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Published by , 2018-10-01 08:47:08



Journal of J. Appl. Biomed.
APPLIED 6: 139–145, 2008


Changes in CD4+ cell count, lipid profile and liver enzymes in HIV infection
and AIDS patients

Palanisamy Pasupathi, Govindaswamy Bakthavathsalam, Ganesan Saravanan1, Ayyaswamy Devaraj

Institute of Laboratory Medicine, K.G. Hospital and Post Graduate Medical Institute, Coimbatore, Tamil Nadu,

1Department of Biochemistry & Biotechnology, Faculty of Science, Annamalai University, Annamalainagar,
Tamil Nadu, India

Received 30th April 2008.
Revised 2nd June 2008.
Published online 16th September 2008.

This study was designed to find the correlation between changes in CD4+ cell count, lipid profile and liver
marker enzymes in HIV-infected and AIDS patients. The study population consisted of 150 subjects, age and
sex-matched and divided into three groups [control subjects (n=50), HIV infected (n=50) and AIDS patients
(n=50)]. We observed a significant reduction in CD4+ cell count in HIV/AIDS patients when compared to
control subjects. Serum levels of total cholesterol, high-density lipoprotein cholesterol (HDL-C) and
low-density lipoprotein cholesterol (LDL-C) were found to be decreased significantly in HIV/AIDS patients
when compared with normal counterparts. On the other hand, the levels of triglyceride (TG) and very
low-density lipoprotein cholesterol (VLDL-C) were markedly elevated in HIV/AIDS patients compared to
normal subjects. The activities of serum aspartate aminotransferase (AST), alanine aminotransferase (ALT)
and alkaline phosphatase (ALP) observed in HIV/AIDS patients were significantly higher than in the control
group. Further, the above mentioned haematological and biochemical variables were found to be affected
more significantly in AIDS patients when compared with HIV infected subjects. Hence, it may be concluded
that CD4+ cell count, lipid profile and liver enzymes can be a good index of disease progression in HIV
infection and AIDS patients.

Key words: HIV – AIDS – CD4+ cell count – lipids – liver enzymes

Palanisamy Pasupathi, Department of Clinical INTRODUCTION
Biochemistry, Institute of Laboratory
Medicine, K.G. Hospital and Post Graduate The acquired immunodeficiency syndrome (AIDS),
Medical Institute, Coimbatore-641 018, Tamil is a fatal illness caused by a retrovirus known as the
Nadu, India human immunodeficiency virus that breaks down
the body’s immune system, infects CD4+ cells
[email protected] initially and progressively leads to AIDS (Rasool et
+91 422 2201201 al. 2008). There are 2.47 million persons in India
+91 422 2211212 living with HIV; equivalent to approximately 0.36%
of the adult population. The revised national
estimate reflects the availability of improved data
rather than a substantial decrease in actual HIV

Pasupathi et al.: Changes in HIV-infected and AIDS patients

prevalence in India. The transmission route is still lipoprotein lipase (LPL) or by stimulating hepatic
predominantly sexual (87.4%); other routes of lipid synthesis through increases in either hepatic
transmission by order of proportion include fatty acid synthesis or re-esterification of fatty acid
prenatal (4.7%), unsafe blood and blood products derived from lipolysis (Grunfeld et al. 1992).
(1.7%), infected needles and syringes (1.8%) and Hypertriglyceridaemia was the first dyslipidaemia
unspecified routes of transmission (4.1%) to be reported in HIV infected patients, but other
(UNAIDS 2006). lipid abnormalities such as hypocholesterolaemia or
hypo HDL cholesterolaemia have also been
Initial cases of advanced immune deficiency reported.
(almost immediately associated with CD4
T-lymphocyte depletion) often with striking The CD4+ lymphocyte is the primary target of
opportunistic infections or malignancies, led to the HIV infection because of the affinity of the virus to
recognition of the AIDS epidemic. Tests for the CD4+ surface marker. Infection with HIV leads
HIV-induced antibodies found a large epidemic, to a progressive impairment of cellular functions,
mostly of those not yet ill but with signs of characterized by a gradual decline in peripheral
progressive immune depletion. Clinical attention blood CD4+ lymphocyte levels which results in an
thus appropriately shifted from AIDS to HIV and increasing susceptibility to a wide variety of
the recognition that HIV infection is a disease in its opportunistic, viral, bacterial, protozoal, and fungal
own right requiring appropriate treatment infections and to certain malignancies also
(Volberding 1989). HIV infects CD4+ cells and can (Khiangte et al. 2007). Thus HIV can make copies
be directly cytotoxic. Other complex mechanisms of its own genome as DNA in the host’s cells such
however, appear important in explaining the as human T4-helper lymphocytes and this leads to
progressive depletion of this key cellular element the elaboration of vast numbers of viral particles
of immunity (Jaworowski et al. 1999, Hazeberg et (Montagnier et al. 1984). Although immunological
al. 2000). Immune-mediated cytotoxicity is dysfunction is common to all AIDS patients, the
probably involved, as T-cell regeneration in the clinical spectrum of HIV infection is diverse and
thymus is also limited by HIV infection (McCune multiple organ involvement is frequently evident
et al. 2000, Smith et al. 2000). Along with CD4 T (Dalgleish et al. 1984). Liver disease has been
cells, macrophages/monocytes are also infected. linked to HIV infection and may manifest as fever
These cells might have a key role in maintaining of unknown origin, hepatomegaly or sub-clinical
and spreading HIV within the body and are abnormalities in liver function tests (Tietz et al.
probably not directly killed by infection. Along 1983, Montagnier et al. 1984). Studies also
with CD4+ cell depletion, infection damages many suggested that the major cause of hepatitis in HIV
components of normal immunity. T-cell patients is infection by a secondary virus called the
proliferative response, especially to HIV antigens, cytomegalo virus. It is also of interest that HIV has
is quickly lost and the repertoire of antigen been detected in the liver cells of AIDS patients. It
recognition diminishes with time. may be that those cells targeted for apoptosis are the
same cells infected with HIV (Cooper et al. 1984).
Men with HIV infection were reported to have
hypocholesterolaemia with and without In various forms of liver disease, serum levels of
hypertriglyceridaemia (Grunfeld et al. 1991, numerous cytosolic, mitochondria and
National AIDS Control Organization - NACO membrane-associated enzymes are increased. The
2003, Anastos et al. 2007). An association between degree of elevation varies with the type of disease.
plasma triglyceride and circulating Alanine and aspartate aminotransferases and
interferon-levels has been observed in persons with alkaline phosphatase are the enzymes that are most
AIDS. However, the mechanism for often measured for evaluation of liver disease or
hypocholesterolaemia in HIV and other infections diseases affecting the liver or in diseases where the
is not known. A pattern of hyperlipidaemia (i.e. liver is implicated (Tietz et al. 1983). The
elevated levels of total cholesterol, low-density knowledge of the intracellular location of enzymes
lipoprotein cholesterol, and triglycerides, and a can therefore assist in determination of the nature
reduced level of high-density lipoprotein and severity of a pathological process if suitable
cholesterol) has been observed in patients treated enzymes are assayed in the blood. The present study
with protease inhibitors (Crook and Mir 1999, was undertaken to find out the relationship between
Ducobu and Payen 2000, Khiangte et al. 2007). changes in CD4+ cell count, lipid profile and liver
Infection can increase plasma triglyceride levels by marker enzymes in HIV infection and AIDS
decreasing the clearance of circulating lipoproteins, patients.
a process considered to be the result of reduced


Pasupathi et al.: Changes in HIV-infected and AIDS patients

MATERIALS AND METHODS statistically significant. There was an increased
number of hypertension sufferers and smokers
Study population observed in AIDS patients compared with HIV
The population was selected consisting of 150 infection and control subjects. Diabetic participants
subjects divided into three groups: HIV infected were defined as those with a fasting blood glucose
patients 50 cases (n=50), AIDS patients 50 cases concentration >120 mg/dl.
(n=50) and an equal number of age- and
sex-matched control subjects (n=50). The study Table 2 shows the levels of CD4+ cell count,
was carried out at the K.G. Hospital and Post total RBC count, WBC count, platelet count,
Graduate Medical Institute, Coimbatore, Tamil hemoglobin, hematocrit and ESR in control, HIV
Nadu, India from January 2006 to January 2008. infected and AIDS patients. The levels of CD4+ cell
For diagnosis and confirmation of HIV infection, count, total RBC count, platelet, hemoglobin and
we followed the National AIDS Control hematocrit were significantly decreased in AIDS
Organization (NACO) recommendations for HIV patients when compared with HIV infected patients
testing (NACO 2003). All the patients were and control subjects. On the other hand, the level of
subjected to detailed history taking and clinical total WBC count and ESR were significantly
examination. The informed consent of the patients increased in HIV infected and AIDS patients. The
was obtained before testing. above mentioned haematological parameters were
found to be more significantly altered in AIDS
Biochemical investigation patients compared with HIV infected subjects.
Red blood cell count, total white blood cell count,
platelet count, total hemoglobin, hematocrit and The plasma concentrations of lipids (total
ESR were determined using a fully automated cholesterol, triglyceride, HDL, LDL and VLDL)
hematology analyzer (Pentra-XL 80, Horiba ABX, and serum enzymes (AST, ALT and ALP) in
USA). Fasting blood glucose, serum total control and HIV infected and AIDS patients are
cholesterol, triglyceride, HDL, LDL and serum depicted in Table 3. The levels of total cholesterol,
enzymes (AST, ALT and ALP) were estimated by HDL and LDL were significantly decreased, while
a fully automated clinical chemistry analyzer the level of triglyceride and VLDL were
(Hitachi 912, Boehringer Mannheim, Germany). significantly increased in AIDS patients when
VLDL cholesterol was calculated by the compared to HIV infected patients and normal
Friedewald equation. The CD4+ lymphocyte count subjects, but the levels of VLDL in the HIV
was estimated by Fluorescence Activated Cell infected patients and control subjects did not differ
Sorter (FACS) count system (Becton Dickinson, significantly. The activities of serum liver marker
USA). enzymes observed in AIDS patients significantly
increased in the HIV infection patients and control
Statistical analysis subjects, The above biochemical variables were
All data were expressed as mean ± SD. The found to be altered more significantly in AIDS
statistical significance was evaluated by student ‘t’ patients when compare with HIV infected subjects.
test (two-tailed). A p value of <0.05 was
considered statistically significant. Statistical DISCUSSION
analyses were performed using the Statistical
Package for the Social Sciences (SPSS Cary, NC, The present study showed that the lipid profile was
USA) version 10.0. altered in HIV infected and AIDS patients.
Alteration in the lipid profile occurred even during
RESULTS the early stages of HIV infection and more so as the
disease progressed. Of the total 50 cases, 46 (92%)
Information about the investigated characteristics is were classified as having AIDS according to
shown in Table 1. The mean age limit was 36 ± 9 Clinical Case Definition of AIDS. This high number
in AIDS patients, 32 ± 5 in HIV infected patients of AIDS cases and the fact that there were no
and 30 ± 6 in control subjects. The decreased body patients in the clinical stage in our study could be
mass index in AIDS patients (25 ± 5.3 kg/m2) due to the fact that patients with HIV infection seek
compared with HIV infected patients (29 ± 6.2 hospital admission only in the late clinical stages
kg/m2) and control subjects (34 ± 6.2 kg/m2) were when they have opportunistic infections (NACO

Previous studies have demonstrated that patients


Pasupathi et al.: Changes in HIV-infected and AIDS patients

with AIDS exhibit highly abnormal total lipid concentrations of HDL cholesterol – also
concentrations in plasma (Mullamitha and Pazare intensified (Rogowska-Szadkowska and
1999). A few authors have determined the levels of Borzuchowska 1999, Ducobu and Payen 2000).
plasma triglycerides, total cholesterol and HDL Consistent with earlier reports, our study also
cholesterol in HIV infected individuals by the level showed similar findings in which the decrease of
of immunological deficiency according to the CD4+ CD4+ count due to disease progression was
cell count, and they also came to the same accompanied by a decrease in total cholesterol,
conclusion: with an increase of immunological HDL and LDL, and an increase in triglyceride and
deficiency and clinical development of HIV VLDL levels.
infection, lipid profile disorders – indicated by an
increase in triglyceride level and decreased Our findings are also consistent with reports
from Ducobu and Payen (2000), who stated that

Table 1. Demographic characteristics of control, HIV infection and AIDS patiens

Characteristic Control subjects HIV infection AIDS patients

Age (years) 30 ± 6 32 ± 5 36 ± 9* x
Sex (Male) 50 50 50
Body mass index (kg/ m2)
Number of subjects with 34 ± 6.5 29 ± 6.2xx 25 ± 7.1*x

smoking 10 (20%) 27 (54%) 29 (58%)
hypertension 4 (8%) 25 (56%) 43 (86%)
diabetes mellitus 8 (16%) 12 (24%)

Values are given as mean ± S.D. from 50 patients
*AIDS patients statistically significant as compared with control subjects
xx HIV infection statistically significant as compared with control subjects
x AIDS patients statistically significant as compared with HIV infection

Table 2. Blood picture of the subjects investigated

Characteristic Control subjects HIV infection AIDS patients

Erythrocyte count (Cells/106 µl) 5.5 ± 0.65 5.1± 0.72xx 3.1 ± 0.61*x
Leukocyte count (Cells/106 µl) 7.8 ± 2.0 9.7 ± 3.2xx 11.3 ± 2.6*x
CD4+ cell count (Cells/µl) 750 ± 95 365 ± 72xx 135 ± 65*x
Hemoglobin (g/dl) 14.7 ± 1.6 12.6 ± 1.8xx 9.6 ± 2.0*x
Hematocrit (%) 44.1 ± 4.2 38.0 ± 4.0xx 27.1 ± 6.1*x
Platelet count (Cells/103 µl) 250 ± 60 95 ± 36xx
ESR (mm/h) 7 ± 4.5 75 ± 26xx 39 ± 52*x
145 ± 35*x
Symbols as in Table 1


Pasupathi et al.: Changes in HIV-infected and AIDS patients

Table 3. Changes in the level of total cholesterol, triglyceride, HDL, LDL, VLDL and serum enzymes in
control, HIV infection and AIDS patiens

Characteristic Control subjects HIV infection AIDS patients

Total cholesterol (mg/dl) 148 ± 23.4 136 ± 25.0xx 120 ± 27.6*x
Triglyceride (mg/dl) 115 ± 24.6 201 ± 20.0xx 392 ± 35.6*x
HDL (mg/dl) 43 ± 5.8xx 20 ± 9.6*x
LDL (mg/dl) 56 ± 7.2 53 ± 15.3xx 45 ± 21.6*x
VLDL (mg/dl) 62 ± 17.2 20 ± 13.0NS
AST (IU/l) 23 ± 17 39 ± 10.0xx 78 ± 15*x
ALT (IU/l) 20 ± 9.3 73 ± 13.2xx 80 ± 28.6*x
ALP (IU/l) 17 ± 9.6 180 ± 20.4xx 175 ± 22.6*x
75 ± 22.8 216 ± 28.6*x
Symbols as in Table 1

HIV infection induced an early decrease of and also an elevated level of cytokines. They
cholesterol and a late increase of triglyceride with a observed that decreased cholesterol and cholesterol
reduction of HDL. These changes were proportional containing lipoproteins in both AIDS and HIV
to the lowering of the CD4+ count, which reflected infection precede the appearance of
the severity of infections, as was the case in our hypertriglyceridaemia. Increased TG levels in AIDS
study. However, some authors (Crook and Mir were primarily due to an increase in VLDLThey
1999, Ducobu and Payen 2000) reported that also raised the possibility that with the development
patients with AIDS had increased levels of LDL of AIDS, subsequent increase in IFN may have
cholesterol, which contradicted our findings. Shor contributed to an increase in plasma triglyceride
Posner et al. (1995) reported similar findings in levels by decreasing the clearance of TG. The
which they showed significantly low levels of total increase of triglyceride catabolism in relation to a
cholesterol, HDL and LDL in HIV infected reduction of lipoprotein lipase activity was
patients, and about 40% of the HIV-infected responsible for these lipid changes. Many cytokines
subjects were demonstrated hypocholesterolaemic such as IFN, IL and TNF probably play a
when compared to seronegative controls. This low pathogenic role in the dyslipedaemia of HIV
level of total cholesterol, HDL and LDL was (Rogowska-Szadkowska and Borzuchowska 1999).
reported to be associated with elevated levels of β-2 Hence, it may be suggested that the lipid profile can
microglobulin. Low cholesterol levels are prevalent be a good index of disease progression in HIV
even during the early stages of HIV and associated infection and AIDS patients.
with a specific alteration in immune function.
Kereveur et al. (1996) stated that Haematological abnormalities are among the
hypocholesterolaemia observed in the early and most common complications of infection with HIV
hypertriglyceridaemia in the later stage of the (Coyle 1997). Depending on the study setting,
infection are due to cytokine effects on different anaemia can be found in 63–95% of those with HIV
enzymes of lipid metabolism. infection at some point during the course of their
disease (Sullivan et al.1998). Chronic
Grunfeld et al. (1991) has reported that thrombocytopenia develops in approximately one
HIV/AIDS is characterized by a high prevalence of third of individuals infected with the human
hypertriglyceridaemia and hypocholesterolaemia, immunodeficiency virus during the course of the


Pasupathi et al.: Changes in HIV-infected and AIDS patients

acquired immunodeficiency syndrome (Walsh et al. cells either mildly or severely in the absence of
1984, Karpatkin 1987, Harbol et al. 1994). other known causes. It is likely that the changes in
haematological and biochemical parameters
In this study, we noticed a significant increase induced by HIV infection will have biological and
in serum liver marker enzymes (ALT, AST and possibly pathological importance in the
ALP) in HIV/AIDS patients compared with the development of AIDS and related complications. It
control group. Our results are also consistent with is also recommended that the results obtained in
the earlier findings of Wildup et al. (1993) who this study be used as baseline in the
recorded a significant increase in the activities of pre-intervention and subsequent management of
the three afore-mentioned enzymes investigated. It HIV infection and AIDS patients.
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