Case Commentaries on Ethical Issues in Dialysis &% Alvin H. Moss Series Editor

Ethical Issues in End-Stage Renal Disease Patients Who Use Illicit Intravenous Drugs

Aamir lqbal and Jean L Holley

Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medlclne, Pittsburgh, Pennsyivanla

Glomerulosclerosis associated with intravenous heroin abuse emerged in the 1970s as a major cause of nephrotic syndrome and end-stage renal disease (ESRD) in urban areas, accounting for 10% of the dialysis population aged 18-45 in such areas (1, 2). With the identification of HIV infection, glomeru- losclerosis in HIV-infected intravenous drug users (IVDU) was recognized as an entity distinct from intravenous drug abuse or “heroin nephropathy” (3). HIV-associated nephropathy is now a major re- nal disorder occurring in IVDU (4, 5 ) .

The ESRD patient using intravenous illicit drugs may raise specific medical and ethical issues, in- volving the choice of a dialysis modality, placement of hemodialysis access, and patient compliance and acceptability for renal transplantation, and general issues of resource allocation and social value. This paper will focus on these topics using a case pre- sentation to illustrate some of the problems con- fronting nephrologists caring for ESRD patients who use illicit drugs. Some possible solutions to the problems presented by IVDU who require dialysis will also be discussed.

Case Presentation

A 41-year-old man with ESRD due to focal seg- mental glomerulosclerosis associated with intrave- nous heroin use had been dialyzing via temporary subclavian catheters for six months. Multiple hemo- dialysis accesses failed due to clotting and infec- tion. He used his dialysis access (both temporary catheters and arteriovenous access) to inject illicit drugs. His most recent arteriovenous graft was in- fected with Candida albicans after injecting intra- venous heroin and cocaine. One surgeon has fol- lowed the patient during his 14 years on dialysis and

Address correspondence to: Jean L. Holley, MD, F1159 Presbyte- rian University Hospital, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213. Seminars in D/a/p/+Vol 8, No 1 (Jan-Feb) 1995 pp 35-38

is currently refusing to place another permanent he- moaccess due to the patient’s on-going use of intra- venous drugs injected through his access.

The patient’s medical history is notable for intra- venous heroin use for 25 years, paranoid schizo- phrenia for 22 years, hypertension, chronic hepati- tis for 12 years, tardive dyskinesia due to psycho- tropic medications, an episode of infective endocarditis, bilateral carpal tunnel release, and ESRD initially treated with intermittent peritoneal dialysis for about one year and then in-center he- modialysis for the past 13 years. He has also had multiple infections, pseudoaneurysms, and failure of hemodialysis accesses (five native vein fistulas and polytetrafluorethylene grafts) necessitating placement of multiple temporary subclavian and in- ternal jugular dialysis catheters. He has never had a permanent cuffed catheter for hemodialysis access. He is hepatitis B surface antibody-positive, surface antigen-negative, hepatitis C antibody-negative, and HIV antibody-negative.

The patient is a cooperative and pleasant man who is generally compliant with his dialysis treat- ments and medications. He has refused to consider renal transplantation and thus has never been for- mally evaluated as a transplant recipient. He lives with his mother and receives Social Security in- come. He left school after the eighth grade, subse- quently receiving a GED diploma. He has per- formed janitorial and food service work intermit- tently for short periods of time (weeks) but has never held steady employment. He continues to use intravenous heroin and a heroidcocaine mixture depending on drug availability and his finances. He has never enrolled in a substance abuse rehabilita- tion program, although, on at least two occasions, he underwent initial evaluation for an inpatient pro- gram but was denied admission because of his ex- tensive medical problems. He recently indepen- dently investigated an outpatient methadone main- tenance program with the encouragement of his mother, physicians, nurses, and social worker in

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36 lqbal and Holley

the dialysis unit. However, after initial evaluation, he failed to continue participation in the program.

Commentary

Difficult or “problem patients” confront all health care providers; conflicts arising from their personalities or behavior alone generally do not al- low a physician to refuse care (6, 7). More specifi- cally, an ESRD patient’s refusal to comply with medications or treatment. does not justify discon- tinuing dialysis (8). Thus, an IVDU who requires dialysis and generally agrees to be dialyzed (despite noncompliance or abusive behavior) should con- tinue to undergo chronic dialysis. This judgment is made because the ethical requirements of medical benefit (dialysis for treating ESRD) and patient will- ingness .(to undergo access placement) have been satisfied (9). If, unlike today, dialysis resources be- come scarce, questions related to the appropriate- ness of renal replacement therapy in IVDU may be raised (see social value issues below) and change the current focus of ethical issues related to dialyz- ing IVDU. Hence, the ethical implications of dia- lyzing an IVDU involve primarily medical issues to minimize complications and risks.

Choosing a Dialysis Modality for an IVDU

Although inequalities in selection of renal re- placement therapy exist (lo), there is little informa- tion specifically evaluating appropriate modes of di- alysis for the IVDU population. Continuous ambu- latory peritoneal dialysis (CAPD) may initially be an attractive form of dialysis for the IVDU because placement of a hemoaccess (and, therefore, an ac- cess for intravenous drugs) is avoided. However, infection remains the most common complication of CAPD and concerns about CAPD-related infection in IVDU are pertinent.

Unfortunately, there is little information about in- fectious complications of IVDU on CAPD. Most available data concern peritonitis rates in HIV- positive patients who are variably found to have higher peritonitis rates (1 1) and infection with viru- lent or unusual organisms (12, 13). Like hemodial- ysis access that provides a route for illicit drug use, drug injection through the peritoneal catheter is possible and should be considered in cases of un- usual or recalcitrant peritonitis (12). In one study, although the number of patients was small (six IVDU), the peritonitis rate in IVDU was not higher than the general HIV-negative population in one program (1 1). More information is needed to assess CAPD-related infection risk in IVDU. However, since peritoneal dialysis-related infection is not the sole risk of CAPD, preferential selection of CAPD as a treatment modality is not likely to be beneficial for ESRD patients who use illicit intravenous drugs; the issue of patient compliance with prescribed di- alysis is an important one in considering an IVDU for CAPD.

CAPD, by its very nature, requires a compliant patient who actively participates in his or her care. Although little studied, it is likely that fears of non- compliance make many nephrologists reluctant to place IVDU on CAPD. Unlike some ESRD patients who are IVDU, our patient is compliant with his hemodialysis treatments and therefore does not present problems that may be experienced with abusive or noncompliant dialysis patients (14, 15). Although there is little information on compliance in IVDU on chronic dialysis, most would agree that for many IVDU on in-center hemodialysis, compli- ance with dialysis appointments, medications, and diet is problematic (16). Few factors affecting com- pliance in the general ESRD population have been identified (16). Specifically, patient demographics and personality characteristics, health status, and knowledge have little consistent effect on compli- ance (16). The IVDU dialysis patient may create complicated compliance issues for the nephrologist and dialysis center that will be case-specific and applicable to individual patients but significantly different from the general compliance issues in di- alysis patients (16).

Thus, concerns about noncompliance with dialy- sis and infection on CAPD likely lead nephrologists to consider hemodialysis for the IVDU. There is no information about modality selection among IVDU themselves, but since in-center hemodialysis is the primary therapy used by all dialysis patients in the United States (17), it is likely that most IVDU with ESRD are on maintenance hemodialysis. Thus, the type of hemodialysis access to be placed is an im- portant issue.

Hemodialysis Access in Intravenous Drug Users

As shown in our case, hemodialysis access can be difficult to maintain in patients who use intravenous illicit drugs. Our patient’s initial access, a native arteriovenous fistula, was lost to infection. Subse- quently, synthetic grafts were required due to the lack of adequate native veins. Multiple grafts were lost because of infection and thrombosis, often after many attempts at declotting thrombosed grafts. In- travenous drug-related infections occur because of the use of either nonsterile equipment or solution. In the 1930s and 1940s, abscesses, thrombophlebi- tis, septicemia, endocarditis, tetanus, and malaria were frequently observed in IVDU (18, 19). Now the spectrum of infection in IVDU also involves viral hepatitis and HIV-related syndromes (18, 19). The presence of an arteriovenous fistula or graft provides a convenient access for intravenous drugs and because of increased use, graft infections occur more commonly in this population, often associated with significant morbidity, including bacteremia and endocarditis (20). A higher rate of infection oc- curs in polytetraflurorethylene (PTFE) grafts com- pared with native fistulas in IVDU (20). Because of the high graft infection rate in IVDU, some advo- cate tunneled central catheters as a primary access

ESRD PATIENTS USING

for such patients, because they are more easily re- moved when infection does occur (20). Temporary central catheters are commonly required in IVDU, often for i.v. access for antibiotics because native vessels are diffusely sclerotic. Venous outflow ob- struction may subsequently develop and compro- mise placement of permanent hemodialysis access, often leading to graft occlusion (20, 21). Frequent infections in IVDU may cause chronically elevated acute phase reactants such as fibrinogen, which, in turn, can cause a hypercoagulable state promoting graft thrombosis (20). Thus, permanent access in IVDU, as illustrated in our case, is fraught with risk. Should we therefore place permanent hemoac- cess in individuals using intravenous illicit drugs and, if so, what type of access?

There are few data comparing the risks and ben- efits of specific types of hemodialysis access in IVDU. Access infection rates are lower in native fistula compared with PTFE grafts (20), but graft placement is often required because sclerotic native veins preclude fistula creation. Infection rates in cuffed silastic catheters is comparable to PTFE grafts in the non-IVDU population (22) but there is no information about comparable infection rates in IVDU. Removal of an infected silastic catheter is certainly easier than removal of an infected graft but sacrifice of subclavian and/or internal jugular veins may complicate future short-term access. Our patient is undoubtedly like many others: silastic catheter or extremity graft or fistula are equally accessible routes for illicit drug administration. Ar- teriovenous access may therefore not really affect a patient’s I.V. drug use, because, as in our case, the patient has already demonstrated a determination to inject drugs (9) regardless.

ILLICIT I.V, DRUGS 37

term association with the surgeon, the referring nephrologist may ethically obtain a second vacular surgical consultation for placement of another per- manent hemodialysis access if conflicting opinions about appropriate treatment plans cannot be re- solved.

Transplantation and the IVDU

During the past three decades, renal transplanta- tion has evolved from an experiment in human bi- ology to an established therapy for ESRD. The po- tential recipient is usually carefully evaluated, in- cluding a psychiatric or social evaluation to establish motivation, compliance, and the absence of ongoing alcohol or substance abuse (24, 25). Since noncompliance is one of the major causes of long-term allograft loss (26) and, additionally, be- cause the shortage of organs limits transplantation rates, many programs stipulate completion of a sub- stance abuse rehabilitation program as a criterion for activation on a transplant waiting list (24, 25). Such criteria may be justified in terms of medical benefit (avoiding the potential complications asso- ciated with allograft rejection), utility, and justice in the setting of scare resources (organs). There is lit- tle information on the effectiveness of such pro- grams in the transplant population. However, one study of eight prisoners with ESRD related to drug use but not actively abusing drugs showed good re- sults: 12-month patient survival of 100% and graft survival of 86% (27). Thus, ESRD due to i.v. drug use entails no intrinsic renal or immunologic con- traindications to successful transplantation. Poten- tial problems with compliance, particularly with im- munosuppression, were avoided in this study be-

Conflict Among Consultants

Another ethical issue raised by our case is the conflict that may arise among consultants about ap- propriate therapy. In our case, the nephrologists (who favor placement of a permanent access) and the surgeon (who prefers that the patient continue using temporary venous catheters for dialysis ac- cess) have differing opinions about appropriate treatment. The conflict has arisen in part due to ethical concerns about hemodialysis access in an IVDU. Patient welfare is paramount in the consul- tation process and should be the cornerstone around which differences in opinion among refer- ring and consulting physicians should be resolved (23).

In cases such as ours, conflicting opinions about the medical implications of placing another perma- nent hemoaccess, with the attendant potential mor- bidity, need to be discussed by the nephrologist and surgeon. Thus, in this case, interpretation of the available literature about the complications of he- modialysis access in IVDU will determine the ap- propriate action, albeit with the caveat of expected future complications. Despite the patient’s long-

cause the transplant recipients were incarcerated

In the wider world, issues of noncompliance in the IVDU loom larger and form the basis of many of the issues related to transplantation in this group of patients. Decisions to accept IVDU patients on transplant recipient waiting lists will therefore be program-specific and individualized on a case-by- case basis. Efforts to enroll patients in drug reha- bilitation programs may require the active interven- tion of nephrologists. The reality of allocation of scarce resources (in this case, organs) likely affects consideration of IVDU as potential recipients of re- nal allografts. If resources become more limited, the IVDU population is likely to be at risk for more stringent entrance criteria.

(27).

Social Value Issues

Finally, in considering ethical problems related to renal replacement therapy in IVDU, global issues should be mentioned. A patient’s responsibility for his or her illness is a complicated issue (9) that im- pacts on health care delivery and society’s view of illness and health care (28). Social value judgments, judgments which hold different social worth for in-

38 lqbal and Holley

dividuals, are underwritten by the belief that values can be judged as better or worse by some accept- able standard. Such judgments obviously require one to define and impose his or her personal stan- dards of worth or value on others. Historically, these types of judgments were made by dialysis se- lection committees in the early days of chronic di- alysis and were subsequently rejected as unfair and undermining to the American society’s view of equality and the value of human life (29). A special case of a social value judgment is the judgment that would penalize a person held to have “caused his or her own illness” (30). These judgments make im- plicit the right of society to abrogate responsibility for the care of individuals who have caused illness through personal choice and irresponsibility. The added issue of allocating scarce resources in an en- vironment that tolerates social value judgments al- lows for the possibility of inequities in health care delivery and, indeed, tyranny of health care (28). Historical and current societal and medical ethical principles argue strongly against the imposition of social value judgments for all patients, including those who use intravenous drugs and require renal replacement therapy. However, the scarcity of available organs for transplantation may force IVDU to satisfy program-specific requirements for rehabilitation before transplantation is considered.

In summary, drug abuse is a common problem in the dialysis population, particularly in certain loca- tions. Significant morbidity from infection and ac- cess-related problems occur in IVDU on hemodial- ysis. Noncompliance with dialysis treatments, diet, and medications is frustrating for caregivers and may lead to obstacles in the provision of health care but does not justify withholding or withdrawing re- nal replacement therapy from these patients. If the principles of medical benefit and patient willingness are the primary considerations, most ethical issues raised in the care of ESRD patients who abuse in- travenous drugs can be recognized and resolved.

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