Risk of Cardiac Implantable Electronic Device Infection in Hemodialysis or Peritoneal Dialysis: Evaluation of a Large End Stage Renal Disease Database

Introduction: Blood stream infection (BSI) in incident hemodialysis (HD) patients is over 20% (Chebrolu, IDSA 2012). Dialysis patients who undergo placement of a cardiac implantable electronic device (CIED) may thus be at an increased risk of CIED infection (CIEDI) as well as endocarditis (IE) and other BSI. We have theorized that the infectious risks of hemodialysis (HD) patients may place them at higher risk for CIEDI when compared to peritoneal dialysis (PD) patients. Methods: We conducted a retrospective cohort study of the United States Renal Data System (USRDS) database to determine the risk of CIEDI and IE among individuals with ESRD on dialysis. We combined the patient demographic characteristic data with the information contained on the CMS Medical Evidence Report (CMS-2728) and Medicare Part A and Part B claims. Data was collected on incident adult ESRD patients from 2005 - 2007. The mode of dialysis was categorized as HD or PD based on CMS-2728. Individuals were followed from the date of first ESRD service through December 31, 2007 to determine the presence of a CIED, device infection, endocarditis, or BSI (based on ICD-9 codes). Individuals were defined as having definite, probable, or possible CIEDI based on the presence of a CIED and ICD-9 coding for device infection, IE, or BSI, respectively. Results: 313,502 incident dialysis patients were available for analysis. 26,120 (8.3%) patients were identified as having CIED. From this group the categories of CIEDI included: 1,082 (4.1%) with definite CIEDI, 1,612 (6.2%) with probable CIEDI, and 5,970 (22.9%) with possible CIEDI. When compared to PD patients, the incidence of CIEDI was significantly higher in HD patients (33.6% (8410/25004) vs 22.8% (254/1113), p < 0.001, for HD vs PD, respectively). Conclusion: Over 8% of incident HD patients from the USRDS had diagnoses consistent with CIEDI, and 4% could be classified as having definite infection. In this cohort, patients on HD were at significantly higher risk of developing CIEDI compared to PD patients. We would speculate this is due, in part, to a higher incidence of asymptomatic bacteremia from regular cannulation of the vasculature with subsequent seeding of the device or pacing leads.