HIV protease inhibitors induce endoplasmic reticulum stress and disrupt barrier integrity in intestinal epithelial cells

Gastroenterology. 2010 Jan;138(1):197-209. doi: 10.1053/j.gastro.2009.08.054. Epub 2009 Sep 2.


Background & aims: Human immunodeficiency virus (HIV) protease inhibitor (PI)-induced adverse effects have become a serious clinical problem. In addition to their metabolic and cardiovascular complications, these drugs also frequently cause severe gastrointestinal disorders, including mucosal erosions, epithelial barrier dysfunction, and diarrhea. However, the exact mechanisms underlying gastrointestinal adverse effects of HIV PIs remain unknown. This study investigated whether HIV PIs disrupt intestinal epithelial barrier integrity by activating endoplasmic reticulum (ER) stress.

Methods: The most commonly used HIV PIs (lopinavir, ritonavir, and amprenavir) were used; their effects on ER stress activation and epithelial paracellular permeability were examined in vitro as well as in vivo using wild-type and CHOP(-)/(-) mice.

Results: Treatment with lopinavir and ritonavir, but not amprenavir, induced ER stress, as indicated by a decrease in secreted alkaline phosphatase activities and an increase in the unfolded protein response. This activated ER stress partially impaired the epithelial barrier integrity by promoting intestinal epithelial cell apoptosis. CHOP silencing by specific small hairpin RNA prevented lopinavir- and ritonavir-induced barrier dysfunction in cultured intestinal epithelial cells, whereas CHOP(-)/(-) mice exhibited decreased mucosal injury after exposure to lopinavir and ritonavir.

Conclusions: HIV PIs induce ER stress and activate the unfolded protein response in intestinal epithelial cells, thus resulting in disruption of the epithelial barrier integrity.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Animals
  • Apoptosis / drug effects
  • Carbamates / pharmacology
  • Cell Line
  • Cell Membrane Permeability / drug effects
  • Endoplasmic Reticulum / drug effects*
  • Endoplasmic Reticulum / metabolism
  • Endoplasmic Reticulum / pathology
  • Furans
  • HIV Infections / drug therapy*
  • HIV Infections / metabolism*
  • HIV Infections / pathology
  • HIV Protease Inhibitors / pharmacology*
  • Intestinal Mucosa / drug effects*
  • Intestinal Mucosa / metabolism
  • Intestinal Mucosa / pathology
  • Lopinavir
  • Male
  • Mice
  • Mice, Inbred C57BL
  • Mice, Mutant Strains
  • Pyrimidinones / pharmacology*
  • Ritonavir / pharmacology
  • Stress, Physiological / drug effects
  • Sulfonamides / pharmacology
  • Transcription Factor CHOP / genetics


  • Carbamates
  • Ddit3 protein, mouse
  • Furans
  • HIV Protease Inhibitors
  • Pyrimidinones
  • Sulfonamides
  • Transcription Factor CHOP
  • Lopinavir
  • amprenavir
  • Ritonavir