Plasma Biomarkers of Risk of Tuberculosis Recurrence in HIV Co-Infected Patients From South Africa

Abstract

There is an urgent need to identify immunological markers of tuberculosis (TB) risk in HIV co-infected individuals. Previously we have shown that TB recurrence in HIV co-infected individuals on ART was associated with markers of systemic inflammation (IL-6, IL1β and IL-1Rα). Here we examined the effect of additional acute inflammation and microbial translocation marker expression on risk of TB recurrence. Stored plasma samples were drawn from the TB Recurrence upon Treatment with HAART (TRuTH) study, in which individuals with previously treated pulmonary TB were screened for recurrence quarterly for up to 4 years. Recurrent TB cases (n = 37) were matched to controls (n = 102) by original trial study arm assignment and ART start date. Additional subsets of HIV infected (n = 41) and HIV uninfected (n = 37) individuals from Improving Recurrence Success (IMPRESS) study were sampled at active TB and post successful treatment completion. Plasma concentrations of soluble adhesion molecules (sMAdCAM, sICAM and sVCAM), lipopolysaccharide binding protein (LBP) and transforming growth factor-beta (TGF-β1, TGF-β2, TGF-β3) were measured by multiplex immunoassays and ELISA. Cytokine data was square root transformed in order to reduce variability. Multivariable analysis adjusted for a number of potential confounders measured at sample time-point: age, BMI, CD4 count, viral load (VL) and measured at baseline: presence or absence of lung cavities, previous history of TB, and WHO disease stage (4 vs 3). The following analytes were associated with increased risk of TB recurrence in the multivariable model: sICAM (aOR 1.06, 95% CI: 1.02-1.12, p = 0.009), LBP (aOR 8.78, 95% CI: 1.23-62.66, p = 0.030) and TGF-β3 (aOR 1.44, 95% CI 1.01-2.05, p = 0.044). Additionally, we observed a positive correlation between LBP and sICAM (r= 0.347, p<0.0001), and LBP and IL-6, identified to be one of the strongest predictors of TB risk in our previous study (r=0.623, p=0.03). These data show that increased risk of TB recurrence in HIV infected individuals on ART is likely associated with HIV mediated translocation of microbial products and the resulting chronic immune activation.

Keywords: HIV; antiretroviral (ARV) therapy; inflammation; microbial translocation; tuberculosis - pulmonary.

Figure 1

Plasma levels of LBP, sMAdCAM, sICAM, sVCAM, TGF-β1, TGF-β2 and TGF-β3 in controls (n = 103) and cases (n = 37) from TRuTH. Analytes were plotted using Box and Whiskers (5-95%). P-values indicated in the figures are the result of univariable conditional logistic regression (please refer to Table 1 for full analysis).

Figure 2

Plasma levels of LBP, sMAdCAM, sICAM, sVCAM, TGF-β1, TGF-β2 and TGF-β3 in HIV uninfected [HIV(-)] and HIV infected [HIV(+)] IMPRESS participants at active TB (active) and post- TB treatment (cure) timepoints. Based on the result of the normality test either parametric: paired t-test (Active vs Cure) and t-test (HIV+ vs HIV-), or non-parametric: Wilcoxon signed rank (Active vs Cure) and Mann-Whitney (HIV+ vs HIV-) tests were used for the analysis. *Statistically significant association after FDR adjustment using 0.05 threshold.