AIDS-Related Alveolar Hemorrhage: Risk Factors

AIDS-Related Alveolar Hemorrhage: Risk FactorsRisk Factors for HIV-Related AH in Univariate Analysis
Characteristics of HIV Infection and Potential Triggering Factors: As shown in Table 1, AH was associated with several factors. Compared with control subjects, patients were significantly more likely to be male, to belong to the homosexual HIV transmission category, and to have mucocutaneous KS. Immunodeficiency was also more severe in the patients, as shown by the higher frequency of prior AIDS-defining conditions, antiretroviral therapy, and PCP prophylaxis, and by a lower mean CD4 + cell count. No differences in age or race were found.
The factors reported to trigger AH are analyzed in Table 2. Thrombocytopenia, a patient-to-control subject APTT ratio exceeding 1.5, and renal failure were significantly more frequent in patients than in control subjects. Conversely, prior congestive heart failure, smoking history, and mechanical ventilation were not significantly associated with AH. buy antibiotics online

Underlying HIV-Related Pulmonary Disorders: At least one associated pulmonary disorder was found in each patient with AH. Conversely, AH was never found in the 17 HIV-infected control subjects without pulmonary symptoms and with normal chest radiograph findings. As expected, PCP and bacterial pneumonia were the most frequent pulmonary disorders in both groups. More interestingly, pulmonary KS, CMV pneumonia, and hydrostatic pulmonary edema were significantly more frequent in patients than in control subjects. Hydrostatic pulmonary edema resulted from HIV-related cardiomyopathy in two patients and from severe renal failure in six patients. Patients with renal failure also had the following very homogeneous clinical features: all were black Africans; and all had a nephrotic syndrome attributed, by renal biopsy specimen, to idiopathic focal and segmental glomerulosclerosis and hyalinosis. Figure 1 shows the frequency of AH according to intercurrent pulmonary conditions. AH was present in most patients with pulmonary KS (75%), CMV pneumonia (83%), and hydrostatic pulmonary edema (100%). The underlying pulmonary diseases in the eight patients with grossly bloody BAL fluid were pulmonary KS (n = 4), CMV pneumonia (n = 2), and PCP (n = 2). The two patients with PCP also had thrombocytopenia (< 60,000 cells/^L).
Risk Factors for HIV-Related AH in Multivariate Analysis
The following four independent risk factors for AH were identified by multivariate analysis (Table 4): pulmonary KS; hydrostatic pulmonary edema; CMV pneumonia; and thrombocytopenia. Conversely, the absence of underlying pulmonary disease was negatively associated with AH.
Fig1
Figure 1. In parentheses are the numbers of diagnoses of pulmonary disorders. Note that the total number of diagnoses is greater than the total number of patients because 18 patients each had two diagnoses. Other diagnoses are detailed in Table 4. The bars represent the percentage of BAL specimens with AH. MB = tuberculosis and nontuberculosis Mycobacterium; IA = invasive aspergillosis.
Table 1—Comparison Between Patients (With AH) and Control Subjects (Without AH) for Main Characteristics of Patients and HIV Infection (Univariate Analysis)

Characteristics With AH(n = 73) Without AH(n = 130) p Value OR (95% CI)
Age, yr 38 ± 10 38 ± 9 NSi 1 (0.9-1.0)
Male/female ratio 5.6 2.2 0.01 2.5 (1.2-5.3)
White/black ratio 2.8 2.4 NSi 1.3 (0.6-2)
HIV transmission category Homosexual 35 (48) 34 (26) < 0.01 2.6 (1.4—4.7)
IV drug user 15 (20) 40 (31) NSi 0.6 (0.3-1.2)
Blood recipient 1 (1.4) 1 (0.8) NSi 1 (0.9-1.0)
Unknown 22 (32) 55 (42) NSi 0.7 (0.4-1)
Prior AIDS-defining condition 41 (56) 48 (37) < 0.01 2.2 (1.2-4)
CD4+ count < 200 cells/mm 65 (89) 100 (77) 0.04 2.4 (1-5.6)
Extrapulmonary KS 16 (22) 13(18) 0.02 2.5 (1.1-5.6)
Prior antiretroviral use 48 (66) 50 (38) < 0.01 2.8 (1.6-5.2)
Prior PCP prophylaxis 48 (66) 57 (44) < 0.01 2.7 (1.5-4.9)

Table 2—Comparison Between Patients (With AH) and Control Subjects (Without AH) for Parameters That Have Already Been Associated With AH in Literature (Univariate Analysis)

Characteristics With AH(n = 73) Without AH(n = 130) p Value OR (95% CI)
Smoker/nonsmoker ratio 0.46 0.45 NSt 1 (0.5-1.9)
Tobacco use, pack-yr 18 ± 14 14 ± 15 NSt 1 (0.97-1.02)
Platelets < 60,000 cells/mm 11 (15) 5 (3.8) < 0.01 4.35 (1.5-12.5)
APTT, patient to control ratio > 1.5 11 (15) 6 (4.6) 0.01 3.7(1.3-10.0)
Thrombin time < 60% 5 (6.8) 3 (2.3) NSt 3.3 (0.7-14.3)
Creatinine > 130 |xmol/L 14(19.2) 12 (9.2) 0.04 2.3 (1.0-5.3)
Prior congestive heart failure 3 (4) 3(2) NSt 1.8 (0.4-2)
Use of mechanical ventilation 3 (4) 2(1.5) NSt 2.7 (0.4-10.7)

Table 4 —Stepwise Logistic Nonconditional Multivariate Regression Analysis for AH-Associated Risk Factors

Risk Factors p Value OR (95% CI)
CMV pneumonia 0.05 9.8 (1-91)
Pulmonary KS 0.003 5.3(1.8-16.7)
Pulmonary edema 0.01 16.4(1.8-142)
Platelet count < 60,000 cells/|xL 0.009 5.6(1.5-20)
Nonpulmonary diseases 0.04 0.1 (0.01-0.90)
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