High Mortality and Graft Loss after Infective Endocarditis in Kidney Transplant Recipients: A Case-Controlled Study from Two Centers

Abstract

Kidney transplant recipients (KTRs) tend to develop infections with characteristic epidemiology, presentation, and outcome. While infective endocarditis (IE) is among such complications in KTRs, the literature is scarce. We describe the presentation, epidemiology, and factors associated with IE in KTRs. We performed a retrospective case/control study which included patients from two centers. First episodes of definite or possible IE (Duke criteria) in adult KTRs from January 2010 to December 2018 were included, as well as two controls per case, and followed until 31 December 2019. Clinical, biological, and microbiological data and the outcome were collected. Survival was studied using the Kaplan–Meier method. Finally, we searched for factors associated with the onset of IE in KTRs by the comparison of cases and controls. Seventeen cases and 34 controls were included. IE was diagnosed after a mean delay of 78 months after KT, mostly on native valves of the left heart only. Pathogens of digestive origin were most frequently involved (six Enterococcus spp, three Streptococcus gallolyticus, and one Escherichia coli), followed by Staphylococci (three cases of S. aureus and S. epidermidis each). Among the risk factors evaluated, age, vascular nephropathy, and elevated calcineurin inhibitor through levels were significantly associated with the occurrence of IE in our study. Patient and death-censored graft survival were greatly diminished five years after IE, compared to controls being 50.3% vs. 80.6% (p < 0.003) and 29.7% vs. 87.5% (p < 0.002), respectively. IE in KTRs is a disease that carries significant risks both for the survival of the patient and the transplant.

Infective endocarditis in solid organ transplant: a review

“…In the French case–control study comparing patients with infective endocarditis and SOT amongst patients with SOT but no infective endocarditis, the former had a survival rate at 1 and 5 years after the index event of 58 and 50% as compared with survival rates of 100 and 85% amongst the latter, respectively. Death-censored graft survival was similarly lower in cases than controls at 1 year (81 vs. 100 months) and 5 years (29 vs. 87 months) [8 ▪ ]. Similarly, Eichenberger et al have reported outcomes of increased mortality, increased need for extracorporeal membrane oxygenation, and/or mechanical ventilation, and greater number of thromboembolic events when infective endocarditis occurs during the index hospitalization for transplantation as compared with patients undergoing transplantation with no infective endocarditis [12 ▪▪ ].…”

“…to be an equally common or even more common agent of infective endocarditis than S. aureus [15 ▪ ,16,19]. Tamzali et al [8 ▪ ] in their case–control study, also found enterococci as the most common cause of infective endocarditis in renal transplant recipients. In contrast, a registry-based study conducted in France and Spain exclusively amongst infective endocarditis in heart transplant recipients showed that Staphylococcus spp.…”

“…Shroff et al [7] found incidence rates of 1.8 and 2.6 per 1000 person-years amongst living donor kidney transplant recipients and deceased donor kidney transplant, respectively. A recent case–control study in France found a mean annual incidence of infective endocarditis of 1% in renal transplant recipients [8 ▪ ]. In a multicenter study in the United States, the cumulative incidence of infective endocarditis in liver transplants was calculated at 1.7% [9].…”

“…Known risk factors for infective endocarditis in the general population have been similarly reported in SOT recipients. For example, independent predictors for infective endocarditis in renal transplant recipients include dialysis time prior to transplantation, end-stage renal disease because of diabetes and older age [7,8 ▪ ,14]. Compared with their nontransplant counterparts, SOT recipients with infective endocarditis are more likely to have indwelling catheters prior to diagnosis and a higher prevalence of diabetes mellitus, liver, and renal medical disease [6 ▪▪ ,12 ▪▪ ,15 ▪ ].…”

“…Fevers seem to be present in 75–100% of patients, alongside acute kidney injury in 40% and embolic phenomena in 38–46% [16,19]. Infection of the left side of the heart, as in the general population, is most common, with the aortic and mitral valve being involved in similar proportion [6 ▪▪ ,8 ▪ ,15 ▪ ]. Mural endocarditis has been found to be present in around 5–10% of cases [16,19], with one study reporting a higher incidence in this finding amongst SOT recipients with infective endocarditis in comparison to their nontransplant counterparts [6 ▪▪ ].…”