Incidence and risk factors for Hemodialysis Reliable Outflow bypass graft infection.

BACKGROUND

Hemodialysis Reliable Outflow (HeRO) graft implantation is performed as a last resort option for hemodialysis access in patients limited by central venous stenosis or occlusion. In this single-center series, we examined the incidence, risk factors, and long-term outcomes of patients with a HeRO graft infection.

METHODS

Institutional medical records were retrospectively reviewed for all HeRO graft procedures performed from 2014 to 2023. Only index procedures were included in this analysis. The primary outcome of interest was HeRO graft infection. Data were analyzed using Kaplan-Meier, univariable, and multivariate analyses.

RESULTS

Over the 10-year study period, 232 patients underwent index HeRO graft surgery with a median follow-up period of 18.5 months. A total of 57 patients (24.6%) were diagnosed with a HeRO graft infection. The estimated 1- and 3-year incidences of graft infection were 14.9% ± 2.6% and 34.2 ± 4.3%, respectively. The median interval from operation to infection was 0.93 years (interquartile range, 0.16-1.88 years). Patients with graft infection were more frequently female (63.2% vs 46.3%; P = .03). Most patients were treated with complete graft resection and intravenous antibiotics (n = 54 [94.7%]). After the infected graft is removed, a nontunneled catheter is used until the infection has been adequately treated. The most common pathogens were Staphylococcus aureus (n = 12 [21.1%]), polymicrobial cultures (n = 11 [19.3%]), and Staphylococcus epidermidis (n = 8 [14.0%]). Primary patency rates were similar between the groups (1 year, 23.8 ± 5.7% vs 37.1 ± 4.1%; log-rank P = .15). However, secondary patency rates were significantly lower among patients with graft infection at 1 year (47.0 ± 6.7% vs 78.6 ± 3.7%) and 3 years (13.8 ± 4.7% vs 59.1 ± 5.4%) (log-rank P < .0001). The median survival after diagnosis of graft infection was 0.95 years (interquartile range, 0.50-2.18 years). On multivariate analysis, only female sex (hazard ratio, 1.89; 95% CI, 1.08-3.31; P = .026) was independently associated with HeRO graft infection.

CONCLUSIONS

The incidence of HeRO graft infection is high and persists for years after the index operation. Patients undergoing HeRO graft implantation should be counseled on the risks and consequences of this complication.