Inflammation biomarkers in HIV infection Laurence WEISS
Feb 23, 2016
Inflammation biomarkers in HIV infection
Laurence WEISS
Predictive biomarkers in HIV infection
1. Reflect• The extent of immune deficiency• The level of HIV replication and of HIV reservoir• The level of chronic immune activation/inflammation• The strength and quality of HIV-specific immune responses
2. Type of biomarkers• Virologic, immunologic, activation/inflammatory and genetic
biomarkers (HLA, CCR5, KIR)• Predictive biomarkers for HIV progression in untreated and/or treated
patients• Predictive biomarkers for the occurrence of co morbidities in patients
with ART-mediated viral suppression
Predictive biomarkers in HIV infection
1. Reflect• The extent of immune deficiency• The level of HIV replication and of HIV reservoir• The level of chronic immune activation/inflammation• The strength and quality of HIV-specific immune responses
2. Type of biomarkers• Virologic, immunologic, activation/inflammatory and genetic
biomarkers (HLA, CCR5, KIR)• Surrogate markers for HIV progression in untreated and/or treated
patients• Surrogate markers for the occurrence of co morbidities in patients with
ART-mediated viral suppression
- Membrane expression of the activation markersHLA-DR (MHC class II), CD38, CD25, CD70- Intranuclear expression of Ki-67 (cell cycle)
T-cell activation markers in the chronic phase of HIV infection
Giorgi, JID 99Leng et al, J.AIDS 2001Hazenberg et al, AIDS 2003
HLA-DR
CD38
CD4
CD8
Healthy donor Survival > 18 M Survival < 6 M
T-cell activation is associated with mortality
PROINFLAMMATORY CYTOKINE NETWORK
COAGULATIONTISSUEFACTOR D-dimer
T-cell activation sCD14
sCD163
Innate immunityMono/M,DC,
NK cell activation
Adaptative immunity
INFLAMMATION
PROINFLAMMATORY CYTOKINE NETWORK
COAGULATIONTISSUEFACTOR
1 2 3 4 5 60
IL-6 C-Reactive Protein
Haptoglobin
a1-glycoprotein acid
D-dimer
APP
HIVOther viruses (CMV, HCV...)Bacterial products (LPS…)
T-cell activation sCD14
sCD163
InnateImmunity
Inflammation
PROINFLAMMATORY CYTOKINE NETWORK
COAGULATIONTISSUEFACTOR D-dimer
T-cell activation sCD14
sCD163
Innate immunityMono/M,DC,
NK cell activation
Adaptative immunity
INFLAMMATION
PROINFLAMMATORY CYTOKINE NETWORK
COAGULATIONTISSUEFACTOR
1 2 3 4 5 60
IL-6 C-Reactive Protein
Haptoglobin
a1-glycoprotein acid
D-dimer
APP
HIVOther viruses (CMV, HCV...)Bacterial products (LPS…)
T-cell activation sCD14
sCD163
sCD14
sCD163…
T-cell activation
Soluble activation biomarkers
– β2- microglobulin, neopterin– hsCRP: acute phase protein– IL-6, IL-1RA, sTNFR: Cytokines and CR of innate immunity– D dimer: marker of procoagulant activity– sCD14: acute phase protein, monocyte activation– sCD163: secreted by activated monocytes/macrophages– ICAM, VCAM: endothelial activation/dysfunction– IP-10: chimiokine produced in response to IFN
Fahey, NEJM 1990, Kuller, PloS Med 2008, Sandler, JID 2011, Burdo, JID 2011
Predictive biomarkers in primary HIV infection
Deeks, Blood 2004
Immune activation set point during early HIV infection: predictive of subsequent CD4 T-cell changes independently
of viral load
CD38-MFIon CD8 T
cells
Time (weeks)
prop
ortio
n w
ith C
D4
> 35
0
Time to a CD4 T-cell count less than 350 cells/mm3
68 recently HIV-infected adults before ART
CD8 T-cell activation set point
The early level of double negative CD4-CD8- T cells predicts the level of T-cell activation at set point
R= -0.76p= 0.004
R= -0.60p= 0.035
Petitjean, Chevalier et al, AIDS 2012
DN T cells might play a role in the control of the harmful systemic immune activation
DN T cells produce anti-inflammatory cytokines
Baseline M6
plas
ma
IL-1
RA
(log
pg/m
L)
IL-1RA
An innate immune setpoint ?
plasma sCD14 at baseline(ng/mL)
plasma IL-1RA at baseline(log pg/mL)
% C
D38
+ HLA
-DR
+
CD
8 T
cells
at M
6
% C
D38
+ HLA
-DR
+
CD
8 T
cells
at M
6
% C
D38
+ HLA
-DR
+
CD
8 T
cells
at M
6
log Th17/Treg ratio at baseline
Acute HIVbaseline
Acute HIVM6
Chronic HIV
(untreated)
Sepsis(S. aureus)
n=27 n=25 n=20 n=10
plas
ma
16S
rDN
A(c
opie
s/µL
)
Chevalier, Plos Path 2013
Innate immune activation set point
plas
ma
sCD
14(n
g/m
L)Baseline M6
sCD14
Predictive biomarkers in untreated chronic infection
T-cell activation, predictive marker of AIDS progression independent of VL
Proportion of CD70+CD4+ T cells > median (—) < median (- - -)
Giorgi, JAIDS 1998Hatzenberg , AIDS 2003
Relationship between T-cell activation and HIV reservoir
• The proportion of HLA-DR+ CD38+/ CD8+ T cells before TI predicts the increase in total HIV-DNA levels between baseline and M12 of TI (ANRS 116 SALTO) (r= 0.552; p = 0.004)
Weiss, PlosOne 2010
• Positive relationship between total HIV-DNA and CD8 and CD4 T-cell activation at 12 months of TI
See poster Weiss et al MOPDA0106
Predictive values of soluble biomarkers in cohort studiesC Reactive Protein Level: associated with AIDS - free survival
Multivariate modelVariable Relative Time
(95% CI)P Value
CRP, mg/L <1.2 1.3-2.3 >2.3
1.00.86 (0.68-1.09)0.63 (0.51-0.79)
0.21<0.001
CD4+ cell count 1.12 (1.08-1.16) <0.001HIV RNA (log10) 0.34 (0.29-0.39) <0.001
Hemoglobin (g/dL) 1.14 (1.06-1.23) <0.001
Lau, Arch Intern Med 2006
N= 513 patients randomly selected from the MACS populationMedian CD4: 532 (IQR 342;721)Median HIV-RNA: 18450 (IQR 5359; 63741)62% AIDS event2709 person-years of follow-up
Fibrinogen and CRP, independent predictors of mortality in the FRAM study
Tien, JAIDS 2010
• 922 HIV-infectedparticipants > 85% on cART (past or present)• 70% with history of AIDS• 50% HIV-RNA BLD• 20% HCV+• 5-year mortality risk
Biomarker levels associated with progression in RCT
• All-cause mortality: higher for patients with CD4> 350 randomly assigned to CD4-guided interruption of ART (DC) than continuous ART (VS)
• Most common causes of death: non AIDS-malignancy, CVD• Case control study (85 cases and 170 matched controls); a study to compare DC and
VS participants for biomarker changes (249 DC and 250 VS)• Baseline IL-6, hsCRP and D-dimer associated with all cause mortality• Higher BL IL-6, D-dimer and hsCRP: related to CVD• IL-6 and D-dimer ↗ at 1 mo in the DC group. Increases related to HIV-RNA levels• BL or latest IL-6 or hsCRP: predictive of OI
• Elevated pre-ART levels of hsCRP, IL-6 and D-dimer: strongly associated with early mortality after ART initiation Ledwaba, PlosOne 2012
• Other markers associated with disease progression (case control ACTG 384 and 5015) : sTNFR-1, sCD27 and sCD40L Kalayjian, JID 2010
Kuller Plos Medicine 2008Rodger JID 2008Duprez PlosOne 2012
SMART
PHIDISA (South Africa trial)
IP10 and sCD163 levels predict subsequent CD4 counts
Predictive inflammatory biomarkers in HIV controllers
Lambotte, IAS 2014, MoAA0102
Predictive biomarkers in patients with chronic infection and ART-mediated
viral suppression
Residual immune activation and inflammation under ART
Hunt, JID, 2003Hunt, JID 2008
Persistence of residual chronic T-cell activation in ART-treated patients
n = 30 HIV+ with CV < 75 c/mL
Despite long-term viral suppression, soluble inflammatory biomarkers remain higher in patients compared to the
general population
0
25
50
75
100
125
150
175
200
IL-6 D-dimer Cystatin-C
UnadjustedAdjusted for age, gender, raceFully adjusted
UnadjustedAdjusted for age, gender, raceFully adjusted
hsCRP
% D
iff. f
rom
Gen
eral
Pop
ulat
ion
(MES
A)
Neuhaus JID 2010
Inflammationwith ongoing
viral replicationInflammation
under ARTInflammationHIV- controls
Monocytes pDCs Innate
ImmunityNK
Adaptativeimmunity
• Nested case-control study in SMART• 74 deaths + 120 CV events + 100 AIDS events (20 NA) / N= 5472• 2 controls/case• Most patients under ART with VL < 400 cp/mL• Baseline plasma sCD14, IFABP, LPS, EndoCAB
SCD14: marker of monocyte activation (acute phase protein) not necessarily indicative of microbial
translocation
Sandler, JID 2011
Plasma levels of sCD14: independent predictor of mortality in the SMART study
Can we improve prediction of mortality by adding inflammatory biomarkers?
• Veterans Aging Cohort Study: 1 302 veterans under ART; 70% with VL <500 c/mL; 154 deaths
• RI= age/CD4/VL• VACS index= RI + Hb/ FIB4 index age, transa, platelets
/HCV/eGFR: better prediction of mortality than any biomarker or than RI (p< 0.001)
• VACS+ inflammatory biomarkers (IL-6, D-dimer, sCD14)
Justice CID 2012
Cardio-VascularDiseases
Cognitive disorders
Inflammation
CANCER
CHRONIC VIRAL
INFECTIONS(HIV)
Osteoporosis
Cardiovascular comorbiditiesIn HIV infection : Alteration in biomarkers known or potentially associated with CVD in non-HIV
infected individuals• HDL cholesterol depletion• Chronic inflammation
( CRP, IL-6, sCD14)• Endothelial activation/dysfunction
( VCAM, ICAM)• Activation of coagulation
( D-dimer)
Only partially normalized during sucessfull ART
Atherosclerotic plaque
Association of soluble CD163 with arterial inflammation
Hypothesis: Arterial inflammation
- > HIV+ pts compared with non-HIV FRS-matched controls
- Correlated to mono/Mф activation (CD163)
• 81 participants. 27 HIV pts under ART (CD4 nadir 100)
• FDG-PET (activated Mф : high metabolic rate)
Variables HIV+ (N= 27) FRS-matched HIV- (N= 27)
HIV- atheroscl (N= 27)
P value
Mean FDG uptake (95% CI)
2.23 (2.07-2.40) 1.89 (1.80-1.97) 2.13 (2.03-2.23) <0.001
CAC score median (IQR)
24.4 (0.92-6) 0 (0-4.8) [N= 24] 425.2 (88.8-1234) [N= 16]
< 0.001
Subramanian JAMA 2012
Lack of association between aortic FDG uptake and CRP or D-dimer in the HIV+ population
FDG
upta
ke
Soluble markers of inflammation & coagulation, but not T-Cell activation, predict non-AIDS defining events during
suppressive ART
• Case-control study of ALLRT subjects (ACTG studies) (ART-naïve at BL and ART-suppressed during FU)
• Cases : non-AIDS death, MI, stroke, non-AIDS cancer, or serious non-AIDS bacterial infection
• Controls (2 - 3/case)
• Greater CD4 change at yr 1 associated with a decreased risk for non-AIDS event (OR per 100 cells increase= 0.81, p= 0.007)
• High T-cell activation: not consistently associated with a non-AIDS-related event
• Higher IL-6,sCD14, sTNFR-I, sTNFR-II, and D-dimer prior to ART independently associated with non AIDS events
Tenorio CROI 2013
Soluble markers of inflammation & coagulation, but not T-Cell activation, predict non-AIDS defining events during
suppressive ART• Case-control study of ALLRT subjects
(ACTG studies) (ART-naïve at BL and ART-suppressed during FU)
• Cases : non-accidental non-AIDS death, MI, stroke, non-AIDS cancer, or serious non-AIDS bacterial infection
• Controls (2 - 3/case)
• Greater CD4 change at yr 1 associated with a decreased risk of non-AIDS event (OR per 100 cells increase= 0.81, p= 0.007)
• High T-cell activation: not consistently associated with a non-AIDS-related event
• Higher IL-6,sCD14, sTNFR-I, sTNFR-II, and D-dimer prior to ART independently associated with non AIDS event
Tenorio CROI 2013
Suboptimal CD4 T-cell gains
Immune senescence
Comorbidities (Accelerated atherosclerosis, arterial inflammation, cognitive
disorders, chronic renal disease, osteoporosis: « Inflam-Aging » , cancers)
↗ Risk of mortality
Persistent Inflammation
under ART CRP, IL-6, IL-1RA, sCD14, sTNFR
D-dimer Fg
Summary
• Levels of immune activation (T-cell activation and inflammation) predict HIV disease progression in untreated patients with primary and chronic infection
• Soluble biomarkers of inflammation and coagulation, but not T-cell activation, predict non-AIDS defining events during suppressive ART
Unresolved issues• Value of these biomarkers to improve CV risk prediction in the HIV-infected
population ?• Significance: just an association or role in pathogenesis ?• Help to identify cellular pathways important in the pathogenesis of HIV
disease • Interventions that target these pathways (e.g. IL-6) and/or the mechanisms
involved in low levels of chronic activation/inflammation (e. g. ongoing low-level viral replication, MT, coinfections..) are warranted (or already in progress) with the ultimate goal to decrease the incidence of non-AIDS related morbidity in HIV-infected patients on virally suppressive ART
All the patients included in the studies
Hôpital Européen G. PompidouChristophe PikettyMaria ManeaErika Bourzam
Hôpital Saint-AntoinePierre-Marie GirardPauline CampaNelly Desplanques
Hôpital TenonLaurence SlamaGilles Pialoux
CHU Carémeau NîmesJean-Philippe LavigneCatherine Dunyach
Mathieu ChevalierGaël PetitjeanCéline DidierDaniel Scott-AlgaraFrançoise Barré-Sinoussi
…and all the physicians that included patients
INSERM U 1018Laurence MeyerChristiane DeveauFeriel Tibaoui
Remerciements
U943Dominique CostagliolaLambert Assoumou
the ANRS 116 SALTO study groupEA 3620 Christine Rouzioux