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Chronic Venous Insufficiency in Human Immunodeficiency Virus Positive Patients Undergoing Highly Active Antiretroviral Therapy

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Chronic Venous Insufficiency in Human Immunodeficiency Virus Positive Patients Undergoing Highly Active Antiretroviral Therapy Journal of Phlebology and Lymphology Chronic Venous Insufficiency in Human Immunodeficiency Virus- Positive Patients Undergoing Highly Active Antiretroviral Therapy Authors: Marcelo Burihan Calil, MD1, Andre Fonseca Duarte, MD2, Catherine Puliti Hermida Reigada, MD3, Adnan Neser, MD1, Felipe Nasser, MD1, Jose Carlos Ingrund, MD1, Viviane de Almeida Jabur, MD4, Patrícia Carla Piragibe Ramos Burihan, MD4, Gilberto Mitsuo Ukita, PhD2 Adress:1 Santa Marcelina Hospital, 2 University of São Paulo, 3 University of Campinas, 4 University of Santo Amaro E-mail: [email protected] *corresponding author Published: april 2011 Received: 16 November 2011 Journal Phlebology and Lymphology 2011; 4:21-30 Accepted: 12 December 2011 Abstract Introduction: The acquired immunodeficiency syndrome (AIDS) is a chronic and progressive disease with an important worldwide epidemiological impact. Likewise, chronic venous insufficiency (CVI) also represents an extremely relevant pathology. There are no studies correlating both of them. Aim: Characterize human immunodeficiency virus (HIV) positive patients undergoing highly active antiretroviral therapy (HAART) as to the presence of varicose veins and CVI of the lower limbs. Method: A descriptive transversal study. 106 HIV positive patients were evaluated. The majority of the patients were assisted in an infectious disease clinic. The non-parametric test of association qui-square (X2) was used. Results:The time of HIV infection was significant associated with the symptom cramps (P = 0.049). The time of HAART showed a significant association in relation to tingling sensation (P= 0.048). Regarding the time of use of zidovudine, a significant association was observed with tingling sensation (P< 0.01) and edema (P= 0.017). A significant association with referred edema (P= 0.016) was also shown. There was also a significant increase in the prevalence of burning sensation after 3 years of lamivudine (P= 0.028). There was a significant association between the use of efavirenz and fatigue in the lower limbs and a significant increase in tingling (P= 0.03). Conclusion: This is the first study investigating the presence of CVI of the lower limbs in HIV infected patients undergoing HAART. Further studies must be encouraged in order to elucidate the real role of the HIV infection and HAART on the worsening of CVI in this group. Key words: venous insufficiency; varicose veins; antiretroviral; HIV Introduction an obstruction of the venous flow, which can lead to The acquired immunodeficiency syndrome (AIDS) is a varicose veins1,2,3. chronic and progressive disease with an important In 1998, Carr described a redistribution of body worldwide epidemiological impact. Likewise, chronic fat and metabolic abnormalities in AIDS patients venous insufficiency (CVI) also represents an extremely undergoing highly active antiretroviral therapy (HAART) relevant pathology. However, there are no studies called liposdistrophy4,5. Some studies have shown risk correlating both of them. factors related to the development of this syndrome, such CVI is defined as an abnormality of the function of as: age, white gender, AIDS severity by CD4 cells and viral the venous system caused by a valvular incompetence or charge and the use and duration of HAART6. changes of the venous wall. It might be related or not to After clinical observation that HIV positive patients undergoing HAART developed varicose veins in Page 21 of 30 Journal of Phebology and Lymphology 2011; 4:21-30 http://www.digitalmedicaljournals.com the lower limbs, a hypothesis has been raised if there are beginning of HAART, time of use of each antiretroviral, any selected role of HAART in the dilatation of the venous total time of HAART, time of HIV infection, CD4+ cell count wall with consequent progression and the worsening of and viral charge at the moment of evaluation were CVI. obtained. During the physical examination, the patients Objective were weighed and measured by the same professional to Characterize human immunodeficiency virus (HIV) positive calculate the BMI for further grouping in the categories patients undergoing HAART as to the presence of varicose according to the World Health Organization (WHO)7: veins and CVI of the lower limbs. underweight (BMI<18.5 kg/m2), normal range (BMI between 18.5 and 24.99 kg/m2), pre-obese (BMI between 25 and 29.99 kg/m2) and obese (BMI>30 kg/m2). Method Firstly, the physical examination was conducted A descriptive transversal study without any conflicts of with the patient in the orthostatic position to evaluate the interest. After signing the free informed term of consent inspection of the lower limbs. Then, the palpation and during the period from February to December 2006, 106 percussion of the small (SSV) and great (GSV) saphenous HIV positive patients were evaluated by one vascular veins from theirs origins to theirs junctions besides the surgeon according to the approved protocol by the palpation of SSV in the popliteal fossa was performed. The Research Ethics Committee of the Municipal Secretary of circumferences of the lower limbs (ankles, legs and thighs) Health in the city of São Paulo (Brazil). This study were obtained with the patient in dorsal decubit and then corresponds to the first phase of a prospective study. the dosalis pedis, posterior tibial, popliteal and femoral These patients were assisted at the Specialized Assistance pulses were palpated. The presence or not of Service (SAE) STD/AIDS Cidade Dutra, at the specialty telangiectasias, reticular veins, dilatation of tributary ambulatory José Bonifácio IV and at the Vascular Surgery veins, small and great saphenous vein insufficiency, Ambulatory of Santa Marcelina Hospital. All of them are dermatitis ocre, eczema, edema and venous ulcer was located in the São Paulo city. The vast majority of the evaluated. As a result of physical examination, the patients patients (91/106) were assisted in the SAE STD/AIDS which were classified regarding the clinical category of CEAP8, is an infectious disease ambulatory. adopting the presence of varicose veins when clinical CEAP The inclusion criterion was HIV patients was equal or higher than 2. undergoing HAART. Those who have never initiated HAART, Asymptomatic patients were informed about the whose data was incomplete, who have denied venous disease and they were advised on prophylactic participating on this study, who had previous surgical measures, such as loss of weight and practice of physical intervention in the lower limbs, who had personal exercises. Patients with CVI were advised in the first antecedent of neoplasias, thrombosis and post-thrombotic consultation to the need of elastic or inelastic syndrome and patients under 18 years old or above 70 compression, drug treatment, and bandage combined with years old were excluded. After applying those criteria, 6 clinical measures in cases of venous ulcer. patients were excluded, characterizing a sample of 100 Firstly, patients were stratified according to the patients. average time of use of HAART. Secondly, if there was a The following criteria were investigated: age, statistic significant result, they were rearranged in the time body mass index (BMI), physical activity, personal interval of use of HAART every two years. This had the antecedents such as arterial hypertension, diabetes proposal of obtaining higher precision of determination in mellitus, smoking status and alcohol intake, personal and which interval of time it would observe the occurrence of family antecedent of varicose veins and deep vein signals and symptoms of the venous disease. thrombosis, number of pregnancies, practice of physical The non-parametric test of association qui-square exercise and use of venotonics and elastic compression (X2) was used to evaluating whether there was a stockings. correlation between the variables analyzed, adopting Symptoms related to the venous disease of the P<.05 as a statistic significant result. Values of P between lower limbs such as leg heaviness, fatigue in the legs, 0.05 and 0.1 were considered marginally significant. burning and tingling sensation, cramps, sensation of swelling and pain were questioned apart from asking whether there was any worsening of them after the beginning of HAART. All the antiretrovirals used since the Page 22 of 30 Journal of Phebology and Lymphology 2011; 4:21-30 http://www.digitalmedicaljournals.com Results venous ulcer). Therefore, the prevalence of varicose veins The average age of the patients was 40.69 years, ranging was 85%. from 21 to 64 years, 51% of which were male. Regarding Tables 1 to 8 show all prevalences obtained by personal antecedents, 50% were smokers or had been the associations between the studied variables and the smokers, 15% had systemic arterial hypertension and 5% time of HIV infection, and the time of use of HAART and had diabetes mellitus. As for the BMI, 52.1% were at each ARV individually. normal range, 33.3% were pre-obese, 14.6% were obese and none of them were underweight. The average time of the HIV infection was 6 years, having 17% of the patients being infected less than 2 years, 20% between 2 and 4 years, 15% between 4 and 6 years, 16% between 6 and 8 Table I. Presence of variable in the lower limbs in patients with less years, 9% between 8 and 10 years and 23% over 10 years. or higher than 6 years of HIV infection. When CD4+ cell count was analyzed, 15% had less than Time of HIV infection 200/mm3, 26% between 200 and 349/mm3, 23% between < 6 years ≥ 6 years 350 and 500/mm3 and 36% were higher than 500/mm3. (n=52) (n=48) The viral charge was undetectable, that is to say below Presence of variable No. (%) No. (%) P value 400 copies/ml, in 70% of the patients, below 10.000 Fatigue 23 (44.23) 24 (50) .564 copies/ml in 8%, between 10.000 and 20.000 copies/ml in Heaviness 20 (38.46) 19 (39.58) .909 5% and over 20.000 copies/ml in 17%.
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