Thirty-Day Postoperative Mortality Among Individuals With HIV Infection Receiving Antiretroviral Therapy and Procedure-Matched, Uninfected Comparators

Abstract

IMPORTANCE Antiretroviral therapy (ART) has converted human immunodeficiency virus (HIV) infection into a chronic condition, and patients now undergo a variety of surgical procedures, but current surgical outcomes are inadequately characterized. OBJECTIVE To compare 30-day postoperative mortality in patients with HIV infection receiving ART with the rates in uninfected individuals. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of nationwide electronic medical record data from the US Veterans Health Administration Healthcare System, October 1, 1996, to September 30, 2010. Common inpatient surgical procedures were grouped using the Healthcare Cost and Utilization Project Clinical Classification System to match HIV-infected and uninfected patients in a 1:2 ratio. Data on 1641 patients with HIV infection receiving combination ART who were undergoing inpatient surgery were compared with data on 3282 procedure-matched, uninfected comparators. Poisson regression models of 30-day postoperative mortality were adjusted for procedure year, age, Charlson Comorbidity Index score, hemoglobin level, albumin level, HIV infection, CD4 cell count, and HIV-1 RNA level. MAIN OUTCOMES AND MEASURES All-cause 30-day postoperative mortality. RESULTS 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 grafting (7.0%). In patients with HIV infection, CD4 cell distributions were 80.0% with 200/µL or more, 16.3% with 50/µL to 199/µL, and 3.7% with less than 50/µL; 74.1% of patients with HIV infection had undetectable HIV-1 RNA. Human immunodeficiency virus infection was associated with higher 30-day postoperative mortality compared with the mortality in uninfected patients (3.4% [56 patients]) vs 1.6% [53]); incidence rate ratio [IRR], 2.11; 95% CI, 1.41–3.17; P < .001). CD4 cell count was inversely associated with mortality, but HIV-1 RNA provided no additional information. After adjustment, patients with HIV infection had increased mortality compared with uninfected patients at all CD4 cell count strata (≥500/µL: IRR, 1.92; 95% CI, 1.02–3.60; P = .04; 200–499/µL: IRR, 1.89; 95% CI, 1.20–2.98; P = .01; 50–199/µL: IRR, 2.66; 95% CI, 1.29–5.47; P = .01; and <50/µL: IRR, 6.21; 95% CI, 3.55–10.85; P < .001). Hypoalbuminemia (IRR, 4.35; 95% CI, 2.78–6.81; P < .001) and age in decades (IRR, 1.47; 95% CI, 1.23–1.76; P < .001) were also strongly associated with mortality. CONCLUSIONS AND RELEVANCE Current postoperative mortality rates among individuals with HIV infection who are receiving ART are low and are influenced as much by hypoalbuminemia and age as by CD4 cell status. Human immunodeficiency virus infection and CD4 cell count are only 2 of many factors associated with surgical outcomes that should be incorporated into surgical decision making.

Postoperative Sepsis Among HIV-Positive Patients with Acute Abdomen at Tertiary Hospital in Sub-Saharan Africa: a Prospective Study

“…The incidence rate ratio for postoperative sepsis in HIV-positive versus HIV-negative participants was 1.035 (95% CI 0.319-3.29; P = 0.47). King et al in a similar study done in a veterans' hospital in the USA found an incidence rate ratio of 2.11 (95% CI 1.41-3.17; P < 001) [9]. This rate was higher than that in our study possibly because they followed-up patients for a longer period.…”

Lung cancer in persons with HIV

“…Several small series and cohorts have reported treatment effectiveness estimates and complication rates for lung cancer therapies in HIV infected patients. Surgical resection is the standard-of-care for early stage lung cancer, and a large ART-era analysis from the Veterans Affairs Health System found that HIV infected patients may continue to experience more frequent surgical complications than uninfected patients[49], although results specific to lung cancer surgery were limited. A comparative study evaluating lung cancer surgical outcomes in a cohort of 22 HIV infected patients compared to uninfected comparators demonstrated more frequent surgical complications and poorer post-surgical survival[25].…”

HIV infection and poor renal outcomes following noncardiac surgery

“…All the established preoperative risk factors for PPRO in noncardiac surgery patients identified in the studies of Kheterpal et al (5,6) were found to be independently associated with a higher risk of PPRO in this study. a CD4 cell count of >200/µL was equivalent to that of an uninfected patient aged >16 years, whereas the mortality risk in a patient with a CD4 cell count of >50/µL was equivalent to that of an uninfected patient aged >47 years (8). It is therefore possible that adequate management of HIV infection in our study population resulted in no overall difference in the levels of risk for PPRO observed between HIV-infected and HIV-uninfected patients.…”