The 1G/1G+1G/2G Genotypes of MMP1 rs1799750 Are Associated with Higher Levels of MMP-1 and Are Both Associated with Lipodystrophy in People Living with HIV on Antiretroviral Therapy

Abstract

In HIV-infected patients, antiretroviral therapy (ART) is associated to adipose tissue redistribution known as lipodystrophy (LD). This study aimed at verifying the association between the polymorphism of the MMP1 gene (rs1799750) (1G/2G) and the serum levels of matrix metalloproteinase 1 (MMP-1) with LD and its subtypes in people living with HIV on ART. This is a cross-secional study. LD was self-reported. The determination of the MMP1 rs1799750 gene polymorphism was performed by real-time PCR, and the serum concentrations of MMP-1 were quantified by the enzyme-linked immunosorbent assay (ELISA) method. Of 404 participants, 204 (51%) were diagnosed with LD, of whom 89 (43%) had mixed lipodystrophy (ML), 72 (35%) had lipohypertrophy (LH), and 43 (22%) had lipoatrophy (LA). There was an association between the genotypes 1G/1G+1G/2G and higher serum levels of MMP-1 (p = .025). There was no association of MMP1 (1G/2G) with LD. Other factors associated with LD were current CD4 ≤ 350 [odds ratio (OR) = 4.85, confidence interval (CI) = 1.78–47.99, p = .0033] and serum MMP-1 levels >6.81 (OR = 2.67, CI = 1.21–6.08, p = .0165). Factors associated with ML: current CD4 ≤ 350 (OR = 5.59, CI = 1.69–20.39, p = .006); with LH: number of antiretroviral regimens used: 2 (OR = 2.06, CI = 1.01–4.20, p = .0460) and 3+ (OR = 2.09, CI = 1.00–4.35, p = .0477), and current CD4 ≤ 350 (OR = 2.08, CI = 1.00–4.24, p = .0461); and with LA: current viral load >40 (OR = 2.52, CI = 1.03–5.91, p = .0372) and current use of zidovudine (OR = 2.97, CI = 1.32–6.54, p = .0074). Higher levels of MMP-1 were associated with genotypes 1G/2G+1G/1G and with LD. Other individual risk factors were independently associated with LD, and its subtypes, suggesting that the pathogenesis itself is differently manifested for each type of LD.

Introduction

Lipodystrophy (LD) is the most important aspect of HIV Lipodystrophy Syndrome and may occur alone or associated with insulin resistance, type 2 diabetes, dyslipidemia, hypertension, endothelial dysfunction, and altered production of cytokines and adipokines.¹ LD is characterized by modifications in the distribution of body fat in infected individuals, and it is divided into three different forms of presentation: lipoatrophy (LA), lipohypertrophy (LH), and mixed lipodystrophy (ML).²

The prevalence of HIV-related LD may range from 20% to 80%, and it is more commonly reported in 50% of individuals on antiretroviral therapy (ART).^3,4 This wide variation may be related to different factors such as geographic location, age, genetics, and lifestyle, as well as methodological differences used for diagnosis among studies.^5

–8

The redistribution of body fat and metabolic abnormalities are considered the most alarming side effect in patients on ART.^9
–11 However, the pathophysiology of LD is not completely elucidated. Genetic studies associating modifications in the redistribution of body fat with proteins involved in adipogenesis, remodeling of the extracellular matrix and inflammation, and molecules involved in these processes, such as matrix metalloproteinase 1 (MMP-1), may contribute toward explaining the heterogeneity in the emergence and severity of LD.

Matrix metalloproteinases are molecules involved in the remodeling of the extracellular matrix, in the differentiation of adipocytes and appear to be inhibited by drugs such as antiretrovirals.¹² In addition, these proteins act in a pro-inflammatory manner by stimulating the production of cytokines, chemokines, and other proteins that regulate several aspects of inflammation and immunity.¹³ The MMP-1, also called collagenase-1, is expressed both in normal cells such as fibroblasts, keratinocytes, endothelial cells, macrophages, chondrocytes, osteoblasts, and osteoclasts, as well as in tumor cells.¹⁴ The gene MMP1 that encodes MMP-1 plays a clinically important role in pathological processes, including rheumatoid arthritis, pancreatitis, non-alcoholic steatohepatitis, and osteoarthritis.^15
–17 It was observed that the single nucleotide polymorphism (SNP) rs1799750 (-1607 1G/2G) of the MMP1 gene modifies its expression levels, in which the 2G allele is related to a higher transcription activity, which may reach up to 20 times more than the 1G allele.^18,19

Montes et al. ¹² evaluated the association of LD in 216 people living with HIV (PLWHIV) on ART with SNP MMP1 (-1607 1G/2G) and serum MMP-1 levels and observed that carriers of the 2G/2G genotype presented higher serum levels of MMP-1 when compared with 1G/1G (p = .02). In addition, they found that carriers of the 2G allele were more frequent in the group with LD, when compared with the group without LD. It is still unknown how exactly and why some PLWHIV develop LD and others do not. Although the use of ARV has been the most studied risk factor,^20

–24 LD is probably a multifactorial event and there are still some unanswered gaps on its etiopathogenesis, suggesting that genetic factors may be involved in this adverse event. Therefore, this study aimed at describing the frequency of LD in 404 PLWHIV on ART and at verifying its association with the rs1799750 polymorphism of the MMP1 gene (-1607 1G/2G) and serum MMP-1 levels.

Methodology

Study population

Between May 2017 and August 19, 404 PLWHIV on ART were recruited. These participants were followed up at the Hospital Universitário Oswaldo Cruz of the Universidade de Pernambuco and Hospital Correia Picanço, which are reference for HIV/AIDS, responsible for the treatment of most patients with HIV/AIDS in the state of Pernambuco. Participants of both genders were included, as they were on ART since 2008, for a minimum period of 3 months.

To define LD, participants answered a standardized questionnaire.⁴ Some of them were excluded after the questionnaire, such as: The patients with AIDS-defining illness or any hospitalization in the 3 months preceding the questionnaire application, those on chronic use of corticosteroids and/or anabolic steroids in the 6 months preceding the questionnaire application, those with a clinical history of Cushing's syndrome, family LD, advanced chronic liver disease, active lymphoma/cancer, or ongoing pregnancy The clinical data of the participants were obtained from medical records. The history of ART, CD4, CD8, and viral load (VL) counts was obtained through the Brazilian National CD4+/CD8+ Lymphocyte Count and Viral Load Network Laboratory Test Control System; and Logistic Medication Monitoring System (known as SISCEL) and Logistic Control System for Antiretroviral Medication (known as SICLOM), respectively.

Deoxyribonucleic acid extraction and genotyping of the MMP1 gene polymorphism

The deoxyribonucleic acid (DNA) of the samples was extracted from whole blood (EDTA) with the Wizard^® Genomic DNA Purification kit, following the manufacturer's instructions. The determination of the MMP1 gene polymorphism (-1607 1G/2G) was performed by real-time PCR, using the TaqMan Genotyping Assays methodology (Thermo Scientific, CA), with the specific probe for the MMP1 gene—rs1799750 (ID: C__34384693_10). The test was performed according to the manufacturer's instructions. The equipment used was Quantistudio5 (Thermo Scientific).

Quantification of serum concentrations of MMP-1

Peripheral blood (5 mL) was collected from each participant, samples were centrifuged, and the sera were stored in aliquots at −80°C. Serum MMP-1 levels were quantified by the enzyme-linked immunosorbent assay (ELISA) method, using RayBiotech MMP Quantibody Human 1 Kit (Norcross, GA), according to the manufacturer's instructions. For the analysis of the association between serum MMP-1 levels and LD, ML, LH, and LA, the MMP-1 median was determined in each group, and then it was compared with the group without LD.

Immune reconstitution, standard inflammation, and immunodeficiency

To characterize the inflammatory profile of the participants, we created three variables that illustrate different clinical conditions and may result in inflammation: “immune reconstitution,” “poorly controlled infection (viremia),” and the last one, which combines both conditions, “inflammation.” The participants were included in each one of the groups mentioned earlier according to the CD4 count and VL. It was observed participants with at least one information and at most four information regarding CD4 and VL.

During the analysis to define the appropriate model, several models of latent classes with a VL and CD4 approach were tested with different cutoff points to obtain the most harmonious model. For CD4, the cutoff point adopted was 500 and for VL, 40 copies (detectable/undetectable).

The following variables were created:

Immune reconstitution: It is characterized by a temporarily positive VL in the initial phase, which decreases over time, and a CD4 count that grows steadily in the four moments of the evaluation.

Immunodeficiency/poorly controlled infection: Characterized by positive VL over the four assessment periods, and low CD4 values over the four periods.

Inflammation: immune reconstitution + immunodeficiency.

Statistical analysis

The Arlequin software (version 3.2) was used to test the Hardy-Weinberg equilibrium. The chi-square test (χ²) with Yates correction was used to test the association between categorical variables and LD. The strength of the association between the studied variables was estimated by the odds ratio (OR), with a 95% confidence interval. When appropriate, the Students' t or Mann–Whitney test was applied, to compare continuous variables, between the two groups. All decisions were made at a significance level of 5%, and the software used was the R Core Team.²⁵

The 404 participants were stratified according to the following parameters: current CD4 (≤350 and >350), immune reconstitution, immunodeficiency, inflammation, current VL (>40 and ≤40), age (≤40 and >40 years), sex, number of antiretroviral regimens used (1, 2 or ≥3), duration of ART (months), current or past zidovudine (AZT) use, time since HIV diagnosis (years), smoking (yes/no), physical activity (yes/no), SNP MMP1 (rs1799750) (1G/1G, 1G/2G, and 2G/2G), and median serum MMP-1 levels (ng/mL).

A univariate analysis was performed to verify the association between clinical cofactors and each LD subtype. Variables with p < .25 were selected for multivariate analysis.

Ethical considerations

The project was approved by the Research Ethics Committee at Hospital Universitário Oswaldo Cruz (Opinion/CEP/HUOC: 1,119,512 on June 23, 2015—CAAE 46413015.9.0000.5192).

Patient and public involvement

Patients or the public were not involved in the design, conduct, reporting, or dissemination plans of our research.

Results

A total of 404 participants signed the consent form after being invited to participate in the research, from May 2017 to August 2019. Participants had already been on ART for at least 3 months (median 64 months, range 3–135). Of these, 67 (16.6%) were on current use of AZT and 207 (51.2%) were exposed to AZT at some point during treatment. Two hundred and four participants (51%), with a median age of 40 years (19–71 years), were diagnosed with LD, of whom 89 (44%) had ML, 72 (35%) had LH, and 43 (21%) had LA. The other 200 (49%) participants, with a median age of 40.5 years (19–62), did not present LD.

The SNP MMP1 (-1607 1G/2G) was in Hardy–Weinberg equilibrium. The allele frequencies are described in Table 1. There was no association between this SNP (-1607 1G/2G) with LD and its subtypes: ML, LH, and LA, when compared with the group without LD (Table 1).

Table 1.

MMP1 Polymorphism (rs1799450) and Serum MMP-1 Levels and Their Association with Lipodystrophy, Mixed Lipodystrophy, Lipohypertrophy, and Lipoatrophy in People Living with HIV on Antiretroviral Therapy

MMP1	LD (+)	LD (−)	OR (CI)	p
2G/2G	64 (0.31)	55 (0.28)	1.00
2G/1G	93 (0.46)	91 (0.45)	0.75 (0.44–1.27)	.2845
1G/1G	47 (0.23)	54 (0.27)	0.88 (0.55–1.39)	.5818
1G/1G	47 (0.27)	54 (0.23)	1.00
2G/2G+2G/1G	157 (0.73)	146 (0.77)	1.24 (0.79–1.94)	.3584
MMP-1 serum levels
≤6.81	26 (0.41)	40 (0.59)	1.00
>6.81	37 (0.59)	28 (0.41)	2.03 (1.02–4.12)	.0458^a
MMP1	ML(+)	ML (−)
2G/2G	28 (0.31)	55 (0.28)	1.00
1G/1G	39 (0.44)	91 (0.45)	0.84 (0.47–1.53)	.5672
2G/1G	22 (0.25)	54 (0.27)	0.80 (0.41–1.57)	.5163
2G/2G+2G/1G	67 (0.75)	146 (0.73)	1.00
1G/1G	22 (0.25)	54 (0.27)	1.13 (0.64–2.03)	.6844
MMP-1 serum levels
≤6.29	13 (0.43)	36 (0.53)	1.00
>6.29	17 (0.57)	32 (0.47)	1.47 (0.62–3.54)	.3817
MMP1	LH (+)	LH (−)
2G/2G	25 (0.35)	55 (0.28)	1.00
2G/1G	32 (0.44)	91 (0.45)	0.61 (0.29–1.27)	.4180
1G/1G	15 (0.21)	54 (0.27)	0.77 (0.42–1.45)	.1934
2G/2G+2G/1G	57 (0.79)	57 (0.73)	1.00
1G/1G	15 (0.21)	54 (0.27)	1.41 (0.75–2.76)	.3038
MMP-1 serum levels
≤5.99	10 (0.43)	36 (0.53)	1.00
>5.99	13 (0.57)	32 (0.47)	1.46 (0.57–3.87)	.4339
MMP1	LA (+)	LA (−)
2G/2G	11 (0.26)	55 (0.28)	1.00
2G/1G	22 (0.51)	91 (0.45)	1.21 (0.55–2.77)	.6412
1G/1G	10 (0.23)	54 (0.27)	0.93 (0.36–2.37)	.8718
2G/2G+2G/1G	33 (0.77)	146 (0.73)	1.00
1G/1G	10 (0.23)	54 (0.27)	0.82 (0.36–1.72)	.6135
MMP-1 serum levels
≤6.37	2 (0.20)	37 (0.54)	1.00
>6.37	8 (0.80)	31 (0.46)	4.77 (1.10–33.21)	.0588

Chi-square test with Yates correction.

LA, lipoatrophy; LD, lipodystrophy; LH, lipohypertrophy; ML, mixed lipodystrophy; MMP-1, matrix metalloproteinase-1; OR, odds ratio.

Regarding serum MMP-1 levels, participants with 1G/2G+1G/1G genotypes presented higher serum MMP-1 levels when compared with the 2G/2G genotype (7.13 × 5.46 ng/mL, respectively, p = .0232) (Fig. 1). There was a higher proportion of participants with higher serum MMP-1 levels (>6.81) in the group with LD, when compared with the group without LD (p = .0458) (Table 1).

FIG. 1.

Association between serum MMP-1 levels and MMP1 genotypes in people living with HIV on antiretroviral therapy. 2G/2G = 5.46 (0.54–21.70), n = 42, 2G/1G+1G/1G = 7.13 (0.49–30.19), n = 88, p = .0232*. *Mann–Whitney test. MMP-1, matrix metalloproteinase-1.

In the univariate analysis, clinical cofactors associated with LD (p < .25) were: current CD4 ≤ 350 (p = .0141), inflammation (p = .0349), number of antiretroviral regimens used (2 p = .0797; 3 + p = .1871), and past use of AZT (p = .1649) (Supplementary Table S1). The cofactors associated with ML (p < .25) were: current CD4 ≤ 350 (p = .0350), immune reconstitution (p = .1358), immunodeficiency (p = .2455), number of antiretroviral regimens used (2 p = .1310; ≥3 p = .3549), and past AZT (p = .0341) (Supplementary Table S2). The cofactors associated with LH (p < .25) were: current CD4 < 350 (p = .0744), current VL >40 (p = .0469), age >40 years (p = .2257), male gender (p = .1649), and number of antiretroviral regimens used (2 regimens: p = .0648; 3+ regimens: p = .0541) (Supplementary Table S3); and the cofactors associated with LA were: current CD4 < 350 (p = .1358), current VL >40 (p = .0349), age >40 years (p = .1302), current use of AZT (p = .0323), and smoking (p = .0245) (Supplementary Table S4).

Tables 2–5 show the results of multivariate analysis for the selected cofactors and their association with LD and its subtypes. Cofactors associated with LD were CD4 ≤ 350 (p = .0033) and serum MMP-1 levels >6.81 (p = .0165). Cofactors associated with ML: CD4 ≤ 350 (p = .006); with LH: number of antiretroviral regimens used: 2 (p = .0460) and 3+ (p = .0477), and CD ≤350 (p = .0461); and with LA: VL >40 (p = .0023) and current use of AZT (p = .0074).

Table 2.

Independent Variables Associated with Lipodystrophy in People Living with HIV on Antiretroviral Therapy

Final model	OR	CI	p
Current CD4 (>350)
≤350	4.85	1.78–47.99	.0033^a
MMP-1 (≤6.81)
>6.81	2.67	1.21–6.08	.0165^a

Multivariate analysis.

CD4, cluster of differentiation; CI, confidence interval; MMP-1, matrix metalloproteinase-1.

Table 3.

Independent Variables Associated with Mixed Lipodystrophy in People Living with HIV on Antiretroviral Therapy

Final model	OR	CI	p
Past use of AZT (No)
Yes	1.82	0.62–5.83	.2852
Current CD4 (>350)
≤350	5.59	1.69–20.39	.0060
MMP-1 (≤6.29)
>6.29	1.67	0.60–4.85	.3325

Multivariate analysis.

AZT, zidovudine; MMP-1, matrix metalloproteinase-1.

Table 4.

Independent Variables Associated with Lipohypertrophy in People Living with HIV on Antiretroviral Therapy

Final model	OR	CI	p
Number of regimen
2	2.06	1.01–4.20	.0460^a
≥3	2.09	1.00–4.35	.0477^a
Current CD4 (>350)
≤350	2.08	1.00–4.24	.0461^a

Multivariate analysis.

Table 5.

Independent Variables Associated with Lipoatrophy in People Living with HIV on Antiretroviral Therapy

Final models	OR	CI	p
Model 1
Current VL (≤40)
>40	15.86	2.88–112.17	.0023
Current use of AZT (No)
Yes	1.05	0.10–7.75	.9646
MMP-1 (≤6.37)
>6.37	4.32	0.74–38.21	.1296
Model 2
Current VL (≤40)
>40	2.52	1.03–5.91	.0372
Current use of AZT (No)
Yes	2.97	1.32–6.54	.0074

Multivariate analysis.

MMP-1, matrix metalloproteinase-1.

There was an association of serum levels of MMP-1 with LA, adjusted by the use of AZT, reducing the OR related to the current use of AZT from 2.97 to 1.05 (Table 5).

Discussion

Increased serum levels of MMP-1 were associated with genotypes 1G/2G+1G/1G, and participants with LD presented higher levels of MMP-1 when compared with those without LD. We did not find an association of SNP MMP1 (rs1799750) with LD, or with its subtypes in PLWHIV on ART. However, clinical and individual cofactors were associated with LD: current CD4 ≤ 350 (p = .0033) and serum MMP-1 levels >6.81 (p = .0165), being different for each subtype.

MMPs can induce damage to host tissue at different levels, disrupting the immune process and activating HIV infection. The overproduction of these enzymes, the failure in controlling their activities and expression, may be involved in the pathogenesis of LD.²⁶

In our study, we did not find an association between the SNP MMP1 (-1607 1G/2G) and LD. Montes et al. ¹² evaluated the SNP MMP1 (-1607 1G/2G) in 216 PLWHIV on ART with LD (41.3 ± 7.9 years) and without LD (43.2 ± 10, 0 years) in Spain. LD was present in 82 participants (38%), unlike our study (51%). In addition, the authors observed an association between a higher frequency of the 2G/2G genotype in participants with LD (41.3% vs. 20.5%, p = .002), when compared with participants without LD.

MMP-1 is inhibited by the metalloproteinase 1 inhibitor (TIMP-1) as well as by a YKL-40 protein, which is secreted by the cells of the vascular stroma fraction of visceral adipose tissue.²⁷ Montes et al. ¹² suggested that the decrease in body fat in LD patients may induce a lower production of YKL-40 and indirectly increase MMP-1 since, in their study, the cohort was largely composed of patients with LA (95%), which may be even more evident in patients with the 2G/2G genotype of the SNP MMP1, in whom the serum levels of MMP-1 were already higher than in those with the 1G/1G genotype. In our study, only 22% of participants presented LA, which could explain the difference in the results.

Ghaffarzadeh et al. ²⁸ evaluated the association between the SNP MMP1 (-1607 1G/2G) and the risk of coronary artery disease (CAD) in 102 patients and 102 healthy Turkish Iranian individuals, and they observed a higher frequency of the genotype 2G/2G and the 2G allele in patients with CAD over 50 years (p < .05). However, Chehaibi et al. ²⁹ evaluated the association between ischemic stroke and the SNP MMP1 (-1607 1G/2G) in 196 patients and 192 control subjects and found no association between the SNP and risk of ischemic stroke (p = .074) in patients with type 2 diabetes mellitus (DM2), even after adjusting for risk factors.

Regarding serum MMP-1 levels, participants with 1G/2G+1G/1G genotypes presented higher serum MMP-1 levels when compared with those with 2G/2G genotypes (p = .0232); participants with LD presented a higher median serum MMP-1 levels (>6.81) when compared with the group without LD (p = .0458).

Hsuan et al. ³⁰ evaluated serum MMP-1 levels in 506 Chinese individuals and observed that the 2G/1G+1G/1G genotypes were associated with higher levels of MMP-1 than the 2G/2G genotype (611.9 × 323.2 pg/mL) (p < .001), corroborating our study. However, Montes et al. ¹² observed higher serum levels of MMP-1 in patients with LD (18.5 ± 48 ng/mL × 10.4 ± 14.5 ng/mL, p = .022). They also found higher serum MMP-1 levels in patients with the 2G/2G genotype, when compared with those with the 1G/1G genotype (18.5 ± 48 ng/mL × 10.4 ± 14.5 ng/mL, p = .022), which is not in accordance to our results.

A possible explanation for the different findings of serum levels and the SNP MMP1 (-1607 1G/2G) would be the imbalance with another SNP in the same gene. Hsuan et al. (2013) studied five SNPs (rs1799750, rs11226373, rs495366, s514921, and rs1144393) closely linked to the MMP1 gene and found an incomplete linkage imbalance of the allele A of rs495366, linked to the 2G allele of the SNP rs1799750 gene MMP1. This allele has been associated with higher expression of the MMP1 gene in previous studies^31,32; however, Hsuan et al. ³⁰ found a lower serum level of MMP-1. These previous studies suggest that although SNP -1607 1G/2G affects the expression of the MMP1 gene, it may not be the main determinant of serum MMP-1 levels in Chinese patients.^31,32

While trying to explain the pathogenesis of LD in PLWHIV, some authors seek to identify individual factors involved, including the type of ARV that is used³³; disorders in the synthesis of cytokines and adipokines, mainly produced by adipose tissue,³⁴ inflammation,³⁵ immune activation,³⁶ and genetic characteristics of the individual.³⁷ In this study, we found that LD and its subtypes (ML, LH, and LA) were associated with distinct factors, which suggests that the physiopathology of each subtype of LD may be different.

Current CD4 ≤ 350 was independently associated with LD, ML, and LH. Koethe³⁶ showed that HIV-infected individuals on ART, who were overweight, presented lower plasma CD4 levels when compared with patients with normal weight. Viladés et al. ³⁸ highlight that individuals with LD presented levels of lipopolysaccharide (LPS) and lipopolysaccharide-binding protein (LBP) that positively correlated with the pre-ART VL and negatively correlated with CD4, suggesting that this would be due to the high degree of inflammation and activation of immunity in these individuals. Baril et al. ³⁹ also highlight that the long duration of HIV infection, as well as the sustainable high VL and low CD4+T lymphocyte count are highly related to the development of LD.

Higher serum levels of MMP-1 (>6.81) were independently associated with LD. Montes et al. ¹² evaluated 216 PLWHIV on ART and also found higher serum levels in patients with LD when compared with the group without LD (18.5 ± 48 × 10.4 ± 14.5, p = .022). MMP-1 plays an important role in the remodeling and degradation of the extracellular matrix, and it is also involved in the differentiation of adipocytes, an important process in the pathogenesis of LD.^40,41

The past use of AZT was independently associated with ML, and the current use of AZT was associated with LA (p = .0448 and p = .0074). The exposure to 2 or 3+ regimens was associated with and LH (p = .0460 and p = .0477, respectively). The residual toxicity of the first-generation nucleoside reverse-transcriptase inhibitors (NRTIs)—stavudine (d4T) and AZT—can affect the adipose tissue, which suggests that this tissue may be sensitized by the effect of ARVs.⁴² Besides, a study with PLWHIV recruited from Copenhagen Comorbidity (COCOMO), with more than 100,000 individuals, showed that cumulative exposure to d4T, AZT, or didanosine (DDI) is associated with long-lasting effects, such as increased visceral adipose tissue, subcutaneous decrease adipose tissue assessed by abdominal computed tomography, as well as being related to the excessive risk of hypertension, increased total cholesterol and low high-density lipoprotein.⁴³

When verifying the association of serum levels of MMP-1 with LA, adjusted by the current use of AZT, we observed that MMP-1 reduced the OR related to the current use of AZT from 2.97 to 1.05 (Table 5); however, the association between MMP-1 and LA did not change or changed slightly. These results suggest that the increase in MMP-1 levels may be the path through which the use of AZT leads to LA. There are several publications showing the association between AZT and LA^12,44,45 and we could hypothesize that it could occur through its effect on the action of MMP-1.

Montes et al.,¹² using logistic regression to study the variables that were associated with LA, demonstrated that the transportation of the MMP1 2G allele, lower serum levels of TIMP-4, higher serum levels of MMP-3, absence of HCV co-infection, d4T treatment, and AZT period of use were variables independently associated to LA. In our study, the use of AZT also showed an independent association with LA.

Among the NRTI, LA is more associated with the use of d4T and AZT. NRTIs deplete mitochondrial DNA by inhibiting mitochondrial DNA polymerase, which may result in adipocyte apoptosis.⁴⁴

The current VL >40 was also an independent factor associated with LA. In the HIV outpatient study, 1,077 patients were evaluated considering changes in the distribution of body fat. LA, in addition to being associated with d4T use, was independently associated with risk factors not related to drug use, such as age >40 years, white race, CD4 < 100 cells/mm³, body mass index loss, and longer duration and severity of the HIV disease itself.⁴⁶ The authors suggest that the cause of LA is multifactorial and may be the result of a long-term HIV infection.

Our results indicate that the subtypes of LD (ML, LH, and LA) are associated with different factors, suggesting a different pathogenesis for each subtype. However, these results need to be interpreted with caution as our study has some limitations. This is a retrospective study; although these patients attend a reference center for HIV care and all treatments are well documented, it is possible that there may have been misclassification in relation to the presence of LD and on the time it appeared. As it is a cross-sectional study, the measurement of MMP-1 levels was not done sequentially and therefore we cannot establish the time sequence between the events (increase of MMP-1 levels) and LD/LA. Another limitation is that the sample size may have been small to study the different subtypes of LD.

Conclusion

This work allowed us to diagnose LD, as well as to identify the individual risk factors associated with LD and its subtypes. Higher serum levels of MMP-1 were associated with genotypes 1G/2G+1G/1G, and participants with LD and LA presented higher levels of MMP-1 when compared with those without LD. Our results suggest that clinical and individual cofactors are also involved in the pathogenesis of LD, being different for each subtype. However, we found neither association of SNP MMP1 (rs1799750) with LD, nor with its subtypes in PLWHIV on ART.

We suggest that further studies should be carried out with sequential serum dosage of MMP-1, before and after the start of ARVs, determine the involvement of MMP-1 and SNPs more accurately as to its applicability as a risk marker for LD/LA and its role in the pathogenesis of these manifestations.

Footnotes

Acknowledgments

The authors thank the Laboratório Central de Saúde Pública Dr. Milton Bezerra Sobral (Lacen PE) for facilitating their access to part of the blood samples collected to quantify the participants' HIV VL, after proper authorization by them. This strategy avoided the need to collect samples for research purposes only.

Authors' Contributions

The authors emphasize that this article followed the instructions given by the Journal and that all authors participated in the article as follows: A.S.d.S., D.d.B.M.-F., T.F.d.M.B., M.d.S.d.M.C., G.T.N.D., L.R.S.V., and R.A.d.A.X. for designing the study, acquiring data, and analyzing and interpreting data; K.P.d.Ó., D.N.d.N., R.d.S.S., I.C.C.F., T.F.d.M.B., and A.S.d.S. by elaborating on the article or critically reviewing it to obtain important intellectual content; and finally, A.S.d.S, D.d.B.M.-F., T.F.d.M.B. and M.d.S.d.M.C. for final approval of the version to be submitted.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported by the Fundação de Amparo a Ciência e Tecnologia de Pernambuco (FACEPE) (APQ-1247-4.01/15 and IBPG-0883-4.01/15). This study was also financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—Brasil (CAPES)—Finance Code 001.

Supplementary Material

Supplementary Table S1

Supplementary Table S2

Supplementary Table S3

Supplementary Table S4

References

Giralt

, Domingo

, Villarroya

: Adipose tissue biology and HIV-infection. Best Pract Res Clin Endocrinol Metab, 2011; 25:487–499.

Guimarães

MMM

, Greco

, Júnior

ARO

, Penido

, Machado

LJC

: Distribution of body fat and lipid and glycemic profiles of HIV-infected patients. Arq Bras Endocrinol Metabol, 2007; 51:42–51.

Sattler

: Body habitus changes related to lipodystrophy. Clin Infect Dis, 2003; 36:S84–S90.

Gelenske

, Farias

FAB

, Ximenes

RAA

, et al.: Risk factors in human immunodeficiency virus/acquired immunodeficiency syndrome patients undergoing antiretroviral therapy in the state of Pernambuco, Brazil: A case-control study. Metab Syndr Relat Disord, 2010; 8:271–277.

Jacobson

, Knox

, Spiegelman

, Skinner

, Gorbach

, Wanke

: Prevalence of, evolution of, and risk factors for fat atrophy and fat deposition in a cohort of HIV-infected men and women. Clin Infect Dis, 2005; 40:1837–1845.

Carr

, Emery

, Law

, et al.: An objective case definition of lipodystrophy in HIV-infected adults: A case-control study. Lancet, 2003; 361:726–735.

Heath

, Hogg

, Chan

, et al.: Lipodystrophy-associated morphological, cholesterol and triglyceride abnormalities in a population-based HIV/AIDS treatment database. AIDS, 2001; 15:231–239.

Leitz

, Robinson

: The development of lipodystrophy on a protease inhibitor-sparing highly active antiretroviral therapy regimen. AIDS, 2000; 14:468.

Lazzaretti

, Gasparotto

, Sassi

MGM

, et al.: Genetic markers associated to dyslipidemia in HIV-infected individuals on HAART. ScientificWorldJournal,, 2013; 2013:608415.

10.

Myerson

: Lipid management in human immunodeficiency virus. Cardiol Clin, 2015; 33:277–298.

11.

Soares

FMG

, Costa

IMC

: Lipoatrofia facial associada ao HIV/AIDS: Do advento aos conhecimentos atuais. An Bras Dermatol, 2011; 86:843–864.

12.

Montes

, Valle-Garay

, Suarez-Zarracina T et al.: The MMP1 (−16071G/2G) single nucleotide polymorphism associates with the HAART-related lipodystrophic syndrome. AIDS, 2010; 24:2499–2505.

13.

Parks

, Wilson

, López-Boado

: Matrix metalloproteinases as modulators of inflammation and innate immunity. Nat Rev Immunol, 2004; 4:617–629.

14.

Kerkela

, Saarialho-Kere

: Matrix metalloproteinases in tumor progression: Focus on basal and squamous cell skin cancer. Exp Dermatol, 2003; 12:109–125.

15.

, Ye

, Yin

, et al.: Association of matrix metalloprotease 1, 3, and 12 polymorphisms with rheumatic heart disease in a Chinese Han population. BMC Med Genet, 2018; 19:27.

16.

Manjari

, Nallari

, Balakrishna

, et al.: Influence of matrix metalloproteinase-1 gene 21607 (1G/2G) (rs1799750) promoter polymorphism on circulating levels of MMP-1 in chronic pancreatitis. Biochem Genet, 2013; 51:644–654.

17.

Ando

, Yokomori

, Tsutsui

, et al.: Serum matrix metalloproteinase-1 level represents disease activity as opposed to fibrosis in patients with histologically proven nonalcoholic steatohepatitis. Clin Mol Hepatol, 2018; 24:61–76.

18.

Rutter

, Mitchell

, Buttice

, et al.: A single nucleotide polymorphism in the matrix metalloproteinase-1 promoter creates an Ets binding site and augments transcription. Cancer Res, 1998; 58:5321–5325.

19.

Affara

, Dunmore

, Sanders

, Johnson

, Print

, Charnock-Jones

: MMP1 bimodal expression and differential response to inflammatory mediators is linked to promoter polymorphisms. BMC Genomics, 2011; 12:43.

20.

Carr

, Samaras

, Thorisdottir

, Kaufmann

, Chisholm

, Cooper

: Diagnosis, prediction, and natural course of HIV-1 protease-inhibitor-associated lipodystrophy, hyperlipidaemia, and diabetes mellitus: A cohort study. Lancet, 1999; 353:2093–2099.

21.

Thiébaut

, Daucourt

, Mercié

, et al.: Lipodystrophy, metabolic disorders, and human immunodeficiency virus infection: Aquitaine cohort, France, 1999. Clin Infect Dis, 2000; 31:1482–1487.

22.

Tsiodras

, Mantzoros

, Hammer

, Samore

: Effects of protease inhibitors on hyperglycemia, hyperlipidemia, and lipodystrophy—A 5-year cohort study. Arch Intern Med, 2000; 160:2050–2056.

23.

Zannou

, Denoeud

, Lacombe

, et al.: Incidence of lipodystrophy and metabolic disorders in patients starting non-nucleoside reverse transcriptase inhibitors in Benin. Antivir Ther, 2009; 14:371–380.

24.

Guaraldi

, Stentarelli

, Zona

, et al.: Lipodystrophy and anti-retroviral therapy as predictors of sub-clinical atherosclerosis in human immunodeficiency virus infected subjects. Atherosclerosis, 2010; 208:222–227.

25.

R Core Team: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. Available at https://www.R-project.org (2018), accessed September 15, 2019 .

26.

Mastroianni

, Liuzzi

: Matrix metalloproteinase dysregulation in HIV infection: Implications for therapeutic strategies. Trends Mol Med, 2007; 13:449–459.

27.

Iwata

, Kuwajima

, Sukeno

, et al.: YKL-40 secreted from adipose tissue inhibits degradation of type I collagen. Biochem Biophys Res Commun, 2009; 388:511–516.

28.

Ghaffarzadeh

, Bagheri

, Khadem-Vatani

, Rad

: Association of MMP-1 (rs1799750) -1607 2G/2G and MMP-3 (rs3025058) -1612 6A/6A genotypes with coronary artery disease risk among Iranian Turks. J Cardiovasc Pharmacol, 2019; 74:420–425.

29.

Chehaibi

, Hrira

, Nouira

, Maatouk

, Hamda

, Slimane

: Matrix metalloproteinase-1 and matrix metalloproteinase-12 gene polymorphisms and the risk of ischemic stroke in a Tunisian population. J Neurol Sci, 2014; 342:107–113.

30.

Hsuan

, Wu

, Hsu

, et al.: Genetic variants associated with circulating MMP1 levels near matrix metalloproteinase genes on chromosome 11q21–22 in Taiwanese: Interaction with obesity. BMC Med Genet, 2013; 14:30.

31.

Brinckerhoff

, Rutter

, Benbow

: Interstitial collagenases as markers of tumor progression. Clin Cancer Res, 2000; 6:4823–4830.

32.

Vincenti

, Brinckerhoff

: Transcriptional regulation of collagenase (MMP-1, MMP-13) genes in arthritis: Integration of complex signaling pathways for the recruitment of gene-specific transcription factors. Arthritis Res, 2002; 4:157–164.

33.

Guaraldi

, Stentarelli

, Zona

, Santoro

: HIV-associated lipodystrophy: impact of antiretroviral therapy. Drugs, 2013; 73:1431–1450.

34.

Tsiodras

, Perelas

, Wanke

, Mantzoros

: The HIV-1/HAART associated metabolic syndrome—novel adipokines, molecular associations and therapeutic implications. J Infect, 2010; 61:101–113.

35.

Samaras

: The burden of diabetes and hyperlipidemia in treated HIV infection and approaches for cardiometabolic care. Curr HIV/AIDS Rep, 2012; 9:206–217.

36.

Koethe

: Adipose tissue in HIV infection. Compr Physiol, 2018; 7:1339–1357.

37.

Guzman

, Vijayan

: HIV-Associated Lipodystrophy. 2020, pp. 1–5. Available at: https://www.ncbi.nlm.nih.gov/books/NBK493183/, accessed December 15, 2020 .

38.

Viladés

, Escoté

, López-Dupla

, et al.: Involvement of the LPS-LPB-CD14-MD2-TLR4 inflammation pathway in HIV-1/HAART-associated lipodystrophy syndrome (HALS). J Antimicrob Chemother, 2014; 69:1653–1659.

39.

Baril

, Junod

, Leblanc

, et al.: HIV-associated lipodystrophy syndrome: A review of clinical aspects. Can J Infect Dis Med Microbiol, 2005; 16:233–243.

40.

De Barros

, Zakaroff-Girard

, Lafontan

, Galitzky

, Bourlier

: Inhibition of human preadipocyte proteasomal activity by HIV protease inhibitors or specific inhibitor lactacystin leads to a defect in adipogenesis, which involves matrix metalloproteinase-9. J Pharmacol Exp Ther, 2007; 320:291–299.

41.

Bouloumie

, Sengene`s C, Portolan

, Galitzky

, Lafontan

: Adipocyte produces matrix metalloproteinases 2 and 9: Involvement in adipose differentiation. Diabetes, 2001; 50:2080–2086.

42.

Lagathu

, Béréziat

, Gorwood

, et al.: Metabolic complications affecting adipose tissue, lipid and glucose metabolism associated with HIV antiretroviral treatment. Expert Opin Drug Saf, 2019; 18:829–840.

43.

Gelpi

, Afzal

, Fuchs

, et al.: Prior exposure to thymidine analogs and didanosine is associated with long-lasting alterations in adipose tissue distribution and cardiovascular risk factors. AIDS, 2019; 33:675–683.

44.

Finucane

, Archer

: Dermatological aspects of medicine: Highly active antiretroviral therapy and the treatment of human immunodeficiency virus. Clin Exp Dermatol, 2010; 35:107–109.

45.

Pacenti

, Barzon

, Favaretto

, et al.: Microarray analasys during adipogenesis identifies new genes altered by antiretroviral drugs. AIDS, 2006; 20:1691–1705.

46.

Lichtenstein

, Ward

, Moorman

, et al.: Clinical assessment of HIV-associated lipodystrophy in an ambulatory population. AIDS, 2001; 15:1389–1398.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.30 MB