@article{fdi:010075658,
  title = {{R}isk score for predicting mortality including urine lipoarabinomannan detection in hospital inpatients with {HIV}-associated tuberculosis in sub-{S}aharan {A}frica : derivation and external validation cohort study},
  author = {{G}upta-{W}right, {A}. and {C}orbett, {E}. {L}. and {W}ilson, {D}. and van {O}osterhout, {J}. {J}. and {D}heda, {K}. and {H}uerga, {H}. and {P}eter, {J}. and {B}onnet, {M}aryline and {A}lufandika-{M}oyo, {M}. and {G}rint, {D}. and {L}awn, {S}. {D}. and {F}ielding, {K}.},
  editor = {},
  language = {{ENG}},
  abstract = {{B}ackground {T}he prevalence of and mortality from {HIV}-associated tuberculosis ({HIV}/{TB}) in hospital inpatients in {A}frica remains unacceptably high. {C}urrently, there is a lack of tools to identify those at high risk of early mortality who may benefit from adjunctive interventions. {W}e therefore aimed to develop and validate a simple clinical risk score to predict mortality in high-burden, low-resource settings. {M}ethods and findings {A} cohort of {HIV}-positive adults with laboratory-confirmed {TB} from the {STAMP} {TB} screening trial ({M}alawi and {S}outh {A}frica) was used to derive a clinical risk score using multivariable predictive modelling, considering factors at hospital admission (including urine lipoarabinomannan [{LAM}] detection) thought to be associated with 2-month mortality. {P}erformance was evaluated internally and then externally validated using independent cohorts from 2 other studies ({LAM}-{RCT} and a {M}edecins {S}ans {F}rontieres [{MSF}] cohort) from {S}outh {A}frica, {Z}ambia, {Z}imbabwe, {T}anzania, and {K}enya. {T}he derivation cohort included 315 patients enrolled from {O}ctober 2015 and {S}eptember 2017. {T}heir median age was 36 years ({IQR} 30-43), 45.4% were female, median {CD}4 cell count at admission was 76 cells/l ({IQR} 23-206), and 80.2% (210/262) of those who knew they were {HIV}-positive at hospital admission were taking antiretroviral therapy ({ART}). {T}wo-month mortality was 30% (94/315), and mortality was associated with the following factors included in the score: age 55 years or older, male sex, being {ART} experienced, having severe anaemia (haemoglobin < 80 g/l), being unable to walk unaided, and having a positive urinary {D}etermine {TB} {LAM} {A}g test ({A}lere). {T}he score identified patients with a 46.4% (95% {CI} 37.8%-55.2%) mortality risk in the high-risk group compared to 12.5% (95% {CI} 5.7%-25.4%) in the low-risk group (p < 0.001). {T}he odds ratio ({OR}) for mortality was 6.1 (95% {CI} 2.4-15.2) in high-risk patients compared to low-risk patients (p < 0.001). {D}iscrimination (c-statistic 0.70, 95% {CI} 0.63-0.76) and calibration ({H}osmer-{L}emeshow statistic, p = 0.78) were good in the derivation cohort, and similar in the external validation cohort (complete cases n = 372, c-statistic 0.68 [95% {CI} 0.61-0.74]). {T}he validation cohort included 644 patients between {J}anuary 2013 and {A}ugust 2015. {M}edian age was 36 years, 48.9% were female, and median {CD}4 count at admission was 61 ({IQR} 21-145). {OR} for mortality was 5.3 (95% {CI} 2.2-9.5) for high compared to low-risk patients (complete cases n = 372, p < 0.001). {T}he score also predicted patients at higher risk of death both pre- and post-discharge. {A} simplified score (any 3 or more of the predictors) performed equally well. {T}he main limitations of the scores were their imperfect accuracy, the need for access to urine {LAM} testing, modest study size, and not measuring all potential predictors of mortality (e.g., tuberculosis drug resistance). {C}onclusions {T}his risk score is capable of identifying patients who could benefit from enhanced clinical care, follow-up, and/or adjunctive interventions, although further prospective validation studies are necessary. {G}iven the scale of {HIV}/{TB} morbidity and mortality in {A}frican hospitals, better prognostic tools along with interventions could contribute towards global targets to reduce tuberculosis mortality.},
  keywords = {{AFRIQUE} {DU} {SUD} ; {ZAMBIE} ; {ZIMBABWE} ; {TANZANIE} ; {KENYA}},
  booktitle = {},
  journal = {{PL}o{S} {M}edicine},
  volume = {16},
  numero = {4},
  pages = {e1002776 [20 p.]},
  ISSN = {1549-1277},
  year = {2019},
  DOI = {10.1371/journal.pmed.1002776},
  URL = {https://www.documentation.ird.fr/hor/fdi:010075658},
}