PREDICTORS OF SHORT-TERM AND LONG-TERM SURVIVAL IN HIV-INFECTED PATIENTS ADMITTED TO THE ICU

Study objectives: To evaluate the prognosis of HIV-infected patients a dmitted to ICUs and to identify factors predictive of short-and long-t erm survival. Design: A prospective study from January 1, 1990, to Dec ember 31, 1992, including all consecutive HIV-infected patients admitt ed to our ICU for the first time. ICU survivors were followed up until January 1, 1994. Setting: An 18-bed infectious diseases ICU in a 1,30 0-bed university hospital in Paris. Patients: Four hundred twenty-one HIV-related admissions were recorded during the study period (33.5% of 1,258 admissions to ICU); 354 HIV-infected patients were first ICU ad missions and were analyzed. Measurements and results: Predictive facto rs on univariate and multivariate analyses (logistic regression and Co x model) for short-and long-term mortality were performed. Respiratory failure was the main cause of admission (49.2%), followed by neurolog ic disorders (26.8%), sepsis (10.2%), heart failure (4.5%), and miscel laneous disorders (9.3%). For these groups, in-ICU and in-hospital mor tality rates were as follows: 16.7% and 33.9%; 23.2% and 41.1%; 38.9% and 58.3%; 25% and 68.8%; and 12.1% and 24.2%, respectively. In-ICU an d in-hospital mortality rates were significantly different across the groups (p=0.026 and 0.002, respectively). Multivariate analysis showed that the in-hospital outcome was significantly associated with functi onal status (p=0.05), time since AIDS diagnosis (p=0.04), HIV disease stage (0.016), simplified acute physiology score (SAPS I) (p=0.06), ne ed for mechanical ventilation (p<0.000001), and its duration (p=0.0001 ). In the 281 patients who were discharged alive from the ICU, cumulat ive survival rates were 51%+/-38% at 6 months, 28%+/-38% at 12 months, and 18%+/-30% at 24 months. Median and crude mean+/-SD survival times were 199 days and 316+/-343 days. Multivariate analysis showed that t he long-term outcome was significantly associated with functional stat us (p=0.000001), weight loss (p=0.00001), the CD4 count (p=0.00001), t he HIV disease stage (p=0.01), the duration of AIDS (p=0.001), the adm ission cause group (p=0.03), and the SAPS I at admission (p=0.00001). Conclusions: The short-term (in-ICU and in-hospital) outcome of HIV-in fected patients was mainly related to the severity of the acute illnes s (SAPS I, cause of admission, need for and duration of mechanical ven tilation), and to the preadmission health status, based on functional status and weight loss. Some of these parameters, in particular the SA PS I and preadmission health status, also influenced the long-term out come. Whereas HIV-related variables had little impact on die in-ICU ou tcome, they were closely related with the in-hospital outcome and even more strikingly with the long-term outcome. Thus, the life expectancy of HIV-infected patients, which depends primarily on the natural hist ory of the HIV infection, is the most powerful determinant of the long -term prognosis. Our results confirm that ICU support for HIV-infected patients should not be considered futile.