Infections in Patients with Chronic Kidney Disease

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There has been a notable lack of research activity regarding major infections in patients with advanced chronic kidney disease. To an outsider, this might seem unexpected, because uremia has long been considered a state of immune hyporesponsiveness and rates of major bacterial infection, like septicemia and pneumonia, are known to be orders of magnitude more likely in dialysis populations than in the general population. This article reviews recent literature on the topic, focusing predominantly on the clinical epidemiology of major bacterial infections in dialysis patients, the links between bacterial infections and cardiovascular disease, and randomized trials of interventions designed to prevent these infections.

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Uremia and susceptibility to infection

Although less well-remarked in the general medical literature, a predisposition to infection seems to be a cardinal feature of advanced kidney disease. For example, postmortem findings in many of the cases described by Bright [5] showed that inflammatory pneumonitis, acute bronchitis, and peritonitis were prominent, suggesting that infection may have contributed to the demise of these unfortunate patients. Advanced uremia has long been considered to be a state of immune hyporesponsiveness. For

Infectious mortality in dialysis populations

Bacterial infection has declined as a cause of death in many countries. For example, the crude death rate in the United States was 841.9 per 100,000 in 2003 [13]. Cardiac diseases were the number one reported cause of death, accounting for 28% of deaths, followed by malignant neoplasms (22.7%) and cerebrovascular disease (6.4%). The combined category of influenza and pneumonia (2.7%) was ranked seventh and septicemia (1.4%) was ranked tenth. In patients with end-stage renal disease during the

Septicemia in dialysis patients

Survival expectations in maintenance populations are guarded. It is generally believed that much of this excess mortality is caused by cardiovascular disease, and research into the problem of cardiovascular disease in chronic kidney disease populations has accelerated considerably over time. Fig. 1 documents noteworthy growth in citation rates for cardiovascular disease in dialysis subjects and minimal growth in citation rates for septicemia. When the search strategy “dialysis (cardiac or heart

Pneumonia in dialysis patients

As with septicemia, reliable epidemiologic information about pneumonia in dialysis populations is scanty, even though it has been known for several years that mortality rates from pulmonary infections are almost 20 times higher than in the general population, even when differences in age, gender, race, and diabetes prevalence are taken into account [22]. The United States Renal Data System typically reports that pneumonia accounts for hospitalization rates of 80 to 100 per hundred patient-years

Associations between major bacterial infections, inflammation, and cardiovascular disease

Pathophysiologic and numerical reasoning both suggest that major bacterial infections, like pneumonia and septicemia, could be responsible for a nontrivial amount of the massive cardiovascular mortality rates seen in dialysis populations. The United States nationwide study, cited previously, tested the hypothesis that the development of septicemia was an intermediate step in the development of cardiovascular disease in dialysis patients, using a segmented time-dependent Poisson regression model

Prevention of infections in patients with chronic kidney disease

Regardless of age and the presence of other comorbid illnesses, it is recommended that patients with chronic kidney disease receive annual influenza vaccination and a single vaccination against Pneumococcus, which should be readministered after 5 years [37]. Observational data suggest that the implementation of these recommendations is suboptimal in populations with advanced chronic kidney disease. For example, one study examined US Medicare reimbursement claims data in the 2-year period before

Prevention of peritonitis in peritoneal dialysis patients

Although worldwide rates continue to fall, peritonitis remains the leading cause of technique failure and still represents a major risk factor for mortality in peritoneal dialysis patients [56], [57]. International guidelines for the treatment of peritonitis have been published [58]; detailed treatment algorithms for overt peritonitis are not described in this document and this section concentrates on potentially preventive strategies.

Most cases of peritonitis are caused by contamination with

Summary

The clinical epidemiology, prevention, and treatment of major infections in patients with chronic kidney disease have yet to be addressed systematically and most of the information has come from dialysis populations. In reality, although it has been conservatively estimated that at least 5% of the general population has serious renal dysfunction, most of this subpopulation is at risk from premature cardiovascular disease, and not end-stage renal disease [73]. Conceptually, it is easy to

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