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Infective endocarditis in dialysis patients: new challenges and old
Timothy Doulton1, Nikhant Sabharwal, Hugh S Cairns
1Renal Unit, Guy's and St. Thomas' Hospital, London, United Kingdom.
Insights
Infective endocarditis (IE) in chronic hemodialysis (HD) patients is a serious risk, with dual-lumen catheters posing a significant threat. However, arteriovenous fistulas also carry high mortality, and abnormal valves increase IE risk.
Area of Science:
- Nephrology
- Infectious Diseases
- Cardiology
Background:
- Chronic hemodialysis (HD) has been a known risk factor for infective endocarditis (IE) since the 1960s.
- Historically, IE in HD patients was strongly linked to dual-lumen catheters for vascular access.
- This study investigates contemporary risk factors and outcomes of IE in the current dialysis era.
Purpose of the Study:
- To examine the risk factors associated with infective endocarditis (IE) in patients undergoing chronic hemodialysis (HD).
- To evaluate the consequences and outcomes of IE in the modern dialysis population.
- To identify specific vascular access methods and patient characteristics contributing to IE development and mortality.
Main Methods:
- A retrospective review of infective endocarditis (IE) cases using the Duke criteria was conducted.
- Data were collected from three major hospitals: St. Thomas' Hospital, Guy's Hospital, and King's College Hospitals.
- The study period spanned from 1980 to 2002, encompassing 28 patients with IE.
Main Results:
- Twenty-seven of the 28 IE patients were on chronic hemodialysis (HD); one was on peritoneal dialysis (PD).
- The most common primary access methods were arteriovenous fistula (AVF) (41.3%) and dual-lumen tunneled catheter (DLTC) (37.9%).
- Staphylococcus aureus was the predominant pathogen (63.3%), and pre-existing abnormal valves were present in over 50% of cases, increasing mortality.
Conclusions:
- Infective endocarditis (IE) in hemodialysis (HD) patients remains a significant clinical challenge.
- While dual-lumen catheters are a risk, arteriovenous fistulas were associated with the highest mortality in this series.
- Preventing valve calcification, a common complication after 5 years on dialysis, may reduce IE incidence and improve outcomes.
Background:
Since the 1960s chronic hemodialysis (HD) has been recognized as a risk factor for the development of infective endocarditis (IE). Historically, it has been particularly associated with vascular access via dual lumen catheters. We wished to examine the risk factors for, and consequences of, IE in the modern dialysis era.
Methods:
Cases of IE (using the Duke criteria) at St. Thomas' Hospital (1980 to 1995), Guy's (1995 to 2002), and King's College Hospitals (1996 to 2002) were reviewed.
Results:
Twenty-eight patients were identified as having developed IE (30 episodes of IE). Twenty-seven patients were on long-term HD and one patient was on peritoneal dialysis (PD). Mean age was 54.1 years, and mean duration of HD prior to IE was 46.3 months. Eight patients were diabetic. Primary HD hemoaccess was an arteriovenous fistula (AVF) in 41.3%, a dual-lumen tunneled catheter (DLTC) in 37.9%, a polytetrafluoroethylene (PTFE) graft in 10.3%, and a dual- lumen non-tunneled catheter (DLNTC) in 4%. The presumed source of sepsis was directly related to hemoaccess in 25 HD patients: DLTC in 48%; AVF in 32%; PTFE in 12%; and DLNTC in 4%. Staphylococcus aureus[including methicillin resistant Staphylococcus aureus (MRSA)] was present in 63.3%. The mitral valve was affected in 41.4% of patients, aortic valve in 37.9% of patients, and both valves were affected in 17.2% of patients. Of note, 51.7% of patients had an abnormal valve before the episode of IE. In 15 cases surgery was undertaken. Fourteen patients survived to discharge, and 12 survived for 30 days. In 15 cases antibiotic treatment alone was employed; in this case, eight patients died and seven survived to discharge.
Conclusion:
This is the largest reported confirmed IE series in dialysis patients. Infective endocarditis in HD patients remains a challenging problem-although hemoaccess via dual-lumen catheters remains a significant risk, many cases developed in patients with AVFs and this group suffered the greatest mortality. An abnormal valve (frequently calcified) was another risk factor; because valve calcification is now common after 5 years on dialysis, more effort in preventing this avoidable form of ectopic calcification may reduce the risk of developing IE.