Hemodialysis access: Influence of the human immunodeficiency virus on patency and infection rates

Abstract

Purpose: The complication rate for patients who are dialysis dependent and infected with the human immunodeficiency virus (HIV) and the role of viral indicators (CD 4 counts) as predictors of these complications are poorly characterized. To determine the influence of HIV status and viral activity on graft patency and infection rates, we retrospectively reviewed our results. Methods: Between June 1993 and March 1997, the charts of 104 patients (HIV+, n = 42; HIV–, n = 62) who required 112 hemodialysis access grafts were reviewed. Of the 112 procedures, 55 (48%) were autologous arteriovenous fistulae (AVF) procedures (HIV+, n = 23; HIV–, n = 32) and 57 (52%) were prosthetic expanded polytetrafluoroethylene grafting procedures (HIV+, n = 27; HIV–, n = 30). Transcutaneous catheter procedures were excluded from the study. The autologous AVF procedures consisted of direct and transposed AVFs. Patency rates were determined by means of life-table analysis. Infection rates and CD 4 counts were compared with the χ 2 test and the Fisher exact test. Significance was accepted at a P value of .05 or less. Results: The cumulative 12-month and 24-month patency rates for prosthetic grafts in patients who were HIV+ were 49% and 21%, respectively, versus 77% and 45% for patients who were HIV–. The differences in the prosthetic graft patency rates between these two groups were significant ( P ≤ .05). The cumulative 12-month and 24-month patency rates for autologous AVF procedures did not differ significantly. The AVF procedure patency rates were 72% and 51%, respectively, in patients who were HIV+ versus 54% and 50% for patients who were HIV–. The prosthetic graft infection rate for patients who were HIV+ and HIV– were 30% and 7%, respectively ( P = .04). However, the infection rates in autologous AVF procedures did not differ between the groups (9% vs 0%; P > .05). The mean CD 4+ cell counts were 174: CD 4+ counts that were less than 200 did not correlate with or predict the development of infection ( P > .05). Conclusion: Our data showed that prosthetic graft infection rates were increased and patency rates were decreased in patients who were HIV+ as compared with patients who were HIV– and HIV+ with autologous AVFs. There were no differences in patency rates or infection rates in patients who had undergone autologous access procedures. Long-term graft patency rates were not affected by HIV status, and CD 4+ lymphocyte counts were not predictive of infection development. Because the prosthetic graft infection rates exceeded those rates of autologous access procedures, we recommend the vigorous use of autologous AVFs in all patients who are HIV+, regardless of CD 4+ count. (J Vasc Surg 1999;29:608-16.)