Epidemiology and Outcomes in Critically Ill Patients with Human Immunodeficiency Virus Infection in the Era of Combination Antiretroviral Therapy

Abstract

Purpose. The impact of critical illness on survival of HIV-infected patients in the era of antiretroviral therapy remains uncertain. We describe the epidemiology of critical illness in this population and identify predictors of mortality. Materials and Methods. Retrospective cohort of HIV-infected patients was admitted to intensive care from 2002 to 2014. Patient sociodemographics, comorbidities, case-mix, illness severity, and 30-day mortality were captured. Multivariable Cox regression analyses were performed to identify predictors of mortality. Results. Of 282 patients, mean age was 44 years (SD 10) and 169 (59%) were male. Median (IQR) CD4 count and plasma viral load (PVL) were 125 cells/mm3 (30–300) and 28,000 copies/mL (110–270,000). Fifty-five (20%) patients died within 30 days. Factors independently associated with mortality included APACHE II score (adjusted hazard ratio [aHR] 1.12; 95% CI 1.08–1.16; p < 0.001), cirrhosis (aHR 2.30; 95% CI 1.12–4.73; p = 0.024), coronary artery disease (aHR 6.98; 95% CI 2.20–22.13; p = 0.001), and duration of HIV infection (aHR 1.07 per year; 95% CI 1.02–1.13; p = 0.01). CD4 count and PVL were not associated with mortality. Conclusions. Mortality from an episode of critical illness in HIV-infected patients remains high but appears to be driven by acute illness severity and HIV-unrelated comorbid disease rather than degree of immune suppression.

Epidemiology and outcome of HIV-infected patients admitted to the ICU in the current highly active antiretroviral therapy era

“…However, despite that proportion of patients receiving HAART is increasing, only 54.8% of our patients were under HAART at admission. These data are comparable to those reported by other countries from our region, 18,28,33 and the level in Spain is higher than in the studies published from countries such as Australia, Brazil, Taiwan and China (in which less than 40% of patients received ART), 22,26,27,29 but far from the 71% reported in the USA by Akgün et al 20 This variability in the percentage of patients who receive ART is reflected in their CD4 T-lymphocyte counts at admission. Among our patients, the median was 167 cells/mm 3 (53.5, 414.0); in studies with a lower percentage of patients receiving ART, the CD4 count is lower, even falling below 50 cells/mm 3 .…”

“…These data are similar to those recently published describing industrialized countries. 22,28,33 However, in the studies by Chiang et al and Xiao et al, the clinical course of the disease was much shorter (less than a year), with a high percentage of diagnoses during admission (approximately 50%). 26,29 At present, it is widely currently recommended that HAART be administered to all HIV-infected patients, regardless of immunovirological profile or symptoms.…”

“…20,23,31 Results from analyses of prognostic factors in this patient group have varied. Some study authors have concluded that the patient's immunovirological condition determines the prognosis, 26,28 while others have stated that prognosis depends on disease severity that led to ICU admission 19,21,22,25,27,33 and comorbidities. 21,22,31 Our study aim was thus to describe the epidemiology of critical pathology in HIV patients in a cohort of patients admitted to ICU, during the current HAART period and to identify factors that predict mortality during hospital admission.…”

Patterns of presentation and survival of HIV‐infected patients admitted to a tertiary‐level intensive care unit

“…With regard to serum albumin concentration, some studies showed that low levels were a nonsignificant predictor of ICU mortality . A study by Morris et al reported that higher levels of serum albumin were significantly associated with an increased odds of survival .…”

Management of HIV-infected patients in the intensive care unit

“…The spectacular improvement of life expectancy in cART-treated patients offers long-term perspectives that justify maximizing the level of supportive care when indicated. Invasive mechanical ventilation (MV, 40-50% of all admissions), vasopressors (15-30%), and renal replacement therapy for AKI (8-15%) are now used as frequently in seropositive individuals as in the general ICU population [5,7,24,33,43,44], with comparable prognoses including in patients at high risk of death such as those admitted following cardiac arrest or with the acute respiratory distress syndrome (ARDS) [45,46]. Last-resort veno-venous or veno-arterial extracorporeal membrane oxygenation can be discussed in selected patients, with auspicious results in published reports [47,48].…”