HIV Patients Taking ART Have Low Postop Mortality

HIV-infected individuals who are receiving modern antiretroviral therapy (ART) have low postoperative mortality rates that are influenced as much by hypoalbuminemia and age as by CD4 cell status, according to a new study.

"Clinicians and patients should consider HIV infection and CD4 cell count as just 2 of many factors associated with surgical outcomes that should be incorporated into surgical decision making," stated the authors, led by Joseph T. King, Jr, MD of the Section of Neurosurgery, Department of Surgery, at the Veterans Affairs Connecticut Healthcare System in West Haven, CN.

ART has converted HIV infections into a chronic condition, and patients now undergo a variety of surgical procedures, but current surgical outcomes have not been inadequately characterized.

Dr King and colleagues set out to compare 30-day postoperative mortality in patients with HIV infection receiving ART with the rates in uninfected individuals. They conducted a retrospective analysis of nationwide electronic medical record data from the US Veterans Health Administration Healthcare System, including 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%).

Among the HIV patients, 80% had CD4 cell counts at least 200/mm³, which is the most common threshold used in surgical decision making, the researchers stated. Only 3.7% of patients had CD4 counts lower than 50/mm³. About three-quarters of patients with HIV infection had undetectable levels of HIV-1 RNA.

“HIV infection was associated with higher 30-day postoperative mortality (3.4%) compared with the mortality in uninfected patients (1.6%),” the researchers stated.

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

In an adjusted analysis, patients with HIV infection had increased death rates at 30 days across all CD4 cell count levels compared with uninfected patients. Hypoalbuminemia, a reflection of nutritional status, and age were also strongly associated with mortality.

An HIV patient with a CD4 cell count higher than 200/mm³ can be expected to have about the same postoperative mortality as an uninfected individual 16 years older, they stated. That is, a 50-year-old patient with HIV infection who is receiving ART has a 30-day postoperative mortality risk that is similar to that of a 66-year-old individual without the infection.

The researchers noted that many uninfected patients have postoperative risks higher than those of HIV-infected patients with CD4 cell counts above 200/mm³. "For example, a 45-year-old HIV-infected patient with a CD4 cell count of 200/mm³ 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 stated.

The study has limitations, they noted. The low mortality rate necessitated pooling of results across surgical procedures. There is no way to tell whether the mortality differential was uniform across various types of surgery. Also, the population consisted primarily of men.

The researchers published their results online February 25, 2015 in JAMA Surgery.