Infective endocarditis in patients receiving long-term hemodialysis

Mayo Clin Proc. 2000 Oct;75(10):1008-14. doi: 10.4065/75.10.1008.


Objective: To ascertain the predominant characteristics of patients receiving long-term dialysis who develop infective endocarditis (IE).

Patients and methods: We reviewed the records of all chronic hemodialysis patients who had IE at Mayo Clinic, Rochester, Minn, between 1983 and 1997.

Results: Twenty episodes of IE occurred in 17 patients. One patient had 3 episodes of IE, and 1 patient had 2 episodes of IE; each episode was caused by a different organism. The mean +/- SD age of our patients was 63 +/- 11 years; there were 13 males; 6 patients had diabetes mellitus; and the mean +/- SD duration of hemodialysis prior to IE was 24.2 +/- 20.5 months. This analysis included 10 episodes of IE (occurring in 9 patients) within the Mayo Clinic Dialysis System during which time 223,358 hemodialysis treatments were delivered, giving a rate of 10 IE episode per 223,336 hemodialysis treatments. Among all 20 IE episodes, there were 14 synthetic arteriovenous grafts, 4 permanent venous dialysis catheters, 2 temporary venous dialysis catheters, and 2 native arteriovenous fistulas (2 accesses in 2 patients), and access had been in place for a mean +/- SD of 15.9 +/- 18.6 months. The portal of infection was the hemodialysis access in 13 episodes of IE. The causative organisms for IE were Staphylococcus aureus in 8 cases, Enterococcus sp in 4 cases, viridans streptococcus in 3 cases, Staphylococcus epidermidis in 2 cases, and 1 case each of Streptococcus bovis, group G beta-hemolytic streptococcus, and Aspergillus sp. The mitral valve was involved in 9 cases, the aortic valve was involved in 5 cases, and the tricuspid and pulmonic valves were involved in 1 case each. Patient survival (after the first episode of IE) was 71% at 30 days; 53% at 60 days; and 35% at 1 year. Echocardiography was performed in 19 episodes of IE. The transthoracic echocardiogram was 62.5% sensitive and 40% specific for the presence of definite or probable vegetations. Univariate analysis for factors affecting 60-day survival show that presence of right-sided IE, vegetation size greater than 2.0 cm3, diagnosis of diabetes mellitus, and initial leukocyte count greater than 12.5 x 10(9)/L were poor prognostic factors. Aortic valve involvement carried a better prognosis.

Conclusions: Infective endocarditis in hemodialysis patients is relatively infrequent but has a high mortality. Patients with synthetic intravascular dialysis angioaccess (synthetic grafts and venous catheters) are more likely to develop IE than patients with native arteriovenous fistulas. Transesophageal echocardiography is a preferred echocardiographic study for suspected cases of IE. Prolonged antibiotic therapy is needed for all patients, and close monitoring is needed for patients with right-sided IE, large vegetations, diabetes mellitus, and an elevated leukocyte count.

MeSH terms

  • Adult
  • Aged
  • Analysis of Variance
  • Aortic Valve / microbiology
  • Arteriovenous Shunt, Surgical / statistics & numerical data
  • Catheterization, Peripheral / statistics & numerical data
  • Catheters, Indwelling / statistics & numerical data
  • Diabetes Mellitus / epidemiology
  • Echocardiography, Transesophageal
  • Endocarditis, Bacterial / epidemiology*
  • Endocarditis, Bacterial / microbiology
  • Enterococcus
  • Female
  • Gram-Positive Bacterial Infections / epidemiology
  • Humans
  • Male
  • Middle Aged
  • Minnesota / epidemiology
  • Mitral Valve / microbiology
  • Prognosis
  • Recurrence
  • Renal Dialysis / statistics & numerical data*
  • Retrospective Studies
  • Staphylococcal Infections / epidemiology
  • Staphylococcus epidermidis
  • Streptococcal Infections / epidemiology
  • Time Factors