Tunneled Catheter-Associated Quadruple Valve Endocarditis

Introduction: The Advancing American Kidney Health (AAKH) initiative was launched in 2019 to establish a new framework for kidney care in the United States (US). Unfortunately, the complexities of addressing health equity were left out of the initiative. Case Description: A 45-year-old African American man experiencing homelessness with untreated schizophrenia, nicotine dependence, and uncontrolled hypertension complicated by End-Stage Renal Disease (ESRD) via tunneled catheter presented to the hospital with fever, rigors, malaise, dyspnea, chest pain, and pain over his tunneled catheter site since catheter exchange 3 weeks ago. His last dialysis session was two days prior. The patient has a history of missed dialysis sessions likely due to his untreated schizophrenia and lack of transportation. Blood cultures showed Methicillin Sensitive Staphylococcus Aureus with echocardiogram revealing vegetations on the pulmonic valve, new mitral and tricuspid valve flail chords, and new severe aortic insufficiency compared to echocardiogram from 2 weeks prior. The patient underwent catheter exchange after a line holiday and negative repeat blood cultures, and was prescribed an intradialytic regimen of cefazolin. Discussion: This unfortunate case of quadruple valve endocarditis is a sobering reminder of the moral obligation of healthcare professionals to care for all individuals, particularly the most vulnerable. Patients with schizophrenia have an increased prevalence of diabetes, hypertension, and cardiovascular disease which are all risk factors for kidney disease. Nephrologists must work closely with psychiatrists, dialysis nurses, and other healthcare providers to create a comprehensive care plan that addresses both the psychiatric and medical needs of the patient. Comanagement with a psychiatrist may implement and support behavioral strategies to improve adherence to dialysis to avoid catastrophic outcomes. Raising awareness in the Nephrology community is a step toward compassionate, inclusive care for our most vulnerable patients.