Cardiac Valve Replacement for Infective Endocarditis in Patients With End-Stage Renal Disease on Hemodialysis: A Case Series and Review of the Literature

Abstract

Complications from vascular access are the leading cause of morbidity in the hemodialysis (HD) population. The use of tunneled catheters (TC) is associated with a greater risk of bacteremia and mortality compared with other types of HD access. Infective endocarditis (IE) is a serious complication occurring in 2% to 5% of patients undergoing HD and is likely secondary to transient bacteremia from repetitive vascular access. This study reviewed outcomes in HD-dependent patients requiring cardiac valve replacement (VR) for IE. A retrospective record review was conducted to identify all patients who underwent VR within a 6-year period (January 2009-December 2014). Inclusion criteria included a diagnosis of IE and end-stage renal disease (ESRD) on HD. Relevant clinical information, including demographics, comorbidities, valve involvement, causative organisms, and type of HD access (arteriovenous fistula [AVF], arteriovenous graft [AVG], or TC) was collected. A total of 1498 patients underwent cardiac VR within the 6-year period. Of these, 168 patients (11.2%) had IE and 120 patients (8.0%) had ESRD on HD. Overall 30-day mortality for VR was 5.0% (75 of 1498). Mortality for patients with IE was 7.1% (12 of 168) and for patients with ESRD on HD was 10% (12 of 120). Thirty-four patients (2.3%) had IE and ESRD on HD. Of these, 13 patients were being dialyzed via AVF, 4 via AVG, and 17 via TC. Mortality occurred in 2 of 13 patients with AVF, 1 of 4 patients with AVG, and 2 of 17 patients with TC, for an overall mortality of 14.7% (5 of 34). IE remains a significant problem in patients with ESRD on HD, particularly when TCs are used for HD access. Although appropriate algorithms have been developed to minimize long-term use of TCs, bacteremia remains a significant problem. We reviewed our institutional experience and the medical literature to determine outcomes in HD-dependent patients with IE requiring VR. Despite mortality rates between 42% and 73% reported in the literature, our mortality rate was 14.7%. Care of these critically ill patients must emphasize early diagnosis and aggressive management to optimize outcomes.