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      Influence of Intravenous Drug Abuse on Vascular Access Placement and Survival in HIV-Seropositive Patients

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          Background: The influence of intravenous drug abuse (IVDA) on hemodialysis access placement practices and access survival in HIV-infected patients is unknown. Methods: We conducted a retrospective study of 60, HIV seropositive, maintenance hemodialysis patients. Type of access and assisted access survival (measured from date of placement) were compared in those with (77%) and without (23%) a history of IVDA. Results: Mean age was 37.8 years, mean baseline serum albumin was 2.9 g/dl and median CD4 count was 222 cells/mm<sup>3</sup>. Fifteen patients, all IVDA, were dialyzed using only tunneled catheters (median number of catheters per person (range): 2.5 (1–11)). There were longer delays in creation of a permanent access (p = 0.08), but no difference in the type of permanent access placed in IVDA versus the non-IVDA group. Over 1,051 cumulative months of access follow-up, 134 tunneled catheters, 28 grafts and 19 fistulae were placed, with observed failure rates of 1 per 4.7 access-months, 1 per 19.7 access-months, 1 per 38.2 access-months, respectively. The adjusted relative hazard of access failure for grafts versus catheters was 0.41 (95% CI: 0.23, 0.72; p = 0.002) and for fistulae versus catheters was 0.21 (95% CI: 0.08, 0.52; p = 0.001). Thirty-two percent of accesses were removed due to infection, an infection removal rate for catheters of 1 per 7.8 access-months and for grafts of 1 per 62.5 access-months; all graft infections occurred in the IVDA group. No fistula was removed due to infection. Conclusion: Fistulae are the first line of choice for hemodialysis access in HIV-seropositive patients regardless of IVDA history; if not feasible, graft placement in non-IVDA or abstinent IVDA patients is recommended. In those with active IVDA, the optimal method of renal replacement therapy and type of hemodialysis access remain uncertain.

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          Most cited references 17

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          The hemodialysis catheter conundrum: hate living with them, but can't live without them.

          Hemodialysis requires reliable recurrent access to the circulation. On a chronic basis, this has been best provided by the use of arteriovenous fistulae and arteriovenous grafts. In recent years, hemodialysis catheters have come to play an increasingly important role in the delivery of hemodialysis. The use of both temporary as well as cuffed hemodialysis catheters has emerged as a significant boon for both patients and practicing nephrologists. The complications, however, associated with each of these hemodialysis catheters, both in terms of anatomic, thrombotic, and infectious issues, have emerged as a major problem with their continued use. This significant morbidity and complication rate has forced many nephrologists to face a basic conundrum: they have come to hate having to deal with the problems inherent in catheter usage, but the enormous utility of these devices have forced physicians to accept the fact they cannot live without them in their current practice. We used a comprehensive literature review to describe the types, use and dilemmas of hemodialysis catheters. This article provides a comprehensive review of both the benefits inherent with the use of these hemodialysis catheters while cataloging their complications and offering some possible solutions. Hemodialysis vascular access catheters are essential in the maintenance of hemodialysis vascular access. However, they have a significant infectious, thrombotic, anatomic complication rate that are detailed with proposed problem-solving guidelines.
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            Prevention of hemodialysis fistula thrombosis. Early detection of venous stenoses.

            Venous dialysis pressures were measured consecutively in 168 chronic hemodialysis patients for 265 patient-years of monitored dialysis. Venous dialysis pressure greater than 150 mm Hg measured by the protocol were considered elevated. Seventy-three patients had elevated venous dialysis pressures and 58 agreed to undergo elective venography (fistulogram). Fifty of 58 patients studied (86%) had significant venous stenoses. A combination of percutaneous transluminal angioplasty (PTA) and surgical revision were used to electively treat these stenoses. Early detection and treatment of these stenoses decreased fistula thrombosis and fistula replacement threefold compared with our earlier experiences. Patients with elevated venous dialysis pressure who were venogramed and treated had an occurrence of fistula thrombosis similar to patients with normal dialysis pressure (0.15 and 0.13 episodes per patient year of dialysis respectively, P = NS). In contrast patients with elevated venous dialysis pressure who refused elective fistulogram and treatment averaged 1.4 episodes of thrombosis per patient year of dialysis (P less than 0.001) compared to both other groups). We conclude that elevated venous dialysis pressure is a reliable method of detecting fistula stenoses and that the elective treatment of these stenoses significantly decreases fistula thrombosis and fistula loss.
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              Comparison of autogenous fistula versus expanded polytetrafluoroethylene graft fistula for angioaccess in hemodialysis.

              A hundred patients with RCAV fistulas we compared with 100 patients with expanded PTFE fistulas created during the same time period. The fistulas were analyzed to compare early and late thrombosis, life table patency, infection rate, venous hypertension, and vascular steal. There was a significantly greater incidence of early thrombosis in the RCAV fistula group. Late thrombosis was seen with equal frequency in both groups. Thirty month patency by life table analysis favored the RCAV group to a significant degree, whereas infections, pseudoaneurysms, venous hypertension, and vascular steal were all more common in the expanded PTFE group. The RCAV fistula remains the ideal form of access but it is less frequently available for women and patients with peripheral vascular disease. Utilization of the expanded PTFE loop fistula requires closer observation and maintenance to keep it functional. Improved methods of patient selection for RCAV fistula using ultrasonographic imaging may allow for increased use of this form of access. Improvement in early patency in RCAV fistulas will magnify the superiority of RCAV fistulas in comparison to expanded PTFE fistulas, however, a prolonged period of venous maturation may be necessary to improve early function.

                Author and article information

                Nephron Clin Pract
                Nephron Clinical Practice
                S. Karger AG
                June 2005
                08 April 2005
                : 100
                : 2
                : c38-c45
                Division of Nephrology, Division of Infectious Disease and The Welch Center for Disease Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Md., USA
                85031 Nephron Clin Pract 2005;100:c38–c45
                © 2005 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 4, Tables: 2, References: 32, Pages: 1
                Self URI (application/pdf): https://www.karger.com/Article/Pdf/85031
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