|Year : 2019 | Volume
| Issue : 2 | Page : 90-95
Levels of interleukin 6 and 10 and their relationship to hematological changes in HIV treatment-naïve and treatment-experienced patients
Iorhen E Akase1, Reginald O Obiako2, Bolanle O. P Musa3, Adefolarin Opawoye1, Alani S Akanmu4
1 Infectious Disease Unit, Department of Medicine, Lagos University Teaching Hospital, Lagos, Nigeria
2 Neurology Unit, Department of Medicine, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Shika Zaria, Nigeria
3 Immunology Unit, Department of Medicine, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Shika Zaria, Nigeria
4 Department of Haematology and Blood Transfusion, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
|Date of Web Publication||04-Nov-2019|
Iorhen E Akase
Infectious Disease Unit, Department of Medicine, Lagos University Teaching Hospital, Lagos
Introduction: Human immunodeficiency virus (HIV) infection is characterized by excessive and dysregulated production of both proinflammatory and antiinflammatory interleukins, which produces various hematological changes. This study described hematological changes in HIV-positive patients in Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Methods and Materials: This was a cross-sectional study involving 88 consecutive patients. They included 44 newly diagnosed antiretroviral treatment (ART)-naïve patients (as the test group), and 44 ART- experienced patients (as the control group). All 88 patients were evaluated for full blood count and CD4+ T-cell count as well as interleukins 6 and 10 assays. Results: The mean packed cell volume in the ART-naïve and the ART-experienced participants were 32.6 ± 5.7% and 38.6 ± 6.0% (P = 0.01). Mean hemoglobin were 10.8 ± 1.80 and 12.8 ± 1.66 g/dL in the ART-naïve and the ART-experienced participants (P = 0.01), whereas the mean corpuscular volume among the ART-naïve patients was 83.9 fL ± 7 and 99.3 fL ± 12 among the ART-experienced patients (P = 0.01). The median total white cell count among the ART-naïve and the ART-experienced patients were 5.6 × 109 and 3.1 × 109 (P = 0.04), whereas their total platelet counts were 227 × 109 ± 116 and 252 × 109 ± 95 (P = 0.29). Conclusion: Use of ART reduces inflammatory response to HIV, thus lowering levels of interleukins 6 and 10 ultimately improving hematological outcomes, except in a few patients who use zidovudine.
Keywords: Antiretroviral therapy, hematological changes, HIV/AIDS, interleukins
|How to cite this article:|
Akase IE, Obiako RO, Musa BP, Opawoye A, Akanmu AS. Levels of interleukin 6 and 10 and their relationship to hematological changes in HIV treatment-naïve and treatment-experienced patients. Sub-Saharan Afr J Med 2019;6:90-5
|How to cite this URL:|
Akase IE, Obiako RO, Musa BP, Opawoye A, Akanmu AS. Levels of interleukin 6 and 10 and their relationship to hematological changes in HIV treatment-naïve and treatment-experienced patients. Sub-Saharan Afr J Med [serial online] 2019 [cited 2019 Dec 16];6:90-5. Available from: http://www.ssajm.org/text.asp?2019/6/2/90/270253
| Introduction|| |
Cytokines are a group of low molecular weight proteins that mediate communication between cells of the immune system. They contribute to chemical signaling pathways in inflammation, immune responses, and hematopoiesis. Inflammatory signaling is important to the function and maintenance of blood cells and is essential to the replication and development of various hematopoietic cell lines.,
Human immunodeficiency virus (HIV) infection produces a heightened state of inflammation in affected individuals, characterized by excessive production of both proinflammatory (e.g., interleukin, IL-6) and antiinflammatory cytokines (e.g., IL-10). This heightened inflammatory state is known to persist even among patients who have successfully suppressed viral replication with antiretroviral medications., Sustained production of inflammatory signals, as occurs in HIV infection, is associated with dysregulated production of hematopoietic cells, with attendant untoward effects on CD4 cell recovery, functional status of patients, recovery from opportunistic diseases, and even the occurrence of long-term metabolic and cardiovascular sequelae due to the adverse immunologic mileau.,,,
Hematological changes are frequently observed at all stages of HIV infection, including anemia, leukopenia, and thrombocytopenia.,, These changes may be due to direct effects of HIV infection, the occurrence of secondary or opportunistic infections and neoplasms, or the result of various medications that are used for treatment.,, Increasingly, the role of a dysfunctional immune response in the setting of chronic inflammation is being recognized as cause of hematological changes among patients with HIV. In most instances, the commencement of antiretroviral treatment (ART) produces improvement in the changes that are due to the direct effect of HIV infection.,, However, the immunomodulatory role of ART, associated with a reduction in the levels of circulation inflammatory cytokines, in the improvement of patients’ hematological indices is being increasingly recognized.,,,
The determination of the disorders of the hematopoietic system is important in HIV patients at every stage of treatment because it affects the choice of drug regimens and predicts the quality of life of these patients., They may also be indicators of severe underlying disease in these patients, and, as such, their measurements are usually undertaken on a regular basis.
The aim of this study was to determine hematological parameters and the relationship of these to the serum concentrations of IL-6 and IL-10, among ART-naïve and ART-experienced HIV-positive patients attending the ART clinic in Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria.
| Methods and materials|| |
This was designed as a comparative cross-sectional study carried out in the outpatient clinic of the ABUTH HIV program. Eighty-eight patients were consecutively selected using convenience sampling. They included 44 newly diagnosed ART-naïve patients (as the test group) and 44 ART-experienced patients (as the control group). The control group had received ARTs for at least 6 months. All patients were evaluated for full blood count and CD4+ cell count as well as IL-6 and IL-10 assays.
Ethical approval for the study was obtained from ABUTH Health Research Ethics Committee (ABUTH HREC). Adequate counseling, informed consent, and confidentiality were applied throughout the course of the research. Data was collected using a researcher-administered questionnaire, which captured the biodata, sociodemographic characteristics, medical history, and the physical examination of the participants. The questionnaire was translated into Hausa language for the benefit of indigenous non-English speaking participants.
The full blood count was measured using the Sysmex XN automated haematology analyzer (Sysmex, Kobe, Japan). The parameters analyzed were packed cell volume (PCV), hemoglobin (Hb), mean corpuscular volume (MCV), total white cell count (WBC), differential WBC, and total platelet count. The levels of both serum IL-6 and IL-10 were assayed using the Quantikine ELISA human IL-6 and IL-10 immunoassay kits by R&D Systems Inc., Minneapolis, USA. The CD4+ T-cell estimation was done with the Partec Cyflow flow cytometer using the CD4 easy count kit (Sysmex Partec GmbH, Görlitz, Germany).
All data were analyzed using Statistical Package for Social Sciences (SPSS), version 20.0, Chicago, IL, USA. Qualitative variables were reported as percentages. Normally distributed quantitative variables (e.g., age, PCV, Hb, MCV, and platelets) were presented as mean and standard deviation, whereas those with uneven distribution (e.g., WBC, CD4 count, and cytokine levels) were presented as median and range. Statistical test of significance was set at 5% alpha level using the Chi-square and Pearson’s correlation for qualitative and quantitative variables, respectively. The Student t test was used to compare the mean age whereas the Mann–Whitney U test was used to compare the medians of WBC, CD4 cells, and IL-6 and IL-10. A subgroup analysis was conducted among the ART-experienced participants to evaluate the relation between cytokine levels and hematologic changes, and ART regimen used by the participants.
| Results|| |
Males constituted 54.5% (48) of the study participants whereas 45.5% (40) were female. The was no significant difference in age across the two groups, with mean age of 34.8 ± 8.2 and 38.3 ± 9.1 years among the ART-naïve and ART-experienced groups, respectively (P = 0.35).
As shown in [Table 1], participants’ PCV, Hb, and MCV were significantly higher among the ART-experienced participants compared to the ART-naïve participants, namely, PCV (0.39 vs. 0.33 L/L, P = 0.01), Hb (12.8 vs. 10.8 g/dL, P = 0.01), and MCV (99.3 vs. 83.9 fL, P = 0.01). The median total WBC was significantly higher in the ART-naïve patients than among the ART-experienced participants (5.6 × 106/dL vs. 3.1 × 109/dL, P = 0.04).
The median CD4+ T-cell count was significantly lower in the ART-naïve group (166 cells/µL), than the ART-experienced patients (463 cells/µL) (P < 0.001). Conversely, the median serum IL-6 and IL-10 concentrations were significantly higher in the ART-naïve group than the ART-experienced patients, namely, IL-6 (6.8 vs. 1.4 pg/mL, P < 0.001) and IL-10 (10.1 vs. 6.0 pg/mL, P = 0.14). Only IL-6 levels were significantly lower in the treatment experienced group. Differences were found in the median concentrations of IL-6 and IL-10 between the sexes.
The female patients were found to have lower median serum IL-6 (2.36 pg/mL) and IL-10 (6.76 pg/mL) concentrations than the male counterparts with IL-6 of 3.74 pg/mL and IL-10 of 7.22 pg/mL, respectively; although the differences were insignificant (P = 0.88 for IL-6 and P = 0.68 for IL-10). Details of these are shown in [Table 2].
Relationships between ILs (IL-6 and IL-10) and hematological parameters
In both the ART-naïve and the ART-experienced participants, higher serum IL-6 concentrations were significantly associated with lower PCV levels (r = −0.544, P = 0.001), Hb levels (r = −0.524, P = 0.01), and MCV (r = −0.325, P < 0.001). The serum IL-10 concentrations were also associated with lower PCV (r = −0.464, P = 0.01), Hb counts (r = −0.427, P = 0.01), and MCV (r = −0.325, P < 0.001). The negative correlation between the IL-6 levels and WBC in both ART-naive and ART-experienced patients was not statistically significant (r = -0.353, p = 0.94). There was a similar relationship between IL-10 in both ART-naive and ART-experienced patients (r = -0.271, p = 0.16).
However, there was no significant relationship between the platelet counts and the serum IL-6 (r = 0.334, p = 0.08)or the serum IL-10 (r = -0.409, p = 0.14) concentrations.
Effect of highly active anti-retroviral therapy (HAART) on hematological and immunological parameters
The distribution of participants according to the ART regimen is shown in [Table 3]. Participants who were on tenofovir disoproxil fumarate (TDF) containing regimens were found to have higher PCV compared to those on AZT-containing regimens (P = 0.01). Also, patients on second-line regimens had higher PCV values than those who were on first-line medications and the ART-naïve patients (P < 0.001), whereas patients on AZT-containing regimens had higher MCV than patients on other regimens (P ≤ 0.001).
| Discussion|| |
HIV infection is characterized by progressive, unrelenting depletion of CD4+ T lymphocytes, immune dysfunction and persistence in the inflammation, with resultant dysregulation of cytokine production., This dysregulated production of cytokines has implications for the long-term outcome of HIV patients. A high level of inflammatory markers, especially in the setting of worsening immune dysfunction, is associated with poor outcomes in HIV patients with anemia. It has also been shown that dysregulation of cytokine production is an independent immunopathogenic factor in HIV infection, as high levels of circulating inflammatory cytokines have been shown to contribute significantly to the replication of HIV and various manifestations of advanced HIV infection.,
The occurrence of anemia among HIV patients is associated with increased morbidity and mortality, with an increase in the occurrence of opportunistic infections, poor functional status, and a low quality of life in HIV.,, In this study, the prevalence of anemia was significantly higher among ART-naïve participants. This is consistent with the fact that these patients are more likely to have malnutrition with deficiencies of both macronutrients and micronutrients., Poor appetite, malabsorption from chronic diarrhea, and increased oxidative stress all contribute to nutritional deficiencies in the setting of HIV, especially ART-naïve patients., Additionally, the immune paresis associated with persistent immune activation and inflammation predisposes HIV-infected patients to various opportunistic infections that may give rise to various degrees of anemia.,,, Many studies have also shown the independent role that the virus itself plays in driving dysfunctional erythropoiesis, with the finding of circulating autoantibodies against endogenous erythropoietin (EPO) thought to be the result of molecular mimicry between EPO and HIV p17 antigen., It has also been shown that HIV inhibits erythropoiesis directly via its action on erythroid precursors at the BFU-E and CFU-E stage. As was the case in this study, other researchers have documented that use of ART improves the anemia of HIV in most patients, with an improvement in functional status, increase in energy levels, and an improved quality of life among patients., The improvement in anemia with use of ART is thought to be due to reduction in immune activation due to control of viral replication, as well as the improvement in malnutrition due to reduced metabolic demand from inflammation and increased appetite, and the control of opportunistic infections as is the case with improving immune function.,,
In addition to the above factors, this study further highlights the role that the persistence of inflammation plays in the occurrence of hematological changes among HIV patients, especially among those who are ART naïve, among whom the disease is characterized by uncoordinated and excessive production of both proinflammatory and antiinflammatory cytokines.,,, There is a clear relationship between chronic inflammation and the occurrence of anemia, as demonstrated in patients who develop the anemia of inflammation (formerly called anemia of chronic disease). The role of inflammatory cytokines on anemia is thought to be mediated via hepcidin, an acute-phase reactant that regulates iron status. Elevated levels of circulating hepcidin are known to mediate the trapping of iron within macrophages and hepatic cells, while reducing intestinal absorption of iron, thereby reducing the availability of iron to developing erythroid cells., This has been reported among patients with chronic diseases as well as with aging, among whom similar findings of persistent inflammation, characterized by high levels of IL-1, IL-6, tumor necrosis factor-α, and other acute-phase reactants have been reported.,
Among the ART-experienced group, the MCV was found to be significantly higher than in the ART-naïve group. This was even more pronounced among participants who were taking AZT-based ART combinations, which is consistent with the widely known complication of macrocytosis with the use of Zidovudine (AZT).,, Zidovudine is known to exert varying degrees of hematotoxicity and bone marrow aplasia leading to cytopenias (cytotoxicity to both myeloid and erythroid precursors), and pure red cell aplasia.,,,,In our study, the median total white cell counts were higher among ART-naïve participants than ART-experienced participants, a finding that is likely due to the more profound inflammation among ART-naïve patients. As stated above, ART-naïve HIV-infected patients have dysregulated cytokine production due to uncontrolled inflammation., Proinflammatory cytokines are known to be potent stimulants for the differentiation and activation of both myeloid and lymphoid cells. In experimental models, the administration of IL-6 is associated with neutrophilia, whereas the use of tocilizumab (a humanized monoclonal antibody against IL-6 receptor) is associated with neutropenia.,
Participants who were ART experienced had lower neutrophil counts than ART-naïve participants. This is consistent with the fact that ART suppresses inflammation, which in turn can account for the above findings. The reduction of inflammation observed with ART is the result of suppression of viral replication, as well as lower incidence of opportunistic infections due to immune recovery., Additionally, the higher mean hematocrit levels among patients on second-line ART may be a reflection of more efficient suppression of inflammatory mediators as participants on first-line regimes were likely to have been on ART for longer, which may be an early indication of a failing regimen., However, our study was cross-sectional, and further longitudinal studies will be better suited to evaluate the effect of ART on some of these observed changes.
This study was limited by our inability to adequately control for age and sex distribution among the ART-naïve and ART-experienced participants because a convenience sampling method was used. Additionally, the study design, being cross-sectional, limited our ability to draw conclusions on some of the observed hematological changes in this study.
| Conclusion|| |
The ART-naïve participants had lower hematocrit, hemoglobin, and MCV measurements but higher WBC counts. Among the ART-experienced participants, high MCV values were especially pronounced in participants who were on AZT-containing regimens. Across both ART-naïve and ART-experienced participants, higher values of IL-6 and IL-10 were associated with lower hematocrit, hemoglobin, and higher WBC counts.
Thus, we conclude that ART reduces inflammatory response to HIV, thus lowering levels of IL-6 and IL-10 ultimately improving hematological outcomes, except in a few patients who use zidovudine.
The authors wish to acknowledge Lilian Okonkwo and Yemi Balogun, both staff in the ART Laboratory in Ahmadu Bello University Teaching Hospital (ABUTH), for their help with sample storage and laboratory analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Akdis M, Aab A, Altunbulakli C, Azkur K, Costa RA, Crameri R et al.
Interleukins (from IL-1 to IL-38), interferons, transforming growth factor β, and TNFα: receptors, functions, and roles in diseases. J Allergy Clin Immunol 2016;138:984-1010.
Hwang D, Kim W-U. Modelling cytokine signalling networks. Nat Rev Rheumatol 2016;13:5-6.
Mocroft A, Reiss P, Gasiorowski J, Ledergerber B, Kowalska J, Chiesi A et al.
Serious fatal and nonfatal non-AIDS-defining illnesses in Europe. J Acquir Immune Defic Syndr 2010;55:262-70.
Akase IE, Musa BOP, Obiako RO, Ahmad Elfulatiy A, Mohammed AA. Immune dysfunction in HIV: a possible role for pro- and anti-inflammatory cytokines in HIV staging. J Immunol Res 2017;2017:1-5.
Katsikis PD, Mueller YM, Villinger F. The cytokine network of acute HIV infection: a promising target for vaccines and therapy to reduce viral set-point? PLoS Pathogens 2011;7:e 1002055.
Moir S, Connors M, Fauci AS. The immunology of HIV virus infection. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 8th ed. Philadelphia: Churchill Livingstone Elsevier 2015. pp. 1526-40.
Ramaseri Sunder S, Hanumanth SR, Nagaraju RT, Neela Venkata SK, Suryadevara NC, Pydi SS et al.
IL-10 high producing genotype predisposes HIV infected individuals to TB infection. Hum Immunol 2012;73:605-11.
Harris RJ, Sterne JAC, Abgrall S, Dabis F, Reiss P, Saag M et al.
Prognostic importance of anaemia in HIV type-1-infected patients starting antiretroviral therapy: collaborative analysis of prospective cohort studies. Antiviral Ther 2008;13:959-67.
Enumah CL, Nwauche CA, Okerengwo A. Anemia and pro-inflammatory cytokines in human immunodeficiency virus infection. Int J Immunol 2016;4:13-8.
Redig AJ, Berliner N. Pathogenesis and clinical implications of HIV-related anemia in 2013. ASH Education Program Book 2013;2013:377-81.
Vishnu P, Aboulafia DM. Haematological manifestations of human immune deficiency virus infection. Br J Haematol 2015;171:695-709.
Johannessen A, Naman E, Gundersen SG, Bruun JN. Antiretroviral treatment reverses HIV-associated anemia in rural Tanzania. BMC Infect Dis 2011;11:190.
Jaganath D, Walker AS, Ssali F, Musiime V, Kiweewa F, Kityo C et al.
HIV-associated anemia after 96 weeks on therapy: determinants across age ranges in Uganda and Zimbabwe. AIDS Res Hum Retroviruses 2014;30:523-30.
Duggal S, Chugh TD, Duggal AK. HIV and malnutrition: effects on immune system. Clin Develop Immunol 2012;2012:784780.
Mocroft A, Lifson AR, Touloumi G, Neuhaus J, Fox Z, Palfreeman A et al.
Haemoglobin and anaemia in the SMART study. Antiviral Ther 2011;16:329-37.
Kerkhoff AD, Wood R, Cobelens FG, Gupta-Wright A, Bekker L-G., Lawn SD. Resolution of anaemia in a cohort of HIV-infected patients with a high prevalence and incidence of tuberculosis receiving antiretroviral therapy in South Africa. BMC Infect Dis 2014;14:3860.
Kerkhoff AD, Vogt M, Wood R, Lawn SD, Meintjes G, Burton R. Relationship between blood concentrations of hepcidin and anemia severity, mycobacterial burden, and mortality among patients with HIV-associated tuberculosis. J Infect Dis 2015;213:61-70.
Mihret A, Abebe M, Bekele Y, Aseffa A, Walzl G, Howe R. Impact of HIV co-infection on plasma level of cytokines and chemokines of pulmonary tuberculosis patients. BMC Infect Dis 2014;14:125.
Freeman ML, Shive CL, Nguyen TP, Younes S-A, Panigrahi S, Lederman MM. Cytokines and T-cell homeostasis in HIV infection. J Infect Dis 2016;214(Suppl 2):S51-S7.
Anyabolu HC, Adejuyigbe EA, Adeodu OO. Undernutrition and anemia among HAART-naïve HIV infected children in Ile-Ife, Nigeria: a case-controlled, hospital based study. Pan Afr Med J 2014;18:77.
Feleke DG, Yemanebrhane N, Gebretsadik D. Nutritional status and CD4 cell counts in HIV/AIDS patients under highly active antiretroviral therapy in Addis Ababa, Ethiopia. J AIDS Clin Res 2017;8:1-8.
Ibeh BO, Nwabunni E. Increased oxidative stress condition found in different stages of HIV disease in patients undergoing antiretroviral therapy in Umuahia (Nigeria). Immunopharm Immunother 2012;34:1060-6.
Borges AH, O’Connor JL, Phillips AN, Rönsholt FF, Sarah Pett, Vjecha MJ et al.
Factors associated with plasma IL-6 levels during HIV infection. J Infect Dis 2015;212:585-95.
Borges ÁH, Weitz JI, Collins G, Baker JV, Lévy Y, Davey RT et al.
Markers of inflammation and activation of coagulation are associated with anemia in antiretroviral-treated HIV disease. AIDS 2014;28:1791-6.
Madu AJ, Ughasoro MD. Anaemia of chronic disease: an in-depth review. Med Principles Pract 2017;26:1-9.
Tsiakalos A, Routsias JG, Kordossis T, Moutsopoulos HM, Tzioufas AG, Sipsas NV. Fine epitope specificity of anti-erythropoietin antibodies reveals molecular mimicry with HIV-1 p17 protein: a pathogenetic mechanism for HIV-1-related anemia. J Infect Dis 2011;204:902-11.
Gibellini D, Clò A, Morini S, Miserocchi A, Ponti C, Re MC. Effects of human immunodeficiency virus on the erythrocyte and megakaryocyte lineages. World J Virol 2013;2:91-101.
Kharb S, Lallar M, Ghalaut P, Bala J, Kumawat M, Nanda S. Hemoglobin and serum ferritin concentration in anemic and nonanemic human immunodeficiency virus females in India. J Health Res Rev 2018;5:22-5. [Full text]
Dash KR, Meher LK, Hui PK, Behera SK, Nayak SN. High incidence of zidovudine induced anemia in HIV infected patients in Southern Odisha. Indian J Hematol Blood Transfusion 2015;31:247-50.
Ejeliogu E, Oguche S, Ebonyi A, Okpe SE, Yiltok ES, Ige O et al.
Zidovudine-induced anemia in human immunodeficiency virus infected children on highly active anti-retroviral therapy in Jos, Nigeria. J Adv Med Pharmaceutic Sci 2014;1:1-10.
Babadoko AA, Hassan A, Mamman AI, Suleiman AM, Ahmed SA. Zidovudine induced bone marrow toxicity: a case report. Highland Med Res J 2007;5:41-2.
Muluken W, Epherem M. Assessment of the prevalence of zidovudine induced anemia among adult HIV/AIDS patients on HAART in an Ethiopian Hospital. Occup Med Health Aff 2018;6:2.
Adediran A, Osunkalu V, Wakama T, John-Olabode S, Akinbami A, Uche E et al.
Impact of HIV infection and zidovudine therapy on RBC parameters and urine methylmalonic acid levels. Interdiscip Perspect Infect Dis 2016;2016:5210963.
Moots RJ, Sebba A, Rigby W, Ostor A, Porter-Brown B, Donaldson F et al.
Effect of tocilizumab on neutrophils in adults with rheumatoid arthritis: pooled analysis of data from phase 3 and 4 clinical trials. Rheumatology 2017;56:541-9.
[Table 1], [Table 2], [Table 3]