Assessment of simple risk markers for early mortality among HIV-infected patients in Guinea-Bissau: a cohort study

Abstract

BackgroundDecisions about when to start an antiretroviral therapy (ART) are normally based on CD4 cell counts and viral load (VL). However, these measurements require equipment beyond the capacity of most laboratories in low-income and middle-income settings. Thus, there is an urgent need to identify and test simple markers to guide the optimal time for starting and for monitoring the effect of ART in developing countries.Objectives(1) To evaluate anthropometric measurements and measurement of plasma-soluble form of the urokinase plasminogen activator receptor (suPAR) levels as potential risk factors for early mortality among HIV-infected patients; (2) to assess whether these markers could help identify patients to whom ART should be prioritised and (3) to determine if these markers may add information to CD4 cell count when VL is not available.DesignAn observational study.SettingThe largest ART centre in Bissau, Guinea-Bissau.Participants1083 ART-naïve HIV-infected patients.Outcome measuresAssociations between baseline anthropometric measurements, CD4 cell counts, plasma suPAR levels and survival were examined using Cox proportional hazards models.ResultsLow body mass index (BMI≤18.5 kg/m2), low mid-upper-arm-circumference (MUAC≤250 mm), low CD4 cell count (≤350 cells/μl) and high suPAR plasma levels (>5.3 ng/ml) were independent predictors of death. Furthermore, mortality among patients with low CD4 cell count, low MUAC or low BMI was concentrated in the highest suPAR quartile.ConclusionsIrrespective of ART initiation and baseline CD4 count, MUAC and suPAR plasma levels were independent predictors of early mortality in this urban cohort. These markers could be useful in identifying patients at the highest risk of short-term mortality and may aid triage for ART when CD4 cell count is not available or when there is shortness of antiretroviral drugs.

Loss to follow-up occurs at all stages in the diagnostic and follow-up period among HIV-infected patients in Guinea-Bissau: a 7-year retrospective cohort study

“…Other studies performed in Africa have found that mortality was inversely related to the rate of LTFU 3. Several of the LTFU risk factors among patients on ART were similar to the mortality risk factors among African HIV-infected patients as described elsewhere 26 27. If a more thorough follow-up had been performed in the study period, the mortality rate would presumably be higher.…”

Soluble urokinase plasminogen activator receptor (suPAR) is a novel, independent predictive marker of myocardial infarction in HIV‐1‐infected patients: a nested case‐control study

“…suPAR has previously been shown to predict mortality in treatment‐naïve HIV‐1‐infected patients . In HIV‐patients initiating ART, mortality was concentrated in the highest suPAR quartile, while patients with a low suPAR level had a low risk of mortality despite low CD4 cell count and low body weight . Thus, suPAR appears to add significant information to other measures of poor prognosis in HIV‐infected patients.…”

Prevalence and predictors of low muscle mass in HIV/viral hepatitis coinfection

“…10,29,30 We further required ART initiation after January 2000 to minimize exposure to nucleoside reverse transcriptase inhibitors, such as zidovudine (AZT), didanosine (DDI), or stavudine (D4T), that are associated with peripheral lipoatrophy. 31-33 …”

“…4,7-10 Mechanisms for muscle mass loss in HIV might include systemic chronic inflammation, increased resting energy expenditure, antiretroviral therapy (ART)-related fat redistribution and metabolic syndrome, and the impact of HIV-associated comborbidities. 7,8,11-14 …”