Impacto de la terapia antirretroviral de gran actividad en los pacientes VIH ingresados en UCI. Experiencia en un hospital de complejidad media-alta

Abstract

Introduction: Infection by human immunodeficiency virus (HIV) weakens the immune system of patients, making them more susceptible to opportunistic infections and serious complications that often require hospitalization in the Intensive Care Unit (ICU). The introduction of Highly Active Antiretroviral Therapy (HAART) in the 1990s changed the prognosis of HIV infection from fatal to chronic, at least in developed countries. Since then, new infections and deaths related to Acquired Immune Deficiency Syndrome (AIDS) have decreased significantly in our environment, as well as the number of patients admitted to the ICU due to opportunistic infections, compared to a growing percentage of patients admitted for diseases not associated with HIV, bringing the survival of these patients closer to that of the general population. The reasons for admission, prognostic factors, and survival of HIV patients in the ICU have been widely described in the pre-HAART era. However, few studies analyze the impact of the current HAART in these patients. A better knowledge of the patterns of admission, reasons for admission, evolution and survival, as well as the prognostic factors after the implementation of HAART in HIV patients in the ICU would allow adjusting the current prognostic scales. Objectives: The general objective of this work is to evaluate the impact of HAART on HIV patients admitted to the ICU of the Universitary Príncipe de Asturias Hospital (Alcalá de Henares, Madrid), analyzing the demographic characteristics, comorbidities, laboratory parameters and evolution of these patients in the different periods of development of antiretroviral treatment (ART) throughout the 30 years of the study: Pre-HAART period (from 1987 to 1996), First period of HAART (from 1997 to 2003, characterized by therapies with high toxicity and dosage complexity) and Current HAART period (from 2004 to January 2018, with treatment regimens that maintain antiviral activity, offering an improved profile in terms of safety and efficacy, with greater dosage comfort and greater experience in its use). More specifically, the objectives were to determine which factors influenced the survival of HIV patients admitted to the ICU, specifically analyzing the management of ART and proposing markers that allow for the establishment of more reliable prognostic scores. Methods: This is an observational, descriptive, retrospective study of HIV-infected patients admitted to the ICU of a hospital of medium-high complexity as described in the different stages already defined of ART, from 1st January 1987 to 31st December 2017. Demographic variables, toxic habits, personal history, variables related to HIV infection, immunovirological status upon admission to the ICU, ART, laboratory determinations and variables related to hospital admission and ICU admission, including the "Accute Physiology and Chronic Health Evaluation II" (APACHE II) score, supportive treatments received, complications, and patient evolution. Statistical treatment was carried out using the SPSS statistical package, version 18 (SPSS Inc, Chicago, IL, USA). The results were divided into three parts: a.) Descriptive study of HIV patients admitted to the ICU in the different ART periods. b). Survival and prognostic factors of HIV patients admitted to the ICU (univariate and multivariate analysis of patient survival, as well as prognostic factors that influenced survival) and c). Comparative analysis of the variables before and after the current HAART (for which two time periods were defined that mark the barrier before and after the current HAART as we know it: "Until 2003" and "From 2004 to 2018"). Results: A total sample of 187 patients was obtained. The HIV population admitted to the ICU was predominantly male, of Spanish nationality, with a mean age of 40 years, intravenous drug users (IVDU) in more than half of the cases, and a high percentage of patients coinfected with hepatitis B and C. Cardiovascular risk factors did not represent a significant percentage. Patients with advanced immunosuppression and without ART at admission predominated. The patient profile varied throughout the three time periods into which the study was divided, highlighting a progressive increase in the number of women and immigrants, the average age of the patients, the increase in the transmission of the infection sexually and cardiovascular risk factors in the post HAART period. During this time, the immunological situation of the patients improved, the reasons for admission associated with HIV infection and the percentage of patients with toxic habits decreased, and more specifically, ADVP. 5% of the patients were diagnosed with HIV in the ICU. The average APACHE II score was 19.85, which predicts a mortality of around 25-40%. Most of the patients were admitted due to acute respiratory failure due to bacterial pneumonia, Pneumocystis jirovecci (PJ) pneumonia, or pulmonary tuberculosis. Mechanical ventilation was required in up to three quarters of the cases, vasoactive drugs in half of them, and extrarenal clearance techniques in smaller percentages, with the need for these techniques assuming a worse prognosis. Better survival was observed in HIV patients who maintained or started HAART upon admission to the ICU and those who had lower values for age, lactic acid levels or on the APACHE II scale. Conclusions: In view of our results, we can say that HAART has had a significant impact on HIV patients admitted to the ICU, modifying the reasons for admission and assuming better survival for these patients. Maintaining or starting HAART along with age and lactic acid levels are independent risk factors for the prognosis of HIV patients in the ICU. These factors, as well as the immunovirological situation of the patient, the adherence and the efficacy of HAART in the case of receiving it, could be taken into account to update future prognostic scales. On the other hand, ICUs have also proven to be a place for screening for HIV infection, and the possibility of this infection in seriously ill patients must be taken into account. The peculiarities of HAART in critical HIV patients make it advisable that the management of these patients be individualized and agreed upon by intensive care physicians and HIV specialists.