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Evidence for the link between markers of inflammation, coagulation and immune

activation and end organ disease

Session: Immune Activation/Inflammation and HIV DiseaseIAS Conference, Rome, July 2011

Jens Lundgren, MD

Chair – INSIGHT’s scientific steering committeeProfessor – Univ. of Copenhagen

Chief physician – Copenhagen University HospitalDirector – Copenhagen HIV Programme

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Linking markers to organ disease:prognostic and surrogate biomarkers

• Prognostic marker– Predicts the risk of disease

• Causal: marker of process involved in pathogenesis• Epiphenomenon: not linked causally (e.g. subclinical stages

of disease itself raises levels)• Surrogate marker

– Change in level reflects the extent of benefit of an clinically beneficial intervention• Occurs sooner after intervention is initiated than the disease

– Surrogates are usually prognostic markers, but the opposite is seldom true

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Validation of surrogate biomarkers

Associated with Clinical

Events

[Case-control or Cohort Studies]

Modify with

Treatment

[Biomarker Studies (Phase II/Pilot/

Vanguard Studies)]

Markers that can be reliably measuredStored specimensProspectively identified and adjudicated eventsExcellent follow-upStudy is large enough to do nested case-controlled studies

[Clinical Trials with Clinical Outcomes]

Rx Effect on Biomarkers Predicts

Rx Effect on Clinical Events

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Median CD4+ During Follow-up

0 0.33

0.670000000000001

1 1.33

1.67

2 2.33

2.67

3 3.33

3.67

4 4.33

4.67

5 5.33

5.67

6 6.33

6.67

70

100

200

300

400

500

600

700

800

IL-2Control

Year

CD

4+

cell

co

un

t (

/µL

)

Avg Difference:160 cells, p<.001

Time spent IL-2 Control

< 300 cells 6% 9%

> 600 cells 57% 36%

IL-2: 2071 1846 1829 1797 1757 1721 1410 878

Control: 2040 1928 1861 1803 1739 1648 1350 824

No. pts

ESPRIT/INSIGHT study group, NEJM 2009

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Primary EndpointOpportunistic Disease or Death

IL-2 ControlNo. Rate* No. Rate* HR (95% CI) p-value

158 1.13 165 1.21 0.93 (0.75, 1.16) 0.52

Predicted HR based on CD4+ difference = 0.74

* rate per 100 person years

ESPRIT/INSIGHT study group, NEJM 2009

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Soluble Biomarkers of Inflammation & Coagulation in HIV

Biological process: Name of marker: Marker of:

Activation of:

immune cells, endothelium, platelets, and coagulation

Interleukin-6 hs-CRPsCD14D-dimerP-selectinsCD40 ligand

LymphocyteAcute phase reactantMacrophage/monocytefibrinolysisplatelets + endotheliumplatelets + endothelium + lymphocytes

Organ dysfunction

hyalyronic acid, FIB-4 NT-proBNPADMAeGFR, protinuria

LiverHeartEndotheliumkidney

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ESPRIT and SMART Control Group: Deaths by D-dimer Quartile at Study Entry

ESPRIT SMARTD-dimer levels:>0.38 g/mL0.26-0.380.19-0.25<0.19

D-dimer levels:>0.37 g/mL0.22-0.370.13-0.21<0.13

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ESPRIT Control Group: Hazard Ratios (D-dimer Q4/Q1) for Death by 4-Year Intervals

1

10

100H

R (

4th/

1st

Qua

rtile

)

p-value = 0.18 for change in HR over follow-up

1st 4 years follow-up > 4 years follow-up

# deaths, quartile 4: 15 24

# deaths, quartile 1: 4 4

HR (95% CI): 3.48 (1.2-10.5) 5.59 (1.9-16.1)

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OR for Mortality Associated with Baseline Biomarker Levels for Early (0-2 years) and Late

(2 > years) Deaths in SMART

Odd

s Ra

tio (4

th/1

st Q

uarti

le)

Paton et al, IAS 2009 (#MOPEA034)Paton et al, IAS 2009 (#MOPEA034)

hsCRP IL-6 D-dimer

Median Level (IQR) ≤ 2 yr > 2 yr ≤ 2 yr > 2 yr ≤ 2 yr > 2 yr

Deaths 3.13 (1.57-7.35)

3.69 (1.5-7.51)

3.58 (2.13-6.86)

3.72 (2.51-5.50)

0.45 (0.24-1.06)

0.31 (0.21-0.55)

Controls 2.08(0.83-4.83)

1.93 (0.84-5.11)

2.14(1.38-3.16)

2.33 (1.53-3.48)

0.24 (0.15-0.45)

0.24(0.15-0.38

# Deaths/Controls 95/188 71/137 92/184 67/133 94/188 69/128

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Association with risk of death is reduced the longer the time from measurement of

biomarker in persons with peripheral arterial disease

Vidula et al, Ann Intern Med 2008

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Trajectories in d-dimer Levels in ESPRIT Control Group at study entry, 12 and 36 Months

N=244

UpperLimit ofnormal

% above ULN(0.25 µg/mL)

39% 39% 42%

No significant change over time

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ESPRIT and SMART Control Group: Hazard Ratios for Quartiles (4th vs. 1st)

of D-dimer Levels at Study EntryESPRIT SMART

Event HR P-value HR P-value

Death 4.5 <.0001 6.0 .0007

AIDS 1.7 .23 5.3 .007

CVD 2.0 .11 2.7 .009

Non-AIDS malignancy 1.8 .14 1.3 .52

Serious Non-AIDS (SNA) 2.4 .003 2.0 .009

SNA or death from non-AIDS 2.3 .0007 2.6 .0002

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Change in D-Dimer* from Study Entry to 1 Month

0

0,1

0,2

0,3

≤ 400 401-10,000 10,000-50,000 >50,000

Month 1 HIV RNA Level (copies/mL)

∆ D

-Dim

er (

µg

/mL

)

P=.0005 for trend

* DC patients on ART at baseline with HIV RNA ≤ 400 copies/mL

Kuller et al, PLoSMed 2008

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D-dimer Levels After Starting ARTin SMART

-0.51

-0.30

0.00

-1

0

1

∆ D

-dim

er (

log

e µ

g/m

L)

P=0.02 for trend

≤ 400(n=77)

401-10,000(n=25)

Month 6 HIV-RNA Level (copies/mL)

>10,000 (n=22)

All participants were off ART at baseline (n=254) Randomized comparison of immediate ART (VS; n=128) or

deferral (D

No difference in IL-6 and hsCRP

All participants were off ART at baseline (n=254) Randomized comparison of immediate ART (VS; n=128) or

deferral (D

No difference in IL-6 and hsCRPBaker et al JAIDS 2011

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SMART: Comparison of Associations with Different Outcomes: Univariate ORs

(4th versus 1st quartile) – Case-Control Analyses

All cause mortality CVD AIDS

D-dimer 12.3 1.9 2.0

IL-6 11.7 3.7 1.7

Small HDL particles 0.13 0.50

sCD14 6.0 1.7 1.4

Total HDL particles 0.18 0.44

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Cellular markers of end organ disease in HIV

• Activation of CD4 and/or CD8 cells and markers of organ disease (cross-sectional studies)– Intima-media thickness (Hsu et al, AIDS 2006, Kaplan et al, JID 2011) and

arterial stiffness (Kaplan et al, Atherosclerosis 2011)• Linked to AIDS/death events

– In cross sectional analysis: • OR= 1.94 for risk of AIDS/death by 17% more %CD8+/HLA-

DR+/CD38+ (Kalayjian et al, JID 2010) • OR=6.5 for AIDS for 4th vs 1st quartile (Smurzynski et al, JAIDS 2010)

– In cohort studies• HR=1.61, P=0.042 (Hunt et al, CROI 2011)

• Still unclear– prognostic marker for organ disease– changes reflect surrogacy for benefit from interventions

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Use of markers in routine clinical practise

• Identify persons at increased risk of disease– Intriguing that D-dimer levels predict risk after multiple years– Unclear which interventions specifically benefits such patients over-

and-above benefits from common interventions used in internal medicine

– Will cause concern• Surrogates of interventions

– Remains to be established

Markers of inflammation and coagulationremains a research tool and

are not yet ready for routine use in HIV medicine

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Summary

• Many markers are prognostic but very few are surrogates of benefit for clinically useful interventions– Establishment of surrogacy is critical when assessing for

potentially useful anti-inflammatory interventions• This research requires large clinical endpoint driven RCT’s

• Soluble markers of inflammatory and coagulation• long-term risk of – particularly fatal - end-organ disease• D-dimer: potential for surrogacy of benefits from ART

– additional research required (e.g. START) • Data emerging on cellular markers of inflammation• Markers of inflammation and coagulation:

– useful tools to advance co-morbidity research agenda, – role in routine clinical practise remains to be determined.

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Acknowledgements

• INSIGHT network incl. executive, scientific and operational committee members + international coordinating centres and affiliated sites– Jim Neaton, Jason Baker, Jacquie Neuhaus, Debby Wentworth,

Andrew Phillips, Calvin Cohen and Steven Deeks• Peter Hunt, UCSF• Division of AIDS, NIAID

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UARTO: High CD8+ T Cell Activation at Month 6 of ART Predicts Subsequent Mortality in

Ugandans with VL<400

Hunt et al, CROI 2011 (306)

In Cox Proportional Hazards models, each 10% increase in the frequency of activated (%CD38+ HLA-DR+) CD8+ T cells was associated with an increased hazard of death even after adjustment for

baseline CD4 count (HR: 1.62, P=0.048) or month 6 CD4 count (HR: 1.61, P=0.042).