Impact of Dialysis Dose and Membrane on Infection-Related Hospitalization and Death

Allon, Michael; Depner, Thomas A.; Radeva, Milena; Bailey, James L.; Beddhu, Srinivasan; Butterly, David W.; Coyne, Daniel W.; Gassman, Jennifer; Kaufman, Allen; Kaysen, George A.; Lewis, Julia A.; Schwab, Steve J.

doi:10.1097/01.asn.0000074237.78764.d1

Cited by 198 publications

(154 citation statements)

References 25 publications

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“…Of interest, fever was much more likely to be a presenting sign in patients with catheter-related bacteremia than in patients with a graft or fistula infection (18% versus 47%). This observation is consistent with a previous report from the HEMO study (2). Approximately two thirds of the infections observed in our catheter-dependent patients were managed in the outpatient arena.…”

Section: Discussionsupporting

confidence: 94%

“…Access-related infections accounted for 77% of infectionrelated hospitalizations in the study presented here, considerably higher than the 21% rate reported in the Hemo- dialysis (HEMO) study (2). The HEMO study observed that catheters were present in 32% of patients hospitalized with access-related infection, although catheters accounted for only 7.6% of all vascular accesses in the study.…”

Section: Discussioncontrasting

confidence: 62%

“…Infection is the second most common cause of death and hospitalization among hemodialysis patients (1)(2)(3). Previous prospective studies have focused on the subset of infections causing death (4) or requiring hospitalization (2,5) without including infections treated in the outpatient setting.…”

Section: Introductionmentioning

confidence: 99%

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The Spectrum of Infections in Catheter-Dependent Hemodialysis Patients

Al-Solaiman¹,

Estrada²,

Allon³

2011

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Catheter-dependent hemodialysis patients may develop access-related and nonaccess-related infections that may be managed in the outpatient arena or in the hospital. The goal of this study was to quantify infections in such patients, to characterize their clinical presentations, and to evaluate factors determining need for hospitalization.Design, setting, participants, & measurements We collected prospective data on the clinical management of catheter-dependent hemodialysis patients with suspected infection at a large dialysis center. We documented the presenting symptoms, type of infection, pathogen, and whether hospitalization occurred.Results An infection was suspected in 305 separate cases and confirmed in 88%. The 268 diagnosed infections included catheter-related bacteremia (69%), another access-related infection (19%), and nonaccess-related infection (12%). The overall frequency of infection was 4.62 per 1000 catheter-days. Hospitalization occurred in 37% of all infections, but it varied greatly (72% for nonaccess-related infection, 34% for catheterrelated bacteremia, and 4% for exit-site infection). Among patients with catheter-related bacteremia, the likelihood of hospitalization varied by pathogen, being 53% for Staphylococcus aureus, 30% for Enterococcus, 23% for Staphylococcus epidermidis, and 17% for gram-negative rods (P Ͻ 0.001). The likelihood of hospitalization was not associated with age, gender, or diabetes. Fever was a presenting symptom in only 47% of cases of catheter-related bacteremia.Conclusions Catheter-dependent patients have a high burden of infection. It is important to evaluate patients with suspected infection for various access-related and nonaccess-related infections. A low threshold is indicated for suspecting catheter-related bacteremia because the patients frequently present without fever.

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Section: Discussionsupporting

confidence: 94%

Section: Discussioncontrasting

confidence: 62%

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The Spectrum of Infections in Catheter-Dependent Hemodialysis Patients

Al-Solaiman¹,

Estrada²,

Allon³

2011

Clinical Journal of the American Society of Nephrology

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“…In fact, as reported in the Hemodialysis (HEMO) study, many hospitalizations in HD patients are related to infections [13] . In another study, high levels of IgG antibodies to bacterial species (associated with destructive periodontal diseases), were associated with elevated C-reactive protein (CRP) levels [14] .…”

Section: Causes Of Inflammationmentioning

confidence: 95%

End-Stage Renal Disease, Inflammation and Cardiovascular Outcomes

Dai

Gołembiewska

Lindholm

et al. 2017

Contributions to Nephrology

151

111

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Despite marked improvements in renal replacement therapy during the last 30 years, the age-adjusted mortality rate in end-stage renal disease (ESRD) patients is still unacceptably high and comparable to that of many malignancies. Cardiovascular disease (CVD) remains the major cause of morbidity and mortality in ESRD patients. However, traditional risk factors can only partially explain the high premature cardiovascular burden in this population. Nontraditional risk factors, including persistent low-grade inflammation, are critical in the pathogenesis of atherosclerosis, vascular calcification, and other causes of CVD and may also contribute to protein-energy wasting and other complications in chronic kidney disease (CKD) patients. Inflammatory biomarkers, such as high sensitivity C-reactive protein and interleukin-6, independently predict mortality in these patients. The causes of inflammation in CKD are multifactorial and include imbalance between increased production (due to multiple sources of inflammatory stimuli such as oxidative stress, acidosis, volume overload, co-morbidities, especially infections, genetic and epigenetic influences, and the dialysis procedure) and inadequate removal (due to decreased glomerular filtration rate or in ESRD patients, inadequate dialytic clearance) of pro-inflammatory cytokines. Though there are currently no established guidelines for the treatment of low-grade inflammation in ESRD patients, several strategies have been proposed, such as lifestyle modifications, pharmacological treatment, and optimization of dialysis. Further studies on pathways involved in pathogenic processes of inflammation in ESRD, and long-term effects of anti-inflammatory interventions targeting production or removal of cytokines or both on premature CVD and clinical outcomes in this patient group are warranted.

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“…Between 1996 and 2001 among a US Medicare cohort of patients who recently started dialysis, the 1-year incidence of infection-related hospitalizations was 32% for those who received HD and 24% for those who received peritoneal dialysis; the 3-year incidence exceeded 50% in both groups [46]. Whereas in the HEMO study, most infection-related hospitalizations were not attributed to vascular access [47], the frequency of access-related infectious hospitalizations was disproportionately higher among patients with catheters compared to grafts or fistulas [47]. Furthermore, there may be repeated bouts of acute tubular necrosis by lowering the blood pressure during each HD session [48], resulting in faster loss of residual kidney function and frequent ischemic events upon hypotensive episodes.…”

Section: Discussionmentioning

confidence: 91%

Estimated Glomerular Filtration Rate at Re-Initiation of Dialysis and Mortality in Failed Kidney Transplant Recipients

2012

American Journal of Kidney Diseases

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Background. Recent observational studies and a controlled trial suggest more favorable outcomes upon later dialysis initiation in chronic kidney disease. The role of estimated glomerular filtration rate (eGFR) in predicting outcome at reinitiation of dialysis in failed kidney transplant recipients is unclear. Methods. Five-year data in a large dialysis organization was linked to the 'Scientific Registry of Transplant Recipients' to identify 747 failed kidney transplant patients with CKD Stage 5, who had restarted dialysis therapy. A propensity score for early (eGFR >10.5 mL/min/1.73m 2 ) versus late reinitiation of dialysis was fit by logistic regression. The mortality hazard ratio (HR) was estimated across tertiles of the fitted score. Results. Patients were 44 ± 14 years old and included 42% women. Male gender {odds ratio (OR), [95% confidence interval (CI)]: 1.82 (1.22-2.73)}, diabetes mellitus [OR: 1.75 (1.14-2.68)] and peripheral vascular disease [OR: 3.55 (1.17-10.77)] were associated with higher odds of early dialysis reinitiation. Each mL/min/1.73m 2 higher eGFR was associated with 6% higher death risk in unadjusted model [HR: 1.06 (1.01-1.11)], and although not significant in fully adjusted models [HR: 1.02 (0.96-1.07)], it was significant in some subgroups including women and younger patients. The death HR of higher eGFR across lowest to highest tertiles of propensity score of early dialysis initiation (corresponding healthiest to sickest patients) were 1.10 (0.98-1.24), 1.00 (0.91-1.10) and 0.99 (0.92-1.07), respectively (P for trend <0.05), indicating a trend toward higher mortality risk with earlier dialysis initiation in the healthiest patients. Conclusions. Earlier return to dialysis therapy in failed kidney transplant patients tends to correlate with worse dialysis survival especially among healthiest and younger patients and women. Additional studies need to verify these findings.

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Impact of Dialysis Dose and Membrane on Infection-Related Hospitalization and Death

Cited by 198 publications

References 25 publications

The Spectrum of Infections in Catheter-Dependent Hemodialysis Patients

The Spectrum of Infections in Catheter-Dependent Hemodialysis Patients

End-Stage Renal Disease, Inflammation and Cardiovascular Outcomes

Estimated Glomerular Filtration Rate at Re-Initiation of Dialysis and Mortality in Failed Kidney Transplant Recipients

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