Trends and outcomes of infective endocarditis in patients on dialysis

Infective Endocarditis in Patients with End-Stage Renal Disease on Dialysis: Epidemiology, Risk Factors, Diagnostic Challenges, and Management Approaches

Infective endocarditis (IE) poses a significant clinical challenge, especially among patients with end-stage renal disease (ESRD) undergoing dialysis, and is associated with high morbidity and mortality rates. This review provides a contemporary discussion of the epidemiology, risk factors, diagnostic challenges, and management strategies for IE among ESRD patients, including a literature review of recent studies focused on this vulnerable population. The review highlights the multifactorial nature of IE risk in ESRD patients, emphasizing the roles of vascular access type, dialysis modality, and comorbid conditions. It also explores the diagnostic utility of different imaging modalities and the importance of a multidisciplinary approach in managing IE, including both medical and surgical interventions. The insights from this review aim to contribute to the improvement of patient outcomes through early recognition, appropriate antimicrobial therapy, and timely surgical intervention when necessary.

Comparative analysis of infective endocarditis in hemodialysis versus non-hemodialysis patients in Iran: implications for clinical practice and future research

BACKGROUND

In hemodialysis (HD) patients, there is a larger frequency of mortality and morbidity associated with infective endocarditis (IE) as opposed to the general population. Despite the increased burden of IE in the HD population, optimal strategies for prevention and management still need to be clarified. Elucidating the distinguishing features and outcomes of IE in HD patients is crucial to guide clinical decision-making and improve prognosis in this high-risk group. However, the details of IE characteristics, specifically in HD patients in the Middle East, are limited.

OBJECTIVE

To compare the clinical characteristics and short-term outcomes of IE between HD and non-HD patients.

METHODS

A retrospective analysis was carried out on 139 patients with infective endocarditis who were referred to a tertiary cardiovascular center in Iran from 2006 to 2018. The participants were split into HD (n = 34) and non-HD (n = 105) groups. Data pertaining to demographic characteristics, comorbidities, microbiological findings, occurrence of complications, therapeutic interventions, and mortality rates during hospital stay were gathered.

RESULTS

Diabetes, hypertension, and congestive heart failure were observed more frequently in HD patients. HD patients were more likely than non-HD patients to have involvement of the right valve (41.2% vs. 20.9%), larger vegetation, and extracardiac emboli. In-hospital mortality was 41.2% for HD patients versus 14.3% for non-HD patients. Mortality remained high after valve surgery in HD patients (38.2% vs. 10.5% in non-HD).

CONCLUSION

HD patients exhibited a distinct clinical profile of IE with worse short-term outcomes, including higher mortality.

Factors Related to the Development of Infective Endocarditis in Hemodialysis Patients in a Third-Level Hospital in Panama

INTRODUCTION

Venous access for hemodialysis (HD) makes patients more susceptible to transient bacteremia, predisposing them to the development of infective endocarditis (IE). Among the risk factors observed in this population are temporary access to HD, hypoalbuminemia, diabetes mellitus, female gender, anemia, and colonization by methicillin-resistant Staphylococcus aureus (MRSA).

METHODOLOGY

A retrospective case-control study with a one-to-two ratio was carried out on patients with chronic kidney disease (CKD) undergoing renal replacement therapy with at least one vascular access for HD at Complejo Hospitalario Dr. Arnulfo Arias Madrid (CHDrAAM) from 2010 to 2020. Sociodemographic variables, past medical history, and data on current HD were studied. The odds ratio (OR) and adjusted odds ratio (aOR) were calculated for the collected variables.

RESULTS

No statistically significant differences between the groups were observed in sociodemographic variables. In terms of past medical history, the cases showed a predominance of coronary disease (47.6% vs 4.8%; OR: 37.27), valvular disease (23.8% vs 0%), and heart failure (33.3% vs 4.8%; OR: 10). In the cases, the use of a temporary catheter was more prevalent (61.9% vs 33.3%; OR: 3.25), and subclavian access was more frequently recorded (28.6% vs 2.4%; OR: 14.4). A short duration of venous access (<30 days) was found in a greater proportion of cases (23.8% vs 4.8%; OR: 6.25). The main pathogen isolated was S. aureus (33.3%), and the most affected valve was the aortic valve (59.1%). Fever was found in 100% of the reported cases, and up to 47.6% presented with a recent murmur.

DISCUSSION

Similar to previous studies conducted in other countries, we identified a history of pre-existing valve disease, the use of a temporary catheter, and recent venous access as risk factors. Contrary to what has been reported in the literature, this study did not find female sex, diabetes mellitus, and hypoalbuminemia as risks.

CONCLUSION

Factors such as a history of coronary artery disease, heart failure, preexisting valvular disease, the use of a temporary catheter, subclavian venous access, and short duration of venous access (<30 days) were identified as risk factors for the development of IE in patients with CKD on HD.

Hemodialysis and its impact on patient characteristics, microbiology, cardiac surgery, and mortality in infective endocarditis

BACKGROUND

Patients with chronic renal failure on hemodialysis carry a significant risk of infective endocarditis (IE), but data on whether these patients differ from other patients with IE in terms of comorbidity, microbiology, rates of surgery and mortality are sparse.

METHODS

Using Danish nationwide registries, all patients with IE diagnosed between February 1, 2010, and May 14, 2018 were identified and categorized into a "hemodialysis group" and a "non-hemodialysis group." Patient groups were compared by comorbidities, microbiological etiology, cardiac surgery, and mortality. Risk factors associated with mortality were assessed in multivariable Cox regression analysis.

RESULTS

In total, 4,366 patients with IE were included with 226 (5.2%) patients in the hemodialysis group. Patients in the hemodialysis group were younger (66.0 years [IQR 53.8-74.9] vs 72.2 years [IQR 62.2-80.0]), had more comorbidities and were surgically treated less often (10.6% vs 20.8%), compared with patients from the nonhemodialysis group. Staphylococcus aureus was more than twice as prevalent (58.0% vs 26.5%). No difference in in-hospital mortality was found between the 2 groups (20.8% vs 18.5%), but 1- and 5-year mortality were significantly higher in the hemodialysis group than in the nonhemodialysis group (37.7% vs 17.7% and 72.1% vs 42.5%, respectively). In adjusted analysis, hemodialysis was associated with higher 1-year (HR = 2.71, 95% CI 2.07-3.55) and 5-year mortality (HR = 2.72, 95% CI 2.22-3.34) CONCLUSIONS: Patients with IE on chronic hemodialysis were younger, had more comorbidity, a higher prevalence of Staphylococcus aureus IE, and a higher mortality than patients without hemodialysis.

Microbiological Etiology in Patients with IE Undergoing Surgery and for Patients with Medical Treatment Only: A Nationwide Study from 2010 to 2020

Microbiological etiology has been associated with surgery for infective endocarditis (IE) during admission, especially Staphylococcus aureus. We aimed to compare patient characteristics, microbiological characteristics, and outcomes by treatment choice (surgery or not). We identified patients with first-time IE between 2010 and 2020 and examined the microbiological etiology of IE according to treatment choice. To identify factors associated with surgery during initial admission, we used the Aalen-Johansen estimator and an adjusted cause-specific Cox model. One-year mortality stratified by microbiological etiology and treatment choice was assessed using unadjusted Kaplan-Meier estimates and an adjusted Cox proportional hazard model. A total of 6255 patients were included, of which 1276 (20.4%) underwent surgery during admission. Patients who underwent surgery were younger (65 vs. 74 years) and less frequently had cerebrovascular disease, cardiovascular disease, diabetes, and chronic kidney disease. Patients with Staphylococcus aureus IE were less likely to undergo surgery during admission (13.6%) compared to all other microbiological etiologies. One-year mortality according to microbiological etiology in patients who underwent surgery was 7.0%, 5.3%, 5.5%, 9.6%, 13.2, and 11.2% compared with 24.2%, 19.1%, 27,6%, 25.2%, 21%, and 16.9% in patients who received medical therapy for Staphylococcus aureus, Streptococcus spp., Enterococcus spp., coagulase-negative Staphylococci, "other microbiological etiologies", and blood culture-negative infective endocarditis, respectively. Patients with IE who underwent surgery differed in terms of microbiology, more often having Streptococci than those who received medical therapy. Contrary to expectations, Staphylococcus aureus was more common among patients who received medical therapy only.

Impact of Chronic Kidney Disease and Dialysis on Outcome after Surgery for Infective Endocarditis

Infective endocarditis (IE) carries a heavy burden of morbidity and mortality in chronic kidney disease (CKD) and hemodialysis (HD) patients. We investigated the risk factors, pathognomonic profile and outcomes of surgically treated IE in CKD and HD patients. We preoperatively identified patients with CKD under hemodialysis (HD group) and compared them with patients without hemodialysis (Non-HD group). Furthermore, we divided the cohort into four groups according to the underlying stage of CKD, with a subsequent outcome analysis. Between 2009 and 2018, 534 Non-HD and 58 HD patients underwent surgery for IE at our institution. The median age was 65.1 [50.6-73.6] and 63.2 [53.4-72.8] years in the Non-HD and HD groups, respectively (p = 0.861). The median EuroSCORE II was 8.0 [5.0-10.0] vs. 9.5 [7.0-12.0] in the Non-HD vs. HD groups (p = 0.004). Patients without CKD had a mortality rate of 5.6% at 30 days and 15.5% at 1 year. Mortality rates proportionally rose with the severity of CKD. Among HD patients, 30-day and 1-year mortality rates were 38.1% and 75.6%, respectively (p < 0.001). Staphylococcus aureus IE was significantly more frequent in the HD group (p = 0.006). In conclusion, outcomes after surgery for IE correlated with the severity of the underlying CKD, with HD patients exhibiting the most unfavorable results. Pre-existing CKD and staphylococcus aureus infection were independent risk factors for 1-year mortality.

Risk factors and survival analysis of haemodialysis complicated with infective endocarditis

The clinical features and risk factors for survival time were analysed in haemodialysis patients complicated with infective endocarditis. A total of 101 infective endocarditis (IE) patients treated at Hangzhou First People's Hospital, from January 1, 2012, to April 1, 2022, were included in the present study. Baseline demographic data and laboratory data were collected for statistical analysis of risk factors and survival time in the IE with haemodialysis group (HD-IE group, n=15) and the IE without haemodialysis group (NHD-IE group, n=86). Haemoglobin, red blood cells, C-reactive protein, procalcitonin, serum albumin, diabetes, invasive procedures, positive blood bacteria culture, heart valve calcification ratio, and left ventricular ejection fraction level were risk factors for infective endocarditis complicated with haemodialysis (P<0.05). Compared with the NHD-IE group, the HD-IE group had an obviously increased risk of mortality (χ²=6.323, P=0.012). The univariate Cox regression analysis showed that age, haemoglobin, red blood cells, serum albumin, left ventricular ejection score, longest vegetation diameter, combined hypotension and diabetes were risk factors for death; furthermore, multivariate Cox regression showed that age (HR=1.187, P=0.015), combined hypotension (HR=0.921, P=0.025) and the longest vegetation diameter (HR=9.191, P=0.004) were independent risk factors affecting the survival of patients. Collectively, the present study revealed that the mortality rate of HD-IE patients was higher than that of NHD-IE patients. Older age, hypotension, and the longest vegetation diameter were independent risk factors affecting the survival of patients. For HD-IE patients, active and effective antibiotic treatment or surgical treatment should be strongly recommended.

Surgical versus medical treatment for infective endocarditis in patients on dialysis: a systematic review and meta-analysis

Infective endocarditis (IE) is a serious infection and causes significant morbidity and mortality. However, the benefit of surgery for endocarditis besides antibiotic treatment in dialysis patients remains controversial. We performed a systematic review of studies published between 1960 and February 2022. Meta-analysis was conducted with a random-effects model to explore the in-hospital, 30, 60, 90, 180-d, and 1-year mortality rates in adult dialysis patients with IE. Sensitivity analysis, subgroup analysis, and meta-regression were performed to explore potential sources of heterogeneity. Confidence of evidence was evaluated by the GRADE system. Thirteen studies were included. The pooled odds ratio of in-hospital mortality was 0.62 (95% confidence interval [CI]: 0.30–1.28, p = .17), with moderate heterogeneity (I² = 62%, p < .01). Three studies reported 30-d mortality, and the pooled odds ratio for surgery compared with medical treatment was even lower (0.36; 95% CI: 0.22–0.61, p < .01), with low heterogeneity (I² = 0%, p = .86). With studies on fewer than 30 patients excluded, the sensitivity analysis revealed a low odds ratio of in-hospital mortality for surgery versus medical treatment (0.52; 95% CI: 0.27–0.99, p = .047), with moderate heterogeneity (I² = 63%, p < .01). Subgroup analysis revealed no significant differences between any two comparator subgroups. Based on a very low strength of evidence, compared with medical treatment, surgical treatment for IE in patients on dialysis is not associated with lower in-hospital mortality. When studies on fewer than 30 patients were excluded, surgical treatment was associated with better survival.

Temporal changes in cardiovascular disease and infections in dialysis across a 22-year period: a nationwide study

BACKGROUND

Cardiovascular diseases (CVD) and infections are recognized as serious complications in patients with end stage kidney disease. However, little is known about the change over time in incidence of these complications. This study aimed to investigate temporal changes in CVD and infective diseases across more than two decades in chronic dialysis patients.

METHODS

All patients that initiated peritoneal dialysis (PD) or hemodialysis (HD) between 1996 and 2017 were identified and followed until outcome (CVD, pneumonia, infective endocarditis (IE) or sepsis), recovery of kidney function, end of dialysis treatment, death or end of study (December 31st, 2017). The calendar time was divided into 5 periods with period 1 (1996-2000) being the reference period. Adjusted rate ratios were assessed using Poisson regression.

RESULTS

In 4285 patients with PD (63.7% males) the median age increased across the calendar periods from 65 [57-73] in 1996-2000 to 69 [55-76] in 2014-2017, (p <  0.0001). In 9952 patients with HD (69.2% males), the overall median age was 71 [61-78] without any changes over time. Among PD, an overall non-significant decreasing trend in rate ratios (RR) of CVD was found, (p = 0,071). RR of pneumonia increased significantly throughout the calendar with an almost two-fold increase of the RR in 2014-2017 (RR 1.71; 95% CI 1.46-2.0), (p <  0.001), as compared to the reference period. The RR of IE decreased significantly until 2009 (RR 0.43; 95% CI 0.21-0.87), followed by a return to the reference level in 2010-2013 (RR 0.87; 95% CI 0.47-1.60 and 2014-2017 (RR 1.1; 95% CI 0.59-2.04). A highly significant (p <  0.001) increase in sepsis was revealed across the calendar periods with an almost 5-fold increase in 2014-2017 (RR 4.69 95% CI 3.69-5.96). In HD, the RR of CVD decreased significantly (p <  0.001) from 2006 to 2017 (RR 0.85; 95% CI 0.79-0.92). Compared to the reference period, the RR for pneumonia was high during all calendar periods (p <  0.05). The RR of IE was initially unchanged (p = 0.4) but increased in 2010-2013 (RR 2.02; 95% CI 1.43-2.85) and 2014-2017 (RR 3.39; 95% CI 2.42-4.75). No significant changes in sepsis were seen.

CONCLUSION

Across the two last decades the RR of CVD has shown a decreasing trend in HD and PD patients, while RR of pneumonia increased significantly, both in PD and in HD. Temporal trends of IE in HD, and particularly of sepsis in PD were upwards across the last decades.

Infective Endocarditis Hospitalizations and Outcomes in Patients With End-Stage Kidney Disease: A Nationwide Data-Linkage Study

Background We investigated the clinical features, microbiology, and short- and long-term outcomes of incident infective endocarditis (IE) hospitalizations in patients with end-stage kidney disease (ESKD) requiring dialysis or with a kidney transplant over 25 years in Scotland. Methods and Results In this retrospective, population-based cohort study linking national hospitalization and mortality data, we identified patients with a history of ESKD and hospitalized with IE in Scotland between January 1, 1990 and December 31, 2014. From January 1, 2008, individual IE hospitalizations were additionally linked to national microbiology data. Multivariable logistic regression, adjusting for patient demographics and comorbidities, evaluated the association between ESKD and all-cause death at 1 and 3 years. Of 7638 incident IE hospitalizations between 1990 and 2014, 2.8% (216/7638) occurred in 210 patients with ESKD and 97.2% (7422/7638) occurred in 7303 patients without ESKD. Positive findings from blood cultures were identified in 42% (950/2267) of incident IE hospitalizations from 2008. Staphylococcus aureus was isolated in 25.9% (21/81) and 12.8% (280/2186) of patients with and without ESKD, respectively (P=0.002). ESKD was associated with an increased odds of death at 1 (44.9% versus 31.4%; adjusted odds ratio [aOR], 2.47, 95% CI, 1.85-3.30;, P<0.001) and 3 years (63.9% versus 42.8%; aOR, 3.77; 95% CI, 2.79-5.12; P<0.001). Conclusions IE is associated with a poor prognosis in patients with ESKD, especially in the longer term. Compared with patients without ESKD, patients with ESKD were twice as likely to die within 1 year, and 3 times as likely to die within 3 years of IE hospitalization.

Short- and long-term outcomes of infective endocarditis admission in adults: A population-based registry study in Finland

Infective endocarditis (IE) is associated with high mortality. However, data on factors associated with length of stay (LOS) in hospital due to IE are scarce. In addition, long-term mortality of more than 1 year is inadequately known. In this large population-based study we investigated age and sex differences, temporal trends, and factors affecting the LOS in patients with IE and in-hospital, 1-year, 5-year and 10-year mortality of IE. Data on patients (≥18 years of age) admitted to hospital due to IE in Finland during 2005-2014 were collected retrospectively from nationwide obligatory registries. We included 2166 patients in our study. Of the patients 67.8% were men. Women were older than men (mean age 63.3 vs. 59.5, p<0.001). The median LOS was 20.0 days in men and 18.0 in women, p = 0.015. In the youngest patients (18-39 years) the median LOS was significantly longer than in the oldest patients (≥80 years) (24.0 vs. 16.0 days, p = 0.014). In-hospital mortality was 10% with no difference between men and women. Mortality was 22.7% at 1 year whereas 5- and 10-year mortality was 37.5% and 48.5%, respectively. The 5-year and 10-year mortality was higher in women (HR 1.18, p = 0.034; HR 1.18, p = 0.021). Both in-hospital and long-term mortality increased significantly with aging and comorbidity burden. Both mortality and LOS remained stable over the study period. In conclusion, men had longer hospital stays due to IE compared to women. The 5- and 10-year mortality was higher in women. The mortality of IE or LOS did not change over time.

Comparison of clinical characteristics and outcomes of infective endocarditis between haemodialysis and non-haemodialysis patients in China

Objective

To clarify differences in clinical characteristics and outcomes between patients with infective endocarditis (IE) receiving long-term haemodialysis (HD group) and those not receiving haemodialysis (non-HD group).

Methods

Medical records of patients with IE, admitted to hospital between January 2010 and December 2017, were retrospectively studied. Clinical characteristics and outcomes were compared between HD and non-HD groups. Risk factors for IE were assessed by COX regression.

Results

Twenty-one HD and 143 non-HD patients were included. Predisposing heart conditions were more frequently observed in the non-HD versus HD group (90.9% versus 19.0%). Inappropriate antibiotic therapy rate before admission and proportion of methicillin-resistant Staphylococcus aureus and Enterococcus-associated IE was higher in the HD versus non-HD group. In the HD group, fewer patients underwent heart surgery (9.5% versus 51.7%), all-cause in-hospital mortality was higher (52.4% versus 21%), and survival rate was lower versus the non-HD group. COX regression analysis revealed that haemodialysis, use of central venous catheter (CVC) and inappropriate antibiotic therapy before admission increased IE mortality, while surgery improved long-term prognosis.

Conclusions

Haemodialysis patients with IE may have higher mortality and lower survival rates than patients with IE not receiving haemodialysis. Haemodialysis, use of CVC and inappropriate antibiotic therapy before admission may increase IE mortality. Surgery may improve long-term prognosis.

Infective Endocarditis in Patients on Chronic Hemodialysis

BACKGROUND

Infective endocarditis (IE) is a common and serious complication in patients receiving chronic hemodialysis (HD).

OBJECTIVES

This study sought to investigate whether there are significant differences in complications, cardiac surgery, relapses, and mortality between IE cases in HD and non-HD patients.

METHODS

Prospective cohort study (International Collaboration on Endocarditis databases, encompassing 7,715 IE episodes from 2000 to 2006 and from 2008 to 2012). Descriptive analysis of baseline characteristics, epidemiological and etiological features, complications and outcomes, and their comparison between HD and non-HD patients was performed. Risk factors for major embolic events, cardiac surgery, relapses, and in-hospital and 6-month mortality were investigated in HD-patients using multivariable logistic regression.

RESULTS

A total of 6,691 patients were included and 553 (8.3%) received HD. North America had a higher HD-IE proportion than the other regions. The predominant microorganism was Staphylococcus aureus (47.8%), followed by enterococci (15.4%). Both in-hospital and 6-month mortality were significantly higher in HD versus non-HD-IE patients (30.4% vs. 17% and 39.8% vs. 20.7%, respectively; p < 0.001). Cardiac surgery was less frequently performed among HD patients (30.6% vs. 46.2%; p < 0.001), whereas relapses were higher (9.4% vs. 2.7%; p < 0.001). Risk factors for 6-month mortality included Charlson score (hazard ratio [HR]: 1.26; 95% confidence interval [CI]: 1.11 to 1.44; p = 0.001), CNS emboli and other emboli (HR: 3.11; 95% CI: 1.84 to 5.27; p < 0.001; and HR: 1.73; 95% CI: 1.02 to 2.93; p = 0.04, respectively), persistent bacteremia (HR: 1.79; 95% CI: 1.11 to 2.88; p = 0.02), and acute onset heart failure (HR: 2.37; 95% CI: 1.49 to 3.78; p < 0.001).

CONCLUSIONS

HD-IE is a health care-associated infection chiefly caused by S. aureus, with increasing rates of enterococcal IE. Mortality and relapses are very high and significantly larger than in non-HD-IE patients, whereas cardiac surgery is less frequently performed.

In-Hospital and Long-Term Outcomes of Infective Endocarditis in Chronic Dialysis Patients

Purpose

To elucidate the in-hospital and long-term outcomes of infective endocarditis (IE) in end-stage kidney disease (ESKD) patients on chronic dialysis and to analyze the risk factors of mortality.

Patients and Methods

The case files of 1,817 patients who were hospitalized for IE over a 14-year period were retrospectively reviewed. Of these, 116 ESKD patients on chronic dialysis were enrolled in this study. Cox’s proportional hazard model was used to evaluate the risk factors of mortality and long-term outcomes.

Results

The in-hospital mortality rate of the 116 enrolled patients was as high as 43.1%. Patients who survived the index admission had a three-year mortality rate of 33%. Univariate analysis was used to compare survivors and non-survivors; poor in-hospital outcomes were associated with the use of a tunneled cuffed catheter for dialysis access, a shorter duration hospitalization, shock or respiratory failure during hospitalization, a higher white blood count, a higher percentage of polymorphonuclear leukocytes, a higher C-reactive protein level, a lower serum albumin level, and a higher total bilirubin level. Following multivariate adjustment, shock (odds ratio, 9.29, with a 95% confidence interval [CI] of 2.78 to 34.24; p<0.001) or respiratory failure (odds ratio, 25.16, with a 95% CI of 5.63 to 153.54; p<0.001) during hospitalization was strongly associated with increased in-hospital mortality. Patients who underwent cardiac operations (odds ratio, 0.22, with a 95% CI of 0.052 to 0.86; p=0.031) had better in-hospital outcomes. Heart failure reduced ejection fraction (HFrEF) at the time of initial hospitalization was an independent risk factor for 3-year mortality (hazard ratio, 3.48, with a 95% CI of 1.09 to 11.09; p=0.035).

Conclusion

The outcomes of IE for ESKD patients on chronic dialysis were poor. Only 56.9% of these patients survived the index admission and their mortality rate over three years was 33%. Shock or respiratory failure during hospitalization was associated with increased in-hospital mortality. Patients who underwent cardiac operations had better in-hospital outcomes. HFrEF at the time of initial hospitalization was an independent risk factor for three-year mortality.

Recent trends in hospital admissions and outcomes of cardiac Chagas disease in the United States

Background:

Chagas disease (CD), caused by Trypanosoma cruzi, has been increasingly encountered as a cause of cardiovascular disease in the United States. We aimed to examine trends of hospital admissions and cardiovascular outcomes of cardiac CD (CCD).

Methods:

Search of 2003-2011 Nationwide Inpatient Sample database identified 949 (age 57±16 years, 51% male, 72.5% Hispanic) admissions for CCD.

Results:

A significant increase in the number of admissions for CCD was noted during the study period (OR=1.054; 95% CI=1.028-1.081; P< 0.0001); 72% were admitted to Southern and Western hospitals. Comorbidities included hypertension (40%), coronary artery disease (28%), hyperlipidemia (26%), tobacco use (12%), diabetes (9%), heart failure (5%) and obesity (2.2%). Cardiac abnormalities noted during hospitalization included atrial fibrillation (27%), ventricular tachycardia (23%), sinoatrial node dysfunction (5%), complete heart block (4%), valvular heart disease (6%)] and left ventricular aneurysms (5%). In-hospital mortality was 3.2%. Other major adverse events included cardiogenic shock in 54 (5.7%), cardiac arrest in 30 (3.2%), acute heart failure in 88 (9.3%), use of mechanical circulatory support in 29 (3.1%), and acute stroke in 34 (3.5%). Overall, 63% suffered at least one adverse event. Temporary (2%) and permanent (3.5%) pacemakers, implantable cardioverter defibrillators (10%), and cardiac transplant (2.1%) were needed for in-hospital management.

Conclusions:

Despite the remaining concerns about lack of awareness of CCD in the US, an increasing number of hospital admissions were reported from 2003-2011. Serious cardiovascular abnormalities were highly prevalent in these patients and were frequently associated with fatal and nonfatal complications.

Infective endocarditis in hemodialysis patients: A 10-year observational single center study

BACKGROUND

The incidence of infective endocarditis (IE) in chronic hemodialysis (CHD) patients remains high, despite the preventive measures implemented by nephrologists, especially the rigorous respect of hygiene, the use of antibiotic locks for catheters and the use of tunneled catheters instead of non-tunneled.

OBJECTIVE

The objective of this study was to determine the clinical, biological, and echocardiographic characteristics, and the prognosis of IE in CHD.

PATIENTS AND METHODS

It was a retrospective study, conducted from December 2010 to March 2020, at the Nephrology and Cardiology units of University Hospital in Oujda, Morocco.

RESULTS

We compiled a series of 31 CHD patients having developed IE. Eleven cases (35.4%) were collected between 2010 and 2015, and 20 cases (64.6%) between 2016 and 2020. The mean age was 47 ± 19 years, 58% were male, and 25.8% of patients had diabetes. Vascular access for hemodialysis was by arteriovenous fistula, non-tunneled catheter, and tunneled catheter in 22.5%, 32.2%, and 45.2%, of the cases, respectively. About 25.8% of patients had benefited from more than two catheters (tunneled or non-tunneled) during the 3 months preceding the occurrence of IE. The mitral, tricuspid, and aortic valves were the site of IE in 41.9%, 41.9%, and 13% of the cases, respectively. Right heart IE and left heart IE were observed in 42% (13 cases) and 58% (18 cases) of cases, respectively. Blood cultures were negative in 58.1% of the cases at the time of diagnosis of IE. Staphylococcus aureus was identified in 69.2% of the cases. Mortality occurred in 54.8% of the cases.

CONCLUSION

IE remains a severe condition in CHD patients with an increasing incidence. Rigorous prevention and screening strategies should be implemented at the hemodialysis centers.

Cardiac transplantation for hypertrophic cardiomyopathy in the United States 2003-2011

Background:

Cardiac transplant (CT) is the sole option in a minority of hypertrophic cardiomyopathy (HC) adults with refractory symptoms or end-stage disease.

Aims/Methods:

We aimed to examine the trends and hospital outcomes of CT in HC using 2003-2011 Nationwide Inpatient Sample database.

Results:

HC comprised 1.1% of CT (151 of 14,277) performed during this time period (age 45±12 years, 67% male, 79% Caucasians). Number of HC CT increased from 2003 to 2011 (odds ratio=1.174; 95% confidence interval=1.102-1.252; P< 0.001). Comorbidities included congestive heart failure (76%), hypertension (23%), chronic kidney disease (23%), hyperlipidemia (19%), diabetes (13%), and coronary artery disease (10%). Acute in-hospital major adverse events occurred in 1 in 4 (23%) patient and 1 in 25 (3.8%) patients died perioperatively. Other major adverse events included allograft rejection or vasculopathy (23%), postoperative stroke or transient ischemic attack (3.5%), acute renal failure (43%), respiratory failure requiring mechanical ventilation (13%), sepsis (10%) or need for blood transfusion (10%). Compared to 1990-2004 United Network of Organ Sharing registry data (n=303), patients in current cohort had more comorbid conditions [diabetes (13%-vs-0%); chronic obstructive lung disease (9%-vs-1%); P < 0.001 for both), were more likely to be male (66%-vs-48% P< 0.001), were less likely to be Caucasian (79%-vs-86%; P < 0.001) or smokers (3%-vs-17%; P < 0.001) and less often required perioperative circulatory support or hemodialysis (17%-vs-49%, P < 0.001 and 3.2%-vs-8.3%, P = 0.04, respectively).

Conclusion:

HC comprises a small proportion of patients undergoing CT. The annual number of CT in HC has increased in recent years at least in part due to inclusion of patients with more comorbid conditions. Transplant recipients in the current cohort, however, required less postoperative circulatory support or renal replacement therapy.

Impact of Chronic Renal Failure on Surgical Outcomes in Patients With Infective Endocarditis

BACKGROUND

Patients with chronic renal failure (CRF) who are undergoing hemodialysis are at increased risk for infective endocarditis (IE). However, outcomes of surgical treatment for IE in these patients have not been well studied.

METHODS

Between 1997 and 2017, 539 patients underwent surgical treatment for IE. Of these patients, 125 were undergoing hemodialysis for end-stage renal disease (ESRD), and 414 had no history of CRF. Primary end points compared in this study were short-term survival and long-term survival.

RESULTS

Preoperatively, dialysis-treated patients had higher incidences of diabetes (43% vs 18%), hypertension (79% vs 49%), congestive heart failure (63% vs 48%), cardiogenic shock (13% vs 5.3), and sepsis (29% vs 18%) (all P < .05). Postoperatively, they experienced higher rates of prolonged mechanical ventilation (54% vs 22%), pneumonia (17% vs 5.6%), sepsis (6.4% vs 1.0%), cardiac arrest (7.2% vs 1.7%), gastrointestinal events (14% vs 5.1%), and operative mortality (14% vs 5.8%) (all P < .05). The 5- and 10-year survival rates were significantly worse in the dialysis-treated group at 29% and 16%, respectively, compared with 72% and 53% in the patients who did not have CRF (P < .001). ESRD was a risk factor for both short-term mortality (odds ratio, 2.0) and long-term mortality (hazard ratio, 2.7). Rates of reoperation in dialysis-treated patients were very low: 5- and 10-year incidences were 0% and 2.0%, respectively.

CONCLUSIONS

In patients with ESRD and IE, poor postoperative outcomes emphasized the importance of prevention and raised the question whether indications for surgical treatment in the general population are appropriate for patients who are dialysis dependent. Additionally, low rates of reoperation supported the use of bioprosthetic valves in these patients.

Infective Endocarditis and Its Short and Long-Term Prognosis in Hemodialysis Patients: A Systematic Review and Meta-analysis

There are some conclusive evidences on infective endocarditis and its poor prognosis in the background of end-stage renal disease in patients undergoing chronic hemodialysis; however the findings on the risk of infective endocarditis and its long-term prognosis are very diverse, requiring a systematic approach to achieve a global statistic. Our study tried to systematically assess the risk profile as well as short- and long-term prognosis of infective endocarditis among hemodialysis patients. To select our pointed studies, a deeply searching was planned among major articles databases including MEDLINE, Web of Science, SCOPUS, Google Scholar, and Cochrane Central Register of Controlled Trials considering the study keywords. Two high-qualified investigators independently assessed the collected papers. The risk of bias for the studies was also assessed according to the Cochrane's guideline and using the QUADAS-2 tool. In final, 18 articles were eligible for the final analysis. The overall prevalence of infective endocarditis among patients under chronic hemodialysis was estimated to be 2.9% (95% confidence interval [CI]: 2.7%-3.1%). Our assessment revealed an overall in-hospital death rate of 29.5% (95% CI: 26.7%-46.6%) and long-term death rate of 45.6% (95% CI: 41.9%-49.3%) in hemodialysis patients suffering infective endocarditis. Poor prognosis with high early and long-term death rates due to infective endocarditis has expected in the background of chronic hemodialysis emphasizing the necessity for its early management by identifying patients which prone to disease along with continuous cardiac monitoring.

Microbiological features, clinical characteristics and outcomes of infective endocarditis in adults with and without hemodialysis: A 10-year retrospective study in Northern Taiwan

BACKGROUND/PURPOSES

Infective endocarditis (IE) is an important cause of morbidity and mortality in hemodialysis (HD) patients. Data on the differences in the microbiological features as well as clinical characteristics and outcomes of HD and non-HD patients with IE are limited.

METHODS

Medical records of patients (aged over 20 years) with IE were retrospectively reviewed from January 2008 to June 2017 in a tertiary care center in Northern Taiwan. Those with definite or possible IE were included in the study. The clinical characteristics, microbiological results, echocardiographic findings and outcomes of patients were analyzed.

RESULTS

Of the 183 patients with definite or possible IE, 47 had undergone HD and 136 had not. Advanced age (67.3 vs. 61.5 years, p = 0.027), more female gender (51.1% vs. 33.8%, p = 0.036), comorbidities (a high Charlson comorbidity index, 8.17 vs. 4.21, p < 0.001), diabetes mellitus (68.1% vs. 35.3%, p < 0.001), and hypertension (85.1% vs. 53.7%, p < 0.001) were commonly observed in HD patients than in non-HD patients. The yield rate of the blood cultures was higher in HD group than in non-HD group (89.4% vs. 72.8%, p = 0.02). The proportion of methicillin-resistant Staphylococcus aureus was significantly higher in HD group than in non-HD group (31.9% vs. 5.9%, p < 0.001). HD patients versus non-HD patients had higher cardiac complication rates (38.3% vs. 14%, p < 0.001).

CONCLUSION

Advanced age, sex (female), comorbidities, diabetes mellitus, and hypertension were more common in HD patients than in non-HD patients with IE. HD patients had higher proportion of methicillin-resistant S. aureus and cardiac complication rates than non-HD patients with IE. Culture-negative IE was more common in non-HD patients.

Chronic dialysis patients with infectious spondylodiscitis have poorer outcomes than non-dialysis populations

Purpose

Infectious spondylodiscitis is a serious disease that can lead to permanent neurological deficit. Because there were only a few case reports or series featuring infectious spondylodiscitis in chronic dialysis patients, we investigated the epidemiology and outcome in the chronic dialysis patients versus general population.

Materials and methods

We retrospectively identified chronic dialysis patients admitted for infectious spondylodiscitis between January 2002 and December 2015. A total of 105 chronic dialysis patients were included, and we performed a 1:2 case-control match on propensity score in non-dialysis patients with infectious spondylodiscitis. The demographic features, clinical manifestation, infection focus, and disease outcome were recorded.

Results

A total of 302 patients entered the final analysis. Chronic dialysis patients less frequently had fever (34.3%), and in the majority, bacterial entry was through dialysis vascular access (30.5%). Methicillin-resistant Staphylococcus aureus (MRSA) comprised the majority of causative pathogen. The chronic dialysis group had longer hospital stay, higher in-hospital mortality, and higher 1-year mortality. The odds ratio of in-hospital mortality was 2.20 compared with the non-dialysis group.

Conclusions

The study highlighted poorer outcome and high frequency of resistant Staphylococcus of infectious spondylodiscitis in chronic dialysis patients. Therefore, high vigilance, prompt recognition, and empiric coverage of MRSA will be important in the management of infectious spondylodiscitis in chronic dialysis patients.

In-Hospital Outcomes of Transcatheter Aortic Valve Implantation in Patients With End-Stage Renal Disease on Dialysis from a Large National Database

The outcomes of patients with end-stage renal disease on dialysis (chronic kidney disease stage 5 on dialysis [CKD 5D]) who undergo transcatheter aortic valve implantation (TAVI) are not well described due to the exclusion of this group in randomized trials. We analyzed the National Inpatient Sample database and compared clinical characteristics and in-hospital outcomes for patients with CKD 5D versus those without CKD 5D (nondialysis group) who underwent TAVI in 2011 to 2014 in the United States. The study population included 1,708 patients (4%) with CKD 5D and 40,481 patients (96%) without CKD 5D who underwent TAVI. Patients with CKD 5D were younger (75.3 ± 9.9 vs 81.4 ± 8.4 years, p <0.001), more likely to be men (62.8% vs 52%, p <0.001), and less likely to be Caucasian (73.6% vs 87.8%, p <0.001). Patients with CKD 5D were more likely to have congestive heart failure (16% vs 11.7%, p <0.001), diabetes with chronic complications (19% vs 5.4%, p <0.001), hypertension (86.5% vs 79.3%, p <0.001), and peripheral vascular disease (34.5% vs 29.4%, p <0.001), but were less likely to have atrial fibrillation (38.6% vs 44.8%, p <0.001) and chronic pulmonary disease (27.5% vs 33.6%, p <0.001). In-hospital mortality was significantly higher in the dialysis group (8.2% vs 4%; adjusted odds ratio 2.21, 95% confidence interval1.81 to 2.69, p <0.001) after adjusting for age, gender, co-morbidities, and hospital characteristics in a robust multivariate regression model. In conclusion, patients with CKD 5D who undergo TAVI have a higher in-hospital mortality than those without CKD 5D.

Carbapenem-Resistant Enterobacteriaceae Infections in Patients on Renal Replacement Therapy

BACKGROUND

Patients on chronic intermittent renal replacement therapy (RRT) are at risk for infection with carbapenem-resistant Enterobacteriaceae (CRE). However, the impact of RRT on outcomes after CRE infections remains to be defined. Here we perform a comparison of outcomes for CRE-infected patients with preserved renal function compared with CRE-infected patients on RRT.

METHODS

Cases and controls were defined from a prospective cohort of CRE-infected patients from the Consortium on Resistance against Carbapenems in Klebsiella and other Enterobacteriaceae (CRACKLE). Cases were defined as CRE-infected patients on RRT at hospital admission, while controls were defined as CRE-infected patients with serum creatinine <2 mg/dL and not receiving RRT at admission. Risk factors for 28-day in-hospital mortality were assessed using multivariable logistic regression. An ordinal ranking of outcomes by desirability analysis was performed.

RESULTS

Patients on RRT were more likely to have diabetes mellitus and cardiac disease than controls. Urinary sources of infection were less common in the RRT group. In RRT patients, 28-day in-hospital mortality was increased as compared with controls: 22/71 (31%) vs 33/295 (11%). RRT remained significantly associated with 28-day in-hospital mortality after adjustment for source of infection, prehospitalization origin, and severity of illness (adjusted odds ratio, 2.27; 95% confidence interval [CI], 1.09-4.68; P = .03). Using univariable desirability of outcome ranking analysis, RRT status was associated with a 68% (95% CI, 61%-74%) chance of a worse disposition outcome.

CONCLUSIONS

Chronic RRT in CRE-infected patients is associated with increased in-hospital mortality and worse disposition outcomes at 28 days.

Trends and outcomes of infective endocarditis in patients on dialysis

Dialysis patients are at high risk for infective endocarditis (IE); however, no large contemporary data exist on this issue. We examined outcomes of 44 816 patients with IE on dialysis and 202 547 patients with IE not on dialysis from the Nationwide Inpatient Sample database from 2006 thorough 2011. Dialysis patients were younger (59 ± 15 years vs 62 ± 18 years) and more likely to be female (47% vs 40%) and African-American (47% vs 40%; all P < 0.001). Hospitalizations for IE in the dialysis group increased from 175 to 222 per 10 000 patients (P _trend  = 0.04). Staphylococcus aureus was the most common microorganism isolated in both dialysis (61%) and nondialysis (45%) groups. IE due to S aureus (adjusted odds ratio [aOR]: 1.79, 95% confidence interval [CI]: 1.73-1.84), non-aureus staphylococcus (aOR: 1.72, 95% CI: 1.64-1.80), and fungi (aOR: 1.4, 95% CI: 1.12-1.78) were more likely in the dialysis group, whereas infection due to gram-negative bacteria (aOR: 0.85, 95% CI: 0.81-0.89), streptococci (aOR: 0.38, 95% CI: 0.36-0.39), and enterococci (aOR: 0.78, 95% CI: 0.74-0.82) were less likely (all P < 0.001). Dialysis patients had higher in-hospital mortality (aOR: 2.13, 95% CI: 2.04-2.21), lower likelihood of valve-replacement surgery (aOR: 0.82, 95% CI: 0.76-0.86), and higher incidence of stroke (aOR: 1.08, 95% CI: 1.03-1.12; all P < 0.001). We demonstrate rising incidence of IE-related hospitalizations in dialysis patients, highlight significant differences in baseline comorbidities and microbiology of IE compared with the general population, and validate the association of long-term dialysis with worse in-hospital outcomes.