Summary
Pneumocystis carinii pneumonia (PCP) in HIV-infected patients remains a life-threatening complication in the course of HIV infection. Despite effective treatment, mortality may still be as high as 10%. The identification of risk factors associated with a lethal outcome might be helpful as a guide to therapy for patients at risk and in the evaluation of new drugs with anti-pneumocystic activity. In a retrospective study 58 first episodes of HIV-associated PCP without prophylaxis were analyzed. Variables associatred univariately with higher mortality were identified. A prognostic rule was established in a multivariate approach using canonical discriminant analysis. Cut-off values for parameters included were determined in order to allow a clinically applicable estimate of the individual risk. Variables associated with early mortality were hemoglobin, hematocrit, platelet count, albumin, total protein, γ-globulins, and AaDO2. LDH values, percentage of neutrophils in the BAL, as well as the cellular immunologic state as indicated by CD4-cell count were not significantly associated with the outcome. The discriminant function yielded the best classification results with the inclusion of hemoglobin, albumin, and γ-globulins (overall accuracy 86%). Two or more of the following parameters were associated with a 14-fold increased risk of in-hospital mortality: hemoglobin less than 10 g/dl, albumin less than 3 g/dl, and γ-globulins less than 1.2 g/dl. This prognostic rule was 80% sensitive and 94% specific with a negative predictive value of 94%, yielding an overall accuracy of 91%. Patients with HIV-associated PCP with a positive prognostic rule have a 14-fold increased risk for in-hospital lethal outcome. This discriminant rule may be helpful in identifying patients at risk.
Zusammenfassung
DiePneumocystis carinii-Pneumonie (PCP) gehört unverändert zu den potentiell lebensbedrohlichen Komplikationen der HIV-Erkrankung. Trotz wirksamer antimikrobieller Therapie ist sie mit einer Letalität von bis zu 10% verbunden. Die Identifikation von Risikofaktoren für einen tödlichen Ausgang könnte Kriterien für therapeutische Eskalationen begründen und sich in der Ermittlung neuer Pneumocystis-wirksamer Medikamente nützlich erweisen. In einer retrospektiven Studie wurden 58 Erstepisoden einer HIV-assoziierten PCP ohne Prophylaxe analysiert. Im univariaten Ansatz wurden Parameter identifiziert, die signifikant mit einem letalen Ausgang assoziiert waren. Anschließend wurde multivariat mittels der kanonischen Diskriminantenanalyse eine prognostische Regel aufgestellt. Um eine klinisch relevante individuelle Risikoabschätzung zu ermöglichen, wurden Schwellenwerte für eingeschlossene Parameter bestimmt. Univariat waren die mittleren Werte des Hämoglobins, Hämatokrits, Thrombozyten, Albumins, Gesamteiweißes, der γ-Globuline und der AaDO2 signifikant mit dem Ausgang der PCP assoziiert. Keine Unterschiede zwischen Überlebenden und Verstorbenen fanden sich für die mittleren Werte der LDH, der Prozentzahl der Neutrophilen in der BAL und der CD4-Zellzahlen. Die Diskriminantenanalyse ergab die besten Klassifikationsergebnisse bei einer Kombination von Hämoglobin, Albumin und γ-Globulinen (Gesamtrichtigkeit der Klassifikation: 86%). Das Vorliegen von mindestens zwei von drei Werten aus Hämoglobin < 10 g/dl, Albumin < 3 g/dl und γ-Globulinen < 1,2 g/dl war mit einem 14fach erhöhten Risiko eines letalen Ausgangs verbunden. Diese prognostische Regel zeigte eine Sensitivität von 80%, eine Spezifität von 94% und einen negativen Vorhersagewert von 94% bei einer Gesamtrichtigkeit von 91%. Patienten mit einer HIV-assoziierten PCP weisen bei Vorliegen von mindestens zwei der drei prognostisch ungünstigen Werte dieser Regel ein 14faches Risiko eines letalen Ausgangs auf. Diese Regel könnte sich somit als hilfreich erweisen, um Risikopatienten zu identifizieren.
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Bauer, T., Ewig, S., Hasper, E. et al. Predicting in-hospital outcome in HIV-associatedPneumocystis carinii pneumonia. Infection 23, 272–277 (1995). https://doi.org/10.1007/BF01716285
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DOI: https://doi.org/10.1007/BF01716285