Version May 2024
INTRODUCTION — In addition to infections associated with dialysis access devices, patients with end-stage kidney disease (ESKD) who require kidney replacement therapy may be susceptible to non-access-related infections. Diagnostic strategies for these infections are similar to those used for patients without kidney disease. However, a higher index of suspicion and a lower threshold for the initiation of a search are appropriate since patients with ESKD are frequently diabetic and/or immunosuppressed because of the retention of uremic toxins. Careful attention to appropriate dosing of antibiotics and the avoidance (if possible) of nephrotoxic drugs in the patient with residual kidney function are also significant issues.
Many of the infections reviewed in this topic are not unique to the patient on dialysis. As a result, although the likelihood of their occurrence may be increased, special considerations and guidelines for the patient on dialysis are not available. Diagnostic and treatment strategies must be tailored to the individual patient, including the consequences of kidney disease and other comorbid conditions, the geographic location, and specific environmental exposures.
A review of the clinical characteristics of infections not related to the dialysis access is presented here. Reviews of access-related infections and the clinical manifestations and treatment of sepsis in patients on dialysis, a complication most commonly due to infection of dialysis access devices, are discussed separately:
●(See "Arteriovenous fistula creation for hemodialysis and its complications".)
●(See "Arteriovenous graft creation for hemodialysis and its complications".)
●(See "Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis".)
●(See "Peritoneal catheter exit-site and tunnel infections in peritoneal dialysis in adults".)
●(See "Tunneled hemodialysis catheter-related bloodstream infection (CRBSI): Management and prevention".)
EPIDEMIOLOGY — Data from the United States Renal Data System (USRDS) indicate that infections are a leading cause of death among patients with end-stage kidney disease (ESKD) [1,2], accounting for approximately 10 to 13 percent of all deaths in 2018 [3-5]. The proportion of deaths due to infection increased with the advent of coronavirus disease 2019 (COVID-19). For example, in patients on peritoneal dialysis in 2020, infections caused nearly 17 percent of fatalities, and COVID-19 was the fourth leading cause of death, at over five percent [6]. Infections are the leading cause of hospitalizations among patients treated with peritoneal dialysis and have been the second leading cause, behind cardiovascular disease, of hospitalizations among patients treated with hemodialysis. However, in 2020, driven by COVID-19, hospitalizations for infectious causes surpassed those for cardiac causes in the hemodialysis population [7].
Compared with the population with normal kidney function, patients with chronic kidney disease (CKD) and ESKD are at higher risk of contracting bacterial infections, particularly urinary tract infections, pneumonia, and sepsis [8-11]. They are also more likely to have an infection at the time of hospitalization [12].
Because of their propensity for causing sepsis, infections related to dialysis access devices are potentially catastrophic [13,14]. The annual mortality secondary to sepsis is 100- to 300-fold higher in patients on dialysis [13] (see "Tunneled hemodialysis catheter-related bloodstream infection (CRBSI): Management and prevention" and "Central venous catheters: Overview of complications and prevention in adults", section on 'Catheter-related infection'). In addition, a prospective study evaluating the outcome of 65 episodes of Staphylococcus aureus bacteremia in patients on hemodialysis (89 percent of which were due to an access) found that metastatic complications and death occurred in 44 and 14 percent of patients, respectively. In contrast, other studies suggest that non-access-related infections are less common and not as devastating, accounting for an overall mortality rate of less than 3 percent [15].
Patients on dialysis are at a higher risk for acquiring infection caused by multidrug-resistant organisms and for death resulting from infection [16]. This is because of their likelihood of requiring treatment that involves invasive devices, their frequent exposure to antibiotics, and their altered immunity [17]. As reported by the USRDS, death due to infection in patients over the age of 65 years is approximately twice that of younger patients [3]. Smoking has been shown to be an important risk factor for infection-related morbidity and mortality among patients on hemodialysis [18].
Among patients undergoing chronic kidney replacement therapy, the most important sites of infection not related to the dialysis access include the following:
●Upper and lower respiratory tract
●Central nervous system
●Gastrointestinal tract (eg, hepatitis and Clostridioides difficile colitis)
●Genitourinary tract
●Skin and bone (eg, cellulitis and osteomyelitis)
RESPIRATORY SYSTEM — Respiratory tract infections in patients on dialysis may be community or hospital acquired. As previously mentioned, respiratory infections are the second leading cause of infection-related deaths.
Upper respiratory tract — Compared with the general population, patients with end-stage kidney disease (ESKD) are not overly susceptible to sinusitis, rhinitis, or pharyngitis. Diagnoses and treatments are therefore similar to those for the general population. However, special attention must be given to accurate drug dosing and the loss of antibiotics across the dialysis membrane among those undergoing hemodialysis. (See "An overview of rhinitis" and "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis".)
Lower respiratory tract — Bronchitis and pneumonia are common in patients on dialysis. In one retrospective study of patients on dialysis, the probability of being hospitalized from pneumonia was 9 and 36 percent at one and five years, respectively [19]. A subsequent observational study found a pneumonia incidence rate of 21.4 events/100 patient-years, with 90.1 percent requiring hospitalization, and a 30-day fatality of 10.7 percent in Medicare patients on dialysis [20]. Significantly higher hospitalizations also occurred in the 12 months following the pneumonia episode, increasing the overall costs [20].
Pneumonia is an important cause of death and hospitalization in patients, carrying significant risk for those with advanced chronic kidney disease (CKD) [21]. Compared with the population with normal kidney function, the rate of pneumonia is three times greater in those with CKD and five times greater in those with ESKD [8]. One-in-five patients with ESKD developed pneumonia during their first year on dialysis, and 42 percent of these required hospitalization [22]. The lengths of hospitalization in CKD and ESKD patients with pneumonia are similar and are four to six times longer than the non-CKD population [8].
A retrospective study of the bacteriology and outcomes of empyema in 84 patients with stage 4 CKD and 40 patients with ESKD found that most empyemas were secondary to pneumonia. Gram-negative organisms were cultured in 67 percent of patients with stage 4 CKD (34 percent were Klebsiella pneumoniae), but aerobic gram-positive organisms predominated in the patients with ESKD (54 percent, with 67 percent of those S. aureus) [23]. Compared with the patients with stage 4 CKD, patients with ESKD had a higher catheter-associated infection rate and lower infection-associated mortality [23].
Compared with patients without kidney disease, bronchitis and pneumonia may be more difficult to diagnose since pulmonary fluid fluctuates markedly with dialysis treatments. Nevertheless, the presence of a productive cough, fever, chills, pleuritic pain, and/or dyspnea suggest an infectious pulmonary process. The diagnosis may be confirmed by sputum evaluation and chest radiograph. Treatment should not be withheld if a high index of suspicion remains, despite the absence of diagnostic test results. (See "Clinical evaluation and diagnostic testing for community-acquired pneumonia in adults" and "Community-acquired pneumonia in adults: Assessing severity and determining the appropriate site of care" and "Treatment of community-acquired pneumonia in adults in the outpatient setting".)
COVID-19 — Patients with ESKD have been disproportionately impacted by the COVID-19 pandemic. COVID-19 in patients with ESKD is discussed in detail elsewhere. (See "COVID-19: Issues related to end-stage kidney disease".)
HUMAN IMMUNODEFICIENCY VIRUS INFECTION — In early studies, survival on dialysis was short in most patients with acquired immune deficiency syndrome (AIDS; only a few months), although some asymptomatic patients or those with early AIDS survived for one to two years. Subsequent studies, however, have noted prolonged survival in infected patients requiring kidney replacement therapy. This is discussed in detail separately. (See "Human immunodeficiency virus and dialysis".)
NERVOUS SYSTEM — Meningitis and infections of the brain parenchyma should be considered in patients on dialysis with fever and/or central nervous system symptoms or findings. An increased risk of central nervous system infection and related mortality has been reported for patients on dialysis [24].
Meningitis — A paucity of literature exists concerning the incidence of meningitis in patients on dialysis. Streptococcus meningitis, an uncommon infection in all adults, was reported as a complication of peritonitis in one patient on peritoneal dialysis [25].
Fungal meningitis has also been reported in patients with end-stage kidney disease (ESKD). Cryptococcal meningoencephalitis, the most frequent manifestation of cryptococcal infection, has been noted with increased frequency among the general patient population because of human immunodeficiency virus (HIV) infection. Involvement of the meninges with Cryptococcus in patients on peritoneal dialysis most commonly results from systemic disease initially arising from infection of the peritoneum [26-28]. (See "Clinical manifestations and diagnosis of Cryptococcus neoformans meningoencephalitis in patients without HIV".)
Herpes zoster — Varicella-zoster virus (VZV) infection causes two clinically distinct forms of disease: varicella (chickenpox) and herpes zoster (shingles) (see "Epidemiology, clinical manifestations, and diagnosis of herpes zoster", section on 'Risk factors').
Chronic kidney disease (CKD) is a risk factor for the development of herpes zoster [29-31]. In one study, compared with patients without ESKD, patients with ESKD on hemodialysis had twice the risk of zoster by 4.7 years of follow-up (adjusted hazard ratio 1.98, 95% CI 1.72-2.27) [30]. Vaccination against herpes zoster for patients with ESKD is discussed at length elsewhere [32]. (See "Immunizations in patients with end-stage kidney disease", section on 'Varicella-zoster virus vaccine'.)
Treatment with antiviral agents such as valacyclovir requires adjustment in dose for patients on dialysis.
Mucormycosis — Mucormycosis, a life-threatening fungal disease, is characterized by fungal sinusitis with invasion of adjacent structures, including the brain. It most commonly occurs in immunocompromised and diabetic patients and patients on dialysis treated with deferoxamine. The fungal infection may be contracted from the environment and then disseminate, frequently affecting the central nervous system and sinuses (rhinocerebral mucor). (See "Fungal rhinosinusitis".)
Patients on hemodialysis in whom aluminum chelation therapy with deferoxamine has been administered at relatively high doses appear to be at significant risk for mucormycosis. Presenting forms of the infection most commonly include rhinocerebral and disseminated disease (31 and 44 percent, respectively). (See "Aluminum toxicity in chronic kidney disease".)
Mucormycosis infecting the peritoneum has also been reported in patients on peritoneal dialysis. In one case report, Rhizopus species grew from cultures obtained from a patient with clinical signs of peritonitis [33]. The patient had no known risk factor for the infection.
The management of these fungal infections is discussed in the appropriate topic reviews.
GASTROINTESTINAL SYSTEM
Gallbladder and biliary disease — A paucity of literature exists concerning the prevalence of cholecystitis and cholecystolithiasis in patients with end-stage kidney disease (ESKD). In an observational study of 179 patients with ESKD who presented to the emergency department with abdominal pain, approximately 6 percent were diagnosed with cholecystitis or biliary colic [34].
The prevalence of cholecystolithiasis in patients with ESKD may be comparable to that in the general population. In one ultrasonographic study, no significant difference was observed in the prevalence of cholecystolithiasis in 73 patients on hemodialysis and a control group (16 and 23 percent, respectively) [35]. A case report of emphysematous cholecystitis in a patient on peritoneal dialysis suggests that ischemia may play a role in the development of this entity [36].
Common bile duct dilatation may occur more commonly among patients with kidney disease due to polycystic kidney disease compared with those without the disorder. In one study, for example, 22 of 55 patients (40 percent) with polycystic kidney disease and varying levels of kidney function were found to have biliary dilatation measuring at least 7 millimeters compared with 5 of 55 controls (9.1 percent) matched for age, sex, kidney function, and duration of dialysis [37]. Whether this is associated with an enhanced risk of biliary infection and/or pathology is unknown.
The clinical presentation and overall management of patients on dialysis with cholecystitis are similar to those without kidney disease. (See "Acute calculous cholecystitis: Clinical features and diagnosis" and "Treatment of acute calculous cholecystitis".)
Visceral leakage causing peritonitis — Peritonitis is a common complication in patients undergoing peritoneal dialysis. Although associated with significant morbidity, it is usually easily treatable (see "Microbiology and therapy of peritonitis in peritoneal dialysis"). However, peritonitis resulting from enteric bacteria is frequently caused by injury to gastrointestinal viscera and may have devastating consequences. Peritonitis acquired by virtue of microscopic perforation may be insidious, with subtle or no radiographic abnormalities despite evolving clinical symptoms. In a review of 230 patients on peritoneal dialysis followed over eight years, approximately 30 percent of peritonitis episodes resulting from enteric organisms were due to documented visceral leakage, including cholecystitis, ischemic bowel disease, viscus perforation, or diverticulitis [38]. Among these 26 patients with visceral disease, 50 percent died, and 30 percent switched to hemodialysis.
Helicobacter pylori infection — The literature is limited with regard to the prevalence of gastroduodenal Helicobacter pylori infection in patients on dialysis. In a study of over 1200 patients with ESKD who underwent an upper endoscopy for transplant evaluation, H. pylori was detected in approximately one-third of the patients [39]. In another study of patients on dialysis, H. pylori was detected by enzyme-linked immunosorbent assay (ELISA) in 33 percent [40]. The prevalence, diagnosis, and management of H. pylori infection in patients on dialysis are discussed separately. (See "Unique aspects of gastrointestinal disease in patients on dialysis".)
Hepatitis — Infectious hepatitis, particularly with hepatitis B and C, is a significant cause of morbidity and mortality in patients on hemodialysis, with hepatitis C being a leading cause of liver disease. Fortunately, the incidence of both hepatitis B and C infections is declining in this patient population.
Discussions concerning the epidemiology, diagnosis, and treatment of hepatitis B and C infections in patients with and without kidney disease are presented separately. (See "Hepatitis C virus infection in patients on maintenance dialysis" and "Hepatitis B virus and dialysis patients".)
Gastroenteritis — Patients with ESKD are susceptible to the same viral gastroenteritides as the general population, although their ability to combat such illnesses may be suppressed. An important issue in patients on dialysis with significant gastrointestinal fluid loss (by vomiting and/or diarrhea) is the accurate assessment of intravascular volume to avoid a substantial decrease in the effective circulating volume with dialysis therapy. Careful attention must therefore be given to variations in blood pressure during the procedure and the accurate determination of dry weight. Acute symptomatic relief may be obtained with the administration of an antidiarrheal agent, such as loperamide given at a dose of 2 to 4 mg by mouth (PO) initially then 2 mg after each unformed stool up to 10 to 12 mg daily.
Diverticulitis — Patients on dialysis develop diverticulitis at least as frequently as patients not on dialysis. An increased incidence is observed in patients with polycystic kidney disease since a majority of such individuals who require dialysis have diverticula. (See "Autosomal dominant polycystic kidney disease (ADPKD): Extrarenal manifestations".)
The presentation of diverticulitis in the chronically ill patient on dialysis may be more insidious than that of the patient without kidney disease. The typical clinical manifestations of a patient presenting with acute diverticulitis are discussed separately. (See "Clinical manifestations and diagnosis of acute colonic diverticulitis in adults", section on 'Clinical manifestations'.)
Management must be individualized but is essentially similar to that for patients not on dialysis (see "Acute colonic diverticulitis: Medical management"). Nonoperative management may be preferred for patients with ESKD who have acute diverticulitis. In one study of 962 patients with ESKD and matched controls >65 years of age who underwent surgical intervention for diverticulitis, those with ESKD had a higher rate of in-hospital mortality and postoperative complications compared with those without ESKD [41].
Clostridioides difficile colitis — Patients on dialysis are particularly susceptible to C. difficile colitis since they are commonly administered antibiotics. Patients on maintenance hemodialysis are more than four times as likely to develop C. difficile infection than individuals not on dialysis [42]. In one study of 62 patients on dialysis and 8 individuals with acute kidney disease, 110 episodes of C. difficile colitis reportedly occurred over a two-year period [43]. In this cohort, infection was associated with a dismal long-term prognosis: 60 of 70 patients died over a follow-up period of five years. The rate of C. difficile was 1.05 per 100 dialysis patient years in a United Kingdom registry [10]. Colonization with toxigenic C. difficile was higher among patients with chronic kidney disease (CKD) in Australia with a relative risk (RR) of 5.78 (95% CI 2.29-14.59) [44].
Another study found that the incidence of C. difficile–associated infection was 10.7 per 1000 admissions for patients with CKD compared with 2.7 per 1000 among other patients (p<0.0001) [45]. In this study, symptoms in patients with CKD included diarrhea (89 percent), fever (53 percent), and ileus or abdominal pain (44 percent). ESKD and being on dialysis, as opposed to CKD stages 3 to 5, appears to be a risk factor for C. difficile colitis for unclear reasons [46,47]. A subsequent retrospective review of C. difficile infections in patients with CKD again showed those on dialysis to be twice as likely to develop C. difficile infections than patients without CKD and 1.33 times more likely than patients with nondialysis CKD [48]. Interestingly, patients on dialysis with C. difficile infection had fewer complications from the infection (colectomy, longer hospitalization, discharge to a health care facility) than those with CKD not on dialysis [48]. A meta-analysis examining 19 studies with 116,875 patients found a higher relative risk of recurrent C. difficile infection (pooled RR 2.73, 95% CI 1.36-5.47), as well as higher mortality in ESKD and CKD patients (RR 1.76, 95% CI 1.32-2.34) [49].
A review of 419,875 patients on incident dialysis in United States Renal Data System (USRDS) data from 2005 to 2008 found 4.25 percent of patients diagnosed with C. difficile infection [50]. Most had either a hospital or intensive care unit (ICU) stay within 90 days. Risk factors for C. difficile infection included age ≥65 years of age (RR 1.76), human immunodeficiency virus (HIV; RR 2.68), and a history of bacteremia (RR 1.74). The relative risk of death was higher in those with cirrhosis (RR 1.76) and those older than 65 years of age (RR 2.28). Recurrent C. difficile occurred in 23.6 percent, more commonly in White Americans [50].
Management of C. difficile colitis in patients on dialysis is similar to the regimen used in patients not on dialysis but with minor dosing adjustments [51]. It is recommended that patients on dialysis with estimated glomerular filtration rates of less than 10 mL/min receive a 50 percent dose reduction of metronidazole [52]; the drug should be administered after hemodialysis [52] (see "Clostridioides difficile infection in adults: Treatment and prevention"). The rise in cases of C. difficile has been accompanied by a resistance to treatment. This has led to the development of alternative treatment strategies for resistant cases. (See "Clostridioides difficile infection in adults: Treatment and prevention".)
GENITOURINARY INFECTION — Urinary tract infections associated with urinary catheterization are among the most common nosocomial infections among hospitalized patients on chronic dialysis [53]. The clinical presentation of urinary tract infection in a patient on dialysis with residual urine production is similar to that of an individual without kidney disease. By comparison, anuric patients may present with only bladder discomfort and/or fever.
High rates of asymptomatic pyuria and bacteriuria — Among asymptomatic patients on dialysis, the presence of pyuria, with or without bacteriuria, is common [54-59]. With few exceptions, we generally do not treat asymptomatic patients who have pyuria and/or bacteriuria. (See "Asymptomatic bacteriuria in adults".)
In a study that included 70 asymptomatic patients on hemodialysis, 36 patients (51 percent) had pyuria [59]. In another study of 43 asymptomatic patients on peritoneal dialysis, 12 (28 percent) had pyuria [57]. The reported prevalence of bacteriuria among asymptomatic patients on dialysis who have pyuria is variable, ranging between 11 and 70 percent [58].
Cystitis — Anuric patients with acute simple cystitis may present with only bladder symptoms (ie, suprapubic discomfort). Management of symptomatic simple cystitis is discussed elsewhere. (See "Acute simple cystitis in adult and adolescent females" and "Acute simple cystitis in adult and adolescent males".)
Pyocystis, defined as a large collection of pus in a nonfunctioning bladder, may occur in anuric patients on dialysis; it is an overlooked cause of fever in this patient population. In this setting, culture most commonly yields multiple organisms. Treatment usually consists of bladder irrigation with antimicrobial solutions and possibly antimicrobial therapy, depending upon the virulence of the pathogen and the clinical state of the patient.
Pyelonephritis — The presentation of pyelonephritis in the patient with and without kidney disease is similar; symptoms or signs may include fever, abdominal pain, dysuria (if not anuric), and flank pain. Patients with end-stage kidney disease (ESKD) due to polycystic kidneys and/or older patients on dialysis may be at increased risk. (See "Autosomal dominant polycystic kidney disease (ADPKD): Evaluation and management of complicated urinary tract infections".)
Treatment of the patient with pyelonephritis is based upon the clinical characteristics of the patient and microbiologic results (see "Acute complicated urinary tract infection (including pyelonephritis) in adults and adolescents"). The treatment of kidney infection in the patient with polycystic kidneys is presented separately. (See "Autosomal dominant polycystic kidney disease (ADPKD): Evaluation and management of complicated urinary tract infections".)
SKIN AND BONE INFECTIONS — Cellulitis and osteomyelitis are significant causes of morbidity in patients on dialysis.
Cellulitis — Cellulitis frequently occurs in the patient with diabetes on dialysis with neurologic and peripheral vascular disease and is an important cause of morbidity in patients on dialysis. Diabetic foot infection poses a serious risk for amputation and must be promptly identified and treated (see "Management of diabetic foot ulcers"). The duration of treatment among these patients is often longer than for immunocompetent nondialysis patients. (See "Acute cellulitis and erysipelas in adults: Treatment".)
Osteomyelitis — Osteomyelitis may result from direct extension of cellulitis, which, as mentioned, is a common occurrence in diabetics, and via hematogenous spread caused by the failure to recognize and remove infected central venous hemodialysis catheters and/or chronic access. A high index of suspicion is therefore appropriate in patients on dialysis, particularly those with diabetes (see "Approach to imaging modalities in the setting of suspected nonvertebral osteomyelitis"). As with patients not on dialysis, treatment is based upon cultured pathogens (when available) and/or empiric regimens. (See "Nonvertebral osteomyelitis in adults: Clinical manifestations and diagnosis".)
Infection and calciphylaxis — Calciphylaxis, a rare complication of the skin microvasculature, affects an estimated 1 percent of patients with end-stage kidney disease (ESKD) per year (see "Calciphylaxis (calcific uremic arteriolopathy)"). This disorder is associated with extensive microvascular calcification and occlusion with thrombosis of the skin, thereby resulting in characteristic violaceous skin lesions. Progression to nonhealing ulcers and sepsis is confounded by secondary infection, which also leads to bloodborne infection and often death [60,61].
METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS — S. aureus bacteremia is common in patients on hemodialysis, with nearly 40 percent of these infections being methicillin resistant (MRSA) [62]. S. aureus bacteremia is usually related to the presence of an indwelling dialysis catheter or arteriovenous graft and/or peritonitis. The widespread use of vancomycin in patients on dialysis is due to the convenience of infrequent dosing related to hemodialysis treatments and the recognition that Staphylococcus species cultured from these populations is often resistant to methicillin [63]. In 2005, the incidence of invasive MRSA infection was 45.2 cases per 1000 patients on dialysis compared with a rate of 0.2 to 0.4 cases per 1000 in the general population [10,64,65].
Many Staphylococcus infections in patients on peritoneal dialysis are actually Staphylococcus epidermidis; this is a less virulent pathogen but one that is also often resistant to methicillin (MRSE). Because vancomycin has been widely used as empiric therapy for the past decade, there is concern about the enhanced incidence of infection resulting from vancomycin-resistant Enterococcus (VRE) [66]. (See "Microbiology and therapy of peritonitis in peritoneal dialysis".)
VANCOMYCIN-RESISTANT ENTEROCOCCUS — The emergence of vancomycin-resistant Enterococcus (VRE) and the rising incidence of VRE infection/colonization pose significant health care risks:
●Colonization of this organism can evolve into serious infection.
●Resistance may be passed to more virulent organisms such as S. aureus.
●The carriage of VRE may render the patient on dialysis unacceptable for kidney transplantation.
VRE bacteremia predominantly affects severely ill patients who have previously received extensive antibiotic therapy [67]. Patients on dialysis, with their propensity for access infection and comorbid conditions requiring prolonged hospitalization, are particularly at risk; however, dialysis vintage has not been found to correlate with the presence of VRE, nor has an increased risk of death been observed in VRE-positive patients [68].
In a meta-analysis of observational studies including nearly 5000 patients on dialysis, approximately 6 percent were found to be colonized with VRE [69]. Risk factors for VRE colonization included hospitalization in the recent past and prior use of antibiotics. Patients colonized with VRE had a higher risk of infection with VRE (odds ratio 21.6, 95% CI 5.3-81.6).
Centers for Disease Control and Prevention (CDC) guidelines mandate that VRE-positive patients on hemodialysis must be isolated during treatment and hospitalizations [70,71]. The acquisition of VRE is also of particular concern among patients on peritoneal dialysis. This is discussed separately. (See "Microbiology and therapy of peritonitis in peritoneal dialysis".)
Linezolid, an antimicrobial used in the treatment of VRE infections, is not well suited as long-term therapy, because myelosuppression (including anemia, leukopenia, pancytopenia, and thrombocytopenia) can develop in patients receiving linezolid for more than two weeks. Such adverse hematologic effects may be more common in patients on dialysis. As an example, in a retrospective case-control study, patients with ESKD, compared with those without kidney disease, had a significantly higher rate of linezolid-associated thrombocytopenia (79 versus 43 percent) and anemia (72 versus 37 percent) [72].
The treatment of VRE is presented separately. (See "Treatment of enterococcal infections".)
ENDOCARDITIS — The major ESKD-specific management issue surrounding infective endocarditis is dialysis access. In patients with a hemodialysis catheter who develop infective endocarditis, catheter removal is warranted. In rare cases, excision of an arteriovenous fistula or graft may be required. These issues are discussed in detail elsewhere. (See "Overview of management of infective endocarditis in adults" and "Tunneled hemodialysis catheter-related bloodstream infection (CRBSI): Management and prevention".)
TUBERCULOSIS — Although the incidence of tuberculosis in patients undergoing dialysis is considered to be relatively low, it appears that patients on dialysis have an enhanced risk for developing tuberculosis. Studies in the United States have reported a 12-fold increased risk of tuberculosis among patients with ESKD compared with the general population [73]. Outside of the United States, a fourfold increase in tuberculosis rates among patients with ESKD has been reported [73]. The prognosis of patients with ESKD who have tuberculosis is uncertain. Some studies suggest that with appropriate treatment the prognosis may be comparable to that of patients without ESKD [74-76]. However, in another study, ESKD was associated with an increased risk of death in older patients with tuberculosis, with a 32.7 percent mortality [77]. Other than attention to appropriate dosing regimens for those with ESKD, the treatment of tuberculosis for patients on dialysis is the same as that for patients not on dialysis. (See "Treatment of drug-susceptible pulmonary tuberculosis in nonpregnant adults without HIV infection".)
There is a heightened awareness of the propensity for immunosuppressed patients, including those on dialysis, to reactivate old or acquire new tuberculosis infections. In a single dialysis center, for example, one infected health care worker apparently transmitted tuberculosis to 29 patients [78].
Affected patients frequently present with fever, anorexia, and weight loss [79]. Involvement of extrapulmonary organs is also common, particularly the lymphatic system and peritoneum [80-82].
Since approximately 30 to 40 percent or more of patients on hemodialysis are anergic, additional clinical testing for the presence of tuberculosis may be appropriate in patients for whom the index of suspicion is high [83-89]. The interferon (IFN)-gamma release assay (IGRA) is generally preferred, over tuberculin skin testing, for diagnosis of latent tuberculosis in patients with ESKD [73]. (See "Tuberculosis infection (latent tuberculosis) in adults: Approach to diagnosis (screening)".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Dialysis".)
SUMMARY AND RECOMMENDATIONS
●Epidemiology – Infections are a leading cause of death among patients with end-stage kidney disease (ESKD), accounting for approximately nearly 17 percent of all fatalities. Access-related infections are the most common and respiratory tract infections are the second most common causes of infection-related deaths. Others include human immunodeficiency virus (HIV) infection, infections of the central nervous system, gastrointestinal tract, genitourinary tract, skin (cellulitis), and bone (osteomyelitis). (See 'Epidemiology' above.)
●Mucormycosis – Patients on dialysis treated with deferoxamine are at increased risk of mucormycosis, a life-threatening fungal disease that most commonly occurs in immunocompromised and diabetic patients. (See 'Mucormycosis' above.)
●Peritonitis – Peritonitis is common in patients undergoing peritoneal dialysis but is usually easily treatable. Peritonitis caused by enteric bacteria is frequently caused by injury to gastrointestinal viscera and may have devastating consequences. (See 'Visceral leakage causing peritonitis' above and "Microbiology and therapy of peritonitis in peritoneal dialysis".)
●Hepatitis – Infectious hepatitis, particularly with hepatitis B and C, is a significant cause of morbidity and mortality in patients on hemodialysis, with hepatitis C being a leading cause of liver disease. The incidence of both hepatitis B and C infections is declining in this patient population. (See 'Hepatitis' above and "Hepatitis C virus infection in patients on maintenance dialysis" and "Hepatitis B virus and dialysis patients".)
●Clostridioides difficile colitis – Patients on dialysis are particularly susceptible to C. difficile colitis since they are commonly administered antibiotics. Mortality and recurrent infections are more common in patients with ESKD than others with C. difficile colitis. Management of C. difficile colitis in patients on dialysis is similar to the regimen used in patients not on dialysis but with dosing adjustments. (See 'Clostridioides difficile colitis' above.)
●Urinary tract infection – Urinary tract infections are the most common nosocomial infections among hospitalized patients on chronic dialysis who have undergone urinary catheterization. Candida is the most frequently observed pathogen. The management of symptomatic urinary tract infection must be tailored to the individual patient on dialysis and the cultured organism. (See 'Genitourinary infection' above and "Acute simple cystitis in adult and adolescent females".)
●Skin and bone infections – Cellulitis is common in the patient with diabetes on dialysis with neurologic and peripheral vascular disease and poses risk for complications, including amputation. Osteomyelitis may result from direct extension of cellulitis or via hematogenous spread from an infected central venous hemodialysis catheter and/or chronic access. (See 'Skin and bone infections' above and "Approach to imaging modalities in the setting of suspected nonvertebral osteomyelitis".)
●Methicillin-resistant Staphylococcus aureus – S. aureus bacteremia is common in patients on hemodialysis and is usually related to the presence of an indwelling dialysis catheter or arteriovenous graft and/or peritonitis. Invasive methicillin-resistant S. aureus (MRSA) infection is more common in the hemodialysis population compared with the general population. (See 'Methicillin-resistant staphylococcus aureus' above.)
●Vancomycin-resistant Enterococcus – Vancomycin-resistant Enterococcus (VRE) colonization is not common among hemodialysis outpatients. Centers for Disease Control and Prevention (CDC) guidelines mandate that VRE-positive patients on hemodialysis must be isolated during treatment and hospitalizations. The carriage of VRE may render the patient on dialysis unacceptable for kidney transplantation. (See 'Vancomycin-resistant enterococcus' above and "Microbiology and therapy of peritonitis in peritoneal dialysis".)
●Tuberculosis – Patients on dialysis have an enhanced risk for developing tuberculosis. Other than attention to appropriate dosing regimens for those with ESKD, the treatment of tuberculosis in patients on dialysis is the same as that for patients not on dialysis. (See 'Tuberculosis' above and "Treatment of drug-susceptible pulmonary tuberculosis in nonpregnant adults without HIV infection".)
●Herpes zoster – Herpes zoster is more common in patients on hemodialysis than in the general population and vaccination is recommended. Treatment with antiviral agents such as valacyclovir requires adjustment in dose for patients on dialysis. (See 'Herpes zoster' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Jean L Holley, MD, FACP, who contributed to earlier versions of this topic review.
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