Survival of HIV-infected patients with critical illness in the era of combination antiretroviral therapy
CCCF ePoster library. Sligl W. Oct 26, 2015; 114750; P32 Disclosure(s): No disclosures or conflicts of interest.
Dr. Wendy Sligl
Dr. Wendy Sligl
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Abstract
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Introduction: Human immunodeficiency virus (HIV) infection has been perceived as an independent marker of poor prognosis in critically ill patients. In the era of combination antiretroviral therapy (ART), however, morbidity and mortality of HIV-infected patients has been drastically reduced, and HIV is now managed as a chronic disease rather than a terminal illness. The impact of an episode of critical illness on survival in this patient population, however, remains uncertain.

Objectives: To describe the epidemiology of critical illness among HIV-infected patients in the ART era and to identify potential predictors of mortality.

Methods: Data were retrospectively collected on all HIV-infected patients admitted to five intensive care units (ICUs) in Edmonton, Alberta from July 2002 to July 2014. Patient demographics, comorbidities including markers of HIV disease severity and control, admission diagnosis, severity of illness, organ failure, and 30-day mortality were collected. Univariate and multivariable (Cox proportional hazards regression) analyses were performed to identify associations with mortality.

Results: During the study period, 282 patients had 343 discrete ICU admissions. Mean age was 44 years (SD 10), 202 (59%) were male, 175 (51%) aboriginal, 203 (59%) co-infected with hepatitis C virus (HCV), and 229 (67%) had addiction problems. Median CD4 count and plasma viral load were 130 cells/mm3 and 20,500 copies/mL just preceding or at the time of admission. Only 133 (39%) patients were being prescribed ART at the time of admission and 33 (10%) were newly diagnosed in the ICU. Most common admission diagnoses were sepsis (50%) followed by respiratory failure (17%). Most patients [259 (76%)] required intubation, 169 (49%) received vasopressor support within 24 hours of admission, and 40 (12%) required renal replacement therapy. Care was limited in 89 (26%) patients and support withdrawn in 53 (16%). Seventy-four (22%) patients died within 30 days of ICU admission.

Correlates of 30-day mortality on univariate analysis included newly diagnosed HIV infection, APACHE II score, shock, and limitations of care or withdrawal of support. On multivariable analysis, APACHE II score (adjusted hazard ratio [aHR] 1.06; 95%CI 1.02–1.09, p=0.001), care limitation (aHR 4.6; 95%CI 2.3-9.2, p<0.001) and support withdrawal (aHR 5.2; 95%CI 2.7-9.8, p<0.001) were independently associated with 30-day mortality. Surprisingly, CD4 count and viral load were not independently associated with mortality.

Conclusion: Mortality from an episode of critical illness in HIV-infected patients remains high in the combination ART era. Substance abuse and HCV co-infection were common in our population. In this relatively young cohort, one in four patients had care limited. APACHE II score, care limitation and support withdrawal were independently associated with mortality. This suggests that HIV-positivity and degree of immune suppression may not be the chief determinants of mortality in this vulnerable population.
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