Value of surgery for infective endocarditis in dialysis patients (original) (raw)
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Value of Surgery for Infective Endocarditis in Dialysis Patient
The Journal of Thoracic and Cardiovascular Surgery, 2017
Objectives: To determine the value of surgery for infective endocarditis (IE) in patients on hemodialysis by comparing the nature and invasiveness of endocarditis in hemodialysis and nonhemodialysis patients and their hospital and long-term outcomes, and identifying risk factors for time-related mortality after surgery. Methods: From January 1997 to January 2013, 144 patients on chronic hemodialysis and 1233 nonhemodialysis patients underwent valve surgery for IE at our institution. Propensity matching identified 99 well-matched hemodialysis and nonhemodialysis patient pairs for comparison of outcomes. Results: Staphylococcus aureus infection was more common in hemodialysis patients than in nonhemodialysis patients (42% vs 21%; P <.0001), but invasive disease was similar in the 2 groups (47%; P ¼ .3). Hospital mortality was 13% and 5-year survival was 20% for hemodialysis patients, 20% below that expected in a general hemodialysis population but 15% above that of hemodialysis patients treated nonsurgically for IE. For matched patients, hospital mortality was 13% for hemodialysis patients versus 5.1% for nonhemodialysis patients (P ¼ .05), and survival at 1 and 5 years was 56% versus 83% and 24% versus 59%, respectively (P < .004). Use of an arteriovenous graft for dialysis access (P ¼ .01) and preoperative placement of a pacemaker (P < .0001) were risk factors for late mortality in hemodialysis patients. For matched patients, freedom from reoperation was similar in the hemodialysis and nonhemodialysis groups (P >.9). Conclusions: Intermediate-term survival after surgery for IE in hemodialysis patients is substantially worse than that in nonhemodialysis patients, but only slightly worse than that in the general hemodialysis population and substantially better than that in hemodialysis patients with IE treated nonsurgically, supporting continued surgical intervention for IE. (
Epidemiology and Clinical Outcomes of Infective Endocarditis in Hemodialysis Patients
The Annals of Thoracic Surgery, 2007
Infective endocarditis is one of the most serious complications of bacteremia in patients undergoing chronic hemodialysis and is more frequent than previously recognized. The aim of our study was to describe the clinical characteristics, outcome, and factors predicting mortality of infective endocarditis in hemodialysis patients. In this retrospective review, all patients on chronic hemodialysis admitted to a 600-bed urban teaching hospital with infective endocarditis over a 15-year period (1990 to 2004), were identified using discharge codes. Modified Duke criteria were retrospectively applied, and patients fulfilling the criteria for definite endocarditis were included in the study. Sixty-nine patients on hemodialysis with definite endocarditis were identified. The predominant type of vascular access was double-lumen catheter (66.7%). The mean duration of dialysis was 37 +/- 32 months. The predominant organism was Staphylococcus aureus (57.9%), of which 57.5% were methicillin susceptible. The most frequently infected valve was mitral (49.3%), followed by aortic (21.7%) and tricuspid (10.1%) valves. The cardiac and neurologic complication rates were 40.6% and 37.7%, respectively. Fifteen patients underwent valvular heart surgery. The overall in-hospital mortality was 49.3% (34 of 69). More patients who had surgery survived than patients who did not (12 of 15 versus 23 of 54; p = 0.018, odds ratio = 5.39, 95% confidence interval: 1.3 to 17.6). On logistic regression, valve surgery was the only independent factor predicting survival (p = 0.023). The prognosis of infective endocarditis in hemodialysis patients is poor, with surgery serving as an independent predictor of survival.
Infective endocarditis in haemodialysis patients: 16-year experience at one institution
NDT Plus, 2008
Objectives. To ascertain the characteristics, outcomes and correlates of mortality in chronic haemodialysis patients with confirmed infective endocarditis (IE). Methods. Patients were identified by computerized discharge diagnosis and chart review of admissions to Saint Louis University hospital from January 1990 through January 2006. Modified Duke Criteria were retrospectively applied to confirm the diagnosis of IE. Survivors and nonsurvivors were compared to identify clinical correlates of IE mortality. Results. We identified 59 patients with IE who had received dialysis for a mean duration of 52.9 ± 58.0 months prior to IE diagnosis. Dialysis access comprised 28 (47.5%) catheters, 26 (44.1%) arteriovenous grafts, 3 (5.1%) arteriovenous fistulas and 2 (3.4%) life sites. The causative organisms were MRSA in 15 (25%), MSSA 12 (20%), S. Epidermidis 10 (17%), Enterococci 8 (14%), multi-organism 6 (10%), gram negative 2 (3%) and VRE 1 (2%). Valves involved were mitral valve in 37 (63%), aortic valve in 10 (17%), tricuspid valve in 3 (5%) and multiple valves in 8 (13%) cases. Patient mortality was 28.8% (n = 17) during hospitalization, 37.9% (n = 22) at 30 days and 63.1% (n = 36) at 1 year. In multivariable logistic regression, the adjusted odds ratio of in-hospital mortality was 3.6-fold higher in those with IE and arteriovenous grafts (P = 0.04, 95% CI 1.04-12.27) compared to other forms of dialysis access. Conclusion. Mortality of IE remains high, despite the availability of potent antibiotics. Patients with arteriovenous grafts who develop IE may face increased risk for in-hospital mortality, perhaps reflecting difficulty eradicating endovascular infection if a graft is involved.
Mortality risk factors in chronic haemodialysis patients with infective endocarditis
2006
Background. It is well documented that infective endocarditis (IE) is strongly associated with morbidity and mortality in haemodialysis (HD) patients. Less clear are the mortality risk factors for IE, particularly in an urban African-American dialysis population. Methods. IE patients were identified from the medical records for the period from January 1999 to February 2004 and confirmed by Duke criteria. The patients were classified as 'survivors' and 'non-survivors' depending on in-hospital mortality, and risk factors for IE mortality were determined by comparing the two cohorts. Survivors were followed as out-patients with death as the endpoint. Results. A total of 52 patients with 54 episodes of IE were identified. A catheter was the HD access in 40 patients (74%). Mitral valve (50%) was the commonest valve involved, and Gram-positive infections accounted for 87% of IE. In-hospital mortality was high (37%) and valve replacement was required for 13 IE episodes (24%). On logistic regression analyses, mitral valve disease [P ¼ 0.002; odds ratio (OR) ¼ 15.04; 95% confidence interval (CI) ¼ 2.70-83.61] and septic embolism (P ¼ 0.0099; OR ¼ 9.56; 95% CI ¼ 1.72-53.21) were significantly associated with in-hospital mortality. Using the Cox proportional hazards model, mitral valve involvement (P ¼ 0.0008; hazard ratio 4.05; 95% CI ¼ 1.78-9.21) and IE related to drug-resistant organisms such as methicillin-resistant Staphyloccus aureus and vancomycin-resistant Enterococcus sp. (P ¼ 0.016; hazard ratio 2.43; 95% CI ¼ 1.18-5.00) were associated with poor outcome after hospital discharge. Conclusions. IE was associated with high mortality in our predominantly African-American dialysis population, when the mitral valve was involved, or septic emboli occurred and if MRSA or VRE were the causal organisms.
Cardiac Surgery in Patients on Dialysis: Decreased 30-Day Mortality, Unchanged Overall Survival
The Annals of Thoracic Surgery, 2008
Background. The risk of cardiac surgery in dialysisdependent patients is high, but little is known about the determinants of survival. We initiated a retrospective multicenter study to overcome this limitation. Methods. Nine centers provided data on 522 patients (70% male, aged 61 ؎ 11 years) who had chronic dialysisdependent renal failure. A 14-year period was covered. Most patients had coronary artery bypass grafting, either with (n ؍ 103) or without (n ؍ 326) valve surgery. Multivariable analysis of survival was explored using Cox models. Results. The proportion of patients with diabetes mellitus increased significantly (from 17%, 1989 to 1993, to 32%, 2000 to 2003; p ؍ 0.021) and was independently associated with 30-day mortality (odds ratio ؍ 3.30, p ؍ 0.001) The mean 30-day mortality was 12% (n ؍ 60), but declined significantly during the study period (from 28%, 1989 to 1993, to 7%, 2000 to 2003; p ؍ 0.003). The 5-year survival probability was 42% (95% confidence interval: 36% to 47%). Patients who had renal transplantation during follow-up (n ؍ 17) had the best survival probability (hazard ratio [HR] ؍ 0.14, p ؍ 0.007). Sinus rhythm (HR ؍ 0.48, p < 0.001) and use of internal thoracic artery grafts (HR ؍ 0.67, p ؍ 0.006) proved beneficial for long-term survival. Predictors of death during long-term follow-up were emergency surgery (HR ؍ 2.25, p ؍ 0.001), diabetes mellitus (HR ؍ 1.46, p ؍ 0.020), number of allogenic transfusions (HR ؍ 1.03/unit, p ؍ 0.015), and age (HR ؍ 1.04/year, p < 0.001). Conclusions. In dialysis-dependent patients, cardiac surgery has become significantly safer in recent years, but the overall prognosis of the patients remains poor. The observed improvements in the perioperative survival do not necessarily translate into an improved longterm prognosis. Diabetes mellitus is an important independent risk factor for perioperative mortality and death during follow-up.
Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis
We sought to compare perioperative outcomes and 2-year survival in a cohort of peritoneal dialysis (PD) patients compared with matched hemodialysis (HD) patients who underwent cardiothoracic surgery at our institution. We obtained a list of all dialysis-dependent patients who underwent cardiac surgery (coronary artery bypass grafting, valve replacement, or both) at our center between 1994 and 2008. All patients undergoing PD at the time of surgery were included in our analysis. Two HD patients matched for age, diabetes status, and Charleston comorbidity score were obtained for each PD patient. The analysis included 36 PD patients and 72 HD patients. Mean age, sex, diabetes status, cardiac unit stay, hospital stay, and operative mortality did not differ by dialysis modality. The incidence of 1 or more postoperative complications (infection, prolonged intubation, death) was higher for HD patients (50% vs. 28% for PD patients, p = 0.046). After surgery, 2 PD patients required conversio...
International Journal of Antimicrobial Agents, 2009
Despite improvements in medical and surgical therapy, IE is still associated with severe prognosis and remains a diagnostic and therapeutic challenge. Aims: To evaluate the impact of standardized diagnostic and therapeutic protocols on the outcome of IE and to correlate the outcome of IE with the compliance to our management-based protocol. Methods: A multidisciplinary task force defined and applied a simplified protocol for IE management including a sampling strategy, the use of 4 antimicrobials only, a standardized duration of treatment, standardized surgical indications, and one year follow-up. Because our protocol was based on a local consensus by physicians and surgeons, it was impossible to randomize the study. To evaluate our protocol we performed a prospective cohort study including all patients treated for IE at our institution to compare the outcome of IE patients before and after implementation of the protocol. Results: The study was divided in 2 periods: period 1 (1991 2001), before implementation of the therapeutic protocol and period 2 (2002 2006) after implementation of our protocol. The risk of dying at the hospital was 2.1 times higher during period 1 when 12.7% of 173 IE patients died versus 4.4% of 160 IE patients during period 2. During period 2, there was a better compliance in antimicrobial therapy, a higher rate of pacemaker ablation, and fewer cases of renal failure. Deaths by embolic events and multiple organ failure syndromes (MOFS) decreased significantly during period 2. Conclusion: The creation of a multidisciplinary task force improved significantly the management of IE and subsequently improved the outcome of IE leading to the lowest mortality rate reported yet in literature.