The rate of adverse clinical events, especially hyperkalemia and infection/sepsis, increase with chronic kidney disease (CKD) stage, particularly once dialysis is initiated, a new study finds. Mortality risks follow a similar trend.

Using the 2004-2017 UK Clinical Practice Research Datalink, Dustin J. Little, MD, of AstraZeneca in Gaithersburg, Maryland, and colleagues identified 310,953 patients with stage 3-5D CKD based on estimated glomerular filtration rate (eGFR).

The investigators found high baseline rates of hypertension (32.1%, 60.4%, and 61.5%) and diabetes (13.1%, 40.1%, and 41.3%) among patients with nondialysis-dependent CKD, prevalent dialysis, and incident dialysis, respectively. Comorbidities were more common, median hemoglobin values were lower, and C-reactive protein values were higher in the dialysis than non-dialysis groups. As eGFR declined, the prevalence of comorbidities generally increased.

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Adverse events

Adverse events rates increased with advancing CKD stage and also with time in the dialysis population, the investigators reported in BMC Nephrology. In the prevalent and incident dialysis groups, the most common adverse clinical events (per 100 person-years) were pneumonia/respiratory infection (18.0 and 19.9), urinary tract infection (UTI; 11.3 and 12.4), infection/sepsis (7.1 and 8.0), and seizure (1.05 and 1.14), respectively. The investigators found that seizure occurred at a 3-fold higher rate in patients on dialysis compared with nondialysis CKD. Overall, adverse events rates were higher among patients on hemodialysis than peritoneal dialysis, particularly pneumonia/respiratory infection and UTI.

In the nondialysis CKD group, the most common adverse events were pneumonia/respiratory infection (9.3 per 100 person-years) and UTI (8.2 per 100 person-years).

The hyperkalemia event rate was 0.67 per 100 person-years for the nondialysis group compared with 4.4 and 5.0 per 100 person-years for the prevalent and incident dialysis groups, respectively. The rate of infection/sepsis was 1.0 per 100 person-years for the nondialysis group compared with 7.1 and 8.0 per 100 person-years in the prevalent and incident dialysis groups, respectively.

The rates of hyperkalemia and infection/sepsis were 6.5- and 6.9-fold higher, respectively, in the dialysis than nondialysis group. Among patients initiating dialysis, rates of hyperkalemia and infection/sepsis were 7.4- and 7.9-fold higher, respectively, compared with patients with nondialysis CKD.

Dr Little’s team explained that hyperkalemia ensues from impaired potassium excretion following eGFR decline. Infections occur more frequently in this population due to their weakened immune systems, frequent catheterization, and increased hospitalizations.

The investigators found increased rates of retinal disorders and hypoglycemia with decreasing eGFR explained by the well-known association between, diabetes, CKD, and retinopathy. Other adverse events also appeared more common among patients initiating or continuing maintenance dialysis vs those with nondialysis CKD including, thyroid disorder, gastrointestinal hemorrhage, tachycardia, acidosis, hepatic events, pancreatitis, rhabdomyolysis, pyelonephritis, anaphylaxis, pure red cell aplasia, and cutaneous adverse reactions.

“Collectively, the increased incidence of adverse clinical events likely reflects the higher comorbidity burden of patients on or transitioning to dialysis versus those with [nondialysis-dependent] CKD,” Dr Little’s team wrote. They noted that the higher adverse events rates among patients on dialysis may be due to an increase in risk factors or monitoring and reporting.


The investigators found the highest risk of mortality within 5 years in the incident dialysis group (58.4%). Mortality risk generally increased with advancing CKD stage with up to half of patients dying after CKD stage 4. Death risks overall were lower among patients on peritoneal dialysis (11.8%-46.4%) compared with hemodialysis (24.1%-61.9%).

“Our findings highlight the need to monitor patients with CKD for comorbidities and complications, as well as signs or symptoms of clinical adverse events, such as hyperkalemia, hypoglycemia, retinal disorders, seizures, and infection/sepsis,” Dr Little and colleagues concluded.

Disclosure: This research was supported by AstraZeneca. Please see the original reference for a full list of disclosures.


Little DJ, Arnold M, Hedman K, Sun P, Haque SA, James G. Rates of adverse clinical events in patients with chronic kidney disease: analysis of electronic health records from the UK clinical practice research datalink linked to hospital data. BMC Nephrol 24(1):91. Published online April 5, 2023. doi:10.1186/s12882-023-03119-z