Dysregulation of tryptophan metabolism in a sub-Saharan HIV/AIDS population

Abstract

The essential amino acid tryptophan is an important substrate for the synthesis of serotonin, melatonin, tryptamine, proteins and the kynurenines. The aim of this study was to investigate tryptophan metabolism along the kynurenine pathway in a low income sub- Saharan HIV/AIDS patient population from the Gauteng Province of South Africa. The first objective was to develop and validate a novel gas chromatography mass spectrometry method to enable reliable quantification of tryptophan and metabolites of the kynurenine pathway in plasma. Validation parameters for the detection of tryptophan, kynurenine, quinolinic acid and nicotinamide conformed to international criteria for newly developed methods. The next objective of the study was to find an appropriate biomarker against which to express the results. Several substances previously described as indicators were assessed and compared, including plasma neopterin, procalcitonin, C-reactive protein, the cytokines IL-2, IL-4, IL-6, IL-10, TNF, and IFN-gamma, as well as factors routinely measured and elsewhere described as biomarkers in HIV, i.e., albumin, the albumin/globulin ratio, haemoglobin and red cell distribution width. Neopterin was shown to be superior as indicator of pro-inflammatory status, as indicator of the degree of immune deficiency, to predict disease progression, to distinguish between patients with and without tuberculosis co-infection and to reflect the success of highly active antiretroviral treatment (HAART). In the analyses of the kynurenine pathway metabolites, tryptophan levels were seen to be significantly lower (24.36 ± 4.14 vs. 43.57 ± 11.85 μmol/l; p<0.0001), while the activity of the enzyme, indoleamine 2,3 dioxygenase (IDO), (K/T:136.03 vs. 52.18; p<0.001), as well as kynurenine (3.21 ± 1.33 vs. 2.14 ± 0.45 μmol/l; p<0.001) and quinolinic acid (4.46 ± 2.32 vs. 0.25 ± 0.058 μmol/l; p<0.001) levels were significantly higher in the total patient group (n=105) than in the control group (n=60). Patients on HAART showed not only significantly higher CD4 counts (296.21 ± 195.50 vs. 170.05 ± 167.26 cells/μl; p=0.003), but also lower inflammatory activity (neopterin: 35.51 ± 35.70 vs. 66.63 ± 40.73 nmol/l; p<0.001 and IL-6: 9.56 ± 12.54 vs. 15.04 ± 19.34 pg/ml; p<0.05), lower IFN-γ (41.43 ± 14.14 vs. 53.68±34.39 pg/ml; p<0.05), higher tryptophan levels (25.13 ± 3.80 vs. 22.04 ± 4.32 μmol/l; p=0.033), lower kynurenine levels (3.08 ± 1.28 vs. 3.58 ± 1.42 μmol/l; p=0.144) and lower quinolinic acid levels (4.03 ± 2.04 vs. 5.77 ± 2.65μmol/l; p=0.072) than patients not on HAART. Tryptophan depletion and IDO activity, as well as the levels of kynurenine and quinolinic acid, were generally greater than in populations from developed countries. Indications are that this can be ascribed to higher levels of inflammatory activity at comparable levels of immune deficiency in the disadvantaged population of this study. The degree of tryptophan depletion and quinolinic acid accumulation found could negatively impact on the physical and neuropsychiatric wellness of the population. Correlations between quinolinic acid, and nicotinamide levels showed a significant contribution of kynurenine pathway metabolism to the plasma levels of nicotinamide. This de novo synthesis of nicotinamide could offer protection against niacin deficiency and NAD depletion in populations with inadequate dietary intake. This is the first study to assess plasma tryptophan, kynurenine, quinolinic acid and nicotinamide levels, as well as IDO activity, pro-inflammatory status and IFN-γ levels, simultaneously in one population and to compare it to that of HIV/AIDS patients in developed countries.