Cytometry Part B (Clinical Cytometry). 2007;72B: Hoen B, Cooper D a, Lampe FC, Perrin L, Clumeck N, Phillips AN, et al. Predictors of virological outcome and safety in primary HIV type 1-infected patients initiating quadruple antiretroviral therapy: QUEST GW PROB3005. Clinical infectious diseases Aug 1;45(3): Misgena DK. The pattern of immunologic and virologic responses to Highly Active Antiretroviral Treatment ( HAART ) : Does success bring further challenges? Ethiop J Health Dev. 2009;25(11). 14. Jiao Y, Hua W, Zhang T, Zhang Y, Ji Y, Zhang H, et al. Characteristics of CD8+ T cell subsets in Chinese patients with chronic HIV infection during initial ART. AIDS research and therapy. BioMed Central Ltd; 2011;8(1): Sukwit S, Chuenchitra T. Distribution of CD38 Molecules on CD3 + and CD8 + T- lymphocyte in Adulthood HIV-1-uninfected Thais. J med Assoc Thai. 2005;88(5): Maartens G, Celum C, Lewin SR. HIV infection: Epidemiology, pathogenesis, treatment, and prevention. The Lancet. Elsevier Ltd; 2014;384(9939): Hattab S, Guihot A, Guiguet M, Fourati S, Carcelain G, Caby F, et al. Comparative impact of antiretroviral drugs on markers of inflammation and immune activation during the first two years of effective therapy for HIV-1 infection : an observational study. BMC infectious diseases. 2014;14(122):