**5. Heart valves with IE in HD**

As mentioned earlier the incidence of IE in HD patients is higher than in general population and it is caused by multiple factors. But it is closely related to frequent episodes of bacteremia related to dialysis access and the predisposition of these patients to present premature degeneration of the heart valves eventually causing bacterial implantation in the valves. This is an issue of major public health presenting a very poor prognosis in short and long term, with 23.5% in-hospital mortality and 61.6% mortality in 1 year.

Despite the high rates of IE and poor prognosis for these patients, there has not been a substantial change in mortality over the past two decades. This can be the result of not having important changes in the therapeutic armamentarium [25]. Reports of multiple studies have shown that left valves with IE in HD patients are affected twice the time compared to the right valves; as well as the mitral valve is affected in more patients than the aortic valve. It is theorized that the thickening of these valves, which is common in this group of patients, can lead to increased susceptibility to acquire IE because of alterations in the laminar flow. Mitral annular calcification, which is also common in ESRD, has also shown increased susceptibility to IE [8].
