Coagulation and Morbidity in Treated HIV Infection

Michael M. Lederman, MD Scott R. Inkley Professor of Medicine

Case Western Reserve University

Although survival has improved, predicted life expectancy still seems shorter in the HIV+ population

Adapted from Lohse N, et al. Ann Intern Med 2007;146:87–95

Prob

abilit

y of S

urviv

al

Pre-HAART (1995–1996)

Early HAART (1997–1999)

Survival from Age 25 Years N= 3,990 1

0.75

0.5

0.25

0

25 30 35 40 45 50 55 60 65 70

Age, years

Late HAART (2000–2005)

Population controls

Many Age-associated Diseases Are More Common in Treated HIV Disease Than In Age-matched Uninfected Persons

• Cardiovascular disease

• Cancer (non-AIDS) • Bone fractures/osteopenia

• Left ventricular dysfunction • Lung Disease • Liver failure • Kidney failure

• Cognitive decline

• Frailty

Multiple factors likely explain this increased risk, including co-morbid conditions, other exposures, ARV drug toxicity

S. Deeks

Inflammation/coagulation predicts morbidity/mortality in HIV infection

in “SMART” • Interleukin-6 • D-dimers • C-reactive protein

• Kuller et al PLOS Medicine ‘08

NWCS 329 • Nested case control study within the ACTG ALLRT cohort • Cases (n=143): Virologically suppressed (VL < 400 copies/ml) ART-

treated subjects with: – Non-accidental death – Non-AIDS morbidity

• Myocardial infarction • Stroke • Malignancy • Serious bacterial infections

• Controls: 2 virologically suppressed subjects matched for: – Age – Gender and sex – Baseline CD4+ T-cells (within 50 cells/mm3) – ART regimen at week 48 (PI- or ABC-containing or not) – Parent study

NWCS 329 in treated HIV Infection, pre-Event Soluble Markers relate to Outcome

IL6Unadjusted <.0012.58 (1.91-3.48)Adjusted* <.0012.48 (1.83-3.35)

IP-10Unadjusted 0.0021.49 (1.16-1.91)Adjusted* 0.0071.42 (1.10-1.84)

sTNFr-IUnadjusted <.0011.99 (1.49-2.66)Adjusted* <.0011.94 (1.45-2.60)

sTNFr-IIUnadjusted <.0011.88 (1.44-2.46)Adjusted* <.0011.81 (1.38-2.38)

Soluble CD14Unadjusted <.0011.74 (1.29-2.35)Adjusted* <.0011.67 (1.23-2.27)

D-DimerUnadjusted <.0012.41 (1.78-3.27)Adjusted* <.0012.38 (1.75-3.25)

CD8+ %DR+38+Unadjusted 0.5161.06 (0.88-1.28)Adjusted* 0.8630.98 (0.80-1.20)

0.50 1.00 4.00

Pre-event Marker P ValueOdds Ratio per 1 IQR increase

*Adjusted by CD4 count

OR for: Death CA MI/Stroke

20.9** 3.1** 2.2** 19.9** 2.9** 2.1**

1.9 1.7* 1.7* 1.8 1.5 1.7*

3.3** 2.3** 2.1**

3.3* 2.2** 2.1**

2.6** 2.1** 1.9**

2.9** 1.9* 2*

2.7* 1.5 1.7 2.8* 1.4 1.7

8.4** 3.2** 2.6** 8.1** 3.1** 2.6**

1.4 1 1

0.8 0.9 0.9

** **

** **

** **

** **

** **

** **

Tenorio J Inf Dis ‘14 Similar findings by Hunt et al JID ‘14

Arteries are inflamed in treated HIV infection

Subramanian et al JAMA ‘12

FSC

SSC

mIg

G1

mIgG2b

CD16

CD14

Monocyte subsets can be identified by expression of CD14 and CD16

HIV- HIV+ Traditional Monocytes

Inflammatory Monocytes

Patrolling Monocytes

Funderburg et al Blood 2012

Proportions of inflammatory and patrolling monocytes are increased in HIV disease

Traditional Inflammatory Patrolling

Funderburg et al Blood 2012

Medium alone LPS Pam3CSK4

IL-8 IL-1B IL-6 IL-10 TNF-a

Monocytes elaborate inflammatory mediators (IL-6, TNF, IL-18, IL-1b, IL-10)

in response to microbial elements

Nick Funderburg

Tissue Factor – a cell surface protein that activates the Extrinsic Coagulation Pathway

Goodsell The Oncologist 2006

Cell surface

Microbial Products may drive coagulation via induction of the procoagulant Tissue Factor on

Monocytes

57.7 10.1

2336 1194 331

78.1

TF MFI

Tissue Factor

No Stim LPS 20ng Flagellin 1ug

Funderburg et al Blood ‘10

HIV- HIV+ <400c/mL HIV+ >400c/mL Cardio CTRLs ACS Patients

%TF

+

Inflammatory and Patrolling monocytes are enriched for the procoagulant Tissue Factor in HIV infection

and in uninfected persons with Acute Coronary Syndromes

Funderburg et al Blood 2012

Traditional Inflammatory Patrolling

Like LPS, oxidized LDL (but not LDL) alters inflammatory profiles of blood monocytes

CD16

CD14

No Stim LPS LDL oxLDL

David Zidar, Nick Funderburg , unpublished

Classical (CD14+CD16-)

Inflammatory (CD14+CD16+)

Patrolling (CD14dimCD16+)

LPS LDL oxLDL No Stim LPS LDL oxLDL No

Stim LPS LDL oxLDL No Stim

***

*** *

***

*** ***

% T

issu

e Fa

ctor

Like LPS, oxidized LDL (but not LDL)

increases Tissue factor expression on blood monocytes

David Zidar, Nick Funderburg

Plasma levels of oxLDL are increased in HIV infection

oxLD

L (u

/mL)

HIV- HIV+ <400c/mL HIV+ >400c/mL Cardio CTRLs ACS Patients

Ox LDL - correlated to sCD14, TF levels on patrolling monocytes and Framingham Risk

Zidar, Funderbug et al

CD8 T cell homeostasis in HIV infection • CD8 T cell expansion is characteristic of untreated HIV

infection -and often persists after ART • These are matured effector cells, often senescent and

“exhausted” yet capable of robust inflammatory cytokine expression

• In setting of ART, expanded CD8 T cells are not HIV-reactive – Drivers of persistent CD8 T cell expansion in this setting are

not defined • CD8 T cell expansion and resultant low CD4/CD8 ratios

predict morbid outcomes in treated HIV infection (Serrano-Villar et al PLOS One ’13, Lee et al JID ‘14, Serrano-Villar PLOS Pathogens ‘14)

Mann-Whitney p=<0.0001

Even with complete virologic control and CD4 T cell restoration, CD8 T lymphocytosis persists for many

years

Carey Shive,, JC Mudd unpublished

Do CD8 T cells contribute to the development of atherosclerotic

plaque?

• Activated CD8+ T cell numbers in blood linked to atherosclerotic plaque in treated HIV

infection (Kaplan ‘11 , Longenecker ‘12)

• And are found within them (Grivel ‘11)

Circulating CD8 T cells exclusively express CX3CR1 or CCR7

CX3C

R1

CD3

JC Mudd, unpublished

CD8 T cells expressing CX3CR1 are relatively (and absolutely) expanded in treated HIV

infection

Healthy control

Treated HIV+

Healthy control

Treated HIV+ CX3C

R1

CCR7 JC Mudd, unpublished

CX3CR1+ CD8 T cells are enriched for protease activated receptor (PAR-1) expression and PAR-1+ cells are increased in

treated HIV-infection

CD3+CD8+CCR7+

16.6%

CD3+CD8+CX3CR1+

CX3C

R1

Par-1

52.0%

CCR7+ CX3CR1+

HIV-

Treated HIV+

PAR-1 is cleaved and activated by Thrombin

Coagulation driven by activated monocytes may recruit and activate CX3CR1+ PAR-1+ CD8 T cells at

endothelial surfaces

Summary • Persons with HIV infection are at increased risk

for cardiovascular and other morbidities of aging: this risk is predicted by indices of coagulation and inflammation

• Monocyte subsets are inflammatory and procoagulant in HIV infection; this phenotype may be driven by microbial products translocated from the damaged gut and by inflammatory lipids

• Mature CD8 T cell numbers are expanded in HIV infection, home to endovascular sites and are linked to ART-era cardiovascular morbidities.

• Coagulation and inflammation collaborate to drive increased CVD risk in treated HIV infection.

Dramatis Personae: CWRU: Nick Funderburg Scott Sieg Benigno Rodriguez Carey Shive JC Mudd Marie Ebner Souheil Younes Clifford Harding Chris Longenecker Grace McComsey David Zidar Brian Clagett Ben Kyi Janet Robinson

The NWCS 329 Team: Allan Tenorio Benigno Rodriguez Steven Deeks Alan Landay Ron Bosch Peter Hunt Evelyn Zheng Supriya Krishnan Arjun Seth

The AIDS Clinical Trials Group AI 076174 The Fasenmyer Foundation

A. Landay S. Deeks L. Margolis S. Sieg

G. Silvestri

J. Brenchley

B. Rodriguez

M. Lederman

Z. Grossman

R. Bosch

C. Harding

R. Sekaly D. Douek

G. Hardy

The Bad Boys of Cleveland

T. Schacker

Not shown: I. Sereti N. Sandler M. Carrington N. Klatt W. Jiang

E.Haddad J . Estes

R. Kalayjian

N. Funderburg

P. Hunt

A. Levine

A. Tenorio

M. Paiardini

J Tilton