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Inflammation Markers and The Risk of Non-AIDS Events

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1 Inflammation Markers and The Risk of Non-AIDS Events
Linda Wittkop Bordeaux Population Health Research Center (Inserm U1219) – Inserm team Multimorbidity and Public Health in Patients with HIV or Hepatitis (MORPH3Eus) University of Bordeaux - ISPED University hospital Bordeaux – Department of Public HEalth

2 Conflict of Interest Speaker: MSD

3 Changing pattern of underlying causes of death
Ending AIDS ? Increasing non-AIDS ? D:A:D Smith et al Lancet 2014; 384:

4 Mortality caused by Non-AIDS events is raising
Similar pattern in the Swiss HIV cohort study (84% of the death were non-AIDS related) Weber et al HIV Med : Mortality from both AIDS and non-AIDS events is decreasing. Morlat et al AIDS 2014, 28:

5 Aging population Increasing life-exptancy Increase of polymorbidity
Schouten et al CID 2014; 59(12): ART-CC The Lancet HIV 2017

6 REASONS for non-AIDS events / age related comorbidities?

7 Deeks Lancet 2013, Deeks Immunity 2013, Appay J Pathol 2008, Aounallah Cytokine&Growth Factor Review 2016, Hunt JID 2016 , Sabin AIDS 2017, Guardaldi AIDS 2017, Lagathu AIDS 2017

8 e.g. IL-6, CRP, D-Dimer, TNF-alpha, IL-1beta, IL-18
INFLAMMATION e.g. IL-6, CRP, D-Dimer, TNF-alpha, IL-1beta, IL-18 Exhaustion of immune resources Immuno-senescence Excessive metabolism Accelerated/ accentuated Aging ? Deeks Lancet 2013, Deeks Immunity 2013, Appay J Pathol 2008, Aounallah Cytokine&Growth Factor Review 2016, Hunt JID 2016 , Sabin AIDS 2017, Guardaldi AIDS 2017, Lagathu AIDS 2017

9 e.g. IL-6, CRP, D-Dimer, TNF-alpha, IL-1beta, IL-18
INFLAMMATION e.g. IL-6, CRP, D-Dimer, TNF-alpha, IL-1beta, IL-18 Exhaustion of immune resources Immuno-senescence Excessive metabolism Accelerated/ accentuated Aging ? Deeks Lancet 2013, Deeks Immunity 2013, Appay J Pathol 2008, Aounallah Cytokine&Growth Factor Review 2016, Hunt JID 2016 , Sabin AIDS 2017, Guardaldi AIDS 2017, Lagathu AIDS 2017

10 Complications – non-AIDS events
INFLAMMATION e.g. IL-6, CRP, D-Dimer, TNF-alpha, IL-1beta, IL-18 Exhaustion of immune resources Immuno-senescence Excessive metabolism Accelerated/ accentuated Aging ? Complications – non-AIDS events Cardiovascular, liver and renal disease, non-AIDS defining cancers, diabetes, neuropsychiatric disorders etc. Deeks Lancet 2013, Deeks Immunity 2013, Appay J Pathol 2008, Aounallah Cytokine&Growth Factor Review 2016, Hunt JID 2016 , Sabin AIDS 2017, Guardaldi AIDS 2017, Lagathu AIDS 2017

11 Inflammation markers and risk of non-AIDS defining events
Higher pre-ART D-Dimers, IL-6 and a higher combined score were associated with an increased risk of serious non-AIDS events after ART start Baker CROI2017 #623 INSIGHT START

12 Inflammation markers and risk of non-AIDS defining events
Serious non-AIDS events Cancer (AIDS and non-AIDS) D-dimer IL-6 IL-6 + D-dimer score hsCRP SAA IL-27 sICAM sVCAM adjusted for age, gender, and treatment group, stratified by geographic location Baker CROI2017 #623 INSIGHT START

13 Inflammation Markers and CVD
Higher IL-6  higher risk for CVD Similar results for CRP and D-dimer Association significant after adjustment for age, gender, race, ART plasma HIV RNA level, CD4+ T cell count, priori AIDS diagnosis, smoking, BMI, prior CVD, diabetes, hypertension, hyperlipidemia treatment, total/HDL cholesterol, ECG abnormalities, hepatitis B or C co-infection and treatment group Duprez PLOS One 2012 SMART

14 Inflammation markers and non-AIDS events
Reference Markers Comorbidities N / N events/cases Study design Baker CROI2017 #623 IL-6, D-Dimer, hsCRP, SAA, IL-27, sICAM, sVCAM Serious Non-AIDS events, CVD, cancers 4299/74 Longitudinal cohort study – START trial Freiberg PLOS One 2016 D-Dimer IL-6 Non-AIDS events 249/28 Prospective observational cohort Duprez PLOS One 2012 IL-6, D-Dimer, CRP CVD 5098/252 Longitudinal cohort study – SMART trial (++ – AUC calculated) Borges AIDS 2013 Infection-related and –unrelated cancers 4408/172 Longitudinal cohort study – SMART, ESPRIT, SILCAAT patients from the control arms Tenorio JID 2014 D-Dimer, IL-6, IP-10, sTNFR1, sTNFR2, sCD14 Non-AIDS evens, CVD, non-AIDS cancers 458/143 Nested case-control – ACTG Longitudinal linked Randomized Trials cohort Capeau AIDS 2012 sTNFR1, CRP, adiponectin Diabetes 366/38 Prospective observational cohort – ANRS CO8 APROCO-COPILOTE Brown Diabetes Care 2010 IL-6, hsCRP, sTNFR1, sTNFR2 110/55 Nested case-control - ACTG Longitudinal linked Randomized Trials cohort

15 Inflammation markers and non-AIDS events
Reference Markers Comorbidities N / N events/cases Study design Baker CROI2017 #623 IL-6, D-Dimer, hsCRP, SAA, IL-27, sICAM, sVCAM Serious Non-AIDS events, CVD, cancers 4299/74 Longitudinal cohort study – START trial Freiberg PLOS One 2016 D-Dimer IL-6 Non-AIDS events 249/28 Prospective observational cohort Duprez PLOS One 2012 IL-6, D-Dimer, CRP CVD 5098/252 Longitudinal cohort study – SMART trial (++ – AUC calculated) Borges AIDS 2013 Infection-related and –unrelated cancers 4408/172 Longitudinal cohort study – SMART, ESPRIT, SILCAAT patients from the control arms Tenorio JID 2014 D-Dimer, IL-6, IP-10, sTNFR1, sTNFR2, sCD14 Non-AIDS evens, CVD, non-AIDS cancers 458/143 Nested case-control – ACTG Longitudinal linked Randomized Trials cohort Capeau AIDS 2012 sTNFR1, CRP, adiponectin Diabetes 366/38 Prospective observational cohort – ANRS CO8 APROCO-COPILOTE Brown Diabetes Care 2010 IL-6, hsCRP, sTNFR1, sTNFR2 110/55 Nested case-control - ACTG Longitudinal linked Randomized Trials cohort

16 Inflammation markers and non-AIDS events
Reference Markers Comorbidities N / N events/cases Study design Baker CROI2017 #623 IL-6, D-Dimer, hsCRP, SAA, IL-27, sICAM, sVCAM Serious Non-AIDS events, CVD, cancers 4299/74 Longitudinal cohort study – START trial Freiberg PLOS One 2016 D-Dimer IL-6 Non-AIDS events 249/28 Prospective observational cohort Duprez PLOS One 2012 IL-6, D-Dimer, CRP CVD 5098/252 Longitudinal cohort study – SMART trial (++ – AUC calculated) Borges AIDS 2013 Infection-related and –unrelated cancers 4408/172 Longitudinal cohort study – SMART, ESPRIT, SILCAAT patients from the control arms Tenorio JID 2014 D-Dimer, IL-6, IP-10, sTNFR1, sTNFR2, sCD14 Non-AIDS evens, CVD, non-AIDS cancers 458/143 Nested case-control – ACTG Longitudinal linked Randomized Trials cohort Capeau AIDS 2012 sTNFR1, CRP, adiponectin Diabetes 366/38 Prospective observational cohort – ANRS CO8 APROCO-COPILOTE Brown Diabetes Care 2010 IL-6, hsCRP, sTNFR1, sTNFR2 110/55 Nested case-control - ACTG Longitudinal linked Randomized Trials cohort

17 Inflammation markers and non-AIDS events
Reference Markers Comorbidities N / N events/cases Study design Baker CROI2017 #623 IL-6, D-Dimer, hsCRP, SAA, IL-27, sICAM, sVCAM Serious Non-AIDS events, CVD, cancers 4299/74 Longitudinal cohort study – START trial Freiberg PLOS One 2016 D-Dimer, IL-6 Non-AIDS events 249/28 Prospective observational cohort Duprez PLOS One 2012 IL-6, D-Dimer, CRP CVD 5098/252 Longitudinal cohort study – SMART trial (++ – AUC calculated) Borges AIDS 2013 Infection- related and – unrelated cancers 4408/172 Longitudinal cohort study – SMART, ESPRIT, SILCAAT patients from the control arms Tenorio JID 2014 D-Dimer, IL-6, IP-10, sTNFR1, sTNFR2, sCD14 Non-AIDS evens, CVD, non-AIDS cancers 458/143 Nested case-control – ACTG Longitudinal linked Randomized Trials cohort Capeau AIDS 2012 sTNFR1, CRP, adiponectin Diabetes 366/38 Prospective observational cohort – ANRS CO8 APROCO-COPILOTE Brown Diabetes Care 2010 IL-6, hsCRP, sTNFR1, sTNFR2 110/55 Nested case-control - ACTG Longitudinal linked Randomized Trials cohort

18 Inflammation markers and non-AIDS events
Reference Markers Comorbidities N / N events/cases Study design Baker CROI2017 #623 IL-6, D-Dimer, hsCRP, SAA, IL-27, sICAM, sVCAM Serious Non-AIDS events, CVD, cancers 4299/74 Longitudinal cohort study – START trial Freiberg PLOS One 2016 D-Dimer, IL-6 Non-AIDS events 249/28 Prospective observational cohort Duprez PLOS One 2012 IL-6, D-Dimer, CRP CVD 5098/252 Longitudinal cohort study – SMART trial (++ – AUC calculated) Borges AIDS 2013 Infection-related and –unrelated cancers 4408/172 Longitudinal cohort study – SMART, ESPRIT, SILCAAT patients from the control arms Tenorio JID 2014 D-Dimer, IL-6, IP-10, sTNFR1, sTNFR2, sCD14 Non-AIDS evens, CVD, non-AIDS cancers 458/143 Nested case-control – ACTG Longitudinal linked Randomized Trials cohort Capeau AIDS 2012 sTNFR1, CRP, adiponectin Diabetes 366/38 Prospective observational cohort – ANRS CO8 APROCO-COPILOTE Brown Diabetes Care 2010 IL-6, hsCRP, sTNFR1, sTNFR2 110/55 Nested case-control - ACTG Longitudinal linked Randomized Trials cohort When additionally adjusted for smoking then CRP and D-dimer were no longer associated

19 Inflammation markers and non-AIDS events
Reference Markers Comorbidities N / N events/cases Study design Baker CROI2017 #623 IL-6, D-Dimer, hsCRP, SAA, IL-27, sICAM, sVCAM Serious Non-AIDS events, CVD, cancers 4299/74 Longitudinal cohort study – START trial Freiberg PLOS One 2016 D-Dimer, IL-6 Non-AIDS events 249/28 Prospective observational cohort Duprez PLOS One 2012 IL-6, D-Dimer, CRP CVD 5098/252 Longitudinal cohort study – SMART trial (++ – AUC calculated) Borges AIDS 2013 Infection-related and –unrelated cancers 4408/172 Longitudinal cohort study – SMART, ESPRIT, SILCAAT patients from the control arms Tenorio JID 2014 D-Dimer, IL-6, IP-10, sTNFR1, sTNFR2, sCD14 Non-AIDS evens, CVD, non-AIDS cancers 458/143 Nested case-control – ACTG Longitudinal linked Randomized Trials cohort Capeau AIDS 2012 sTNFR1, CRP, adiponectin Diabetes 366/38 Prospective observational cohort – ANRS CO8 APROCO-COPILOTE Brown Diabetes Care 2010 IL-6, hsCRP, sTNFR1, sTNFR2 110/55 Nested case-control - ACTG Longitudinal linked Randomized Trials cohort

20 IP-10 only when measured pre-event
Inflammation markers and non-AIDS events Reference Markers Comorbidities N / N events/cases Study design Baker CROI2017 #623 IL-6, D-Dimer, hsCRP, SAA, IL-27, sICAM, sVCAM Serious Non-AIDS events, CVD, cancers 4299/74 Longitudinal cohort study – START trial Freiberg PLOS One 2016 D-Dimer, IL-6 Non-AIDS events 249/28 Prospective observational cohort Duprez PLOS One 2012 IL-6, D-Dimer, CRP CVD 5098/252 Longitudinal cohort study – SMART trial (++ – AUC calculated) Borges AIDS 2013 Infection-related and –unrelated cancers 4408/172 Longitudinal cohort study – SMART, ESPRIT, SILCAAT patients from the control arms Tenorio JID 2014 D-Dimer, IL-6, IP-10, sTNFR1, sTNFR2, sCD14 Non-AIDS evens, CVD, non-AIDS cancers 458/143 Nested case-control – ACTG Longitudinal linked Randomized Trials cohort Capeau AIDS 2012 sTNFR1, CRP, adiponectin Diabetes 366/38 Prospective observational cohort – ANRS CO8 APROCO-COPILOTE Brown Diabetes Care 2010 IL-6, hsCRP, sTNFR1, sTNFR2 110/55 Nested case-control - ACTG Longitudinal linked Randomized Trials cohort IP-10 only when measured pre-event

21 Inflammation markers and non-AIDS events
Reference Markers Comorbidities N / N events/cases Study design Baker CROI2017 #623 IL-6, D-Dimer, hsCRP, SAA, IL-27, sICAM, sVCAM Serious Non-AIDS events, CVD, cancers 4299/74 Longitudinal cohort study – START trial Freiberg PLOS One 2016 D-Dimer, IL-6 Non-AIDS events 249/28 Prospective observational cohort Duprez PLOS One 2012 IL-6, D-Dimer, CRP CVD 5098/252 Longitudinal cohort study – SMART trial (++ – AUC calculated) Borges AIDS 2013 Infection-related and –unrelated cancers 4408/172 Longitudinal cohort study – SMART, ESPRIT, SILCAAT patients from the control arms Tenorio JID 2014 D-Dimer, IL-6, IP-10, sTNFR1, sTNFR2, sCD14 Non-AIDS evens, CVD, non-AIDS cancers 458/143 Nested case-control – ACTG Longitudinal linked Randomized Trials cohort Capeau AIDS 2012 sTNFR1, CRP, adiponectin Diabetes 366/38 Prospective observational cohort – ANRS CO8 APROCO-COPILOTE Brown Diabetes Care 2010 IL-6, hsCRP, sTNFR1, sTNFR2 110/55 Nested case-control - ACTG Longitudinal linked Randomized Trials cohort

22 Overview ? Reference Markers Comorbidities N / N events/cases
Study design Baker CROI2017 #623 IL-6, D-Dimer, hsCRP, SAA, IL-27, sICAM, sVCAM Serious Non-AIDS events, CVD, cancers 4299/74 Longitudinal cohort study – START trial Freiberg PLOS One 2016 D-Dimer, IL-6 Non-AIDS events 249/28 Prospective observational cohort Duprez PLOS One 2012 IL-6, D-Dimer, CRP CVD 5098/252 Longitudinal cohort study – SMART trial (++ – AUC calculated) Borges AIDS 2013 Infection-related and –unrelated cancers 4408/172 Longitudinal cohort study – SMART, ESPRIT, SILCAAT patients from the control arms Tenorio JID 2014 D-Dimer, IL-6, IP-10, sTNFR1, sTNFR2, sCD14 Non-AIDS evens, CVD, non-AIDS cancers 458/143 Nested case-control – ACTG Longitudinal linked Randomized Trials cohort Capeau AIDS 2012 sTNFR1, CRP, adiponectin Diabetes 366/38 Prospective observational cohort – ANRS CO8 APROCO-COPILOTE Brown Diabetes Care 2010 IL-6, hsCRP, sTNFR1, sTNFR2 110/55 Nested case-control - ACTG Longitudinal linked Randomized Trials cohort

23 Overview ? Reference Markers Comorbidities N / N events/cases Study design Baker CROI2017 #623 IL-6, D-Dimer, hsCRP, SAA, IL-27, sICAM, sVCAM Serious Non-AIDS events, CVD, cancers 4299/74 Longitudinal cohort study – START trial Freiberg PLOS One 2016 D-Dimer, IL-6 Non-AIDS events 249/28 Prospective observational cohort Duprez PLOS One 2012 IL-6, D-Dimer, CRP CVD 5098/252 Longitudinal cohort study – SMART trial (++ – AUC calculated) Borges AIDS 2013 Infection-related and –unrelated cancers 4408/172 Longitudinal cohort study – SMART, ESPRIT, SILCAAT patients from the control arms Tenorio JID 2014 D-Dimer, IL-6, IP-10, sTNFR1, sTNFR2, sCD14 Non-AIDS evens, CVD, non-AIDS cancers 458/143 Nested case-control – ACTG Longitudinal linked Randomized Trials cohort Capeau AIDS 2012 sTNFR1, CRP, adiponectin Diabetes 366/38 Prospective observational cohort – ANRS CO8 APROCO-COPILOTE Brown Diabetes Care 2010 IL-6, hsCRP, sTNFR1, sTNFR2 110/55 Nested case-control - ACTG Longitudinal linked Randomized Trials cohort Heterogeneous results concerning the association between inflammation markers and non-AIDS events Some studies with small sample sizes / event numbers Power? confounding factors? Timing of measurement ? evolution of markers ?

24 Early ART Deeks Lancet 2013, Deeks Immunity 2013, Appay J Pathol 2008, Aounallah Cytokine&Growth Factor Review 2016, Hunt JID 2016 , Sabin AIDS 2017, Guardaldi AIDS 2017, Lagathu AIDS 2017

25 Early ART INFLAMMATION Excessive metabolism Accelerated/ accentuated
Aging ? Exhaustion of immune resources Immuno-senescence Deeks Lancet 2013, Deeks Immunity 2013, Appay J Pathol 2008, Aounallah Cytokine&Growth Factor Review 2016, Hunt JID 2016 , Sabin AIDS 2017, Guardaldi AIDS 2017, Lagathu AIDS 2017

26 Early ART DECREASE ? Changing pattern ? INFLAMMATION
Excessive metabolism Accelerated/ accentuated Aging ? Exhaustion of immune resources Immuno-senescence DECREASE ? Changing pattern ? Complications – non-AIDS events Cardiovascular, liver and renal disease, non-AIDS defining cancers, diabetes, neuropsychiatric disorders and bone abnormalities Deeks Lancet 2013, Deeks Immunity 2013, Appay J Pathol 2008, Aounallah Cytokine&Growth Factor Review 2016, Hunt JID 2016 , Sabin AIDS 2017, Guardaldi AIDS 2017, Lagathu AIDS 2017, Hunt et al JID 2016: 2014 (Suppl2)

27 Early ART Other Interventions? Even more DECREASE ? INFLAMMATION
Excessive metabolism Accelerated/ accentuated Aging ? Exhaustion of immune resources Immuno-senescence INFLAMMATION Even more DECREASE ? Complications – non-AIDS events Cardiovascular, liver and renal disease, non-AIDS defining cancers, diabetes, neuropsychiatric disorders and bone abnormalities Deeks Lancet 2013, Deeks Immunity 2013, Appay J Pathol 2008, Aounallah Cytokine&Growth Factor Review 2016, Hunt JID 2016 , Sabin AIDS 2017, Guardaldi AIDS 2017, Lagathu AIDS 2017

28 Conclusion (1) Some inflammation markers have been linked with an increased risk of non-AIDS events Several inflammation markers were not associated with the risk of non-AIDS events Underlying mechanisms of inflammation are complex Specific markers for specific Non AIDS events ? Specific profiles ? Different markers in an aging population? Lagathu et al AIDS (Suppl2):S105-S119

29 Conclusion (2) Too small sample sizes/small number of events for some specific non-AIDS events Markers were mainly measured before ART start Many patients are on successful ART since years with sustained virological suppression Inflammation markers continue to decrease over time? Still predictors?

30 Conclusion (3) Data from observational cohorts on the topic are scarce
Biobanks Longterm follow-up Could help us To study effect over the long-term in ART treated patients Markers non-AIDS events/specific non-AIDS events Association between markers and markers evolution and risk of non-AIDS events To assess whether the biomarkers added a « predictive/pronostic value » Describe whether the upscale of ART to patients irrespectively of CD4 cell count changes the pattern of co-morbidities

31 Acknowledgments BPH Inserm U2129/Team MORPH3Eus: L Wittkop F Bonnet G Chêne F Dabis FA Dauchy M Dupon M Hessamfar JP Joseph S Lawson-Ayayi P Mercié P Morlat JL Pellegrin I Pellegrin PhD students D. Barger A Ozanne M Rondy Some collaborators: BPH/Team SISTM: R. Thiebaut, L Richert BPH/Team Biostat: H. Jacqmin Gadda, D. Commenges, P Joly, K Leffondre, C. Proust-Lima CHU de Bordeaux: P Duffau, C Cazanave UMR 5234: M Kann, ME Lafon, H Wodrich

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