Abstract
Children exposed to antiretroviral therapy (ART) are at risk of developing metabolic complications. The association between gene polymorphisms and the development of dyslipidemia in children post ART initiation was studied. Children initiating first-line ART were followed for 2 years at the National Institute for Research in Tuberculosis (Chennai, India), and St. John's Medical College Hospital (Bangalore, India). Clinical examination and fasting serum lipid profiles were measured every 6 months. Participants were genotyped for the polymorphisms in the APOC3 gene (rs2854116; rs2854117, and rs5128). Changes in lipid levels from baseline to months 6, 12, and 24, and the difference between the various genotype variants were analyzed using a modified analysis of variance test. Study enrolled 393 ART-naive HIV-infected children (mean age: 7.6 ± 3 years, mean weight: 18 ± 6) of whom 289 (75%) were started on nevirapine (NVP)-based ART and the remaining 96 (25%) were started on efavirenz-based ART. Only children carrying the GG allele of rs5128 genotype showed a decrease in CD4% and serum triglycerides pre-ART. An increasing trend of total cholesterol, high-density lipoprotein cholesterol (HDL-c), and low-density lipoprotein cholesterol were seen at 6 months in both EFZ and NVP groups, which subsequently stabilized by 12 months irrespective of genotype variants. Genotype variants of APOC3 (rs2854116 and rs2854117 polymorphism) did not show significant changes in serum lipid levels after 24 months of ART, whereas rs5128 polymorphism with “G” allele showed an association with HDL-c levels when on NVP-based ART. Our results suggest that ART plays a major role in normalizing lipid levels in HIV-infected children and APOC3 polymorphisms may not play a significant role in ART-induced dyslipidemia.
Keywords: gene polymorphism, antiretroviral therapy, dyslipidemia, APOC3, high-density cholesterol, prospective study
Introduction
Antiretroviral therapy (ART) not only increases the life expectancy of people living with HIV but may also be associated with a spectrum of metabolic disturbances leading to an increased risk of cardiovascular morbidity.1,2 Children initiating ART early in life are exposed to these drugs for a longer duration of time and are at higher risk of developing these metabolic complications in their lifetime.3,4 Dyslipidemia is one such complication, mostly presenting as hypertriglyceridemia and low levels of high-density lipoprotein cholesterol (HDL-c).3 However, not all children exposed to ART develop these complications. Susceptibility to developing these complications varies among individuals and could be influenced by genetic variability, triggered by diet and drugs like efavirenz or protease inhibitors.5
The apolipoprotein gene (APOC3) is a member of the APOA1/C3/A4/A5 gene cluster, located in chromosome 11 region 11q23.6 This gene is associated with plasma lipid homeostasis and acts as a noncompetitive inhibitor of lipoprotein lipase activity, playing an important role in triglyceride (TGL)-rich lipoprotein catabolism, transport and clearance of lipoprotein remnants from the bloodstream. Studies have shown an association between polymorphisms of the APOC3 gene and a predisposition to high TGL and low HDL-c levels in plasma.7–9 A cohort in France found that carriers of APOC3 variant alleles (−455 1/−482 1) displayed higher levels of TGL (3.72 vs. 2.57 mmol/L), and a lower fat mass (13.9% vs. 19.7%) than patients with nonvariant alleles (−455 0/−482 0),7 whereas another study showed that Hispanics on a protease inhibitor-based ART had a significantly smaller increase in TGL among patients with variant alleles at APOC3 (−482, −455, and Intron 1) when compared with patients with the wild-type genotypes.8 APOC3 gene variants are one of the regulators for TGL level changes in human metabolism, which as evident from above studies, may vary by race/ethnicity.
Many studies have suggested that APOC3 polymorphism of rs2854116; rs2854117, and rs5128 are closely linked with metabolic syndrome in adults, including Indians.10–13 Hence we selected these polymorphisms to look at their combined effect and to explore their association with HIV-infected children on ART in India. As HIV-associated dyslipidemia is accompanied by impaired lipolysis with increase in TGL and decreases in HDL-c, we hypothesized that in HIV-infected children the polymorphisms in the APOC3 gene could be an important factor contributing to the deleterious effect of ART-induced dyslipidemia. Hence, we aimed to study the effect of APOC3 polymorphism on dyslipidemia in HIV-infected children 24 months after initiation of a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based ART.
Materials and Methods
Study design and participants
We recruited children initiating first-line ART in the HIV-Associated Lipodystrophy Syndrome (HALS) study from 2010 through 2015 at the National Institute for Research in Tuberculosis (Chennai, India), and St. John's Medical College Hospital (Bangalore, India). The details of the HALS study are given elsewhere but in brief HALS study is a prospective cohort study that aimed to determine the incidence of lipodystrophy and dyslipidemia among HIV-infected children 2–12 years of age initiating first-line ART in southern India.14 The ART regimen consisted of two nucleoside reverse transcriptase inhibitors (NRTIs—lamivudine and stavudine/zidovudine) and an NNRTI [either nevirapine (NVP) or efavirenz in children >3 years]. Follow-up was done at 3, 6, 9, and 12 months after treatment initiation. No child was being treated with lipid-lowering drugs at the commencement of the study. The study was approved by the Institutional Ethics Committee of participating institutions. Informed written consent was obtained from the guardian and assent from the child, if applicable.
Clinical and laboratory measurements
Detailed clinical and physical examination of each child in the study was performed. Adherence to ART was monitored by pill count. Fasting serum glucose, total cholesterol, TGL, HDL-c, and low-density lipoprotein cholesterol (LDL-c) were measured once every 6 months using the autoanalyzer. CD4 percentage and absolute CD4+ T cell counts were measured using the FACSCount flow cytometer (Beckton Dickinson Biosciences, San Jose, CA) and plasma viral load was estimated using the Roche COBAS AmpliPrep/Cobas TaqMan HIV-1 Test, v2.0.
Genotyping
Genomic DNA was extracted from whole blood using the QIAamp DNA Blood Mini Kit (Qiagen, Hilden, Germany) and quantitated on Thermo Fisher's NanoDrop 2000 Spectrophotometer (NanoDrop Technologies, Inc., Wilmington, DE). Participants were genotyped for the polymorphisms in the APOC3 gene (rs2854116, rs2854117, and rs5128) using polymerase chain reaction followed by direct Sanger's chain termination sequencing assay in a 3100 Avant Genetic Analyzer (Applied Biosystems).
Statistical analysis
Data analysis was performed using SPSS software, version 19.0. All data are presented as mean (standard deviation), except where otherwise stated. Elevated plasma total cholesterol and TGL were defined as total cholesterol ≥200 mg/dL and TGL ≥150 mg/dL, and HDL-c < 40 mg/dL was taken as abnormal.15 We compared the continuous normally distributed data using Student's t-test and proportions by the chi-square test. The Hardy–Weinberg equilibrium for the expected and observed genotype frequencies for the three single nucleotide polymorphism (SNP) were tested with the chi-square test. The difference in baseline characteristics between the two treatment groups was assessed through the chi-square test for categorical variables. To assess whether changes in lipid levels at months 0, 6, and 12 were significantly different from baseline in NVP and efavirenz-based ART group and whether these changes were significantly different between the various genotype variant, a modified analysis of variance test was used. A p-value of <.05 was considered as statistically significant.
Results
Characteristics of participants
During 2010–2015, 393 ART-naive HIV-infected children were enrolled in the study and initiated on first-line ART at the study sites. The mean age of the cohort was 7.6 ± 3 years; mean CD4 percentage at the time of enrollment was 16% (range: 1%–54%); and median HIV-1 RNA at enrollment was 5.1 log10 copies/mL (range: 3.5–5.7 log10 copies/mL). Of the 393 participants, 289 (75%) of these children were started on NVP and 96 (25%) on efavirenz-based first-line ART along with lamivudine and stavudine or zidovudine. Eight children were on the triple nucleoside regimen in this cohort.
Effects of polymorphism on metabolic variables
Children were genotyped for the polymorphisms in the APOC3 gene and segregated according to genotype variants of rs2854116, rs2854117, and rs5128. The minor allele frequencies among our study population were 0.43 (T), 0.49 (C), and 0.37 (C), respectively for rs2854116, rs2854117, and rs5128 polymorphisms and the genotype distributions followed Hardy–Weinberg equilibrium. The demographic, clinical, and metabolic profile of the children based on rs2854116, rs2854117, and rs5128 polymorphism did not show any difference in their baseline parameters, except for a decrease in CD4% and serum TGL among those children carrying the GG allele of rs5128 genotype polymorphism. The baseline clinically relevant characteristics of the patients included in the study are summarized in Table 1.
Table 1.
Baseline Main Clinical and Demographic Characteristics of HIV-Infected Children Based on APOC3 Genotype
| Characteristics at study entry | Mean (SD) |
Mean (SD) |
Mean (SD) |
p |
|---|---|---|---|---|
| TT carriers (n = 67) | TC carriers (n = 184) | CC carriers (n = 122) | ||
| APOC3 (rs2854116) | ||||
| Age in years | 7.7 (3) | 7.7 (3) | 7.4 (3) | .67 |
| Weight in kg | 18.3 + 6 | 17.9 (6) | 18.2 (6) | .90 |
| BMI | 14. 2 (2) | 14.1 (2) | 14.3 (2) | .58 |
| CD4 cell count (cells/mm3) | 504.4 (495) | 541.8 (443) | 513.7 (419) | .78 |
| CD4 percentage | 14.3 (8) | 17.1 (8) | 16.1 (8) | .08 |
| Viral load (copies/mL) | 399,653.03 | 513,078.52 | 550,523.53 | .72 |
| Total cholesterol (mg/dL) | 132.3 (34) | 130.9 (33) | 129.4 (35) | .84 |
| Serum TGL (mg/dL) | 133.1 (61) | 149.7 (79) | 141.5 (77) | .27 |
| Serum HDL-c (mg/dL) | 28.4 (10) | 29.1 (11) | 29.1 (11) | .91 |
| Serum LDL-c (mg/dL) | 80.4 (28) | 78.2 (28) | 77.9 (29) | .82 |
| Blood glucose (mg/dL) | 83.2 (13) | 85.5 (12) | 85.8 (18) | .46 |
| C reactive protein |
3.4 (4) |
2.3 (3) |
2.3 (3) |
.06 |
| |
TT carriers (n = 97) |
TC carriers (n = 185) |
CC carriers (n = 91) |
|
| APOC3 (rs2854117) | ||||
| Age in years |
7.2 (3) |
7.7 (3) |
7.8 (3) |
.41 |
| Weight in kg |
18.0 (7) |
18.1 (6) |
18.2 (6) |
.95 |
| BMI |
14.4 (2) |
14.2 (2) |
14.1 (2) |
.46 |
| CD4 cell count (cells/mm3) |
537.5 (448) |
532.6 (436) |
504.4 (465) |
.81 |
| CD4 percentage |
16 (8) |
173 (9) |
14.7 (8) |
.04 |
| Viral load (copies/mL) |
524,350.54 |
529,640.72 |
431,997.21 |
.82 |
| Total cholesterol (mg/dL) |
128.5 (36) |
132.7 (34) |
129.4 (33) |
.54 |
| Serum TGL (mg/dL) |
140.7 (73) |
151.3 (81) |
132.7 (65) |
.14 |
| Serum HDL-c (mg/dL) |
28.9 (12) |
29.5 (11) |
28.1 (10) |
.53 |
| Serum LDL-c (mg/dL) |
78 (29) |
79.1 (29) |
78.3 (27) |
.93 |
| Blood glucose (mg/dL) |
86.6 (19) |
85.2 (12) |
83.5 (13) |
.40 |
| C reactive protein |
2.2 (3) |
2.3 (3) |
3.3 (4) |
.05 |
| |
GG carriers (n = 143) |
GC carriers (n = 177) |
CC carriers (n = 50) |
|
| APOC3 (rs5128) | ||||
| Age in years |
7.5 (3) |
7.7 (3) |
7.2 (3) |
.63 |
| Weight in kg |
18.2 (6) |
17.8 (6) |
17.9 (7) |
.89 |
| BMI |
14.3 (2) |
14.0 (2) |
14.6 (2) |
.08 |
| CD4 cell count (cells/mm3) |
513.4 (486) |
521.7 (396) |
638.1 (524) |
.21 |
| CD4 percentage |
14.8 (8) |
17.9 (9) |
16.4 (8) |
.01 |
| Viral load (copies/mL) |
622,090.56 |
459,912.52 |
333,397.66 |
.29 |
| Total cholesterol (mg/dL) |
128.7 (32) |
133.9 (37) |
126.9 (32) |
.27 |
| Serum TGL (mg/dL) |
133.6 (64) |
154.6 (83) |
142.2 (75) |
.04 |
| Serum HDL-c (mg/dL) |
27.6 (10) |
30.2 (12) |
28.8 (13) |
.12 |
| Serum LDL-c (mg/dL) |
78.2 (27) |
80.0 (29) |
73.8 (27) |
.38 |
| Blood glucose (mg/dL) |
83.3 (13) |
86.4 (16) |
86.4 (13) |
.14 |
| C reactive protein | 2.7 (4) | 2.2 (3) | 2.5 (3) | .42 |
BMI, body mass index; HDL-c, high-density lipoprotein cholesterol; LDL-c, low-density lipoprotein cholesterol; SD, standard deviation; TGL, triglycerides.
Effects of gene polymorphism and ART type on lipid profile, 12 months post ART
When compared with baseline values, there was a significant increase in total cholesterol, TGL, HDL-c, and LDL-c at 12 months post ART. However, no differences in the lipid profile were seen among children carrying different genotype variants of the rs2854116; rs2854117, or rs5128 SNPs of APOC3. However, in APOC3 (rs5128), a slight trend toward higher HDL-c was seen in individuals with the “G” allele (Table 2).
Table 2.
Changes in Serum Lipid Levels in HIV-Infected Children 12 Months After Initiation of Non-Nucleoside Reverse Transcriptase Inhibitor-Based Antiretroviral Therapy Based on APOC3 Genotype
| Variables | Baseline |
12 Months |
p |
Baseline |
12 Months |
p |
Baseline |
12 Months |
p |
p Value (between genotype) |
|---|---|---|---|---|---|---|---|---|---|---|
| TT (N = 58) | TC (N = 150) | CC (N = 101) | ||||||||
| APOC3 (rs2854116) | ||||||||||
| Weight | 18.3 (6.0) | 21.6 (6.9) | .00 | 18.4 (5.6) | 21.3 (6.4) | .00 | 18.5 (6.6) | 21.3 (7.2) | .00 | 1.00 |
| Total cholesterol (mg/dL) | 134.5 (32.4) | 163.1 (38.9) | .00 | 132.0 (33.7) | 161.2 (35.5) | .00 | 129.3 (36.3) | 164.2 (34.6) | .00 | 1.00 |
| TGL (mg/dL) | 135.0 (63.6) | 120.9 (79.7) | .18 | 145.5 (70.0) | 117.3 (72.5) | .00 | 135.4 (74.9) | 116.6 (58.2) | .02 | 1.00 |
| HDL-c (mg/dL) | 28.6 (10.2) | 49.4 (13.5) | .00 | 29.7 (10.7) | 49.4 (15.5) | .00 | 30.1 (11.3) | 48.1 (15.8) | .00 | 1.00 |
| LDL-c (mg/dL) |
80.3 (27.1) |
92.5 (30.0) |
.01 |
78.1 (27.3) |
90.0 (27.6) |
.00 |
77.3 (29.7) |
95.6 (29.5) |
.00 |
1.00 |
| |
TT (N = 79) |
TC (N = 152) |
CC (N = 78) |
|
||||||
| AP0C3 (rs2854117) | ||||||||||
| Weight |
18.5 (6.7) |
21.2 (7.3) |
.00 |
18.4 (5.7) |
21.4 (6.5) |
.00 |
18.4 (5.8) |
21.5 (6.7) |
.00 |
1.00 |
| Total cholesterol (mg/dL) |
127.5 (36.1) |
165.9 (35.3) |
.00 |
134.2 (24.5) |
162.4 (35.8) |
.00 |
130.7 (32.6) |
159.3 (36.2) |
.00 |
1.00 |
| HDL-c (mg/dL) |
29.8 (11.6) |
47.4 (16.2) |
.00 |
30.3 (10.8) |
49.6 (15.6) |
.00 |
28.1 (9.9) |
48.6 (13.8) |
.00 |
1.00 |
| TGL (mg/dL) |
136.9 (74.1) |
121.5 (60.3) |
.07 |
144.2 (70.4) |
118.1 (71.8) |
.001 |
135.5 (67.4) |
112.1 (73.7) |
.02 |
1.00 |
| LDL-c (mg/dL) |
76.6 (29.8) |
97.5 (30.1) |
.00 |
79.3 (28.1) |
90.5 (28.4) |
.00 |
77.9 (25.9) |
60.3 (27.5) |
.001 |
1.00 |
| |
GG (N = 120) |
GC (N = 144) |
CC (N = 41) |
|
||||||
| AP0C3 (rs5128) | ||||||||||
| Weight |
18.5 (6.3) |
21.4 (7.1) |
.00 |
18.2 (5.4) |
21.3 (6.2) |
.00 |
17.9 (6.6) |
20.6 (7.2) |
.00 |
1.00 |
| Total cholesterol (mg/dL) |
129.5 (32.4) |
160.2 (35.4) |
.00 |
135.9 (36.9) |
165.6 (37.2) |
.00 |
125.5 (33.6) |
162.1 (33.7) |
.00 |
.16 |
| HDL-c (mg/dL) |
27.5 (9.5) |
48.1 (15.0) |
.00 |
31.6 (11.4) |
49.8 (14.9) |
.00 |
29.6 (12.4) |
46.5 (17.5) |
.00 |
.06 |
| TGL (mg/dL) |
134.3 (64.6) |
119.1 (83.3) |
.08 |
148.3 (76.5) |
118.7 (63.6) |
.00 |
134.3 (66.3) |
115.9 (41.8) |
.07 |
.52 |
| LDL-c (mg/dL) | 78.3 (26.6) | 90.8 (28.9) | .00 | 80.5 (29.1) | 94.2 (30.3) | .00 | 70.9 (26.8) | 93.0 (23.9) | .00 | .37 |
Looking at the effect of type of ART with respect to genotype variants, an increasing trend of total cholesterol, HDL-c, and LDL-c was seen at 6 months in both EFZ and NVP group, which subsequently stabilized by 12 months irrespective of genotype variants (Figs. 1–3).
FIG. 1.
(a) Changes in lipid profile in HIV-infected children 12 months after initiation of Efavirenz-based ART based on APOC3 (rs2854116) genotype. (b) Changes in lipid profile in HIV-infected children 12 months after initiation of Nevirapine-based ART based on APOC3 (rs2854116) genotype. ART, antiretroviral therapy.
FIG. 2.
(a) Changes in lipid profile in HIV-infected children 12 months after initiation of Efavirenz-based ART based on APOC3 (rs2854117) genotype. (b) Changes in lipid profile in HIV-infected children 12 months after initiation of Nevirapine-based ART based on APOC3 (rs2854117) genotype.
FIG. 3.
(a) Changes in lipid in HIV-infected children12 months after initiation of Efavirenz-based ART based on APOC3 (rs5128) genotype. (b) Changes in lipid in HIV-infected children12 months after initiation of Nevirapine-based ART based on APOC3 (rs5128) genotype.
Effects of gene polymorphism on lipid profile, 24 months post ART
In a subgroup of this cohort, the mean lipid levels between baseline and 24 months post ART were compared, which showed an increase in total cholesterol, HDL-c, and LDL-c, and a decline in TGL from baseline, irrespective of NNRTI type in the treatment regimen (Table 3). Genotype variants of APOC3 (rs2854116 and rs2854117 polymorphism) did not show statistically significant changes in serum lipid levels after 24 months of ART, whereas the presence of the “G” allele in APOC3 rs5128 polymorphism showed a significant increase in plasma HDL-c levels after 24 months of NVP-based ART (Table 3).
Table 3.
Changes in Serum Lipid Levels in HIV-Infected Children 24 Months After Initiation of Non-Nucleoside Reverse Transcriptase Inhibitor-Based Antiretroviral Therapy Based on APOC3 Genotype
| Allele | Baseline |
24 Months |
p Value (time) |
p Value (genotype) |
Baseline |
24 Months |
p Value (time) |
p Value (genotype) |
|
|---|---|---|---|---|---|---|---|---|---|
| EFZ (n = 45) | EFZ (n = 45) | ||||||||
| AP0C3 (rs2854116) | |||||||||
| Total cholesterol (mg/dL) | CC | 141.2 (35.0) | 160.4 (34.0) | .03 | .943 | 132.2 (35.8) | 163.7 (34.4) | .000 | .608 |
| TC | 137.6 (25.8) | 162.5 (19.5) | .000 | 129.9 (34.9) | 158.2 (35.6) | .000 | |||
| TT | 144.6 (18.0) | 165.7 (21.1) | .38 | 129.5 (32.5) | 155.3 (30.7) | .000 | |||
| HDL-c (mg/dL) | CC | 31.3 (12.9) | 45.8 (11.8) | .000 | .48 | 30.2 (11.0) | 49.7 (13.6) | .000 | .28 |
| TC | 33.6 (6.9) | 50.3 (12.3) | .000 | 29.6 (11.3) | 52.5 (15.6) | .000 | |||
| TT | 37.6 (5.5) | 40.6 (2.1) | .43 | 29.1 (10.8) | 46.6 (15.1) | .000 | |||
| TGL (mg/dL) | CC | 121.1 (46.8) | 104.8 (44.1) | .20 | .72 | 144.3 (86.2) | 111.0 (66.1) | .01 | .73 |
| TC | 126.1 (59.1) | 87.8 (42.6) | .02 | 143.9 (70.5) | 104.9 (57.4) | .000 | |||
| TT | 109.0 (49.9) | 84.6 (24.0) | .57 | 126 (56.4) | 110.2 (51.7) | .24 | |||
| LDL-c (mg/dL) | CC | 88.0 (32.4) | 95.6 (27.1) | .35 | .58 | 77.1 (29.0) | 93.1 (26.9) | .000 | .49 |
| TC | 78.9 (22.3) | 94.3 (17.8) | .004 | 74.9 (28.4) | 85.9 (25.3) | .001 | |||
| TT |
85.0 (12.1) |
108.0 (23.6) |
.31 |
75.5 (27.3) |
87.7 (24.4) |
.24 |
|||
| |
EFZ (n = 45) |
NVP (n = 169) |
|||||||
| AP0C3-(rs2854116) | |||||||||
| Total cholesterol (mg/dL) |
CC |
140.1 (24.7) |
166.3 (17.9) |
.04 |
.96 |
126.3 (32.5) |
154.1 (28.3) |
.000 |
.38 |
| TC |
138.6 (20.1) |
161.7 (18.4) |
.000 |
131.7 (35.5) |
160.1 (37.9) |
.000 |
|||
| TT |
141.0 (36.6) |
159.7 (37.9) |
.06 |
132.7 (35.1) |
163.8 (32.3) |
.000 |
|||
| HDL-c (mg/dL) |
CC |
36.1 (7.6) |
49.0 (8.5) |
.02 |
.062 |
27.4 (10.4) |
47.2 (14.3) |
.000 |
.07 |
| TC |
32.8 (6.2) |
48.5 (13.0) |
.000 |
30.5 (11.2) |
52.5 (15.6) |
.000 |
|||
| TT |
31.4 (14.5) |
45.7 (12.0) |
.003 |
30.5 (11.4) |
49.6 (13.7) |
.000 |
|||
| TGL (mg/dL) |
CC |
108.4 (48.9) |
84.4 (28.2) |
.24 |
.27 |
131.4 (66.2) |
108.3 (54.9) |
.04 |
.81 |
| TC |
124.2 (56.8) |
85.9 (41.7) |
.02 |
145.0 (74.9) |
106.5 (57.7) |
.000 |
|||
| TT |
127.0 (49.6) |
112.5 (45.1) |
.36 |
141.9 (80.0) |
110.6 (67.3) |
.02 |
|||
| LDL-c (mg/dL) |
CC |
82.0 (20.0) |
110.4 (20.7) |
.05 |
.92 |
74.3 (26.2) |
86.3 (23.3) |
.01 |
.56 |
| TC |
81.1 (23.9) |
95.6 (17.3) |
.01 |
75.6 (28.6) |
87.6 (27.2) |
.001 |
|||
| TT |
87.1 (33.5) |
93.9 (29.6) |
.49 |
77.5 (30.1) |
93.3 (25.3) |
.000 |
|||
| |
EFZ (n = 44) |
NVP (n = 164) |
|||||||
| AP0C3-5128 | |||||||||
| Total cholesterol (mg/dL) |
GG |
140.3 (23.4) |
161.6 (19.5) |
.01 |
.4 |
125.6 (32.6) |
152.8 (29.4) |
.000 |
.08 |
| GC |
143.3 (36.9) |
166.1 (33.1) |
.01 |
134.5 (34.3) |
164.9 (39.3) |
.000 |
|||
| CC |
131.8 (21.5) |
151.2 (19.7) |
.07 |
127.6 (38.0) |
159.5 (25.1) |
.000 |
|||
| HDL-c (mg/dL) |
GG |
35.8 (6.0) |
46.9 (8.2) |
.001 |
.69 |
26.5 (9.5) |
48.9 (14.9) |
.000 |
.05 |
| GC |
31.5 (10.9) |
50.0 (15.7) |
.000 |
31.3 (11.5) |
51.8 (15.4) |
.000 |
|||
| CC |
31.4 (13.2) |
44.8 (6.1) |
.002 |
32.4 (11.6) |
46.8 (11.2) |
.001 |
|||
| TGL (mg/dL) |
GG |
116.1 (46.7) |
97.6 (44.5) |
.18 |
.89 |
131.9 (64.5) |
103.5 (52.9) |
.004 |
.26 |
| GC |
127.9 (55.2) |
91.9 (45.4) |
.04 |
153.2 (82.9) |
111.3 (62.2) |
.000 |
|||
| CC |
126.6 (60.8) |
101.1 (37.9) |
.29 |
126.8 (63.3) |
119.8 (70.1) |
.71 |
|||
| LDL-c (mg/dL) | GG |
81.8 (22.3) |
96.7 (18.2) |
.01 |
.29 | 75.2 (28.3) |
84.5 (22.4) |
.02 |
.49 |
| GC |
82.2 (28.3) |
98.3 (25.2) |
.16 |
76.7 (28.1) |
92.2 (29.0) |
.000 |
|||
| CC | 75.0 (32.3) | 86.1 (22.3) | .44 | 71.3 (28.1) | 89.8 (23.8) | .002 | |||
NVP, nevirapine.
Discussions
Our study shows an association between a polymorphism in APOC3 rs5128 “G” variant and expression of high HDL-c levels after 24 months of treatment with NVP-based ART. We could not demonstrate any link between the other variants of APOC3, namely rs2854116 and rs2854117 polymorphism, with changes in lipid levels in HIV-infected children on NNRTI-based ART. Although we observed an increase in total cholesterol, HDL-c, LDL-c, and a decline in TGL also at 24 months post ART, the plasma levels did not exceed the upper limit of normal. With the longer intake of ART beyond 24 months, there is a possibility of dyslipidemia and this requires identification of specific polymorphism in candidate genes that might predispose to dyslipidemia.
Although we did not find any association between gene polymorphism and serum TGL or total cholesterol levels, studies have shown that variants of APOC3 and APOA5 are associated with ART-induced dyslipidemia.7,9,16,17 Overexpression of APOC3 synthesized by the liver and intestine, results in higher TGL levels. Miller et al. found an association between APOC3 promoter polymorphisms C-482T and T-455C with metabolic syndrome in Caucasian, South Asians, and African Americans.17 APOC3 rs5128 genotype GC was associated with increased plasma TGL levels and risk of metabolic syndrome compared with those with other rs5128 genotypes.11 A longitudinal study in a HIV-1-infected pediatric cohort from Argentina showed a significant effect of the APOC3 genotype for the prediction of total cholesterol levels. The differences observed between the genotypes seemed to depend on the combination of and duration of exposure to ART at the time of the plasma lipid level measurements.16 It has also been suggested that APOC3 polymorphism genotyping could even identify patients at risk for hypertriglyceridemia and lipoatrophy.7 In our cohort, we found an association only with HDL-c levels. Children with rs5128 genotype GG had higher levels of HDL-c after 12 months of ART, and this was more evident with NVP-based ART. Unlike these studies, no association was found between APOC3 (rs5128) polymorphism and plasma lipid levels in HIV-infected cohorts from Brazil and Hongkong.18,19
It has been demonstrated that the APOC3 rs10892152 polymorphism predisposes HIV-1-infected individuals treated with a PI-based regimen to an unfavorable lipid profile.8,9 Although severe dyslipidemic profiles were noticed after PI-based ART regimens in patients with APOC3 variant,7 instances of NNRTI-induced dyslipidemia also have been linked to gene polymorphism. It has been demonstrated that NNRTI-based ART significantly increased HDL-c values in patients with G/G genotype of APOC3 rs10892151 polymorphism.9 Similar to them we also found an association between G/G genotype of APOC3 rs5128 polymorphism and an increase in plasma HDL-c levels, after 24 months of NVP-based ART. Also, being a carrier of “C” variant of APOC3 rs5128 polymorphism could be a determinant of the variation in other lipid levels. During follow-up, children with homozygous C/C genotype had a lesser increase of total cholesterol and LDL-c when on EFZ-based ART. A similar effect has also been shown among carriers of rs10892151 “A” variant.9 A meta-analysis has also shown the association between APOC3 rs5128 polymorphism and HDL-c levels.10 In our cohort, the presence of “G” variant of rs5128 polymorphism had a significant reduction in the TGL levels when on NVP-based regimen. Further studies in a larger population are required to confirm the protective effect of the C/C genotype observed in our study like those explained in HIV-negative individuals.
Significant associations between the APOC3 rs2854116 polymorphism and higher levels of TGL and lower levels of HDL-c were found in a meta-analysis.10 In another study, 20 SNPs of 13 genes involved in lipid metabolism and transport were evaluated in 438 HIV-infected individuals receiving ART, and the results showed that SNPs in the ABCA1, APOA5, and APOC3 genes contributed to high TGL, whereas SNPs in the APOA5 and CETP genes contributed to low HDL-c.20 In our cohort, only a trend toward an association between APOC3 rs2854117 polymorphism and higher levels of TGL was detected. Guardiola et al. also found a similar result in their cohort, where none of the polymorphisms in APOE or APOC3 showed any significant association with lipid parameters.21
Our main study limitation was that systematic follow-up of children initiated on ART under program setting was done only for 2 years post ART initiation. Long-term follow-up for at least 5 years can add more light to the long-term effect of ART in the presence of specific gene polymorphism. Also, our sample size was small for gene studies.
Conclusions
In conclusion, our findings indicate that ART plays a major role in normalizing lipid levels, which are one of the markers of disease progression. Although genetic predisposition helps to explain the variability among patients with respect to the effects of ART on dyslipidemia, in our cohort, APOC3 gene polymorphisms did not play a significant role in the development of dyslipidemia in HIV-infected children from south India. More studies with larger sample sizes are required to prove the association between gene polymorphism and ART-induced dyslipidemia.
Acknowledgments
The authors thank the staff of the Departments of Clinical Research, Biochemistry, Biostatistics, and the HIV Laboratory of the ICMR-National Institute for Research in Tuberculosis, for their active participation in the study. They also thank the medical officers and staff of ART centers in Government Hospital for Thoracic Medicine (Chennai, India), Government Vellore Medical College and Hospital (Vellore, India), Government Rajaji Hospital (Madurai, India), St. John's Medical College Hospital and Indira Gandhi Institute of Child Health (Bangalore, India), TANSACS and National AIDS Control Organization for their support and co-operation in the conduct of the study. They extend their sincere gratitude to all the patients who participated in this study. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Author Disclosure Statement
The authors declare that they have no competing financial interests.
Funding Information
Research reported in this publication was supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health under award number R01AI084390 and ICMR-National Institute for Research in Tuberculosis.
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