Underweight and acute malnutrition are associated with adverseoutcomes
1
Results Poor nutritional status at enrolment is common among young HIV-infected children. Percent of children with nutritional z-scores <-2 and <-3 at enrolment in the program. Low weight-for-age and low weight-for- height are significantly associated with adverse outcomes within the first year after enrolment. Kaplan Meier plot of time since enrolment until adverse event (death or lost to follow-up) by categories of weight-for-age (WAZ, left), height-for-age (HAZ, middle) and weight- for-height (WHZ right) z-scores. Patients were censored at time of transfer- out/decentralization or at a maximum of 6 years of follow-up. P-values were calculated using log-rank tests. This study has met the criteria approved by the MSF ERB for analysis of routinely collected program data, as approved by the Medical Director. No conflict of interest of the authors. Contact Dr. Jan Walter, MSFCH-Maputo- [email protected] Method We conducted a retrospective analysis on a cohort of 625 HIV positive children below 5 years of age, enrolled at the Chamanculo Hospital in Maputo, Mozambique, between 2003 and 2010. We used data entered in an electronic monitoring system (Fuchia). We tested associations of underweight, stunting and acute malnutrition, with time until death or loss to follow-up (LTF) using Kaplan-Meier plots and Cox proportional hazard modeling. Analyses were conducted using SAS 9.2. Severe underweight was associated with younger age, enrolment after 2008, low CD4 cell percentage, other nutritional markers, and intriguingly late initiation of treatment. Characteristics at enrolment by category of weight –for-age z-score. When adjusted for CD4 cell percentages, WHO stage, antiretroviral treatment, both acute malnutrition and underweight were associated with about a threefold risk of adverse outcomes during the first year of treatment. Cox-proportional hazard modeling of adverse events within the first year after enrolment (41 [7%] deaths and 86 [14%] losses to follow-up). Underweight and acute malnutrition are associated with adverse outcomes among young HIV-infected children in Maputo, Mozambique 48 (9%) 118 (19%) 148 (28%) z <-3 [n (%)] 91 (17%) 213 (34%) 273 (51%) z <-2 [n (%)] 536 620 531 N with data Jan Walter¹, Verena Moreno¹, Celeste Gracia Edwards¹, Johnny Lujan², Annick Antierens², Lucas Molfino¹, Angels Prieto¹, Mafalda Chissano¹ and Micaela Serafini² ¹ MSF Maputo, Mozambique; ² MSF Geneva, Switzerland # numbers may be smaller due to missing values 502 118 N # <0.0001 75 (18%) 73 (69%) Weight for age <-3 z- score <0.0001 5 (1%) 43 (41%) Weight for height <-3 z- score 0.29 332 (66%) 72 (61%) Started ART within 6 months 0.0008 193 (38) 26 (22%) Started ART within 30 days 0.75 14 (3%) 2 (2%) TB at enrolment 0.0003 17 (13, 23) 14 (10, 19) CD4% at enrolment <0.0001 246 (50%) 101 (89%) WHO stage III or IV at enrolment [n (%)] 0.0005 162 (32%) 19 (16%) Enrolment before 2008 [n (%)] 0.13 246 (49%) 67 (57%) Sex [n(%)] male 0.009 25 (13, 41) 17 (12, 26) Age in months [median (IQR)] ≥-3 <-3 P-value Weight-for-age z-score Conclusion Despite of ART, HIV-infected children with underweight or acute malnutrition are at increased risk of adverse outcomes during the first year after enrolment. These children thus require special clinical attention. Further analysis need to be conducted to better understand the underlying etiology. Introduction MSF-CH has been following a large cohort of HIV-infected children in Maputo, Mozambique. However, a thorough analysis of factors associated with adverse outcomes has not been done. Poor nutritional status is known to be a risk factor for mortality among HIV-infected children. According to UNICEF data stunting, wasting and underweight is important in the general population of children in Mozambique. Acknowledgements We thank the mother and their children for contributing data. The Ministry of Health and MSF staff for taking care of HIV children as well as data collection. Aim To evaluate the potential association between poor nutritional status and adverse outcomes of an MSF-supported treatment program in Maputo, Mozambique. CI=confidence interval, # numbers may be smaller due to missing values,* modeled as time-dependent covariates, § adjusted for all variables shown. 436 625 N # 3.4 (1.6, 7.3) 7.2 (5.0, 10.4) Weight-for-height z-score <-2* 7.5 (4.9, 11.4) Weight-for-height z-score <-3* 4.2 (2.9, 6.0) Weight-for-age z-score <-2* 3.1 (1.4, 6.5) 5.9 (4.1, 8.5) Weight-for-age z-score <-3* 0.4 (0.2, 0.7) 0.4 (0.2, 0.6) ART start* 1.6 (0.8, 3.2) TB * 0.7 (0.5, 1.0) 0.9 (0.7, 1.2) CD4 per 10% increase at enrolment 0.6 (0.3, 1.0) 1.4 (1.0, 2.0) WHO stage III or IV * 0.3 (0.2, 0.5) Enrolment before 2008 1.0 (0.7, 1.4) Male sex 1.0 (0.9, 1.0) 1.0 (0.9, 1.0) Age at enrolment per months increase Adjusted hazard ratio (95% CI) § Unadjusted hazard ratio (95% CI) W 2 2-censored 1 1-censored 0 0-censored H 2 2-censored 1 1-censored 0 0-censored 0 1000 2000 0 1000 2000 0 1000 2000 1.0 0.9 0.5 0.8 0.6 0.7 0.4 z-score ≥ -2 ≥ -3 to -2 <-3 Time since enrolment in the program [days] Survival WAZ p<0.0001 HAZ p=0.11 WHZ p<0.0001 0% 20% 40% 60% 80% 100% height-for-age z- score weight-for-age z- score weight-for-height z- score % of patients with data z-score <-3 z-score <-2
description
Jan Walter, Verena Moreno, Celeste Gracia Edwards, Johnny Lujan, Annick Antierens, Lucas Molfino, Angels Prieto, Mafalda Chissano and Micaela Serafini
Transcript of Underweight and acute malnutrition are associated with adverseoutcomes
Results
Poor nutritional status at enrolment is common among young HIV-infected children.
Percent of children with nutritional z-scores <-2 and <-3 at enrolment in the program.
Low weight-for-age and low weight-for-height are significantly associated with adverse outcomes within the first year after enrolment.
Kaplan Meier plot of time since enrolment until adverse event (death or lost to follow-up) by categories of weight-for-age (WAZ, left), height-for-age (HAZ, middle) and weight-for-height (WHZ right) z-scores. Patients were censored at time of transfer-out/decentralization or at a maximum of 6 years of follow-up. P-values were calculated using log-rank tests.
This study has met the criteria approved by the MSF ERB for analysis of routinely collected program data, as approved by the Medical Director.
No conflict of interest of the authors.
Contact Dr. Jan Walter, [email protected]
Method
We conducted a retrospective analysis on a cohort of 625 HIV positive children below 5 years of age, enrolled at the ChamanculoHospital in Maputo, Mozambique, between 2003 and 2010.
We used data entered in an electronic monitoring system (Fuchia). We tested associations of underweight, stunting and acute malnutrition, with time until death or loss to follow-up (LTF) using Kaplan-Meier plots and Cox proportional hazard modeling. Analyses were conducted using SAS 9.2.
Severe underweight was associated with younger age, enrolment after 2008, low CD4 cell percentage, other nutritional markers, and intriguingly late initiation of treatment.
Characteristics at enrolment by category of weight –for-age z-score.
When adjusted for CD4 cell percentages, WHO stage, antiretroviral treatment, both acute malnutrition and underweight were associated with about a threefold risk of adverse outcomes during the first year of treatment.
Cox-proportional hazard modeling of adverse events within the first year after enrolment (41 [7%] deaths and 86 [14%] losses to follow-up).
Underweight and acute malnutrition are associated w ith adverseoutcomes among young HIV-infected children in Maput o, Mozambique
48 (9%)118 (19%)148 (28%)z <-3 [n (%)]
91 (17%)213 (34%)273 (51%)z <-2 [n (%)]
536620531N with data
Jan Walter¹, Verena Moreno¹, Celeste Gracia Edwards¹, Johnny Lujan², Annick Antierens², Lucas Molfino¹, A ngels Prieto¹, Mafalda Chissano¹ and Micaela Serafini²
¹ MSF Maputo, Mozambique; ² MSF Geneva, Switzerland
# numbers may be smaller due to missing values
502118N #
<0.000175 (18%)73 (69%)Weight for age <-3 z- score
<0.00015 (1%)43 (41%)Weight for height <-3 z- score
0.29332 (66%)72 (61%)Started ART within 6 months
0.0008193 (38)26 (22%)Started ART within 30 days
0.7514 (3%)2 (2%)TB at enrolment
0.000317 (13, 23)14 (10, 19)CD4% at enrolment
<0.0001246 (50%)101 (89%)WHO stage III or IV at enrolment [n (%)]
0.0005162 (32%)19 (16%)Enrolment before 2008 [n (%)]
0.13246 (49%)67 (57%)Sex [n(%)] male
0.00925 (13, 41)17 (12, 26)Age in months [median (IQR)]
≥-3<-3
P-valueWeight-for-age z-score
Conclusion
Despite of ART, HIV-infected children with underweight or acute malnutrition are at increased risk of adverse outcomes during the first year after enrolment.
These children thus require special clinical attention.
Further analysis need to be conducted to better understand the underlying etiology.
Introduction
MSF-CH has been following a large cohort of HIV-infected children in Maputo, Mozambique. However, a thorough analysis of factors associated with adverse outcomes has not been done.
Poor nutritional status is known to be a risk factor for mortality among HIV-infected children. According to UNICEF datastunting, wasting and underweight is important in the general population of children in Mozambique.
Acknowledgements
We thank the mother and their children for contributing data. The Ministry of Health and MSF staff for taking care of HIV children as well as data collection.
Aim
To evaluate the potential association between poor nutritional status and adverse outcomes of an MSF-supported treatment program in Maputo, Mozambique.
CI=confidence interval, # numbers may be smaller due to missing values,* modeled as time-dependent covariates, § adjusted for all variables shown.
436625N #
3.4 (1.6, 7.3)7.2 (5.0, 10.4)Weight-for-height z-score <-2*
7.5 (4.9, 11.4)Weight-for-height z-score <-3*
4.2 (2.9, 6.0)Weight-for-age z-score <-2*
3.1 (1.4, 6.5)5.9 (4.1, 8.5)Weight-for-age z-score <-3*
0.4 (0.2, 0.7)0.4 (0.2, 0.6)ART start*
1.6 (0.8, 3.2)TB *
0.7 (0.5, 1.0)0.9 (0.7, 1.2)CD4 per 10% increase at enrolment
0.6 (0.3, 1.0)1.4 (1.0, 2.0)WHO stage III or IV *
0.3 (0.2, 0.5)Enrolment before 2008
1.0 (0.7, 1.4)Male sex
1.0 (0.9, 1.0)1.0 (0.9, 1.0)Age at enrolment per months increase
Adjusted hazard ratio (95% CI)§
Unadjusted hazard ratio (95% CI)
W
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z-score
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≥ -3 to -2
<-3
Time since enrolment in the program [days]
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WAZp<0.0001
HAZp=0.11
WHZp<0.0001
0%
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height-for-age z-score
weight-for-age z-score
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ata
z-score <-3z-score <-2
