http://informahealthcare.com/rnf ISSN: 0886-022X (print), 1525-6049 (electronic) Ren Fail, 2014; 36(4): 658–660 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/0886022X.2014.883910
STATE OF THE ART REVIEW
Infectious complications of prosthetic arteriovenous grafts for hemodialysis: prevention is better than cure Georgios Galanopoulos1,2 and Constantinos Lambidis2 Department of Pharmacology, Medical School, University of Athens, Athens, Greece and 2Department of Vascular Surgery, ‘‘Iaso` General’’ Hospital of Athens, Athens, Greece Abstract
Keywords
Synthetic arteriovenous grafts for hemodialysis constitute the second choice in comparison with native arteriovenous fistulas. Lower patency rates and significantly more frequent infections are the main disadvantages of hemodialysis grafts over fistulas. Infectious complications could vary between a simple local erythema at a puncture site that resolves easily with antibiotics to septicemia and death. As a corollary, this kind of complications continue to be among the most important causes of morbidity and mortality in end-stage renal disease patients receiving long-term hemodialysis. The cornerstone is prevention of infections. It is generally accepted that following simple measures during the intervention of graft insertion and consecutively in every hemodialysis session could consistently reduce the risk of infection.
Arteriovenous graft, complication, hemodialysis, infection, prosthetic graft
Introduction End-stage renal disease (ESRD) constitutes a nosological entity with an incidence that is continuously increasing in a galloping way worldwide.1 Recent epidemiological data reveal the amplitude of the problem. The number of patients requiring hemodialysis is growing by 8% per year.2 Population ageing and diabetic nephropathy play an important role as a means of renal impairment. Patients on hemodialysis, as renal replacement therapy, require a valid vascular access. Autogenous fistulae provide important advantages over synthetic grafts or permanent tunneled catheters, such as better patency rates and lower complication rates. However, when a fistula cannot be constructed, a synthetic arteriovenous (AV) graft constitutes the next choice. Arteriovenous graft infection is not a rare complication, composing a considerable source of morbidity and mortality among patients on hemodialysis. Additionally, the fact that synthetic grafts are more prone to infections could explain, at least in part, the increased mortality rate, by 15%,3 of patients dialyzing on synthetic grafts compared to those dialyzing on fistulae.
Classification and etiology An AV graft infection developing within 30 days from surgery is called early, while an infection needing430 days to develop Address correspondence to Georgios Galanopoulos, 38, Pontou St., 14572 Athens, Greece. Tel: +302107462563; E-mail: [email protected]
History Received 5 November 2013 Accepted 28 December 2013 Published online 10 February 2014
is called late. It is noteworthy that early infections are strictly connected to the operation itself while late infections mainly to cannulation. Repeated cannulations, three times a week, constitute a major risk for bacterial inoculation. It is not to underestimate that the cannulation of a graft may result in hematoma (especially in the case of grafts with immediate accessibility) or in pseudoaneurysm formation, thus significantly increasing the risk of infection. Sometimes, graft thrombectomy may be followed by an infectious complication. In addition, a thrombosed and abandoned graft could be secondarily infected, although not in use.4–6 Late infections are by far the most frequent. From a bacteriological point of view, most graft infections are caused by Gram-positive cocci. Staphylococcus aureus and methicillin-resistant S. aureus are the most frequently cultured bacteria.7 Gram-negative rods are less frequent. Patients with ESRD present an ‘‘endogenous’’ increased susceptibility to infectious complications related to renal impairment per se or to other comorbidities, such as diabetes mellitus. The activity of neutrophils – chemotaxis, phagocytosis, intracellular enzymatic killing and toxic oxygen radical production – is significantly reduced in ESRD.8 Uremic toxins also interfere with neutrophil function, causing further suppression of the immune response of these patients.9 In this, immune recession could be added the depressed antibody response and the impaired lymphocyte-mediated cellular immunity.10 On the other hand, the presence of diabetes is common among patients with ESRD, rendering them even more prone to infections. Diabetes is considered responsible for the impaired leucocyte function presented in these
20 14
Ren Fail Downloaded from informahealthcare.com by Kainan University on 04/27/15 For personal use only.
1
Ren Fail Downloaded from informahealthcare.com by Kainan University on 04/27/15 For personal use only.
DOI: 10.3109/0886022X.2014.883910
patients. Additionally, migration of neutrophils and macrophages, which is crucial in the immune response, is altered.11 Another point of interest is that uremia can frequently lead to reduced food consumption and even malnutrition of these patients with low albumin levels and consequential further impairment of the immune response.12 Other comorbidities such as autoimmune diseases, on corticosteroid treatment could play a role in graft infections. Furthermore, poor personal hygiene constitutes an important risk factor especially in case of thigh graft infection. For that reason, many authors suggest against placement of thigh grafts. Some studies have shown that older patients are more susceptible to infectious complications.13,14 Another point of interest is the interaction between iron metabolism and immune response. From in vitro studies, interesting data have been revealed: iron overload could interfere with phagocytic function of neutrophils,15 rendering these patients more prone to infections. Increased levels of iron could also facilitate bacterial growth.
Diagnosis Graft infections may occur with local signs of inflammation or purulence. The graft may present a purulent collection at a puncture site, at the surgical incision or even along its entire length. An intense erythema at the infection site may be accompanied by edema, tenderness, skin breakdown, pain and systemic signs of infection, such as fever and chills. However, it must be underlined that even if there are not any clinical signs of graft infection, it should always be suspected, especially in case of leucocytosis, fever of unknown origin and in the absence of another septic source.
Treatment The treatment modalities depend on several factors. The onset of the infection is an important parameter, because an early infection is usually connected to the intervention of graft placement. Poor asepsis with graft colonization by bacteria or even unsuccessful hemostasis with perigraft hematoma formation and subsequent infection are some frequent causes of early graft infections, which usually involve the entire graft. For this reason, antibiotic administration and graft removal is the treatment of choice. In case of a localized and well-delimited access site infection, the graft can be salvaged with antibiotics only or in case of persistent infection with partial graft removal. The infected part of the graft is removed and the infected perigraft zone is bypassed using a short segment of a new graft, which is positioned in a new tunnel. The interposition graft is connected with the old one through two end-to-end anastomoses. With the exception of the interposition graft, the rest can be used promptly for hemodialysis, with no need for temporary catheter placement. An infection extended along the entire length of the graft must be treated with total graft removal. The outflow vein can be easily ligated without any consequences or with minimal edema of the limb. On the contrary, removal of the infected graft at the arterial anastomosis requires repair of the defect using an autologous patch, usually from the great saphenous vein. In this case, temporary catheter placement is mandatory
Prosthetic arteriovenous grafts for hemodialysis
659
in order to perform hemodialysis, while a new vascular access is needed. In case of an extended infection along the graft, which nevertheless does not seem to involve the arterial anastomosis, a short segment of the old graft can be left in situ with no need for arterial repair. As a general principle, the incisions made for infected graft removal may be loosely approximated or may be left open in order to heal by secondary intention. Polyfilament sutures must be avoided because they can serve as a nidus for bacteria perpetuating the infection. Ally of the surgical treatment should be the antibiotic administration.
Preventing the infection Patients with ESRD, especially after several years of hemodialysis, have limited anatomic sites available for access creation. When an infection results in graft removal, the access and consequently the anatomic site are lost. Additionally, graft infection could result in severe systemic infections, like endocarditis, osteomyelitis, septic arthritis, septic pulmonary emboli, brain abscess or even death.16–22 Hospitalization is often needed for antibiotic and analgesic administration, after surgical treatment of the infection, increasing patients hardship. It is not to underestimate the economic repercussion of a graft infection due to the loss of the graft, the need for a temporary central venous catheter as well as the need for a new vascular access. There are some simple measures to take in order to avoid or to minimize the risk of graft infection. Prophylactic antibiotic administration prior to graft insertion is mandatory. In our practice, a double intravenous antibiotic scheme (second-generation cephalosporin and metronidazole) is administered 1 h prior to surgery, followed by 3 or 4 days of p.o.s. second-generation cephalosporin administration. Others prefer only a single preoperative dose of vancomycin. Antibiotics are not enough to prevent a graft infection, if there is not a meticulous sterile surgical technique. During insertion, the contact of the graft with the skin must be avoided. Choosing a correct subcutaneous plane for graft insertion is of paramount importance. Inserting the graft very superficially could be perilous because skin erosion with subsequent graft infection becomes possible. Another important technical point is bleeding prevention during graft insertion in the subcutaneous tunnel. Hemostasis must be cautious because perigraft hematoma formation may result in poor graft incorporation and infection. The last measure to be taken but by no means least in importance, is that PTFE grafts must be used after 2–3 weeks from placement. We suggest puncturing the graft 20 days after its insertion, in order to allow a complete incorporation into the perigraft subcutaneous tissue. A complete incorporation does not leave any space around the graft for bacterial multiplication. Furthermore, puncturing a graft that is not well incorporated into the subcutaneous tissue may result in perigraft hematoma and subsequent infection. By adopting these simple measures, early infections can be largely prevented. On the other hand, late infections occur primarily because of inadequate aseptic conditions during graft cannulation on
660
G. Galanopoulos and C. Lambidis
hemodialysis sessions. Inadequate skin prepping with antiseptic solutions prior to puncture can cause inoculation of bacteria of skin origin and subsequent infection. Additionally, insertion of the needles in a wrong way can damage the graft causing pseudoaneurysm formation, which could later result in infection. Consequently attention must be paid from dialysis nurses during graft puncture.
Ren Fail Downloaded from informahealthcare.com by Kainan University on 04/27/15 For personal use only.
Our experience We retrospectively reviewed our patients with ESRD in whom a synthetic PTFE graft was inserted during the period from January 2009 to July 2012. Eighty-five grafts were inserted in 60 patients. Forty-five were male. The mean age was 58 years old (range 31–85). Sixty-eight over 85 grafts were inserted in the upper arm, 10 in the forearm and 7 were saphenofemoral grafts. Diabetes was present in 30% of the patients. The median follow up was 24 months. Graft infection was not frequent in our patients. Only four grafts were infected (three upper arm grafts and one forearm graft) and all of them were late infections. Two out of four were puncture site infections, limited in a short area of 3–4 cm of the graft. The other two extended along the major part of the grafts including the arterial anastomosis. Only one of the patients with graft infection was diabetic and another one was on corticosteroid therapy for a systemic disease. At first clinical appearance of graft infection, cultures were obtained and all patients received an empiric antibiotic scheme. This antibiotic scheme consisted of a secondgeneration cephalosporin, metronidazole and an aminoglycoside. There was no need to change the antibiotics in base of the sensitivities. The bacterial agents responsible for the infections in our specimen were: S. aureus in three and Enterobacter faecalis in one. All the infections were not resolved with 3–4 weeks of antibiotic administration and consequently surgical treatment was adopted. The puncture site infections were treated with a short bypass, while in the other two the entire graft was removed with subsequent patch angioplasty of the artery. Patients treated by bypassing the infected zone continued to use their grafts apart from the interposition graft, which was punctured after 20 days. On the other hand, a temporary jugular catheter was inserted to patients with total graft removal until a new vascular access was created and matured for cannulation.
Conclusion Infectious complications of synthetic arteriovenous grafts for hemodialysis are not so rare. Such complications could lead to loss of the vascular access and to other severe septic complications or even death. A high index of suspicion is always needed in order to start the treatment promptly. Most of graft infections could be avoided by taking some simple measures during surgery and mainly in every hemodialysis session.
Ren Fail, 2014; 36(4): 658–660
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
References 1. Lambidis C, Galanopoulos G. Primary brachial vein transposition for hemodialysis access: report of a case and review of the literature. Hemodial Int. 2013;17(3):441–443. 2. Shaheen F, Al-Khader A. Epidemiology and causes of end stage renal disease (ESRD). Saudi J Kidney Dis Transplant. 2005; 16(3):277–281. 3. Pisoni RL, Arrington CJ, Albert JM, et al. Facility hemodialysis vascular access use and mortality in countries participating in DOPPS: an instrumental variable analysis. Am J Kidney Dis. 2009; 53:475–491. 4. Ayus JC, Sheikh-Hamad D. Silent infection in clotted hemodialysis access grafts. J Am Soc Nephrol. 1998; 9:1314–1317. 5. Sheikh-Hamad D, Ayus JC. The patient with a clotted PTFE graft developing fever. Nephrol Dial Transplant. 1998;13:2392–2393. 6. Nassar GM, Ayus JC. Clotted arteriovenous grafts: a silent source of infection. Semin Dial. 2000;13:1–3. 7. Li Y, Friedman JY, O’Neal BF, et al. Outcomes of Staphylococcus aureus infection in hemodialysis-dependent patients. Clin J Am Soc Nephrol. 2009;4:428–434. 8. Cohen G, Haag-Weber M, Ho¨rl WH. Immune dysfunction in uremia. Kidney Int Suppl. 1997;62:S79–82. 9. Chonchol M. Neutrophil dysfunction and infection risk in end-stage renal disease. Semin Dial. 2006;19(4):291–296. 10. Descamps-Latscha B, Chatenoud L. T cells and B cells in chronic renal failure. Semin Nephrol. 1996;16(3):183–191. 11. Joshi N, Caputo G, Weitekamp M, Karchmer A. Infections in patients with diabetes mellitus. N Engl J Med. 1999;341: 1906–1912. 12. Powe N, Jaar B, Furth S, Hermann J, Briggs W. Septicemia in dialysis patients: incidence, risk factors and prognosis. Kidney Int. 1999;55(3):1081–1090. 13. Wick G, Grubeck-Loebenstein B. Primary and secondary alterations of immune reactivity in the elderly: impact of dietary factors and diseases. Immunol Rev. 1997;160:171–184. 14. Lemaoult J, Szabo P, Weksler ME. Effect of age on humoral immunity, selection of the B-cell repertoire and B-cell development. Immunol Rev. 1997;160:115–126. 15. Waterlot Y, Cantinieaux B, Hariga-Muller C, De MaertelaereLaurent E, Vanherweghem JL, Fondu P. Impaired phagocytic activity of neutrophils in patients receiving hemodialysis: the critical role of iron overload. Br Med J. 1985;291(6494):501–504. 16. Kessler M, Hoen B, Mayeux D, Hestin D, Fontenaille C. Bacteremia in patients on chronic hemodialysis: a multicenter prospective survey. Nephron. 1993;64:95–100. 17. Marr KA, Kong L, Fowler VG, et al. Incidence and outcome of Staphylococcus aureus bacteremia in hemodialysis patients. Kidney Int. 1998;54:1684–1689. 18. Quarles LD, Rutsky EA, Rostand SG. Staphylococcus aureus bacteremia in patients on chronic hemodialysis. Am J Kidney Dis. 1985;6(6):412–419. 19. Robinson DL, Fowler VG, Sexton DJ, Corey RG, Conlon PJ. Bacterial endocarditis in hemodialysis patients. Am J Kidney Dis. 1997;30(4):521–524. 20. Obrador GT, Levenson DJ. Spinal epidural abscess in hemodialysis patients: report of three cases and review of the literature. Am J Kidney Dis. 1996;27:75–83. 21. Peacock SJ, Curtis N, Berendt AR, Bowler IC, Winearls CG, Maxwell P. Outcome following hemodialysis catheter-related Staphylococcus aureus bacteraemia. J Hosp Infect. 1999; 41(3):223–228. 22. Kovalik E, Albers F, Raymond J, Conlon P. A clustering of cases of spinal epidural abscess in hemodialysis patients. J Am Soc Nephrol. 1996;7:2264–2267.
STATE OF THE ART REVIEW
Infectious complications of prosthetic arteriovenous grafts for hemodialysis: prevention is better than cure Georgios Galanopoulos1,2 and Constantinos Lambidis2 Department of Pharmacology, Medical School, University of Athens, Athens, Greece and 2Department of Vascular Surgery, ‘‘Iaso` General’’ Hospital of Athens, Athens, Greece Abstract
Keywords
Synthetic arteriovenous grafts for hemodialysis constitute the second choice in comparison with native arteriovenous fistulas. Lower patency rates and significantly more frequent infections are the main disadvantages of hemodialysis grafts over fistulas. Infectious complications could vary between a simple local erythema at a puncture site that resolves easily with antibiotics to septicemia and death. As a corollary, this kind of complications continue to be among the most important causes of morbidity and mortality in end-stage renal disease patients receiving long-term hemodialysis. The cornerstone is prevention of infections. It is generally accepted that following simple measures during the intervention of graft insertion and consecutively in every hemodialysis session could consistently reduce the risk of infection.
Arteriovenous graft, complication, hemodialysis, infection, prosthetic graft
Introduction End-stage renal disease (ESRD) constitutes a nosological entity with an incidence that is continuously increasing in a galloping way worldwide.1 Recent epidemiological data reveal the amplitude of the problem. The number of patients requiring hemodialysis is growing by 8% per year.2 Population ageing and diabetic nephropathy play an important role as a means of renal impairment. Patients on hemodialysis, as renal replacement therapy, require a valid vascular access. Autogenous fistulae provide important advantages over synthetic grafts or permanent tunneled catheters, such as better patency rates and lower complication rates. However, when a fistula cannot be constructed, a synthetic arteriovenous (AV) graft constitutes the next choice. Arteriovenous graft infection is not a rare complication, composing a considerable source of morbidity and mortality among patients on hemodialysis. Additionally, the fact that synthetic grafts are more prone to infections could explain, at least in part, the increased mortality rate, by 15%,3 of patients dialyzing on synthetic grafts compared to those dialyzing on fistulae.
Classification and etiology An AV graft infection developing within 30 days from surgery is called early, while an infection needing430 days to develop Address correspondence to Georgios Galanopoulos, 38, Pontou St., 14572 Athens, Greece. Tel: +302107462563; E-mail: [email protected]
History Received 5 November 2013 Accepted 28 December 2013 Published online 10 February 2014
is called late. It is noteworthy that early infections are strictly connected to the operation itself while late infections mainly to cannulation. Repeated cannulations, three times a week, constitute a major risk for bacterial inoculation. It is not to underestimate that the cannulation of a graft may result in hematoma (especially in the case of grafts with immediate accessibility) or in pseudoaneurysm formation, thus significantly increasing the risk of infection. Sometimes, graft thrombectomy may be followed by an infectious complication. In addition, a thrombosed and abandoned graft could be secondarily infected, although not in use.4–6 Late infections are by far the most frequent. From a bacteriological point of view, most graft infections are caused by Gram-positive cocci. Staphylococcus aureus and methicillin-resistant S. aureus are the most frequently cultured bacteria.7 Gram-negative rods are less frequent. Patients with ESRD present an ‘‘endogenous’’ increased susceptibility to infectious complications related to renal impairment per se or to other comorbidities, such as diabetes mellitus. The activity of neutrophils – chemotaxis, phagocytosis, intracellular enzymatic killing and toxic oxygen radical production – is significantly reduced in ESRD.8 Uremic toxins also interfere with neutrophil function, causing further suppression of the immune response of these patients.9 In this, immune recession could be added the depressed antibody response and the impaired lymphocyte-mediated cellular immunity.10 On the other hand, the presence of diabetes is common among patients with ESRD, rendering them even more prone to infections. Diabetes is considered responsible for the impaired leucocyte function presented in these
20 14
Ren Fail Downloaded from informahealthcare.com by Kainan University on 04/27/15 For personal use only.
1
Ren Fail Downloaded from informahealthcare.com by Kainan University on 04/27/15 For personal use only.
DOI: 10.3109/0886022X.2014.883910
patients. Additionally, migration of neutrophils and macrophages, which is crucial in the immune response, is altered.11 Another point of interest is that uremia can frequently lead to reduced food consumption and even malnutrition of these patients with low albumin levels and consequential further impairment of the immune response.12 Other comorbidities such as autoimmune diseases, on corticosteroid treatment could play a role in graft infections. Furthermore, poor personal hygiene constitutes an important risk factor especially in case of thigh graft infection. For that reason, many authors suggest against placement of thigh grafts. Some studies have shown that older patients are more susceptible to infectious complications.13,14 Another point of interest is the interaction between iron metabolism and immune response. From in vitro studies, interesting data have been revealed: iron overload could interfere with phagocytic function of neutrophils,15 rendering these patients more prone to infections. Increased levels of iron could also facilitate bacterial growth.
Diagnosis Graft infections may occur with local signs of inflammation or purulence. The graft may present a purulent collection at a puncture site, at the surgical incision or even along its entire length. An intense erythema at the infection site may be accompanied by edema, tenderness, skin breakdown, pain and systemic signs of infection, such as fever and chills. However, it must be underlined that even if there are not any clinical signs of graft infection, it should always be suspected, especially in case of leucocytosis, fever of unknown origin and in the absence of another septic source.
Treatment The treatment modalities depend on several factors. The onset of the infection is an important parameter, because an early infection is usually connected to the intervention of graft placement. Poor asepsis with graft colonization by bacteria or even unsuccessful hemostasis with perigraft hematoma formation and subsequent infection are some frequent causes of early graft infections, which usually involve the entire graft. For this reason, antibiotic administration and graft removal is the treatment of choice. In case of a localized and well-delimited access site infection, the graft can be salvaged with antibiotics only or in case of persistent infection with partial graft removal. The infected part of the graft is removed and the infected perigraft zone is bypassed using a short segment of a new graft, which is positioned in a new tunnel. The interposition graft is connected with the old one through two end-to-end anastomoses. With the exception of the interposition graft, the rest can be used promptly for hemodialysis, with no need for temporary catheter placement. An infection extended along the entire length of the graft must be treated with total graft removal. The outflow vein can be easily ligated without any consequences or with minimal edema of the limb. On the contrary, removal of the infected graft at the arterial anastomosis requires repair of the defect using an autologous patch, usually from the great saphenous vein. In this case, temporary catheter placement is mandatory
Prosthetic arteriovenous grafts for hemodialysis
659
in order to perform hemodialysis, while a new vascular access is needed. In case of an extended infection along the graft, which nevertheless does not seem to involve the arterial anastomosis, a short segment of the old graft can be left in situ with no need for arterial repair. As a general principle, the incisions made for infected graft removal may be loosely approximated or may be left open in order to heal by secondary intention. Polyfilament sutures must be avoided because they can serve as a nidus for bacteria perpetuating the infection. Ally of the surgical treatment should be the antibiotic administration.
Preventing the infection Patients with ESRD, especially after several years of hemodialysis, have limited anatomic sites available for access creation. When an infection results in graft removal, the access and consequently the anatomic site are lost. Additionally, graft infection could result in severe systemic infections, like endocarditis, osteomyelitis, septic arthritis, septic pulmonary emboli, brain abscess or even death.16–22 Hospitalization is often needed for antibiotic and analgesic administration, after surgical treatment of the infection, increasing patients hardship. It is not to underestimate the economic repercussion of a graft infection due to the loss of the graft, the need for a temporary central venous catheter as well as the need for a new vascular access. There are some simple measures to take in order to avoid or to minimize the risk of graft infection. Prophylactic antibiotic administration prior to graft insertion is mandatory. In our practice, a double intravenous antibiotic scheme (second-generation cephalosporin and metronidazole) is administered 1 h prior to surgery, followed by 3 or 4 days of p.o.s. second-generation cephalosporin administration. Others prefer only a single preoperative dose of vancomycin. Antibiotics are not enough to prevent a graft infection, if there is not a meticulous sterile surgical technique. During insertion, the contact of the graft with the skin must be avoided. Choosing a correct subcutaneous plane for graft insertion is of paramount importance. Inserting the graft very superficially could be perilous because skin erosion with subsequent graft infection becomes possible. Another important technical point is bleeding prevention during graft insertion in the subcutaneous tunnel. Hemostasis must be cautious because perigraft hematoma formation may result in poor graft incorporation and infection. The last measure to be taken but by no means least in importance, is that PTFE grafts must be used after 2–3 weeks from placement. We suggest puncturing the graft 20 days after its insertion, in order to allow a complete incorporation into the perigraft subcutaneous tissue. A complete incorporation does not leave any space around the graft for bacterial multiplication. Furthermore, puncturing a graft that is not well incorporated into the subcutaneous tissue may result in perigraft hematoma and subsequent infection. By adopting these simple measures, early infections can be largely prevented. On the other hand, late infections occur primarily because of inadequate aseptic conditions during graft cannulation on
660
G. Galanopoulos and C. Lambidis
hemodialysis sessions. Inadequate skin prepping with antiseptic solutions prior to puncture can cause inoculation of bacteria of skin origin and subsequent infection. Additionally, insertion of the needles in a wrong way can damage the graft causing pseudoaneurysm formation, which could later result in infection. Consequently attention must be paid from dialysis nurses during graft puncture.
Ren Fail Downloaded from informahealthcare.com by Kainan University on 04/27/15 For personal use only.
Our experience We retrospectively reviewed our patients with ESRD in whom a synthetic PTFE graft was inserted during the period from January 2009 to July 2012. Eighty-five grafts were inserted in 60 patients. Forty-five were male. The mean age was 58 years old (range 31–85). Sixty-eight over 85 grafts were inserted in the upper arm, 10 in the forearm and 7 were saphenofemoral grafts. Diabetes was present in 30% of the patients. The median follow up was 24 months. Graft infection was not frequent in our patients. Only four grafts were infected (three upper arm grafts and one forearm graft) and all of them were late infections. Two out of four were puncture site infections, limited in a short area of 3–4 cm of the graft. The other two extended along the major part of the grafts including the arterial anastomosis. Only one of the patients with graft infection was diabetic and another one was on corticosteroid therapy for a systemic disease. At first clinical appearance of graft infection, cultures were obtained and all patients received an empiric antibiotic scheme. This antibiotic scheme consisted of a secondgeneration cephalosporin, metronidazole and an aminoglycoside. There was no need to change the antibiotics in base of the sensitivities. The bacterial agents responsible for the infections in our specimen were: S. aureus in three and Enterobacter faecalis in one. All the infections were not resolved with 3–4 weeks of antibiotic administration and consequently surgical treatment was adopted. The puncture site infections were treated with a short bypass, while in the other two the entire graft was removed with subsequent patch angioplasty of the artery. Patients treated by bypassing the infected zone continued to use their grafts apart from the interposition graft, which was punctured after 20 days. On the other hand, a temporary jugular catheter was inserted to patients with total graft removal until a new vascular access was created and matured for cannulation.
Conclusion Infectious complications of synthetic arteriovenous grafts for hemodialysis are not so rare. Such complications could lead to loss of the vascular access and to other severe septic complications or even death. A high index of suspicion is always needed in order to start the treatment promptly. Most of graft infections could be avoided by taking some simple measures during surgery and mainly in every hemodialysis session.
Ren Fail, 2014; 36(4): 658–660
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
References 1. Lambidis C, Galanopoulos G. Primary brachial vein transposition for hemodialysis access: report of a case and review of the literature. Hemodial Int. 2013;17(3):441–443. 2. Shaheen F, Al-Khader A. Epidemiology and causes of end stage renal disease (ESRD). Saudi J Kidney Dis Transplant. 2005; 16(3):277–281. 3. Pisoni RL, Arrington CJ, Albert JM, et al. Facility hemodialysis vascular access use and mortality in countries participating in DOPPS: an instrumental variable analysis. Am J Kidney Dis. 2009; 53:475–491. 4. Ayus JC, Sheikh-Hamad D. Silent infection in clotted hemodialysis access grafts. J Am Soc Nephrol. 1998; 9:1314–1317. 5. Sheikh-Hamad D, Ayus JC. The patient with a clotted PTFE graft developing fever. Nephrol Dial Transplant. 1998;13:2392–2393. 6. Nassar GM, Ayus JC. Clotted arteriovenous grafts: a silent source of infection. Semin Dial. 2000;13:1–3. 7. Li Y, Friedman JY, O’Neal BF, et al. Outcomes of Staphylococcus aureus infection in hemodialysis-dependent patients. Clin J Am Soc Nephrol. 2009;4:428–434. 8. Cohen G, Haag-Weber M, Ho¨rl WH. Immune dysfunction in uremia. Kidney Int Suppl. 1997;62:S79–82. 9. Chonchol M. Neutrophil dysfunction and infection risk in end-stage renal disease. Semin Dial. 2006;19(4):291–296. 10. Descamps-Latscha B, Chatenoud L. T cells and B cells in chronic renal failure. Semin Nephrol. 1996;16(3):183–191. 11. Joshi N, Caputo G, Weitekamp M, Karchmer A. Infections in patients with diabetes mellitus. N Engl J Med. 1999;341: 1906–1912. 12. Powe N, Jaar B, Furth S, Hermann J, Briggs W. Septicemia in dialysis patients: incidence, risk factors and prognosis. Kidney Int. 1999;55(3):1081–1090. 13. Wick G, Grubeck-Loebenstein B. Primary and secondary alterations of immune reactivity in the elderly: impact of dietary factors and diseases. Immunol Rev. 1997;160:171–184. 14. Lemaoult J, Szabo P, Weksler ME. Effect of age on humoral immunity, selection of the B-cell repertoire and B-cell development. Immunol Rev. 1997;160:115–126. 15. Waterlot Y, Cantinieaux B, Hariga-Muller C, De MaertelaereLaurent E, Vanherweghem JL, Fondu P. Impaired phagocytic activity of neutrophils in patients receiving hemodialysis: the critical role of iron overload. Br Med J. 1985;291(6494):501–504. 16. Kessler M, Hoen B, Mayeux D, Hestin D, Fontenaille C. Bacteremia in patients on chronic hemodialysis: a multicenter prospective survey. Nephron. 1993;64:95–100. 17. Marr KA, Kong L, Fowler VG, et al. Incidence and outcome of Staphylococcus aureus bacteremia in hemodialysis patients. Kidney Int. 1998;54:1684–1689. 18. Quarles LD, Rutsky EA, Rostand SG. Staphylococcus aureus bacteremia in patients on chronic hemodialysis. Am J Kidney Dis. 1985;6(6):412–419. 19. Robinson DL, Fowler VG, Sexton DJ, Corey RG, Conlon PJ. Bacterial endocarditis in hemodialysis patients. Am J Kidney Dis. 1997;30(4):521–524. 20. Obrador GT, Levenson DJ. Spinal epidural abscess in hemodialysis patients: report of three cases and review of the literature. Am J Kidney Dis. 1996;27:75–83. 21. Peacock SJ, Curtis N, Berendt AR, Bowler IC, Winearls CG, Maxwell P. Outcome following hemodialysis catheter-related Staphylococcus aureus bacteraemia. J Hosp Infect. 1999; 41(3):223–228. 22. Kovalik E, Albers F, Raymond J, Conlon P. A clustering of cases of spinal epidural abscess in hemodialysis patients. J Am Soc Nephrol. 1996;7:2264–2267.
