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Valvular heart disease (VHD) is highly prevalent in patients with end-stage kidney disease (ESRD) and has been identified in up to 14% of patients. Mortality among dialysis patients hospitalised for valvular heart disease is high compared with all other dialysis patients (adjusted hazard ratio by Cox regression, 1.35; 95% [CI], 1.25-1.46). Recommendations for valve type selection during valve replacement surgery in patients with ESKD depend on patient age, reasonable life expectancy, and hospital experience.
Objective: The aim of this case is to document and analyze the treatment and management process of a young patient with chronic kidney disease and concomitant valvular heart disease. We aim to review the clinical decisions regarding aortic and mitral valve replacement, management of associated infectious complications, and subsequent renal transplantation.
>Case report: A 19-year-old female patient was diagnosed with chronic kidney disease of unknown etiology at the age of 14. At the age of 16, she underwent automated peritoneal dialysis for six months with several episodes of bacterial peritonitis resulting in loss of abdominal cavity. She progressed to hemodialysis three times a week and was listed for cadaveric kidney transplantation. After 24 months on hemodialysis, she was admitted with a 15-day history of fever, dyspnoea on exertion, and lower limb edema. The echocardiogram showed a dilated left atrium (59 ml/m2), an ejection fraction of 59%, vegetations on both mitral valves, severe aortic valve insufficiency with prolapsed vegetations in the ventricle, and a non-coronary cusp perforation. Blood cultures were positive for Enterococcus fecalis and she was treated with ampicillin and ceftriaxone for 16 days until negative results were obtained. She underwent aortic valve replacement with a No. 16 mechanical prosthesis and mitral valve replacement with a No. 27 mechanical prosthesis. After surgery, she completed a 42-day course of antibiotics and received heparin anticoagulation. A follow-up echocardiogram showed a slightly dilated left atrium with normally functioning mechanical prosthetic valves in both the mitral and aortic positions. Six months after her cardiac surgery, she started the renal transplant protocol with specialist discharge, no residual diuresis, and panel reactive antibody (PRA) class I at 0% and class II at 0%. After 15 days, she received a cadaveric kidney transplant (A02, DRB1-14, DQB1-03) with basiliximab and corticosteroid induction, demonstrating adequate diuresis and reduced azotemia. Cardiac function was normal, and renal Doppler ultrasound showed a normal-sized graft with normal echogenicity and a resistance index of 0.6. She is currently on oral prednisone, tacrolimus, mycophenolate for maintenance immunosuppression and warfarin for her heart.
>Case report:
Discussion: The most recent American College of Cardiology/American Heart Association guidelines recommend valve selection based solely on shared decision-making, including discussion of the risks of anticoagulation with mechanical valves versus the risks of degeneration with bioprosthetic valves, taking into account patient preferences. Non-tissue (mechanical) valve implantation is indicated in patients under 60 years of age and requires lifelong anticoagulation. An observational study of 887 waiting list patients found that those who received mechanical valves were younger than 50 years and had fewer comorbidities.