Research On The Sepsis And Immune Function Of Patients Infected HIV In Perioperative Period

Background and AimsAcquired immunodeficiency syndrome (AIDS) caused by human immuno-deficiency virus (HIV) includes a serious infectious disease. UNAIDS and the World Health Organization report, the number of people living with HIV worldwide continues to grow in 2009, reaching an estimated 33.4 million,260 million people worldwide were newly infected with HIV, there are 180 million people die of AIDS, AIDS has become the fourth largest cause of death in humans. Chinese Ministry of Health, by the end of 2009,estimated that the number of people living with HIV is about 74 million,48 thousand persons were newly infected in 2009, and 26 thousand people died by AIDS, HIV epidemic still continues to rise in China.HIV invaded the human body mainly infects the CD4+ T lymphocytes and cells expressed CD4 molecules including mononuclear macrophage, dendritic cells and glial cells. HIV can break and destroy CD4+ T lymphocytes by three ways such as killing directly, the cytotoxic effect or through the induction of some cytokines to impair the immunity system of human. The depletion of CD4+ T cells can lead to memory CD8+ T cell immature and loss of function, reduce the ability of inhibiting HIV replication, killing cells infected HIV and blocking HIV invading new target cell.Sepsis is caused by infection with systemic inflammatory response syndrome, a variety of severe trauma, burns, hypoxia, reperfusion injury and complications after surgery. Sepsis can be further developed into septic shock and multiple organ dysfunction syndrome (MODS), is a worldwide main cause of death of patients in intensive care unit (ICU). With the highly active antiretroviral therapy are widely used, the quality of life of people with AIDS have been greatly improved, and their survival time are much longer, so the demand for surgical treatment of HIV/AIDS increasingly higher. But in general hospitals, routine testing HIV antibody before surgery, once found patients infected with HIV, doctors often tactfully refused surgical treatment, many HIV infected people lost good time of treatment because of lack of timely surgery. One of the reasons to refuse operation for persons infected HIV is that many HIV patients in immunocompromised, surgical complications, the high incidence of perioperative period sepsis and death risks. Research shows that in 2010 American Journal of Surgery reported that in 1997-2007 in Atlanta, Grady Memorial Hospital,77 patients with HIV infection on abdominal surgery,42 cases (55%) had infectious complications,23 patients (30%) died.At present, few hospitals specially afford treatment for patients infected HIV in China, and lack risk assessment system of perioperative period sepsis. In the surgical needs of people with AIDS increasing,to reduce the HIV patients rate of perioperative period sepsis and reduce mortality not only has the value of academic research, but also has broad social significance. The study plans to analysis of the relationship between sepsis and the change of T cell subsets and the peripheral blood materials in the situation of the surgical trauma stimulation, explore the factors of sepsis, assess and screen sensitivity indicators to improve the perioperative period treatment of HIV patients and reduce the incidence and mortality of sepsis.Materials and Methods1 MaterialsFrom 2009 to 2010, the Shanghai Public Health Clinical Center Surgical requirements treated 298 surgical cases. Among them,144 cases were HIV patients, 154 cases were non-HIV infected patients (including 96 cases of hepatitis and 58 cases of TB), HIV patients were all confirmed detected by the method of Western blot (WB) in disease prevention and control(CDC); There were 130 patients appear perioperative period sepsis in 298 cases.2 MethodsUsing nested case-control study, to follow up and interview the cases untill two weeks after surgery, observe the occurrence of perioperative period sepsis, and the patients with sepsis were allotted to case group, the patients without sepsis were allotted to control group. We used automatic biochemical to test component of peripheral blood such as white blood cells, hemoglobin, platelets, albumin, and used flow cytometry to test CD4+T cells and CD8+ T cells in peripheral blood in the period of preoperative and 2 weeks after operation in all of the surgery patients. Among HIV patients, we use real time quantitative reverse transcription polymerase chain reaction apparatus (Real-time PCR) to detect HIV viral load preoperative. To assess operative risk, select the appropriate surgical approach, and postoperative symptomatic treatment.3 ContentsComparing components of CD4+T cells, CD8+ T cells, CD4/CD8, WBC, hemoglobin, platelets, albumin in peripheral blood between HIV infection group and non-HIV infection group, to research the influence of HIV infection on the immune function of surgical patients.Comparing components of CD4+T cells, CD8+ T cells, CD4/CD8, WBC, hemoglobin, platelets, albumin in peripheral blood between sepsis group and non-sepsis group, to research the influence of sepsis on the immune function of surgical patients.By Using factorial analysis, we investigate the main effect and interaction of HIV infection and sepsis on the patients' CD4+ T cells and CD8+T cells in peripheral blood of patients.By using binary logistic regression, we analysed the possible influence factors of perioperative period sepsis in the cases infected HIV.4 Statistic and analysisTo Use EPIDATA3.0 establish a database, double entry, use SAS 9.1 software to process and analyse the data, quantitative data were described by x±s, compared the difference between groups with analysis of variance, multiple comparisons using SNK test; qualitative data using contingency table chi-square test, the rate of adjustment of multiple comparisons test with Bonferroni method. Level data using CMH chi-square trend test. Pearson correlation analyses the linear correlation between variables, two factors and two levels materials were analyzed using two-level factorial analysis, non-conditional binary Logistic regression selected influence factors. Significance level a= 0.05.ResultsPart1 The results of 298 surgical cases1 From 2009 to 2010, the Shanghai Public Health Clinical Center Surgery treated 298 patients, including 144 cases infected HIV,96 cases infected HBV,58 cases infected TB, the rate of sepsis was 43.62%. The post-operative mortality of HIV patients was 3.47%;2 The rate of sepsis in HIV patients was higher than that in HBV patients (x2=30.40, P<0.01), and was no significant difference with TB patients(x2=0.07, P=0.79);3 Drainage of abscess cleared had the highest incidence of sepsis (65.63%); the incidence of sepsis had a negative linear correlation with before surgery CD4+T cells (r=-0.99, P<0.05), preoperative CD8+T cells (r=-0.99, P<0.05) before surgery CD4/CD8 (R=-0.94, P<0.05), postoperative CD4+ T cells (r=-0.97, P= 0.03).4 Preoperative CD4+ T cells had positive correlation with preoperative CD8+ T cells (r =0.253, P=0.003), preoperative CD4/CD8 (r=0.580, P<0.01), preoperative hemoglobin (r=0.341, P<0.01). In particularly, when the pre-operative CD4+ T cells was lower than 200cell/ul, with the value of CD4+ T cells reduced, the positive correlation between CD4+ T cells and CD4/CD8 increased.5 HIV infection and sepsis both make CD4+ T cells and CD8+T cells decreased significantly, but no significant interaction between the two factors;6 Binary Logistic regression analysis showed that HIV infection, surgical classification, preoperative CD4+T cells are significant factors of sepsis (P<0.05). The risk of sepsis in HIV patients is 20.46 (OR95% CI:3.91-107.12) times than that in the cases without HIV, the risk of sepsis in orthopedic surgery patients is 21.58 (OR95% CI:2.22-210.35)times than that in splenectomy patients, the risk of sepsis in abscess drainage clear is 20.83 times than that in splenectomy (OR95% CI:1.57-276.92).Part2 The results of 144 surgical cases infected HIV1 The number of gastrointestinal surgery was the most in HIV patients (31.94%), the hepatobiliary surgery patients had the highest incidence of sepsis(81.82%).2 There were no significant difference of sepsis incidence in HIV patients among various age group (x2=4.06, P=0.398) and gender (x2=0.32, P=0.76), there were no significant difference of sepsis incidence among incidence of hepatobiliary surgery sepsis, tumor biopsy and resection orthopedic surgery (P>0.05), but higher than that of the gastrointestinal tract surgery and surgery (P<0.05);3 HIV viral load taken to base ten logarithmic transformation, the HIV viral load of sepsis group (2.19±0.97) was not different with non-sepsis group (1.60±0.04), we still can not believe that HIV viral load quantity has a relationship with sepsis;4 There were negative correlation between HIV viral load before surgery and preoperative CD4+T cells (r=-0.562, P<0.01), and there also were negative correlation between HIV viral load before surgery and preoperative CD4/CD8 (r=-0.34, P=0.03);5 The levels of CD4+T cells before surgery had negative linear correlation with the incidence of sepsis (r=-0.99, P<0.05), had positive linear correlation with preoperative CD8+T cells (r=0.253, P=0.003), preoperative CD4/CD8 (r=0.580, P <0.01), preoperative hemoglobin (r=0.341, P<0.01), showed no linear relationship with the white blood cells, platelets, and albumin (P> 0.05);6 Multivariate Logistic regression analysis showed that preoperative CD4+T, postoperative hemoglobin and platelet levels after surgery had significant influence on the incidence of sepsis of HIV patients (P<0.05). lower level of preoperative CD4+T was 2.81 times risk of sepsis than that of higher level(OR95% CI:1.56-5.05); postoperative hemoglobin decrease of one grade each,2.54-fold increased risk of sepsis (OR95% CI:1.18-5.47); decreasing by a post-operative platelet levels, 1.97-fold increased risk of sepsis (OR95% CI:1.13-3.42).Conclusion1 The 298 objects in this research were surgery cases combined HIV, HBV, TB infection. The incidence of sepsis in HIV patients was the highest. Compared with the international relevant results, the mortality rate of HIV patients of this study is lower in perioperative period.2 The main factors of the incidence of sepsis in perioperative period HIV patients include the preoperative value of CD4+ T cells, the postoperative level of hemoglobin and the value of platelets after surgery.3 The main factors affected sepsis in all surgical cases included HIV infection, surgical classification, level of CD4+ T cells before surgery. 4 HIV viral load before surgery had negative linear relationship with preoperative CD4+ T cells and CD4/CD8 before surgery, but had no significant correlation with sepsis.5 Preoperative value of CD4+ T cells had positive linear correlation with the value of preoperative CD8+ T cells, before surgery CD4/CD8, had no correlation with hemoglobin, white blood cells, platelets, albumin, had negative linear correlation with the incidence of sepsis. Preoperative value of CD8+ T cells and CD4/CD8 had negative correlation with the incidence of sepsis.