Serum albumin levels and depression in people living with Human Immunodeficiency Virus infection: a cross-sectional study
Introduction
Human Immunodeficiency Virus (HIV) infection is a chronic inflammatory disease [1] due to the chronic activation of both the adaptive and innate immune systems [2], [3], [4]. HIV infection may increase inflammation directly by viral replication and indirectly by adverse effects caused by virus replication in the gut mucosa [2], [3], [4]. The virus rapidly spreads throughout the gut-associated lymphoid tissue leading to the loss of CD4 + T cells directly and indirectly to epithelial injury [5], [6], [7]. The loss of mucosal integrity exposes the gut mucosa to proinflammatory microbial products such as lipopolysaccharides, which also drive inflammation [8]. HIV-mediated mucosal damage also passes translocated microbial products on to the liver, contributing to hepatic damage, impaired microbial clearance, and impaired protein synthesis that enhances inflammation [9], [10], [11].
One of the important bioactive molecules that may capture the dynamic process of inflammation in HIV-infection is albumin. Albumin is a negative acute phase response protein synthesized in the liver [12] and is an important marker of inflammation. Under inflammatory conditions, the transcapillary escape rate of albumin may increase several-fold [13]. An increase leakage of albumin during an inflammatory response could be one of the important reasons for hypoalbuminaemia in a chronic inflammatory condition [14]. In addition, HIV infection might lower albumin levels through a different mechanism. For instance, the transcapillary escape rate of albumin may increase due to the disruption of barrier function of the endothelium by the HIV-1 Tat-1 protein [15]. The serum albumin levels in HIV-infected persons are lower than in healthy individuals [16]. Studies suggest that low serum albumin levels are associated with higher risk of cardiovascular disease in HIV-infected persons [16], [17]. Thus, serum albumin could have an important prognostic value in HIV-infected persons, as it is an important predictor of survival [16], [17]. More importantly, serum albumin has special significance in developing countries because it is an inexpensive and widely available measurement.
Depression is a highly prevalent co-morbid condition occurring in all stages of HIV infection [18]. The prevalence rate of depression is at least two to three times higher for HIV-infected persons [18] compared to the general population [19]. Depression and low serum albumin levels are frequently reported among HIV-infected persons however, the role of serum albumin levels in depression has not been studied in this population. A growing body of evidence suggests [20], [21], [22] that low serum albumin levels are associated with various mental health problems in populations other than HIV-infected persons. Low serum albumin levels associated with clinical depression are probably related to increase catabolism of albumin due to inflammation [23].
In this context, we considered that an investigation in an HIV-infected population might provide useful information about the association of serum albumin levels with depressive symptoms among immune-deficient persons with chronic inflammation. Thus, this study aimed to assess the association between serum albumin levels and depressive symptoms in HIV-infected persons, while accounting for important confounding variables including anti-retroviral therapy (ART) and serum C-reactive protein (CRP) and zinc concentrations. As albumin plays an important role in immune and inflammatory mechanisms [12], [24] and reduces risk of depression [23], [25], [26], we hypothesized that increased concentrations of serum albumin levels would be associated with decreased symptoms of depression in HIV-infected persons. Our study would add new information on correlates of depression among HIV-infected population, apart from previous studies' findings on socio-demographic, psychological, and social risk factors of depression [27], [28], [29], [30].
Section snippets
Study design and setting
We conducted a cross-sectional study among HIV-infected persons living in the Kathmandu, Lalitpur, and Bhaktapur districts (Kathmandu Valley) of Nepal. Nepal has faced a concentrated epidemic of HIV with a high prevalence of infection in specific groups, such as injecting drug users (6.3%), female sex workers (4.2%), men who have sex with men (3.8%), and labor migrants to India (1.8%) [31], [32]. About 50,200 people aged 15–49 years are living with HIV, with a prevalence of 0.3% in the general
Results
The mean (SD) serum albumin levels (g/dL) for all participants, men and women were 4.55 (0.58), 4.57 (0.61), and 4.52 (0.52), respectively. The prevalence rates of depression in all participants, men, and women were 25.4%, 22.4%, and 29.1%, respectively. The prevalence rate of depression among participants with low and high serum albumin levels were 33.33% and 17.53%, respectively.
Table 1 shows demographic and clinical characteristics of the 310 HIV-infected participants by serum albumin
Discussion
In our cohort of HIV-infected persons, we observed significant inverse linear relationships between serum albumin levels and depressive symptoms score. This association was independent of potential cardiovascular, life-style, and HIV-related clinical and treatment confounding factors. To our knowledge, this is the first study exploring the association between serum albumin levels and depressive symptoms among HIV-infected persons.
We found that the prevalence of depression was lower among
Acknowledgements
This study was partially supported by the Grant-in-Aid for Young Scientists (B) (22790581), Japan Society for the Promotion of Science, The Ministry of Education, Culture, Sports, Science and Technology, Japan and by the Grant for Research on Global Health and Medicine (No. 21A-2) from the National Center for Global Health and Medicine, Japan. The funding agency had no role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the
Conflict of interest
All authors declare that they have no conflicts of interest.
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