The influence of human immunodeficiency virus infection and intravenous drug abuse on complications of hemodialysis access surgery

Abstract

To examine the influence of human immunodeficiency virus (HIV) infection on complications in dialysis access surgery, a review was performed on patients undergoing hemodialysis at two major metropolitan medical centers over a 30-month period. One hundred eight patients underwent a total of 169 graft procedures; mean follow-up was 1412 months. There were 18 (17%) patients who were HIV-positive who had no symptoms, 11 (10%) patients with acquired immunodeficiency syndrome (AIDS), and 79 (73%) patients who were HIV-negative. Twenty-three percent (25108) of patients had a history of intravenous drug abuse (IVDA), most of whom also had either AIDS or asymptomatic HIV infection. Dialysis procedures included 44 autogenous reconstructions (26%), 117 polytetrafluoroethylene (PTFE) grafts (69%), and 8 (5%) procedures of unknown type. Arteriovenous fistula or graft thrombosis was a frequent complication. The overall 12-month graft patency rate was 41%, and patients with HIV infection or a history of IVDA did not have a significantly increased risk of thrombosis. Multivariate analysis showed that the use of PTFE as opposed to autogenous reconstruction was the only significant risk factor found for occlusion within the first 12 months after operation (p < 0.01). Twenty-five graft infections occurred, all in PTFE grafts. The PTFE graft infection rate was 43% in patients with AIDS, 36% in patients who were HIV-positive and who had no symptoms, and 15% in patients who were HIV-negative (p < 0.05). Patients with a history of IVDA had a 41% PTFE graft infection rate versus a 13% infection rate in patients who did not have a history of IVDA (p < 0.01). Patients with AIDS had a markedly limited cumulative survival rate, 62% at 1 year after operation. In conjunction with these data, guidelines are discussed for the management of hemodialysis access in patients with HIV infection. In particular, in such patients PTFE arteriovenous grafts should be avoided because of alarmingly high graft infection rates.