ARV induces long-acting effects?

• Neurological symptoms AZT +/- 3TC Blanche et al Lancet 1999

• Persistent hyperlactatemia AZT +/- 3TCNoguera et al Ped Inf Dis J 2003

• Altered hematopoïesis AZT +/- 3TC Lechenadec et al AIDS 2003

• Altered myocardal contractility AZT +/- 3TC Lipshultz et al J Am Coll Cardiology 2011

Neutrophils count in perinatally AZT exposed children until 8 years

AZT exposed

ECS AIDS 2005;19:1071

AZT unexposed

AZT-induced long-lasting impairment

of hematopoieisis

Is there hematopoietic Is there hematopoietic stem cell CD34+ genotoxic stem cell CD34+ genotoxic

alteration ?alteration ?I Schmutz Andre, E Six, M Cavazzana-Calvo, S Kaltenbach F Mavillio, Paris and Modena

Lechenadec AIDS 2003, ECS AIDS 2004, Pacheco J Inf Dis 2006…etc

Validation by qRT-PCR

Cord blood cells CD34+ cells

Affymetrix Gene chip

analysisBioinformatic

analysis

Transcriptional profiling analysis

of CD34+ hematopoietic

stem cells

HIV neg AZT- exposedand control newborn

Gene expression in CD34+ cord blood cells of AZT exposed newborn

Maternités : A. Béclère, L. Mourrier, Bichat, Lariboisière, Cochin, Necker.

***

Cord blood cell immunophenotyping: hematopoietic stem cells (HSC)

and multipotent progenitors(MPP )

Lin-CD38-CD34+CD90-Lin-CD38-CD34+CD90+

CD34+

213 genes up-regulated in ARV-treated cells

90 genes down-regulated in ARV-treated cells

ND vs ARV pvalue 0.05 Fold Change 1.5

Gene expression profilesControl vs AZT-exposed CD34+

Genes functionsIngenuity® functional clustering analysis

Cellular Growth and Proliferation

Cell Death

Cell Cycle

DNA Replication, Recombination and Repair

ALOX12 ALOX12 CCL5AXL CASP1 AXL CCNE1BAMBI CASP3 CCNE1 CD180C7orf68 CCL2 CCNE2 IL1BCASP1 CCL5 CDK1 ITGB3CASP3 CCR1 DDX17 MDM2CCL2 CDK1 EGF ORC6CCL5 CTTN GDF15 PDE5ACCNE1 EGF H19 PDGFACCNE2 GDF15 HMGA2 TFPI2CCR1 GIMAP5 ID1 VPRBPCD36 HMGA2 ID2 WRNCDK1 ICAM1 IL1B  COL4A1 ID1 ITGB3  DDX17 IL1B KLHL2  

EGF ITGB3 KNTC1  GBP1 ITGB5 MDM2  GDF15 LGALS8 MDM4  HMGA2 MDM2 ORC6  ICAM1 MDM4 PDK3  ID1 NFIL3 PRKCA  ID2 PDGFA PTAFR  IL1B PF4 RPS6KA2  ITGA2B PPBP VPRBP  ITGB3 PRKCA WRN  ITGB5 PTAFR    KDM4C      MDM2      MDM4      PDE5A      PDGFA      PF4      PLD1      PRKCA      PTAFR      PTCH1      PTGS1      PTPRJ      TFPI2      VPRBP      WRN      

The effect involves particularly regulator genes of chromosomal instability

– centrosome amplification (Cyclin E1 and E2)

– checkpoint defect (Rae1)

– dysregulation of cell-cycle proteins (Mdm2) – microtubule attachment and chromosome

segregation (TUBB, MARK4)

These major cell cycle regulators

are involved in chromosome segregation

Stem Cells and DNA Damage:Persist or Perish?

A. Lane Cell 2010;142, 360–362

Increased aneuploidy in cord blood lymphocytes from AZT-exposed newborn

Proportional increase of micronuclei

Median (%): 6.6 vs 18.7 p<0.001

Summary

• These findings are reminiscent of cellular and animal AZT exposure experiments

• Aneuploidy appears as the result of DNA damage induced by AZT integration

• They confirm significant in vivo genotoxicity in cord blood cells after exposure to AZT in utero

• Unknown long-term clinical consequences

Signification clinique ?

• Hématopoïèse à long terme ?

• Risque de cancer hematopoïétique ?

• Autre cancer ?

AZT in utero exposure and risk of cancer

To date , no global increased risk

• 9127 AZT or AZT+3TC exposed children

• Median age : 5.4 y

• >53 000 patient- year

• 10 cases observed vs 9.6 expected

French Cohort . Benhammou AIDS 2008

6 nouveaux cas de cancers repérés depuis l’analyse de 2007

Nouveau croisement avec registre SFCE prévu

Suites….

• Données de Primeva

• Comparaison de différentes combinaisons d’ARV avec ces outils moléculaires– Observationnelles– Randomisées ?