An investigation into the clinical, biochemical, immunological and epigenetic factors in black South Africa women with preeclampsia and HIV.
Introduction: Preeclampsia (PE) and HIV/AIDS contribute significantly to adverse maternal and perinatal outcomes globally. The treatment of PE remains empiric, however in HIV infection, highly active antiretroviral therapy (HAART) is used routinely for maternal health and the prevention of vertical transmission in pregnancy. The relationship between PE and HIV /HAART remains controversial and despite extensive research, the pathophysiology of both conditions is not fully understood. Contemporary and new research strategies include immunological and genetic aspects of PE and HIV, and clinical and biochemical effects associated with HAART. Aims and Objectives: The aims of the study were to determine: (1) the association of HIV and HAART with clinical and biochemical indices in women with PE, (2) the effects of HAART in relation to inflammatory cytokines in PE and HIV, and (3) the role of gene polymorphisms in preeclamptic women with HIV on HAART. The specific objectives of the study were to identify significant differences (p>0.05) in the routine clinical and laboratory indices between the preeclamptic groups, (2) to identify significant changes in pro-inflammatory cytokines IL2, TNFα, IFNɣ and IL6 in relation to HIV / HAART and preeclampsia, and (3) to determine the association of single nucleotide polymorphisms (SNP) miRNA 27a (rs 895819T>C) and miRNA 146a ( rs 2910164G>C) with preeclampsia risk and susceptibility to associated factors. Materials and Methods: A prospective cohort study was conducted between July 2013 and September 2014 at Prince Mshiyeni Memorial Hospital in Durban, South Africa. To maintain ethnographic and anthropometric consistency, a standard cohort of one hundred and ninety three (193) Black women of Zulu ethnicity comprising 4 groups: i.e. uninfected normotensive (50; 26%), infected normotensive (45; 23%), uninfected preeclamptic (53; 28%) and infected preeclamptic women (45; 23%) was recruited during pregnancy after ethical approval and informed consent and followed until delivery. Women with gestational hypertension, renal disease, diabetes mellitus, chronic hypertension and collagen vascular disease were excluded. Specific patient characteristics, clinical features, laboratory indices, and complications were analysed descriptively. Serum levels of pro-inflammatory cytokines TNF-α, IFN- γ, IL2 and IL6 were determined, using commercially available kits and Cytometric Bead Array (CBA). Genotyping using PCR and the TaqMan® SNP genotyping assay for single nucleotide polymorphisms miRNA 27a rs895819T>C and miRNA 146a rs 2910164G>C was performed and analysed in relation to preeclampsia risk, susceptibility to related clinical features and pro-inflammatory cytokines. Comparative data was recorded and analysed descriptively. Results: Our results indicate that the clinical features, laboratory indices, and complications among HIV infected preeclamptic women on HAART is similar to uninfected preeclamptic women. However, gammaglutamyl transferase (GGT), a hepatic enzyme, was markedly elevated (p=0.001) in HIV infected preeclamptic women on HAART. There were significant decreases in pro-inflammatory cytokines IL2 (p=0.010), TNF-α (p=0.045), and IL6 (p=0.005), in normotensive women on HAART compared with uninfected women and significant decreases in IL2 (p=0.000) and TNFα (p=0.000) in preeclamptic women on HAART compared with uninfected preeclamptic women. In the genotype analyses, we found that the variant genotypes (GC/CC) in miRNA 146a were significantly associated with lower severe preeclampsia risk (OR: 0.34, 0.12-0.99; p=0.048), especially in the presence of HIV/HAART (OR: 0.11; 0.02-0.68, p= 0.018), and the variant genotype (TC/CC) in miRNA 27a was associated with an elevated BMI in preeclamptic women (32.57 vs 29.25; p= 0.06), especially in the presence of HIV/HAART (33.47 vs 27.87; p=0.005). Conclusion: The effects of HIV and HAART influence biochemical, immunological and genetic aspects in women with preeclampsia. Gammaglutamyl transferase, a hepatic enzyme, was markedly elevated and suggests a possible compounding effect on the liver, which is a target organ for preeclampsia and the side effects of HAART. Current management guidelines remain appropriate, however serial hepatic function tests are necessary in clinical practice. The prevention of obesity is also necessary to reduce long term cardiovascular complications associated with these conditions. The immune reconstitutive effects of HAART include a reduction in pro-inflammatory cytokines in normotensive women as well as in preeclamptic women, which may have a bearing on the clinical course of preeclampsia in women on HAART. MiRNA 27a and miRNA 146a are endogenous small RNAs that post transcriptionally regulate gene expression and are implicated in a plethora of pathophysiological processes related to preeclampsia and its related features. TC/CC and GC/CC genotype variants in the functional single nucleotide polymorphisms (SNP) microRNA27a (rs 895819 T>C) and microRNA 146a (rs 2910164G>C were associated with obesity and severe preeclampsia respectively. Obesity is a wellrecognised risk factor for preeclampsia, and severe preeclampsia is associated with increased morbidity and mortality. These findings demonstrate the importance of molecular genetics and inflammatory mediators in preeclampsia, the pathogenesis of which remains multifactorial in origin.