Pre-dialysis CKD Is a Risk Factor for Serious Infection

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Lower eGFR and higher ACR are associated with an elevated risk of infection-related hospitalization and infection-related death.
Lower eGFR and higher ACR are associated with an elevated risk of infection-related hospitalization and infection-related death.

Patients with earlier stages of chronic kidney disease (CKD) are at elevated risk for serious infections, a new study suggests.

In a study of 9697 white and black individuals aged 53 to 75 years who participated in the ARIC (Atherosclerosis Risk in Communities) study, both lower estimated glomerular filtration rate (eGFR) and higher urinary albumin-to-creatinine ratio (ACR) were associated with increased risks of infection-related hospitalization and infection-related death, Kunihiro Matsushita, MD, PhD, of Johns Hopkins Bloomberg School of Public Health in Baltimore, and colleagues reported online ahead of print in the American Journal of Kidney Diseases.

The findings have important clinical implications for infection prevention programs, such as those involving vaccination and prevention of healthcare-acquired infections, they noted. “Currently, albuminuria is not taken into account in this context. Thus, our results suggest that these programs could be expanded to include persons with less severely decreased kidney function, including those with elevated albuminuria,” Dr Matsushita and colleagues wrote.

Of the 9697 individuals, 2701 were hospitalized with infection and 523 subsequently died within 30 days of discharge during 13.6 years of follow up.  Compared with an eGFR of at least 90 mL/min/1.73 m2 , an eGFR of 15 to 29, 30 to 59, and 60-89 mL/min/1.73 m2 was associated with a 2.6, 1.5, and 1.07 times increased risk for infection-related hospitalization, respectively. An eGFR of 15 to 29 and 30 to 59 mL/min/1.73 m2 was associated with a 3.76 and 1.62 times increased risk of infection-related death, respectively.

Albuminuria of any degree also was associated with increased risks. The risks for infection-related hospitalization were 2.30, 1.56, and 1.34 times higher with ACRs above 300, 30 to 299, and 10 to 29 mg/g, respectively, compared with an ACR below 10 mg/g as a reference. Risks of death from infection were elevated 3.44, 1.57, and 1.39 times, respectively.

The investigators adjusted for a range of relevant demographic and clinical factors such as body mass index, smoking, diabetes, chronic obstructive pulmonary disease, cancer, and steroid use.

The findings were consistent among infection types, including pneumonia, kidney and urinary tract infections, bloodstream infections, and cellulitis. Bloodstream infections showed the greatest hazard ratios among patients with an eGFR of 15 to 29 mL/min/1.73 m2 or an ACR above 300 mg/g. These values were associated with a 3-fold and 3.7-fold higher risk of bloodstream infection, respectively, compared with reference values.

Dr Matsushita and colleagues cited uremic toxins and oxidative stress as potential mechanisms increasing infection risk among CKD patients.

With respect to study limitations, the researchers noted that the study involved CKD patients aged 53 to 75, so the results possibly may not apply to younger or older patients.

Reference

1.    1. Ishigami J, Grams ME, Chang AR, Carrero JJ, Coresh J, Matsushita K. CKD and Risk for Hospitalization With Infection: The Atherosclerosis Risk in Communities (ARIC) Study. AJKD. doi: 10.1053/j.ajkd.2016.09.018.

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