Mortality In HIV-infected Patients Research Articles

Factors predicting survival for HIV-infected patients with respiratory failure

Background: Despite improved treatment modalities, the mortality of HIV infected patients admitted to the intensive care unit with respiratory failure remains high. To help ICU physicians in advising HIV infected patients whether to undergo mechanical ventilation, we retrospectively investigated prognostic factors predicting hospital outcome for HIV-infected patients, admitted to a medical intensive care unit with respiratory failure before the era of highly-active anti-retroviral therapy.Methods: A retrospective chart review was carried out of all HIV-infected patients with respiratory failure admitted to the medical ICU of a Dutch University Hospital between 1991 and 1997.Results: In the six year period, 29 HIV-infected patients were admitted to the ICU for respiratory failure. Mechanical ventilation, CD4 cell count, APACHE II score, APACHE III score, ARDS and length of ICU stay all differed significantly between survivors and non-survivors. However, a multivariate analysis only showed the need for mechanical ventilation as an independent risk factor for mortality. The only combination of factors able to accurately predict mortality for the individual patient was the development of ARDS and the requirement of mechanical ventilation.Conclusions: The combination of mechanical ventilation and ARDS accurately predicts hospital outcome in HIV-infected patients presenting with respiratory failure before the HAART era.

Bacteremia in HIV-infected patients: short-term predictors of mortality.

To identify characteristics associated with mortality in HIV-infected patients with bacteremia, 88 bacteremic episodes in 80 HIV-infected patients were prospectively identified over a 5-month period and observed for 30 days. Demographic, clinical, laboratory, and radiologic data were collected. Mean and median age was 41 years. Most study subjects were homosexual men. Median CD4 count was 20 cells/mm3. Gram-positive organisms predominated (65%). The most common source of bacteremia was intravascular catheters (45%). Overall mortality was 30%. A history of malignancy, three or more opportunistic infections, shock, low hemoglobin, source of bacteremia other than an intravascular catheter, resistance to therapy, and a second bacteremic episode during the study period, were all found to be independent predictors of mortality. In this cohort of HIV-infected patients, most of whom were severely immunosuppressed, several factors were found to be significantly and independently associated with mortality.

Risk factors for recurrent bleeding and mortality in human immunodeficiency virus–infected patients with acute lower GI hemorrhage

Background: Little is known about lower gastrointestinal (GI) hemorrhage in the human immunodeficiency virus (HIV)–infected population. Our aim was to determine the underlying causes, the clinical outcome, and the risk factors for recurrent bleeding and mortality in HIV-infected patients with acute LGIH. Methods: We reviewed the medical records of consecutive HIV-infected patients with acute lower GI hemorrhage who were evaluated with endoscopy from January 1992 through January 1997 at Bellevue Hospital Center. Results: During the 5-year study period, 312 patients with acute lower GI hemorrhage underwent colonoscopy (n = 233) or flexible sigmoidoscopy (n = 79). Cytomegalovirus colitis (25.3%), lymphoma (12.2%), and idiopathic colitis (12.2%) were the most common causes identified. Within 30 days of presentation, recurrent bleeding occurred in 17.6% of patients. Independent predictors of recurrent bleeding included the presence of at least one comorbid illness, a hemoglobin level of less than 8 gm/dL, a platelet count of less than 100,000/mm 3, and major stigmata of hemorrhage. The 30-day mortality from lower GI hemorrhage was 14.4%, and the presence of comorbid disease, recurrence of bleeding, and surgical intervention were found to be the only independent predictors of mortality in this patient population. Conclusions: Acute lower GI hemorrhage in HIV-infected patients is most commonly caused by cytomegalovirus colitis and is associated with a high short-term morbidity and mortality. (Gastrointest Endosc 1999;49:748-53.)

Treatment and Prophylaxis of Disseminated Mycobacterium Avium Complex in HIV-Infected Individuals

To review the pathophysiology, epidemiology, treatment, and prophylaxis of disseminated Mycobacterium avium complex (MAC) infection in HIV-infected individuals. A MEDLINE (January 1966-July 1997) and AIDSLINE (January 1980-July 1997) search of basic science articles pertinent to the MAC infection in HIV-infected patients. All articles were considered for possible inclusion in the review. Pertinent information, as judged by the authors, was selected for discussion. The organism, epidemiology, and pathophysiology of disseminated MAC are discussed for background. A review of clinical trials for the treatment and prophylaxis of disseminated MAC are presented, along with unresolved issues concerning these topics. The incidence of disseminated MAC has increased dramatically with the AIDS epidemic. The infection can lead to increased morbidity and mortality in HIV-infected patients. Treatment regimens for patients with a positive culture for MAC from a sterile site should include two or more drugs, including clarithromycin. Prophylaxis against disseminated MAC should be considered for patients with a CD4 cell count of less than 50/mm3.

Size and duration of zidovudine benefit in 1003 HIV-infected patients: U.S. Army, Navy, and Air Force natural history data. Military Medical Consortium for Applied Retroviral Research.

The study's objectives were to determine the size and duration of benefits of early versus delayed versus late treatment with zidovudine (ZDV) on disease progression and mortality in HIV-infected patients, and whether patients rapidly progressing before ZDV treatment had a different outcome from those not rapidly progressing before ZDV. The design was an inception cohort of 1003 HIV-infected patients. One hundred and seventy-four of the 1003 patients were treated before CD4 counts fell to <400 x 10(9)/L, ("early treatment"); 183 of 1003 patients were treated after CD4 counts fell to <400 x 10(9)/L but before clinical disease developed ("delayed treatment"); and 646 of the 1003 patients had either been treated after clinical disease developed or had not been treated at all by the end of follow-up ("late treatment"). Outcomes were progression to clinical HIV disease and mortality. The relative risk (RR) of progression for early versus delayed treatment was 0.58 (p < .03), and durability of ZDV benefits on progression was estimated at no more than 2.0 years; however, this estimate had wide confidence intervals. The RR of progression for delayed versus late treatment was 0.54 p < .0001, and durability of ZDV benefits was estimated at 1.74 years; this estimate had narrow confidence intervals. Survival was better for the early versus delayed treatment (RR = 0.55), but this difference was not statistically significant. In the subgroup of patients with more rapid CD4 decline prior to ZDV therapy, significant benefits on progression were observed for early versus delayed ZDV therapy (RR = 0.42, p = .02) and delayed versus late ZDV therapy (RR = 0.51; p = .0004). Duration of benefit was estimated to be 4.5 years (early versus delayed) and 1.7 years (delayed versus late). For patients with less rapid pre-ZDV decline in CD4 levels, a significant progression benefit was observed for delayed versus late therapy (RR = 0.50; p = .02). Duration of benefit in this subgroup was estimated to be 1.8 years. No significant benefit was found for early versus delayed treatment (RR = 1.12) in the less rapid pre-ZDV CD4 cell decline subgroup. Early treatment compared with delayed treatment was associated with a sizable reduction in HIV progression, but the duration of benefits was estimated to last only about 2 years. Delayed treatment compared with late treatment with ZDV was associated with substantial reduction of progression, but this reduction was also clearly limited in duration. Benefits on progression and mortality for the early treatment group were heavily dependent on the pre-ZDV CD4 slope. In the subgroup of patients with the most rapid pre-ZDV CD4 cell declines, the duration of benefit was much longer, possibly as long as 4 years.

Pre-AIDS mortality in HIV-infected individuals in England, Wales and Northern Ireland, 1982-1996.

To assess pre-AIDS mortality in HIV-infected patients in England, Wales and Northern Ireland during the period 1982-1996. Surveillance data on pre-AIDS and AIDS deaths reported to the PHLS-AIDS Centre were analysed. Pre-AIDS mortality was estimated as the proportion of pre-AIDS deaths among all deaths in HIV-infected people. Trends over time in the number of pre-AIDS and AIDS deaths were compared using Poisson regression with logarithmic link. Causes of pre-AIDS deaths were recorded. Comparisons were made between the pre-AIDS and the AIDS death groups by logistic regression for: age, location of residence at death, year of death and risk exposure. Four-hundred and sixty-eight pre-AIDS deaths and 8574 AIDS deaths were identified. Pre-AIDS mortality accounted for 5.0% of HIV-related deaths. Trends over time in the number of pre-AIDS and AIDS deaths were not significantly different (P=0.11). Reported causes of pre-AIDS death included pneumonia (92), liver disease (62), septicaemia (51), malignancies (49), suicide (45), cardiopulmonary causes (46), haemorrhage (42), overdose (24) and accidental causes (24). Factors positively associated with pre-AIDS death were injecting drug use, haemophilia and blood transfusion, residence outside the Thames regions, and death at an older age. Pre-AIDS mortality represents a substantial proportion of HIV mortality, particularly where injecting drug use is a frequent route of HIV transmission.

Histoplasmosis: update 1998.

Histoplasmosis continues to be an important cause of morbidity and mortality in HIV-infected patients. Significant new developments since its last

GUIDELINES FOR IMMUNIZATIONS IN HIV-INFECTED PATIENTS

Patients infected with the human immunodeficiency virus HIV are at high risk for infectious complications. Opportunistic pathogens cause significant morbidity and mortality in HIV-infected patients, and medications used for prophylaxis have gained wide acceptance. In addition, more common viral and bacterial pathogens cause significant morbidity and mortality in this patient population. Immunizations against common pathogens have historically been successful in controlling and potentially eradicating infectious agents. There are several features of HIV-infected patients; however, that have brought controversy to the subject of immunizations, and therefore regular immunization schedules for these patients have not gained wide acceptance. Features to consider for each immunization include the risk of acquiring the pathogen, the efficacy and side effects of the vaccine, and the potential for HIV viral activation from vaccination. Ignoring the potential consequences of HIV viral activation, immunizations that are considered otherwise safe to administer include inactivated vaccines, such as pneumococcal vaccine and influenza vaccine, and immunoglobulin preparations. In general, live vaccines are contraindicated in HIV-infected patients, with the exception of measles, mumps, and rubella (MMR). Because data pertaining to the quantitative effect of immunization on viral activation have only recently been available, first this research is summarized, followed by a discussion of the use of specific protective immunizations in persons with HIV infection. Table 1 summarizes available data on comparative efficacy, evidence for viral activation, and current public health service recommendations.

Pp65 antigenemia as a marker of future CMV disease and mortality in HIV-infected patients.

We retrospectively evaluated the role of pp65 antigenemia (AGM) as a marker of cytomegalovirus (CMV) disease and mortality in 241 HIV-infected patients with fever. Of 225 patients in whom CD4 count was available, 189 (84%) had counts below 100/microL and 209 (92.8%) below 200/microL, 149 patients had negative AGM (AGM-) and 92 had positive AGM (AGM+), AGM+ patients were at a more advanced stage of HIV disease, as evaluated by CD4 count (p < 0.001) and prior AIDS diagnosis (p < 0.001). Overall, 29 patients (12%) presented concomitant CMV disease (18 retinitis): 24 (26%) in the AGM+ group and 5 (3.3%) in the AGM- group (p < 0.001). AGM had a negative predictive value of 96.6% but a positive predictive value of 26% which increased to 65% if a cut-off of > 10 CMV-positive cells/10(5) leukocytes was considered. The cumulative rate of future CMV disease at 3 months was 0% in AGM patients, 3% in patients with AGM 1-10/10(5) and 36% in patients with AGM > 10/10(5). In a multivariate analysis, no antiretroviral therapy, AGM+ and CMV disease were independently associated with mortality. The role of AGM as a marker of present CMV disease is limited. However, quantitative AGM may select patients at a high risk of future CMV disease. In addition, AGM may be a marker of shorter survival in severely immunosuppressed HIV-infected patients.

RENAL COMPLICATIONS IN HIV DISEASE

Renal consequences of HIV disease are diverse: some unique attributable to HIV infection per se and some coincidental reflecting the nature and severity of underlying primary illness. In addition, renal sequelae may also be iatrogenic, owing to a variety of therapeutic agents employed in the management of HIV infection. Renal failure from any cause, both reversible (acute) and irreversible (ESRD), contributes greatly to morbidity and mortality in HIV-infected patients. An understanding of the spectrum of renal derangements is essential for clinicians to manage patients with HIV disease better.

Comparison of Community-Acquired Pneumonia Requiring Admission to Hospital in HIV-and Non-HIV-Infected Patients

To compare community-acquired pneumonia (CAP) in hospitalized human immunodeficiency virus (HIV)-infected patients with that in hospitalized non-HIV-infected patients by assessing presenting characteristics, etiology and outcomes. Retrospective chart review. A tertiary care centre in Halifax, Nova Scotia. Thirty-two HIV-infected patients requiring hospitalization for treatment of CAP were identified from September 1991 to October 1993 and compared with 33 age-matched non-HIV-infected patients who presented with pneumonia during the same period. The two populations were comparable in age, sex and race. Fifty per cent of the HIV-infected and 20.8% of the non-HIV-infected patients had had a previous episode of pneumonia. Pneumocystis carinii pneumonia (PCP) accounted for 16 of the 32 episodes of CAP in the HIV-infected patients, while none of the non-HIV-infected patients had PCP. Pneumonia secondary to Streptococcus pneumoniae was more common in the non-HIV-infected patients (five versus one, P=0.02). Vital signs and initial PO(2) did not differ between the two groups. White blood cell count was lower at admission for the HIV population (5.7×10(9)/L versus 12.7×10(9)/L, P=0.003). The HIV patients were more likely to undergo bronchoscopy (27.7% versus 0%, P<0.001). The length of stay in hospital, transfer to the intensive care unit and necessity for intubation were the same for both groups. The in-hospital mortality for HIV-infected patients was eight of 32 (25%) while for the non-HIV-infected patients it was none of 33 (P=0.002). Patients with HIV infection who present with CAP are more likely to have PCP, to have had a past episode of pneumonia and to die while in hospital than age- and sex-matched non-HIV-infected patients with CAP.