Doulton Timothy, Sabharwal Nikhant, Cairns Hugh S, Schelenz Silke, Eykyn Susannah, O'Donnell Patrick, Chambers John, Austen Conell, Goldsmith David J A
Renal Unit, Guy's and St. Thomas' Hospital, London, United Kingdom.
Kidney Int. 2003 Aug;64(2):720-7. doi: 10.1046/j.1523-1755.2003.00136.x.
Since the 1960s chronic hemodialysis (HD) has been recognized as a risk factor for the development of infective endocarditis (IE). Historically, it has been particularly associated with vascular access via dual lumen catheters. We wished to examine the risk factors for, and consequences of, IE in the modern dialysis era.
Cases of IE (using the Duke criteria) at St. Thomas' Hospital (1980 to 1995), Guy's (1995 to 2002), and King's College Hospitals (1996 to 2002) were reviewed.
Twenty-eight patients were identified as having developed IE (30 episodes of IE). Twenty-seven patients were on long-term HD and one patient was on peritoneal dialysis (PD). Mean age was 54.1 years, and mean duration of HD prior to IE was 46.3 months. Eight patients were diabetic. Primary HD hemoaccess was an arteriovenous fistula (AVF) in 41.3%, a dual-lumen tunneled catheter (DLTC) in 37.9%, a polytetrafluoroethylene (PTFE) graft in 10.3%, and a dual- lumen non-tunneled catheter (DLNTC) in 4%. The presumed source of sepsis was directly related to hemoaccess in 25 HD patients: DLTC in 48%; AVF in 32%; PTFE in 12%; and DLNTC in 4%. Staphylococcus aureus[including methicillin resistant Staphylococcus aureus (MRSA)] was present in 63.3%. The mitral valve was affected in 41.4% of patients, aortic valve in 37.9% of patients, and both valves were affected in 17.2% of patients. Of note, 51.7% of patients had an abnormal valve before the episode of IE. In 15 cases surgery was undertaken. Fourteen patients survived to discharge, and 12 survived for 30 days. In 15 cases antibiotic treatment alone was employed; in this case, eight patients died and seven survived to discharge.
This is the largest reported confirmed IE series in dialysis patients. Infective endocarditis in HD patients remains a challenging problem-although hemoaccess via dual-lumen catheters remains a significant risk, many cases developed in patients with AVFs and this group suffered the greatest mortality. An abnormal valve (frequently calcified) was another risk factor; because valve calcification is now common after 5 years on dialysis, more effort in preventing this avoidable form of ectopic calcification may reduce the risk of developing IE.
自20世纪60年代以来，慢性血液透析（HD）一直被认为是感染性心内膜炎（IE）发生的一个危险因素。从历史上看，它特别与通过双腔导管建立的血管通路有关。我们希望研究现代透析时代IE的危险因素及后果。
回顾了圣托马斯医院（1980年至1995年）、盖伊医院（1995年至2002年）和国王学院医院（1996年至2002年）确诊的IE病例（采用杜克标准）。
确定有28例患者发生了IE（30次IE发作）。27例患者接受长期HD治疗，1例患者接受腹膜透析（PD）。平均年龄为54.1岁，IE发作前HD的平均持续时间为46.3个月。8例患者患有糖尿病。主要的HD血管通路中，动静脉内瘘（AVF）占41.3%，双腔带隧道导管（DLTC）占37.9%，聚四氟乙烯（PTFE）移植物占10.3%，双腔非隧道导管（DLNTC）占4%。25例HD患者败血症的推测来源与血管通路直接相关：DLTC占48%；AVF占32%；PTFE占12%；DLNTC占4%。金黄色葡萄球菌[包括耐甲氧西林金黄色葡萄球菌（MRSA）]占63.3%。41.4%的患者二尖瓣受累，37.9%的患者主动脉瓣受累，17.2%的患者两个瓣膜均受累。值得注意的是，51.7%的患者在IE发作前瓣膜异常。15例患者接受了手术。14例患者存活出院，12例患者存活了30天。15例患者仅采用抗生素治疗；在这种情况下，8例患者死亡，7例患者存活出院。
这是报道的透析患者确诊IE病例系列中最大的一组。HD患者的感染性心内膜炎仍然是一个具有挑战性的问题——尽管通过双腔导管建立血管通路仍然是一个重大风险，但许多病例发生在有AVF的患者中，且该组患者死亡率最高。瓣膜异常（常为钙化）是另一个危险因素；由于透析5年后瓣膜钙化现在很常见，在预防这种可避免的异位钙化方面付出更多努力可能会降低发生IE的风险。
