Hemochromatosis Gene Polymorphisms,
Mitochondrial Haplogroups, and Peripheral
Lipoatrophy during Antiretroviral Therapy
Todd Hulgan,1Pablo Tebas,2Jeffrey A. Canter,1Kathleen Mulligan,3,aDavid W. Haas,1Michael Dubé,4
Steven Grinspoon,5Gregory K. Robbins,5Alison A. Motsinger,1and Asha R. Kallianpur,1for the AIDS Clinical Trials
Group 384 and A5005s Study Teams
1Vanderbilt University School of Medicine, Nashville, Tennessee;2University of Pennsylvania, Philadelphia, Pennsylvania;3University of California
at San Francisco, San Francisco, California;4Indiana University School of Medicine, Indianapolis, Indiana; and5Massachusetts General Hospital,
Harvard University, Boston, Massachusetts
(See the editorial commentary by Lichtenstein on pages 784–6.)
Antiretroviral therapy (ART)–associated lipoatrophy involves mitochondrial dysfunction. Iron
gene (HFE) polymorphisms have been associated with ART-induced neuropathy. We assessed relationships between
these variants and lipoatrophy.
The AIDS Clinical Trials Group 384 study randomized ART-naive individuals to receive didanosine-
stavudine or zidovudine-lamivudine, combined with efavirenz and/or nelfinavir. Substudy A5005s evaluated fat
distribution by dual-energy X-ray absorptiometry (DEXA). We characterized HFE polymorphisms 845G?A and
187C?G and European mitochondrial haplogroups in A5005s participants who consented to genetic analyses.
Among 96 participants (58% were white, and 10% were female) with baseline and 48 or 64 week DEXA
data, the median limb fat change was ?8.8% (interquartile range, ?28.7% to ?15.6%). HFE 187C/G heterozygotes
(n ? 23)hadlesslimbfatlossthan187C/Chomozygotes(n ? 71)(?6.1%vs.?12.5%;P ? .02)andwerelesslikely
interval,0.10–0.95;P ? .04).Amongnon-Hispanicwhiteparticipants,medianlimbfatchangewas?26.1%among
drial haplogroups (P ? .07).
phy during ART in A5005s. These associations should be replicated in other studies.
Potent antiretroviral therapy (ART) has reduced mor-
bidity and mortality due to acquired immunodeficiency
immunodeficiency virus type 1 (HIV) infection include
2 nucleoside reverse-transcriptase inhibitors (NRTIs)
NRTI inhibition of mitochondrial DNA (mtDNA)
polymerase-? may contribute to treatment-limiting
(i.e., lipoatrophy) is believed to result from mitochon-
Received 10 August 2007; accepted 15 October 2007; electronically published
21 February 2008.
Potential conflicts of interest: D.W.H. has received research grants from Ba-
varian Nordic, Boehringer-Ingelheim, Bristol-Meyers Squibb, Gilead Sciences,
Merck, Tanox, and Tibotec; and is on Scientific Advisory Boards for GlaxoSmith-
Kline and Tibotec. M.P.D. has served as a consultant to Pfizer, GlaxoSmithKline,
Gilead, Bristol-Myers Squibb, and Tibotec; has served on the speakers’ bureau and
received honoraria from Pfizer, GlaxoSmithKline, Gilead, Bristol-Myers Squibb, and
Merck; and has received research grants from Pfizer, GlaxoSmithKline, Gilead,
Bristol-Myers Squibb, Merck, TheraTec and Serono. S.G. has received research
grants from Bristol-Meyers Squibb and GlaxoSmithKline. All other authors report
no potential conflicts of interest.
Presented in part: 14th Conference on Retroviruses and Opportunistic Infections,
February 2007, Los Angeles, CA.
The Journal of Infectious Diseases
© 2008 by the Infectious Diseases Society of America. All rights reserved.
Financial support: Adult AIDS Clinical Trials Group, funded by the National
Institute of Allergy and Infectious Diseases (grants UO1 AI068636 and AI38858);
National Institutes of Health (awards AT002508 [to T.H.] and AI46339 and AI54999
[to D.W.H.]); and Vanderbilt-Meharry Center for AIDS Research (award AI54999
aCurrent affiliation: North Carolina State University, Raleigh, North Carolina.
Reprints or correspondence: Dr. Todd Hulgan, Div. of Infectious Diseases,
Vanderbilt University School of Medicine, 345 24th Ave. N., Ste. 105, Nashville, TN
M A J O R A R T I C L E
● JID 2008:197 (15 March)
● Hulgan et al.
by guest on December 27, 2015
thymidine-analogue NRTIs (stavudine or zidovudine) are most
frequently associated with lipoatrophy, and switching from
stavudine or zidovudine to NRTIs with lower affinity for
Other putative risk factors for lipoatrophy include male sex,
white race, lower pre-ART weight, greater cumulative NRTI ex-
posure, more-advanced HIV disease, and a tumor necrosis fac-
tor (TNF)–? gene promoter polymorphism [7–9]. Recent data
have also suggested use of the protease inhibitor nelfinavir as a
possible risk factor .
macrophages to adipose tissues, possibly in response to disease-
associated and/or drug-associated mitochondrial damage .
Oxidative stress induced by mitochondrial dysfunction and
macrophage-mediated cytokine/chemokine release may pro-
mote these toxic complications. In lipoatrophy the exuberant
inflammatory response is associated with adipocyte toxicity and
apoptosis . Only some persons exposed to NRTIs develop
significant lipoatrophy, suggesting a genetic predisposition
among certain individuals. Studies to identify genetic suscepti-
bility factors in lipoatrophy may improve drug selection at the
time of ART initiation and lead to new strategies for preventing
and managing this complication.
ipants who received ART that included didanosine and stavu-
neuropathy in persons heterozygous for the hemochromatosis
(HFE) mutation 845G?A and a trend toward protection from
this complication in carriers of another common variant, HFE
187C?G . Hereditary hemochromatosis is a genetic iron-
overload disorder, usually resulting from a homozygous mis-
sense mutation (nucleotide 845G?A) that substitutes tyrosine
for cysteine at position 282 in the HFE gene . Although
845G?A heterozygotes rarely develop hemochromatosis, they
which substitutes aspartate for histidine at position 63, is also
of iron overload [14, 17, 18]. The reduced toxic neuropathy ob-
served in carriers of HFE polymorphisms may occur by a num-
macrophage iron transport defect associated with the 845G?A
polymorphism is known to lead to a lower-than-normal iron
content in these cells; macrophage iron deficiency may, in turn,
ing macrophage-mediated inflammation. Alternatively, an im-
proved supply of iron to metabolically active cells such as neu-
rons may benefit mitochondrial function in HFE carriers,
rendering these individuals less susceptible to NRTI-associated
The human mitochondrial genome comprises circular,
double-stranded DNA (i.e., mtDNA) that encodes ribosomal
RNAs, transfer RNAs, and 13 polypeptides that are essential for
oxidative phosphorylation. Stable single-nucleotide polymor-
phisms (SNPs) in the mitochondrial genome define mitochon-
drial haplogroups, the distribution of which has been used to
map prehistoric human migrations [19, 20]. We previously
logroup T and peripheral neuropathy among participants in
ACTG 384 .
We hypothesized that HFE polymorphisms and/or stable
SNPs in the mtDNA, such as those defining mitochondrial hap-
volving participants from the A5005s metabolic substudy of
ACTG 384, examined relationships between HFE polymor-
phisms, mitochondrial haplogroups, and limb fat changes dur-
ing NRTI-containing ART.
PATIENTS AND METHODS
Study participants and design.
multicenter clinical trial to evaluate initial HIV treatment strat-
egies in adults [22, 23]. Briefly, volunteers were enrolled in the
United States and Italy in 1998 and 1999. Eligibility criteria in-
cluded a plasma HIV-1 RNA load of ?500 copies/mL and ?7
days of prior ART. Patients were randomized to receive 3- or
4-drug therapy with didanosine-stavudine or zidovudine–lami-
vudine in combination with efavirenz, nelfinavir, or both. Reg-
imen failure was defined by virologic and toxicity-related crite-
ria, and the primary end point was time to failure of the second
regimen or discontinuation of all study medications. Self-
reported race/ethnicity categories were “white, non-Hispanic,”
“black, non-Hispanic,” and “Hispanic”; we hereafter refer to
these groups as white, black, and Hispanic, respectively.
The ACTG A5005s substudy (described elsewhere ) en-
157 subjects from 18 sites underwent whole-body, dual-energy
X-ray absorptiometry (DEXA) that was analyzed centrally at
baseline and every 16 weeks thereafter. Ninety-six individuals
had specimens available from the ACTG Human DNA Reposi-
tory (protocol A5128 ) at the Vanderbilt Center for Human
Genetics Research (Nashville, TN) and had DEXA results avail-
able at baseline and at week 48 or 64 after the initiation of ART.
Many ACTG 384/A5005s study participants did not participate
mographic and clinical characteristics of participants from
ilar to the characteristics of those who did not .
The 384, A5005s, and A5128 studies were approved by the
institutional review boards at each site, and all participants pro-
ACTG 384 was a randomized,
HFE Gene Polymorphisms and Lipoatrophy
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