Clinical epidemiology of infectious disease among patients with chronic kidney disease

Abstract

Infectious disease is recognized as an important complication among patients with end-stage renal disease, contributing to excess morbidity and health care costs. However, recent epidemiological studies have revealed that even mild to moderate stages of chronic kidney disease (CKD) substantially increase risk of infection. Regarding underlying mechanisms, evidence suggests various aspects of altered immune response in patients with CKD including impaired function of T cells, B cells and neutrophil. Multiple conditions surrounding CKD, such as older age, diabetes, and cardiovascular disease are important contributors in the increased susceptibility to infection in this population. In addition, several mechanisms impairing immune function have been hypothesized including accumulated uremic toxins, increased oxidative stress, endothelial dysfunction, low-grade inflammation, and mineral and bone disorders. In terms of prevention strategies, influenza and pneumococcal vaccines are most feasible and important. Nevertheless, the extent of vaccine utilization in CKD has not been well documented. In addition, antibody response to vaccination may be reduced in CKD patients, and thus a vaccine delivery strategy (e.g., dose and frequency) may need to be optimized among patients with CKD. Through this review, we demonstrate that infection is a major but underrecognized complication of CKD. As CKD is recognized as a serious public health issue, dedicated research is needed to better characterize the burden of infectious disease associated with CKD, understand the pathophysiology of infection in patients with CKD, and develop effective strategies to prevent infection and its sequela in this high risk population.

Keywords: Bloodstream infections; Chronic kidney disease; Infections; Influenza vaccination; Pneumococcal vaccination; Pneumonia; Renal failure.

Fig. 1

Adjusted hazard ratio of hospitalization with infection by eGFR and ACR categories. GFR glomerular filtration rate, ACR albumin-to-creatinine ratio. Green: low risk; yellow: moderately increased risk; orange: high risk; red, very high risk. For each category, hazard ratio and its 95% confidence interval were presented in the first row, and n = denotes number of events and number of individuals in the second row. The model was adjusted for age, race, sex, body mass index, smoking status, alcohol consumption, education level, use of antineoplastic agents and steroids, hypertension, diabetes, history of cancer, chronic obstructive pulmonary disease, prior heart failure, prior coronary disease, and prior stroke. Reprinted from reference 15 with permission

Fig. 2

Potential mechanisms increasing infection in chronic kidney disease. CKD chronic kidney disease, CVD cardiovascular disease