Postop mortality low in HIV patients on ART

Last Updated: 2015-03-06

By Reuters Staff

NEW YORK (Reuters Health) - In HIV-infected patients on modern antiretroviral therapy (ART), postoperative death rates are low and influenced as much by age and nutritional status as immune system function (CD4 cell counts), new research shows.

"Clinicians and patients should consider HIV infection and CD4 cell count as just two of many factors associated with surgical outcomes that should be incorporated into surgical decision making," the study team concludes in a report online now in JAMA Surgery.

ART has turned HIV infection into a chronic disease, and patients with HIV are now candidates for a range of surgical procedures, but surgical outcomes are unclear. Until now, no study has compared surgical outcomes among HIV-infected patients receiving modern ART and uninfected individuals matched by surgical procedure.

Dr. Joseph T. King, Jr., of the Veterans Affairs Connecticut Healthcare System in West Haven and colleagues did just that. Their analysis included 1641 HIV patients receiving ART and 3282 uninfected patients.

The most common procedures in both groups were cholecystectomy (10.5%), hip arthroplasty (10.5%), spine surgery (9.8%), herniorrhaphy (7.4%) and coronary artery bypass surgery (7.0%).

Eighty percent of HIV patients had CD4 cell counts at least 200/mm3, the most common threshold used in surgical decision making, the authors note. Only 3.7% of patients had CD4 counts lower than 50. Roughly three quarters of HIV-infected patients also had undetectable levels of HIV-1 RNA.

The HIV cohort had a "relatively low" 30-day postoperative mortality rate of 3.4% (56 patients), although higher than in the uninfected cohort (1.6%, 53 patients), the researchers report.

CD4 cell count was inversely associated with mortality, but viral suppression provided no additional information.

In adjusted analyses, patients with HIV infection had increased death rates at 30 days across all CD4 cell count levels compared with uninfected patients. Poor nutritional status (hypoalbuminemia) and age were also strongly associated with mortality.

The authors say an HIV-infected individual with a CD4 cell count higher than 200 can be expected to have a postoperative mortality rate akin to that of an uninfected individual 16 years older; "a 50-year-old (surgery) patient with HIV infection who is receiving ART has a 30-day mortality risk similar to that of a 66-year-old individual without the infection," they note.

They caution, however, that the association between HIV infection, CD4 cell count and mortality should be viewed in context: Many uninfected patients have postoperative risks higher than those of HIV-infected patients with CD4 cell counts above 200. "For example, a 45-year-old HIV-infected patient with a CD4 cell count of 200/L or more had a lower rate of 30-day postoperative mortality than did any 65-year-old uninfected patient or a 45-year-old uninfected patient with hypoalbuminemia," they report.

They point out that the low mortality rate necessitated pooling results across surgical procedures, and they can't say whether the mortality differential was uniform across various types of surgery. Another limitation is the population: veterans consisting primarily of men.

The study had no commercial funding and the authors have no relevant disclosures. They did not respond to request for comment by press time.

SOURCE: http://bit.ly/1DSWEzu

JAMA Surg 2015.