Cytomegalovirus reactivation and mortality in patients with acute respiratory distress syndrome.
Cytomegalovirus reactivation and mortality in patients with acute respiratory distress syndrome.
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DOI：
10.1007/s00134-015-4071-z
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发表时间：
2016-03
影响因子：
38.9
通讯作者：
Cremer OL
中科院分区：
文献类型：
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作者：
Ong DSY;Spitoni C;Klein Klouwenberg PMC;Verduyn Lunel FM;Frencken JF;Schultz MJ;van der Poll T;Kesecioglu J;Bonten MJM;Cremer OL
巨细胞病毒（CMV）再激活经常发生在急性呼吸窘迫综合征（ARDS）患者中，并与死亡率增加有关。然而，目前尚不清楚这种关联是否代表不良结局的独立风险。我们的目的是评估CMV再激活对免疫功能正常的ARDS患者死亡率的影响。我们前瞻性研究了2011年至2013年在荷兰的两个三级重症监护病房中CMV血清检测阳性并在4天后保持机械通气的免疫功能正常的ARDS患者。每周测定血浆中的CMV载量。使用竞争风险考克斯回归，CMV再激活状态作为时间依赖性暴露变量。随后，在敏感性分析中，我们使用边缘结构模型调整了疾病严重程度的演变，直到重新激活。在399例ARDS患者中，271例（68%）CMV血清学阳性，其中74例（27%）发生再激活。调整混杂和竞争风险后，CMV再激活与ICU死亡率总体增加相关（调整后的亚分布风险比（SHR）2.74，95% CI 1.51-4.97），这是死亡率增加趋势的联合作用所致（直接效应;原因特异性风险比（HR）1.58，95% CI 0.86-2.90）和成功脱机率降低（间接效应;原因特异性HR 0.83，95% CI 0.58-1.18）。这些关联仍然存在于敏感性分析中。第30天ICU死亡率的人群归因分数为23%（95%CI 6-41）（风险差异4.4，95%CI 1.1-7.9）。CMV再激活与CMV血清阳性的免疫功能正常的ARDS患者的病死率增加独立相关。本文的在线版本（doi：10.1007/s 00134 -015-4071-z）包含补充材料，可供授权用户使用。
Cytomegalovirus (CMV) reactivation occurs frequently in patients with the acute respiratory distress syndrome (ARDS) and has been associated with increased mortality. However, it remains unknown whether this association represents an independent risk for poor outcome. We aimed to estimate the attributable effect of CMV reactivation on mortality in immunocompetent ARDS patients. We prospectively studied immunocompetent ARDS patients who tested seropositive for CMV and remained mechanically ventilated beyond day 4 in two tertiary intensive care units in the Netherlands from 2011 to 2013. CMV loads were determined in plasma weekly. Competing risks Cox regression was used with CMV reactivation status as a time-dependent exposure variable. Subsequently, in sensitivity analyses we adjusted for the evolution of disease severity until onset of reactivation using marginal structural modeling. Of 399 ARDS patients, 271 (68 %) were CMV seropositive and reactivation occurred in 74 (27 %) of them. After adjustment for confounding and competing risks, CMV reactivation was associated with overall increased ICU mortality (adjusted subdistribution hazard ratio (SHR) 2.74, 95 % CI 1.51–4.97), which resulted from the joint action of trends toward an increased mortality rate (direct effect; cause specific hazard ratio (HR) 1.58, 95 % CI 0.86–2.90) and a reduced successful weaning rate (indirect effect; cause specific HR 0.83, 95 % CI 0.58–1.18). These associations remained in sensitivity analyses. The population-attributable fraction of ICU mortality was 23 % (95 % CI 6–41) by day 30 (risk difference 4.4, 95 % CI 1.1–7.9). CMV reactivation is independently associated with increased case fatality in immunocompetent ARDS patients who are CMV seropositive. The online version of this article (doi:10.1007/s00134-015-4071-z) contains supplementary material, which is available to authorized users.