**5. Experience of the assistance service of metabolic diseases secondary to antiretroviral therapy for patients with dyslipidemia**

Assistance Service of Metabolic Diseases Secondary to Antiretroviral Therapy (HAART) of the João de Barros Barreto University Hospital (HUJBB), Brazilian national reference in transmissible infectious diseases and AIDS, actually, assist about 99 HIV carriers' patients with lipodystrophy syndrome. Into this service, the authors develop a Project titled Lipodystrophy and Antiretroviral Therapy, financed by The State of Pará Research Foundation (FAPESPA), Research Program for the Unified Health System (PPSUS). One of the Project's purposes was the implantation of the lipodystrophy ambulatory care.

The HUJBB lipodystrophy ambulatory care works with team composed by an endocrinologist, a nutrition doctoral student, two medicine M.Sc students, four medical undergraduate students. The medical accompaniment is performed once a week. In the first service is diagnosed the clinical form of lipodystrophy and requested the proper tests (total cholesterol, HDL, LDL, triglycerides, fasting glucose test, oral glucose tolerance, insulin, abdominal ultrasonography to hepatic steatosis diagnostic and computed tomography for evaluation of visceral lipohypertrophy and electrocardiogram). The first patient's return is around 45 days and subsequently every three months for medical accompaniment. Each medical consultation is also performed medical history, measurement of blood pressure, heart auscultation, anthropometric evaluation (measurements of weight, height, skin folds) and bioimpedance. In addition, if need be the patient is referred to other professionals of the multidisciplinary team HUJBB.

Dyslipidemia in Patients with Lipodystrophy in the Use of Antiretroviral Therapy 435

lipodystrophy and dyslipidemia accompanied by the Assistance Service of Metabolic Diseases Secondary to Antiretroviral Therapy, João de Barros Barreto University Hospital, Pará, Brazil. The ambulatory care authors conducted an intervention study with outpatient HIV-positive with lipodystrophy syndrome, in use of HAART in the period October 2006 to December 2007. Patients were evaluated every quarter for four visits. This study followed all the guidelines contained in Resolution 196/1996 of the National Committee for Ethics in Research (CONEP), being approved by the Ethics in Human Research of the Center for Tropical Medicine, Federal University of Para, according to opinion of approval No. 058/2006, to date of October 19, 2006. The sample consisted of patients with positive serology for HIV, use of HAART for at least 12 months, with clinical diagnosis of lipodystrophy. We selected only adult patients, aged 20 to 60 years, of both sexes. All were invited and agreed to participate by reading and signing the

We excluded all patients with mental illness, malignant tumors, and chronic users of glucocorticoids, Diabetes Mellitus and dyslipidemia diagnosed before starting HAART and those who did not achieve at least three follow-up visits clinical and nutritional care at the

To collect data we used a treatment protocol for metabolic evaluation, nutritional counseling and patient outcomes, among several details registered there were: patient identification, socio-economic, personal and family morbidity history, time of HIV diagnosis, time of HAART treatment, clinical history and biochemical tests. Among the lipodystrophy syndrome metabolic changes were required tests to total serum cholesterol, LDL-C, HDL-C

We studied 29 patients, 17 (59%) and 12 (41%), male and females, respectively, with an average age of 46.07 (± 9.04) years. In males, the average age was 47.59 (± 7.66) years, median 46 years, whereas in females the mean age was 43.92 (± 10.67) years, median 44. The

In regarding to lipodystrophy syndrome classification, was observed that 11 (37.91%), 2 (6,9%) and 16 (55,17%) patients demonstrated lipoatrophy, lipohypertrophy and mixed syndrome, respectively. There is no sex association with lipoatrophy and mixed syndrome (p= 0.4138, OR= 0.3750, IC 95%= 0.0744 – 1.8891), whilst lipohypertrophy syndrome had predominance in females. It is assumed when calculating Odds Ratio to lipohypertrophy presence, was noted that female chance present lipohypertrophy is 2.66 times more, However, the results have not

Free and Informed Consent Term - FICT.

Ambulatory care of Lipodystrophy HUJBB.

and triglycerides for dyslipidemia analysis (Sposito et al., 2007).

most prevalent age group for both sexes was 41 to 50 years.

been significant (p=0.4130, IC 95% 0.5294 a 13.4334), data shown in Figure 2.

**Variable Total Sample Mean ± SD Median**  Age (years) 77 44.5 ± 9.6 45.0 ART Time (years) 77 6.9 ± 4.1 7.0 Time of HIV (years) 77 8.3 ± 5.4 8.0 BMI (kg/m²) 76 24.5 ± 4.2 23.9 Fasting glucose (mg/dL) 72 103.4 ± 27.7 98.5 Total Cholesterol (mg/dL) 76 218.9 ± 59.7 220.0 Triglycerides (mg/dL) 76 373.3± 393.8 280.5 HDL-c (mg/dL) 60 40.8 ± 13.34 39 Male HDL-c 36 37.4 ± 11.7 37.0 Female HDL-c 24 46.0 ±14.2 46.5 LDL-c (mg/dL) 58 115.6 ± 45.4 117.9 Legend: ART – Antiretroviral Therapy, BMI – body mass index, SD standard deviation. Table 2. Distribution of mean and median values of some variables in patients with

Of the accompanied patients with lipodystrophy syndrome in this ambulatory care, 77% (n = 77) have dyslipidemia and presents the following profile: 67.9% were male, mean age of 44.5 years, average time of HIV infection of 8, 3 years, average time of use of antiretroviral therapy for 6.9 years and body mass index of 24.5 kg/m2. Regarding risk factors, it is observed that 18.2% are smokers, 40.3% alcoholics, 71.4% sedentary and 45.5% had hepatic steatosis. Regarding the classification of nutritional status (WHO, 1995) 58.4% are eutrophic, thin 6.5% and 35.1% overweight/obesity. Among the co morbidities studied, it appears that 24.7% and 21.1% are hypertensive and diabetics, respectively. When stratifying the lipodystrophy syndrome, according to the clinical manifestations, 35.1%, 10.4% and 54.5% of patients had lipoatrophy, hypertrophy and mixed syndrome, respectively. Concerning average serum lipid levels, there is high levels blood of cholesterol and triglycerides, low HDL-C, and LDL-C within the normal range. In regard to dyslipidemia classification (Sposito et al., 2007), have been observed that 48.7% of patients have mixed hyperlipidemia, 32.9% hypertriglyceridemia, low HDL-C 10.5% and 7.9% isolated hypercholesterolemia (Table 1 and 2). In the assessment of cardiovascular risk by Framingham Risk Score was found that more than 30% of the sample had medium and high cardiovascular risk.


Legend: SH - systemic hypertension; \*\* WHO, 1995; \*\*\* Sposito et al., 2007

Table 1. Patients profile with lipodystrophy and dyslipidemia accompanied by the Assistance Service of Metabolic Diseases Secondary to Antiretroviral Therapy, João de Barros Barreto University Hospital, Pará, Brazil.

Of the accompanied patients with lipodystrophy syndrome in this ambulatory care, 77% (n = 77) have dyslipidemia and presents the following profile: 67.9% were male, mean age of 44.5 years, average time of HIV infection of 8, 3 years, average time of use of antiretroviral therapy for 6.9 years and body mass index of 24.5 kg/m2. Regarding risk factors, it is observed that 18.2% are smokers, 40.3% alcoholics, 71.4% sedentary and 45.5% had hepatic steatosis. Regarding the classification of nutritional status (WHO, 1995) 58.4% are eutrophic, thin 6.5% and 35.1% overweight/obesity. Among the co morbidities studied, it appears that 24.7% and 21.1% are hypertensive and diabetics, respectively. When stratifying the lipodystrophy syndrome, according to the clinical manifestations, 35.1%, 10.4% and 54.5% of patients had lipoatrophy, hypertrophy and mixed syndrome, respectively. Concerning average serum lipid levels, there is high levels blood of cholesterol and triglycerides, low HDL-C, and LDL-C within the normal range. In regard to dyslipidemia classification (Sposito et al., 2007), have been observed that 48.7% of patients have mixed hyperlipidemia, 32.9% hypertriglyceridemia, low HDL-C 10.5% and 7.9% isolated hypercholesterolemia (Table 1 and 2). In the assessment of cardiovascular risk by Framingham Risk Score was

found that more than 30% of the sample had medium and high cardiovascular risk.

Variables Total Sample n % Male 52 67.5 Female 25 32.5 Smoking 77 14 18.2 Alcoholism 77 31 40.3 Sedentary 77 55 71.4 Diabetes mellitus 77 17 21.1 SH \* 77 19 24.7

Diabetes 77 37 48.1 Hypertension 77 55 71.4 Dyslipidemia 72 28 38.9 Hepatic steatosis 66 30 45.5

Thinness\*\* 05 6.6 Eutrophic 44 57.9 Overweight/Obesity 27 35.5

Lipoatrophy 27 35.1 Hypertrophy 8 10.4 Mixed 42 54.5

Mixed Hyperlipidemia 37 48.7 Hypertriglyceridemia 25 32.9 Low HDL 8 10.5 Isolated hypercholesterolemia 6 7.9

Table 1. Patients profile with lipodystrophy and dyslipidemia accompanied by the Assistance Service of Metabolic Diseases Secondary to Antiretroviral Therapy, João de

Legend: SH - systemic hypertension; \*\* WHO, 1995; \*\*\* Sposito et al., 2007

Family history

Nutritional status\*\* 76

Lipodystrophy 77

Classification of dyslipidemia\*\*\* 76

Barros Barreto University Hospital, Pará, Brazil.


Legend: ART – Antiretroviral Therapy, BMI – body mass index, SD standard deviation.

Table 2. Distribution of mean and median values of some variables in patients with lipodystrophy and dyslipidemia accompanied by the Assistance Service of Metabolic Diseases Secondary to Antiretroviral Therapy, João de Barros Barreto University Hospital, Pará, Brazil.

The ambulatory care authors conducted an intervention study with outpatient HIV-positive with lipodystrophy syndrome, in use of HAART in the period October 2006 to December 2007. Patients were evaluated every quarter for four visits. This study followed all the guidelines contained in Resolution 196/1996 of the National Committee for Ethics in Research (CONEP), being approved by the Ethics in Human Research of the Center for Tropical Medicine, Federal University of Para, according to opinion of approval No. 058/2006, to date of October 19, 2006. The sample consisted of patients with positive serology for HIV, use of HAART for at least 12 months, with clinical diagnosis of lipodystrophy. We selected only adult patients, aged 20 to 60 years, of both sexes. All were invited and agreed to participate by reading and signing the Free and Informed Consent Term - FICT.

We excluded all patients with mental illness, malignant tumors, and chronic users of glucocorticoids, Diabetes Mellitus and dyslipidemia diagnosed before starting HAART and those who did not achieve at least three follow-up visits clinical and nutritional care at the Ambulatory care of Lipodystrophy HUJBB.

To collect data we used a treatment protocol for metabolic evaluation, nutritional counseling and patient outcomes, among several details registered there were: patient identification, socio-economic, personal and family morbidity history, time of HIV diagnosis, time of HAART treatment, clinical history and biochemical tests. Among the lipodystrophy syndrome metabolic changes were required tests to total serum cholesterol, LDL-C, HDL-C and triglycerides for dyslipidemia analysis (Sposito et al., 2007).

We studied 29 patients, 17 (59%) and 12 (41%), male and females, respectively, with an average age of 46.07 (± 9.04) years. In males, the average age was 47.59 (± 7.66) years, median 46 years, whereas in females the mean age was 43.92 (± 10.67) years, median 44. The most prevalent age group for both sexes was 41 to 50 years.

In regarding to lipodystrophy syndrome classification, was observed that 11 (37.91%), 2 (6,9%) and 16 (55,17%) patients demonstrated lipoatrophy, lipohypertrophy and mixed syndrome, respectively. There is no sex association with lipoatrophy and mixed syndrome (p= 0.4138, OR= 0.3750, IC 95%= 0.0744 – 1.8891), whilst lipohypertrophy syndrome had predominance in females. It is assumed when calculating Odds Ratio to lipohypertrophy presence, was noted that female chance present lipohypertrophy is 2.66 times more, However, the results have not been significant (p=0.4130, IC 95% 0.5294 a 13.4334), data shown in Figure 2.

Dyslipidemia in Patients with Lipodystrophy in the Use of Antiretroviral Therapy 437

When analyzing only the sample of patients who were taking hypolipidemic (n = 7), there was no statistically significant changes in the levels of serum total cholesterol, LDL-C and

> 264.0 (±128.2)

136.6 (±56.3)

996.0 (±1300.0)

Table 3. Comparison of mean only of lipid profile of patients who were taking

**N (%)** 

Normal levels 3 (27.27) 0 (0.00) 7 (43.75) 0.3840

Normal levels 9 (81.82) 1 (50.00) 14 (87.50) 0.4141

Normal levels 1 (9.09) 0 (0.00) 5 (31.25) 0.2849

Normal levels 3 (27.27) 1 (50.00) 5 (31.25) 0.3023

10 (90.91) 2 (100.00) 11 (68.75)

8 (72.73) 1 (50.00) 11 (68.75)

Table 4. Association between lipid profile and lipodystrophy syndrome, Pará, Brazil 2006-

2 (18.18) 1 (50.00) 2 (12.50)

8 (72.73) 2 (100.00) 9 (56.25)

hypolipidemic therapy for the clinical follow-up of four nutritional consultations, Pará,

In assessing relation between lipids and lipodystrophy syndrome, there was no significant

**Lipohypertrophy** 

**1º 2º 3º 4º p value\*** 

219.3 (±60.9)

89.7 (±46.04)

415.0 (±209.3)

**Mixed N (%)** 

0.6626

0.2539

0.0503

**p value** 

216.7 (± 69.2)

108.8 (±29.6)

488.3 (±637.6)

triglycerides (Table 3).

Triglycerides 597.0

\* Legend: *Friedman* test.

Brazil 2006-2008.

Total Cholesterol

LDL cholesterol

HDL cholesterol

Abnormal levels

Abnormal levels

Abnormal levels

Abnormal levels

2008.

Triglycerides

207.7 (±40.2)

91.7 (±45.6)

association, as sample data in Table 4.

Legend: N - number of patients. Test: Partitioning Chi-square.

**Lipoatrophy N (%)** 

**Lipodystrophy Syndrome**

(±300.1)

**Biochemical Tests** 

Cholesterol Total

LDL cholesterol

Fig. 2. Distribution of the lipodystrophy syndrome in relation to sex, Pará, Brazil 2006-2008.

The HAART temporal analysis showed that there was a growing evolution of lipoatrophy and lipohypertrophy presence in association with prolonged use of HAART (p = 0.0485, p = 0.0393, respectively).

Among the 29 patients, 6 were taking hypolipidemic. The lipid profile found in patient's evaluation, including those who had made use hypolipidemic therapy, was no statistically significant changes on the total cholesterol and LDL-C, however, for the HDL-C and triglycerides had significant differences between the first and last clinical follow-up nutritional (Figure 3).

Legend: (A) Total cholesterol, (B) LDL-C, (C) and HDL-C (D) triglycerides, distributed by quarters. Dependent t-test for paired samples.

Fig. 3. HIV patients Serum lipids who did not use hypolipidemic, distributed by quarters, 2006-2008 Para-Brazil.


When analyzing only the sample of patients who were taking hypolipidemic (n = 7), there was no statistically significant changes in the levels of serum total cholesterol, LDL-C and triglycerides (Table 3).

\* Legend: *Friedman* test.

436 Dyslipidemia - From Prevention to Treatment

Fig. 2. Distribution of the lipodystrophy syndrome in relation to sex, Pará, Brazil 2006-2008. The HAART temporal analysis showed that there was a growing evolution of lipoatrophy and lipohypertrophy presence in association with prolonged use of HAART (p = 0.0485,

Among the 29 patients, 6 were taking hypolipidemic. The lipid profile found in patient's evaluation, including those who had made use hypolipidemic therapy, was no statistically significant changes on the total cholesterol and LDL-C, however, for the HDL-C and triglycerides had significant differences between the first and last clinical follow-up

Legend: (A) Total cholesterol, (B) LDL-C, (C) and HDL-C (D) triglycerides, distributed by quarters.

Fig. 3. HIV patients Serum lipids who did not use hypolipidemic, distributed by quarters,

p = 0.0393, respectively).

nutritional (Figure 3).

Dependent t-test for paired samples.

2006-2008 Para-Brazil.

Table 3. Comparison of mean only of lipid profile of patients who were taking hypolipidemic therapy for the clinical follow-up of four nutritional consultations, Pará, Brazil 2006-2008.

In assessing relation between lipids and lipodystrophy syndrome, there was no significant association, as sample data in Table 4.


Legend: N - number of patients. Test: Partitioning Chi-square.

Table 4. Association between lipid profile and lipodystrophy syndrome, Pará, Brazil 2006- 2008.

Dyslipidemia in Patients with Lipodystrophy in the Use of Antiretroviral Therapy 439

commonly observed in patients infected with HIV make it difficult to change lifestyle (personal and food) as suggested by Quintaes & Garcia (1999) Chencinski & Garcia (2006). There was also that patients profile evaluated before intervention reflected increase in serum total cholesterol and triglycerides, and lowering HDL-C as described in the literature (Caar et al. 1998; Hadigan et al. 2006; Having Hofstede et al., 2003; Abreu et al., 2006), disagreeing with main studies analyzed only about LDL-C, where most patients remained within normal range. Lipid disorders and association with lipodystrophy syndrome were common in all patients, especially in mixed syndrome, according to studies by Thiebaut et al. (2000)

The lipid abnormalities evolution in patients after clinical and nutritional intervention during study noted significant changes of lowering triglycerides and increase in HDL-C, regardless of hypolipidemic use. The increased levels of HDL-C have been associated with decreased cardiovascular risk, as has been discussed in the work of Manninen et al. (1988). Where was reported that for every 1% increase in HDL-C was 3% reduction in coronary events and Pedersen et al. (1998) who said that for each 1% increase in HDL-C there was 1%

The lipid profile of patients before and after nutritional intervention clinically observed that patients who had shown serum levels of triglycerides, total cholesterol and fractions (LDL-C and HDL-C) normal at first, had increasing them at the end of treatment. These patients had borderline values facilitating risk of increased total cholesterol, LDL-C and triglycerides and decreased HDL-C associated with nutrition acceptance less than 75%. Other patients in the first consultation showed values above the reference levels for total cholesterol, LDL-C and triglycerides as well as lowering HDL-C, reaching normal values due to good acceptance to nutritional care. The remaining patients showed levels of total cholesterol, LDL-C fractions, HDL-C and triglycerides changed during the research; probably was not able to perceive the importance of nutritional treatment. There were also cases of patients who had their lipid profile within the normal range, suggesting that not only the use of HAART interfered with these metabolic changes, but also other factors may be implicated as genetic predisposition. In regarding to lipodystrophy syndrome, the cholesterol and LDL-C means demonstrated it more significant in lipoatrophy than mixed syndrome compared before and after intervention. Triglyceride levels showed independent growing in despite to lipodystrophy

The physiopathology by which HAART determines HIV lipodystrophy syndrome, dyslipidemia therefore remains unknown. Second Andrade & Hutz (2002), the lipid serum levels are multifactorial characteristics, determinate by genetic and environmental factors, highlighting the genetic variability found in those genes that can affect the response to

The authors of the lipodystrophy ambulatory care are developing a research paper about a case-control study conducted from December 2009 to July 2012. For data collection is being performed a clinical, epidemiological and nutritional evaluation where are registered information about patient identification, socio-economic conditions, personal and family history of morbidity, time of HIV diagnosis, HAART treatment duration, medication used - HAART, viral load, CD4 counts, clinical history, biochemical tests for dyslipidemia classification, anthropometric analysis and, APOAI and APOAV apolipoprotein polymorphism evaluation. This study aims to investigate these polymorphisms in an attempt

to discover the main causes responsible for this metabolic disorder, the dyslipidemia.

reduction in coronary events, both independently of changes in LDL-C levels.

syndrome, while HDL-C showed changed levels in mixed syndrome.

drugs used in hyperlipidemia treatment.

and Haugaard et al. (2005).

In assessing comparison of mean of lipid profile of all patients before and after the clinical and nutritional intervention (first and fourth visit), there was a significant difference between the levels of total cholesterol, LDL-C, HDL-C and triglycerides between the lipoatrophy and mixed syndrome (p> 0.05) (Table 5). No analysis was performed on the lipohypertrophy syndrome due to be there of only two patients.


Table 5. Comparison of mean of lipid profile of all patients, including who were taking hypolipidemic therapy before and after the intervention in lipodystrophy syndrome, Pará, Brazil 2006-2008.

The manifestation of lipodystrophy syndrome with regard to gender did not present significant differences for lipoatrophy or mixed syndrome. However, the syndrome was related to female lipohypertrophy corroborating other studies (Galli et al., 2002; Heath et al., 2002) and disagreeing with most published data has been shown increased risk of lipoatrophy syndrome among women. Tien et al. (2003) in prospective study of lipodystrophy syndrome risk among HIV-infected women and non-infected observed a risk 2,1 times more of develop lipoatrophy in infected women with virus than non-infected, whereas it did not differ lipohypertrophy syndrome between the two groups and the most prevalent de form lipodystrophy was mixed syndrome (81%). Van Griensven et al. (2007) evaluated the lipodystrophy syndrome prevalence among patients using stavudine in antiretroviral therapy and found lipoatrophy syndrome prevalence in 9.8% of patients on stavudine and 4.9% with lipohypertrophy syndrome. The HAART temporal analysis showed that there was a growing evolution of the appearance of lipoatrophy and lipohypertrophy associated with HAART prolonged use, as demonstrated by studies of Lichtenstein et al. (2005) and Goujard et al. (2003).

As regards the evaluation of metabolic changes associated with use of HAART coupled with the treatment of nutritional guidance, it must be pointed out that some factors may have affected the outcome of this work as the low adherence to medical treatment, nutrition, failure to follow the previous recommendations for achieving of biochemical tests and the small sample size of patients available for this study. This difficulty in adhering to medical treatment and/or diet therapy was also found by other authors (Quintaes & Garcia, 1999; Ceccato et al. 2004; Parenti et al., 2005; Barros et al. 2007; Chencinski & Garcia, 2006). The reluctance of patients to nutritional treatment may be related to low purchasing power (Barros et al., 2007), cultural and dietary habits proper to the Amazon region, who abuse food that are rich in lipids. In addition to psychosocial factors of patients, where the prejudice, social isolation and emotional disorders such as anxiety and depression

In assessing comparison of mean of lipid profile of all patients before and after the clinical and nutritional intervention (first and fourth visit), there was a significant difference between the levels of total cholesterol, LDL-C, HDL-C and triglycerides between the lipoatrophy and mixed syndrome (p> 0.05) (Table 5). No analysis was performed on the

(±41.84) 0.3744 198.14

(±34.67) 0.2308 110.37

(±15.92) 0.6809 42.14

(±259.21) 0.9133 220.86

The manifestation of lipodystrophy syndrome with regard to gender did not present significant differences for lipoatrophy or mixed syndrome. However, the syndrome was related to female lipohypertrophy corroborating other studies (Galli et al., 2002; Heath et al., 2002) and disagreeing with most published data has been shown increased risk of lipoatrophy syndrome among women. Tien et al. (2003) in prospective study of lipodystrophy syndrome risk among HIV-infected women and non-infected observed a risk 2,1 times more of develop lipoatrophy in infected women with virus than non-infected, whereas it did not differ lipohypertrophy syndrome between the two groups and the most prevalent de form lipodystrophy was mixed syndrome (81%). Van Griensven et al. (2007) evaluated the lipodystrophy syndrome prevalence among patients using stavudine in antiretroviral therapy and found lipoatrophy syndrome prevalence in 9.8% of patients on stavudine and 4.9% with lipohypertrophy syndrome. The HAART temporal analysis showed that there was a growing evolution of the appearance of lipoatrophy and lipohypertrophy associated with HAART prolonged use, as demonstrated by studies of

As regards the evaluation of metabolic changes associated with use of HAART coupled with the treatment of nutritional guidance, it must be pointed out that some factors may have affected the outcome of this work as the low adherence to medical treatment, nutrition, failure to follow the previous recommendations for achieving of biochemical tests and the small sample size of patients available for this study. This difficulty in adhering to medical treatment and/or diet therapy was also found by other authors (Quintaes & Garcia, 1999; Ceccato et al. 2004; Parenti et al., 2005; Barros et al. 2007; Chencinski & Garcia, 2006). The reluctance of patients to nutritional treatment may be related to low purchasing power (Barros et al., 2007), cultural and dietary habits proper to the Amazon region, who abuse food that are rich in lipids. In addition to psychosocial factors of patients, where the prejudice, social isolation and emotional disorders such as anxiety and depression

Table 5. Comparison of mean of lipid profile of all patients, including who were taking hypolipidemic therapy before and after the intervention in lipodystrophy syndrome, Pará,

**Lipoatrophy Mixed p-value Lipoatrophy Mixed p-value** 

(± 39.26)

(±50.44)

(±9.25)

(±193.46)

185.58

86.33

44.92

218.90

(±45.97) 0.5538

(±32.10) 0.2313

(±14.64) 0.4504

(±179.92) 0.9829

lipohypertrophy syndrome due to be there of only two patients.

 **Before After** 

183.00

94.54

40.28

310.75

Total

LDL cholesterol

HDL cholesterol

cholesterol 196.91

Triglycerides 299.36

Brazil 2006-2008.

(±35.05)

112.42 (±40.61)

37.91 (±11.65)

(±27.77)

Lichtenstein et al. (2005) and Goujard et al. (2003).

commonly observed in patients infected with HIV make it difficult to change lifestyle (personal and food) as suggested by Quintaes & Garcia (1999) Chencinski & Garcia (2006).

There was also that patients profile evaluated before intervention reflected increase in serum total cholesterol and triglycerides, and lowering HDL-C as described in the literature (Caar et al. 1998; Hadigan et al. 2006; Having Hofstede et al., 2003; Abreu et al., 2006), disagreeing with main studies analyzed only about LDL-C, where most patients remained within normal range. Lipid disorders and association with lipodystrophy syndrome were common in all patients, especially in mixed syndrome, according to studies by Thiebaut et al. (2000) and Haugaard et al. (2005).

The lipid abnormalities evolution in patients after clinical and nutritional intervention during study noted significant changes of lowering triglycerides and increase in HDL-C, regardless of hypolipidemic use. The increased levels of HDL-C have been associated with decreased cardiovascular risk, as has been discussed in the work of Manninen et al. (1988). Where was reported that for every 1% increase in HDL-C was 3% reduction in coronary events and Pedersen et al. (1998) who said that for each 1% increase in HDL-C there was 1% reduction in coronary events, both independently of changes in LDL-C levels.

The lipid profile of patients before and after nutritional intervention clinically observed that patients who had shown serum levels of triglycerides, total cholesterol and fractions (LDL-C and HDL-C) normal at first, had increasing them at the end of treatment. These patients had borderline values facilitating risk of increased total cholesterol, LDL-C and triglycerides and decreased HDL-C associated with nutrition acceptance less than 75%. Other patients in the first consultation showed values above the reference levels for total cholesterol, LDL-C and triglycerides as well as lowering HDL-C, reaching normal values due to good acceptance to nutritional care. The remaining patients showed levels of total cholesterol, LDL-C fractions, HDL-C and triglycerides changed during the research; probably was not able to perceive the importance of nutritional treatment. There were also cases of patients who had their lipid profile within the normal range, suggesting that not only the use of HAART interfered with these metabolic changes, but also other factors may be implicated as genetic predisposition.

In regarding to lipodystrophy syndrome, the cholesterol and LDL-C means demonstrated it more significant in lipoatrophy than mixed syndrome compared before and after intervention. Triglyceride levels showed independent growing in despite to lipodystrophy syndrome, while HDL-C showed changed levels in mixed syndrome.

The physiopathology by which HAART determines HIV lipodystrophy syndrome, dyslipidemia therefore remains unknown. Second Andrade & Hutz (2002), the lipid serum levels are multifactorial characteristics, determinate by genetic and environmental factors, highlighting the genetic variability found in those genes that can affect the response to drugs used in hyperlipidemia treatment.

The authors of the lipodystrophy ambulatory care are developing a research paper about a case-control study conducted from December 2009 to July 2012. For data collection is being performed a clinical, epidemiological and nutritional evaluation where are registered information about patient identification, socio-economic conditions, personal and family history of morbidity, time of HIV diagnosis, HAART treatment duration, medication used - HAART, viral load, CD4 counts, clinical history, biochemical tests for dyslipidemia classification, anthropometric analysis and, APOAI and APOAV apolipoprotein polymorphism evaluation. This study aims to investigate these polymorphisms in an attempt to discover the main causes responsible for this metabolic disorder, the dyslipidemia.

Dyslipidemia in Patients with Lipodystrophy in the Use of Antiretroviral Therapy 441

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