Risk of Infective Endocarditis in Patients with End Stage Renal Disease

Abstract

Background and objectives: Endocarditis is a serious complication in patients treated with RRT. The study aimed to examine incidence and risk factors of endocarditis in patients with ESRD.

Design, setting, participants, & measurements: The Danish National Registry on Regular Dialysis and Transplantation contains data on all Danish patients receiving renal replacement (hemodialysis, peritoneal dialysis, or kidney transplantation) for ESRD. Incidence of endocarditis was estimated for each RRT modality. Independent risk factors of endocarditis were identified in multivariable Cox regression models.

Results: From January 1st, 1996 to December 31st, 2012, 10,612 patients (mean age 63 years, 36% female) initiated RRT (7233 hemodialysis, 3056 peritoneal dialysis, 323 pre-emptive kidney transplantation). Endocarditis developed in 267 (2.5%); of these 31 (12%) underwent valve surgery. The overall incidence of endocarditis was 627 per 100,000 person-years in patients receiving RRT. Incidence was higher in patients receiving hemodialysis compared with those receiving peritoneal dialysis or kidney transplantation (1092 per 100,000 person-years, 212 per 100,000 person-years, and 85 per 100,000 person-years, respectively). Adjusted hazard ratios for endocarditis in patients receiving hemodialysis were 5.46 (95% confidence interval [95% CI], 3.28 to 9.10) and 0.41 (95% CI, 0.18 to 0.91) for kidney-transplanted recipients, respectively, as compared with patients in peritoneal dialysis. The incidence of endocarditis in hemodialysis recipients with central venous catheters was more than two-fold higher as compared with those with arteriovenous fistulas. Overall mortality, subsequent to endocarditis, was 22% in-hospital and 51% at 1 year. The first 6 months in RRT, aortic valve disease, and previous endocarditis were identified as significant risk factors of endocarditis.

Conclusions: Patients receiving RRT have a high incidence of endocarditis, in particular during hemodialysis treatment using central venous catheters. The first 6 months in RRT, aortic valve disease, and previous endocarditis are significant risk factors for developing endocarditis.

Keywords: Aortic Valve; Central Venous Catheters; Endocarditis; Heart Defects, Congenital; Heart Valve Diseases; Incidence; Kidney Failure, Chronic; Middle Aged; RRT; Registries; dialysis access; end stage kidney disease; hemodialysis; kidney; kidney transplantation; mortality; peritoneal dialysis; renal dialysis; risk factors; vascular access.

Graphical abstract

Figure 1.

The incidence of infective endocarditis increased significantly in the ESRD population compared to the increase in incidence of RRT during the period 1996–2012. The P value denotes the significant increase in the incidence of infective endocarditis in the ESRD population compared with the increase in the incidence of RRT recipients, adjusted for the background population, across the study period.

Figure 2.

The relative time in central venous catheter increased during the period 1996–2012. Relative time spent in central venous catheter as proportion of overall time spent in RRT (hemodialysis [central venous catheter (cuffed and uncuffed), arteriovenous fistula, arteriovenous graft], peritoneal dialysis, and kidney transplantation) on the basis of the study population and distributed over each year of study.

Figure 3.

The incidence rate of infective endocarditis was high in hemodialysis vascular accesses. 95% CI, 95% confidence interval; CVC, central venous catheter.