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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2016  |  Volume : 27  |  Issue : 6  |  Page : 1200-1206
Infective endocarditis in chronic hemodialysis: A transition from left heart to right heart


1 Department of Nephrology, Medical School, University Mohammed the First, Oujda, Morocco
2 Department of Cardiology, Medical School, University Mohammed the First, Oujda, Morocco
3 Department of Vascular Surgery, Medical School, University Mohammed the First, Oujda, Morocco
4 Department of Anesthesia, Medical School, University Mohammed the First, Oujda, Morocco

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Date of Web Publication28-Nov-2016
 

   Abstract 

Infective endocarditis (IE) of the left heart is the most frequent type of IE in chronic hemodialysis (CHD) (in 90% of cases) whereas involvement of the right heart is rare. The aim of this study was to determine the clinical, biological, and echocardiographic characteristics, as well as the prognosis of IE in CHD. This is a retrospective study conducted at the Center of Nephrology and Hemodialysis in Oujda, Morocco. Over a period of 56 months, we compiled data on a series of 11 CHD patients with IE. Their mean age was 40.5 ± 14 years, 72% were male and 27.3% had diabetes. All patients had native valve. All patients had bacteremia preceding the episode of IE. The tricuspid valve was the site of IE in 45% of the cases. Cardiac complications were observed in 72% of the patients and mortality was observed in 72% of cases. The period from IE diagnosis to death was 9 ± 6 days. In our study, the tricuspid valve was the most affected valve of IE in CHD.

How to cite this article:
Bentata Y, Haddiya I, Ismailli N, El Ouafi N, Benzirar A, El Mahi O, Azzouzi A. Infective endocarditis in chronic hemodialysis: A transition from left heart to right heart. Saudi J Kidney Dis Transpl 2016;27:1200-6

How to cite this URL:
Bentata Y, Haddiya I, Ismailli N, El Ouafi N, Benzirar A, El Mahi O, Azzouzi A. Infective endocarditis in chronic hemodialysis: A transition from left heart to right heart. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2020 Aug 13];27:1200-6. Available from: http://www.sjkdt.org/text.asp?2016/27/6/1200/194612

   Introduction Top


Cardiovascular disease and infections comprise the two main causes of mortality in chronic hemodialysis (CHD). [1],[2],[3],[4] In this context, infective endocarditis (IE) is a frequent and dangerous complication. The incidence of IE is estimated to be more than 300 cases per 100,000 people in CHD, compared to three to nine cases per 100,000 in the general population. [5],[6] IE of the left heart is the most frequent type in the general population and is usually found in more than 90% of cases, whereas involvement of the right heart is rare. [2],[3] The aim of this study was to determine the clinical, biological, and echocardiographic characteristics, complications, treatment, and prognosis of IE in CHD.


   Patients and Methods Top


This is a retrospective study covering the fiveyear period from December 1, 2010, to December 30, 2015, which was conducted at the Nephrology and Dialysis Unit of Al Farabi Regional Hospital and University Hospital in Oujda, Morocco. All CHD patients with a minimum dialysis duration of one month and in whom the diagnosis of IE was based on the Duke criteria were included in the study. [7] All statistical calculations were performed using Statistical Package for the Social Sciences software version 21.0. Quantitative variables were expressed as mean ± standard deviation or as medians and interquartile range, depending on their distribution.


   Results Top


Over a period of 56 months, we compiled a series of eleven CHD patients having developed IE. In this period, 187 patients were on conventional CHD. Thus, the prevalence of IE was 5.8%. Their mean age was 40.5 ± 14 years, 72.7% were male, 81.8% had a low socioeconomic level, 54.5% lived in rural areas, and 27.3% of patients had diabetes. Nearly 36.4% of the patients were smokers. No patients used injectable drugs. One patient was viral hepatitis B and C positive (case no. 2). No patient was human immunodeficiency virus positive. One patient was under tuberculosis treatment for pulmonary tuberculosis (case no. 11). All patients had native valves. Vascular access for hemodialysis was arteriovenous fistula, tunneled catheter, and nontunneled catheter in 27.3%, 27.3%, and 45.5% of the cases, respectively. All patients had fever (>38.5°C) and bacteremia preceding the episode of IE, of whom 54.5% had hypotension (systolic blood pressure <80 mm Hg). All the patients had anemia (hemoglobin <8 g/L) and high C-reactive protein and sedimentation rates. Blood cultures were negative in 63.6% of the cases. The tricuspid, mitral, and aortic valves were the site of IE in 45.5%, 36.4%, and 18.2% of the cases, respectively. All patients received medical treatment based on vancomycin, amikacin, and ceftazidime. No patient received surgical treatment because we didn't have the required means to afford it.

Cardiac, pulmonary, and cerebrovascular complications were observed in 72.7%, 72.7%, and 27.3% of the cases, respectively [Table 1]. One patient had aortic dissection (case 10). Mortality occurred in 72.7% of the cases. The median interval from IE diagnosis to death was 6.5 (4-17) days. [Table 1] reports the demographic, clinical, biological, and echocardiographic characteristics of the nine CHD patients having developed IE.
Table 1: Demographic, clinical, biological, and echocardiographic characteristics upon admission and evolution data of chronic hemodialysis patients presenting an infective endocarditis (n = 11).

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   Discussion Top


IE of the right heart accounts for 5-10% of IE cases in the general population and 90% of IE in patients who are injection drug users. IE in patients with intravascular catheters (CHD, intensive care, oncology, etc.), prosthetic valves, and pacemakers and/or other intracardiac devices only accounts for <10% of all right-sided IE. [8],[9],[10] In more than 90% of the cases, the tricuspid valve is involved.

IE has been recognized as a complication of hemodialysis since 1966. [11] Since then, several studies have been published of relatively a small series of patients.

In CHD, IE of the right heart remains rare and its frequency varies from 0% to 26% depending on the study. [12],[13],[14],[15],[16],[17],[18] The tricuspid valve is the main location, while involvement of the pulmonary valve is exceptional. On the other hand, involvement of the mitral valve in CHD is found in 40- 56% of the cases, the aortic valve in 21-43% of the cases, and concomitant involvement of the mitral and aortic valves is found in 10-20% of the cases. [12],[13],[14],[15],[16],[17],[18]

Thus, and contrary to what might be expected, the most frequent site of IE in the CHD patients is in the left heart and not the right heart, despite the fact that these patients may have central venous catheters.

The pathophysiology of IE in CHD is complex and not completely understood. It is based mainly on the cardiac valvular and perivalvular abnormalities classically found at an early stage of chronic renal failure (CRF). [19],[20],[21],[22] Mitral and aortic valves are the sites of early and significant changes in the course of CRF. These changes are related to alterations of calcium/ phosphorous metabolism typically found in CRF and are manifested by valvular and perivalvular calcifications. All conditions that increase stress on the mitral and aortic valves and perivalvular structures would be expected to accelerate these abnormalities. Systemic hypertension, aortic stenosis, and hypertrophic obstructive cardiomyopathy remain the most frequent situations that are associated with an increased left ventricular pressure. [23],[24] These abnormalities are more pronounced when the duration of CRF and dialysis is long. [25] Immunodepression of the CHD patients and repeated manipulation of the vascular access also play an important role in the development of IE. [26]

In contrast, the tricuspid and pulmonary valves do not undergo change during CRF because they are in a low-pressure cardiac system. Bacterial overgrowth during IE thus occurs more easily on the cardiac valves previously damaged, explaining the high prevalence of involvement of left-sided valves and the rarity of right-sided valvular involvement during IE in CHD.

The Duke criteria for the diagnosis of IE do not distinguish between left-sided and rightsided endocarditis and do not take account of the particularities of the environment in which IE develops. While fever and heart murmur predominate in IE of the left heart, fever and lung impairment are the main signs of IE of the right heart. These nonspecific signs explain the great delay in diagnosis.

In our series, the prevalence of IE in CHD was 5.8% and the reported prevalence of IE in CHD by various series ranges from 2.7 to 6%. [27],[28]

IE was right-sided in more than 50% of cases, whereas its frequency does not exceed 20% in published series. [13],[14],[15] In some series, no rightsided involvement was found. [12],[16],[29],[30] Our patients were relatively young and 60% of them had CHD duration of <3 months. These demographic data agree with epidemiological data provided by national studies in our country. [31] The mean age in the other series was higher, in general approaching 60 years. [14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29]

Why was the frequency of right-sided IE so high in our series? Our patients had undergone several catheter insertions and had developed septicemias following a catheter-related infection. These episodes of septicemia were difficult to control with conventional antibiotic therapy due to the difficulty of identifying the causative organism prior to therapy and the virulence of these germs. This explains the frequency of IE during these episodes of septicemia. However, the predominant involvement of the tricuspid valve is not yet completely understood in this context. Might the reason for this finding be related to the location of this valve? It is the first valvular line of contact with the blood flow arriving from the vena cava and massively enriched with bacterial particles.

Might the tricuspid valve be modified in certain CHD patients and not in others, and what could be the causes of such modification? Is it possible that the massive influx of pathogenic germs through the central veins to the right heart, situated as the first line of contact with the left heart, might play a role in the physiopathology of IE in CHD?

In other series, IE occurred in patients with native arteriovenous fistula in 6%-75% of cases. [13],[14],[15],[16],[17],[18],[30],[32] The clinical and echocardiographic features of IE in chronic HD reported by recent studies are shown in [Table 2].
Table 2: Characteristics of IE in chronic hemodialysis patients according to different studies.

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Moreover, the antibiotic therapy previously received for the septicemia episodes makes it difficult to identify the organism causing IE, which explains the negative blood cultures found in 63.6% of cases in our series.

The mortality rate in CHD related to IE is 13%-61% depending on the series, all cardiac sites included. [12],[13],[14],[15],[16],[17],[18],[30],[32] The first 30-60 days after the diagnosis of IE are associated with the highest mortality in patients receiving dialysis with IE. Therefore, this period requires strict monitoring, during which time repeated echocardiography, adjustment of medications, surgery if needed, and removal of infected catheter may be most beneficial in reducing mortality. In our study, mortality was observed in 72.7% of cases and all mortalities occurred during the first 30 days after the diagnosis of IE.

The vulnerabilities of the patients and diagnostic delays as shown by the size of vegetations revealed by echocardiography explain to a great extent the high mortality in our series. Strict respect of aseptic procedures during any manipulation of the vascular access and early detection of any infection of the vascular access continue to offer the only sure approaches to reduce the incidence of IE in CHD. However, prevention is often difficult to achieve in a developing country where human and material resources remain inadequate.

Conflict of interest: None declared.

 
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Correspondence Address:
Y Bentata
Department of Nephrology, Medical School, University Mohammed the First, Oujda
Morocco
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DOI: 10.4103/1319-2442.194612

PMID: 27900966

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