Risk factors for early mortality on antiretroviral therapy in advanced HIV-infected adults.
Risk factors for early mortality on antiretroviral therapy in advanced HIV-infected adults.
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DOI：
10.1097/qad.0000000000001606
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发表时间：
2017-10-23
期刊：
影响因子：
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通讯作者：
Adult AIDS Clinical Trials Group A5274 (REMEMBER) Study Team
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作者：
Bisson GP;Ramchandani R;Miyahara S;Mngqibisa R;Matoga M;Ngongondo M;Samaneka W;Koech L;Naidoo K;Rassool M;Kirui F;Banda P;Mave V;Kadam D;Leger P;Henestroza G;Manabe YC;Bao J;Kumwenda J;Gupta A;Hosseinipour MC;Adult AIDS Clinical Trials Group A5274 (REMEMBER) Study Team
许多艾滋病毒感染者患有晚期艾滋病毒疾病。这些患者在开始抗逆转录病毒治疗（ART）后面临很高的死亡风险，但这些患者死亡的危险因素尚不清楚。我们使用了一项多中心随机试验的数据，该试验比较了开始 ART 且 CD4 计数 <50 个细胞/mm3 的 HIV 感染成人的经验性结核病治疗与预防性结核病治疗，以评估开始 ART 后 48 周内死亡的危险因素。 Cox 比例风险模型适合评估基线和 ART 开始后 4 周时存在的特征，包括第 4 周的 CD4 细胞反应和新的机会性感染 (OIs)。在 850 名受试者中，ART 前 CD4 计数中位数为 18 个细胞/mm3，其中 67 名 (7.9%) 死亡。死亡的基线危险因素包括淋巴结肿大、CD4 计数较低、血清白蛋白较低、白细胞 (WBC) 计数较高、中性粒细胞百分比升高和血红蛋白较低。在第 4 周有数据的 746 名参与者中，死亡者 (n=43) 与存活者的 CD4 计数和病毒载量中位变化分别为 26 与 56 个细胞/mm3 和 -2.7 与 -2.7 log10 拷贝/mL。第 4 周 CD4 计数每降低 20 个细胞/mm3，第 4 周后死亡风险就会增加 20%（调整后 HR 1.20、1.01–1.42，p=0.038）。有证据表明，在 ART 的第一个月内，活动性感染和次优的免疫反应与接受结核病预防治疗的晚期 HIV 患者在开始 ART 后第一年的死亡有关。降低该人群早期死亡率的策略值得进一步研究。
Many HIV-infected individuals present with advanced HIV disease. These patients are at high risk of death after antiretroviral therapy (ART) initiation, but risk factors for death in these patients are unclear. We used data from a multi-site randomized trial comparing empiric versus preventive TB therapy in HIV-infected adults initiating ART with CD4 counts <50 cells/mm3 to evaluate risk factors for death within 48 weeks after ART initiation. Cox proportional hazards models were fit to evaluate characteristics present at baseline and at 4 weeks after ART initiation, including the week 4 CD4 cell response and new opportunistic infections (OIs). Of 850 enrolled, the median pre-ART CD4 count was 18 cells/mm3 and 67 (7.9%) died. Baseline risk factors for death included lymphadenopathy, lower CD4 count, lower serum albumin, high white blood cell (WBC) count, elevated neutrophil percent, and lower hemoglobin. Among 746 participants with data at week 4, the median changes in CD4 count and viral load for those who died (n=43) vs. survived were 26 vs. 56 cells/mm3 and −2.7 vs. −2.7 log10 copies/mL, respectively. Each 20 cell/mm3 lower change in week 4 CD4 count was associated with a 20% increased risk of post week-4 mortality (adj. HR 1.20, 1.01–1.42, p=.038). Evidence of active infection and sub-optimal immunologic response during the first month of ART are associated with death in the first year after ART initiation in those with advanced HIV disease taking TB preventative therapy. Strategies to reduce early mortality in this population warrant further investigation.