key: cord-1025399-mmv509e2 authors: Pant, Abhishek; Prasai, Astha; Rauniyar, Anmol Kumar; Adhikary, Laxman; Basnet, Krity; Khadka, Tunam title: Pneumonia in Patients with Chronic Kidney Disease Admitted to Nephrology Department of a Tertiary Care Center: A Descriptive Cross-sectional Study date: 2021-10-31 journal: JNMA J Nepal Med Assoc DOI: 10.31729/jnma.7074 sha: 30952adef90e1d06ec4a7f1c040817836b62290f doc_id: 1025399 cord_uid: mmv509e2 INTRODUCTION: Chronic Kidney Disease is an independent risk factor for pneumonia. The risk of hospitalization, Intensive Care Unit and ventilator requirement, in-hospital death is high in pneumonia patients with chronic kidney disease. This study aims to find the prevalence of pneumonia in patients with chronic kidney disease admitted to nephrology department of a tertiary care center. METHODS: A descriptive cross-sectional study was conducted among all the hospital records of pneumonia patients with Chronic Kidney Disease admitted to the Nephrology department between April 2019 and April 2021. Ethical clearance was obtained from the Institutional Review Committee of same institute (Reference number: 0505202106). Statistical Package for the Social Sciences version 20 was used for analysis. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: Of the total 407 patients with Chronic Kidney Disease, 78 (19.1%) (95% Confidence Interval= 15.28-22.92) had pneumonia. Among the 78 pneumonia patients, 17 (21.8%) were Stage 3, 13 (16.7%) Stage 4 and 48 (61.5%) Stage 5 of chronic kidney disease. Forty Seven (60.3%) required Intensive Care Unit (ICU), 19 (24.4%) required ventilator and 22 (28.2%) of the patient expired in hospital. The most commonly isolated organisms were Severe Acute Respiratory Syndrome Coronavirus 2 which was 13 (16.6%) followed by Strepotococcus pneumoniae which was 8 (10.2%). CONCLUSIONS: The prevalence of pneumonia in Chronic Kidney Disease was observed higher in our study compared to other studies. Infections are a major cause of morbidity and mortality in Chronic Kidney Disease (CKD) patients. The relationship is mutual: not only infections are severe and difficult to manage in CKD, but infections also contribute to the progression of CKD and complicate its management. 1 Lower respiratory tract infections e.g. Pneumonia are common occurrences in CKD patients and are associated with increased risk of hospitalization, cardiovascular events and mortality. 2 CKD has long been considered an independent risk factor for pneumonia. The risk of pneumonia is up to 1.97 fold higher in CKD patients-1.4 times higher for outpatient pneumonia and even higher, i.e., 2.17 times for inpatient pneumonia compared with patients without CKD. 2 This study aims to find the prevalence of pneumonia in patients with chronic kidney disease admitted to nephrology department of a tertiary care center. The mean age of the cases was 60.43±17.55 years (minimum 20 years, maximum 92 years). Forty-one (52.6%) of the cases were diabetic and 28 (35.9%) were active smokers. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was the most commonly isolated organism followed by Streptococcus pneumoniae and Klebsiella pneumoniae ( Table 2) . A combination of Beta-Lactam and Macrolide was the most commonly used antibiotic regimen for the treatment of pneumonia in CKD under maintenance hemodialysis and not under dialysis as described (Table 3) . CKD compromises the host's ability to fight, especially affecting the cell-mediated immune system. The role of uremia in increasing the susceptibility of CKD patients to infections has also been well studied by researchers. Uremia has been linked to impairment in neutrophil 4, 5 and lymphocyte functioning. 6, 7 Patients who receive hemodialysis for the treatment are at further increased risk of infection as it requires vascular access, exposure to injectable medications, dialyzers, and equipment among others. 8, 9 Studies suggest that the pneumonia-related mortality rate in CKD could be as high as 14-16 times as compared to the general population. 2 The patient receiving hemodialysis are twice as susceptible to pneumonia compared to other forms of renal replacement therapy (RRT) such as renal transplant and peritoneal dialysis 10 and the mortality rate is 14-16 times higher than the general population. 11 The prevalence of pneumonia in our study was significantly higher than another similar national study. 3 One possible reason behind this could be the inclusion of Covid-19 pneumonia in our study that was prevalent during the duration of our study. The mean age of the study was 60.43±17.55 years which was quite similar to a study conducted in Taiwan with a mean age of 64±16.0. 2 Forty one (52.6%) of the patients were diabetic similar to the report from USRDS. 12 Our study reports a high frequency of ICU requirement 47 (60.3%) and ventilator requirement 19 (24.4%) in CKD patients with pneumonia. This was significantly higher than the study by Viasus, et al. who reported ICU requirement of 8.9% and ventilator requirement of 7.9%. 13 The average length of hospital stay for pneumonia in a study in Spain was 5-7 days 14 and 5.4 days according to US-Healthcare and Cost Utilization Project which is lower than the mean of 8.97±9.47 days in our study. Also, the in-hospital mortality was higher at 28.2.% in our study as compared to the report by James et al. which reported 21% death within 30 days of hospitalization with pneumonia. 15 This is probably due to the increased severity of pneumonia in CKD patients although the difference in the quality of care between the developed and developing nations might be a factor here as well. The same study also reported that with a decrease in eGFR from 60 to less than 30/ml/min/1.73m 2 , the incidence rate of death after hospitalization with pneumonia increased from 0.17 to 8.55 deaths/1000. 15 This was consistent with our study, where the highest death was reported among CKD Stage 5-15 (68.1%). SARS-CoV-2 was the most commonly isolated organism with a total of 13 (16.6%). Covid-19 pneumonia is a newly emerging disease with very limited data. The most recent studies have suggested an increased severity of COVID-19 disease, length of hospitalization, ICU admission and mortality observed in CKD patients. 16 We observed 5 deaths (38.4%), 8 ICU admissions (61.5%), 3 ventilator requirements (23.0%) in this subgroup. Ten out of the thirteen SARS-CoV-2 pneumonia were reported in CKD Stage 5. A study by Carlson, et al. reported a similar pattern where they reported that eGFR was inversely associated with the rate of hospital diagnosed COVID-19. 17 However, the sample size is too small for any conclusions and the authors advocate for a separate study on this emerging topic. Otherwise, the most commonly isolated organism was Streptococcus pneumoniae similar to other studies 8 with a frequency of 8 (10.2%). We also tried to assess the pattern of antibiotics use in hospitalized pneumonia patients with CKD receiving maintenance hemodialysis and compared it to the CKD patients not under dialysis. Two-drug combination therapy was mostly preferred in both maintenance hemodialysis and not under dialysis groups which were 26 (56.5%) and 18 (56.2%) respectively. The most commonly used dual therapy in either group was a combination of Beta-Lactam and Macrolide which was 13 (28.3%) and 12 (37.5%) in maintenance hemodialysis and not under dialysis groups respectively. The use of multidrug (more than 2 antibiotics) for the treatment of pneumonia was higher in CKD patients under maintenance hemodialysis which was 16 (34.8%) than pneumonia patients with CKD and not under dialysis which was 9 (28.1%). This is probably because hemodialysis is associated with increased infection-related comorbidities as well as multidrugresistant organisms. 8, 11 This study has a few limitations. First, this is a retrospective study conducted in a single institution and many data were subjectively evaluated. Secondly, the severity index of pneumonia (PSI) was not taken into account due to the lack of medical records. This could affect certain outcomes especially the length of hospital stay, ICU and ventilator requirement and in-hospital mortality. Finally, not all the medical records had culture reports, therefore the isolated organisms reported in our study may not represent the true picture. Therefore careful interpretation and application of the findings of this study are advised. In conclusion, the prevalence of pneumonia in CKD was much higher in our study compared to another similar national study. CKD and Infectious Diseases in Asia Pacific: Challenges and Opportunities Risk of pneumonia among patients with chronic kidney disease in outpatient and inpatient settings: a nationwide populationbased study. Medicine (Baltimore) Prevalence of Respiratory Manifestations in Chronic Kidney Diseases; A Descriptive Cross-sectional Study in A Tertiary Care Hospital of Nepal The influence of uraemia and haemodialysis on neutrophil phagocytosis and antimicrobial killing Uremia impairs monocyte and monocyte-derived dendritic cell function in hemodialysis patients B lymphopenia in uremia is related to an accelerated in vitro apoptosis and dysregulation of Bcl-2 T-cell activation follows Th1 rather than Th2 pattern in haemodialysis patients Infections in hemodialysis: a concise review -Part 1: bacteremia and respiratory infections Infections in hemodialysis: a concise review. Part II: blood transmitted viral infections Chronic Kidney Disease, Dialysis, and Transplantation Clinical characteristics of patients with hemodialysis-associated pneumonia compared to patients with non-hemodialysis community-onset pneumonia Pneumonia in incident dialysis patients-the United States Renal Data System Epidemiology, clinical features and outcomes of pneumonia in patients with chronic kidney disease Risk factors of treatment failure in community acquired pneumonia: implications for disease outcome CKD and risk of hospitalization and death with pneumonia Clinical features, management, and outcome of hemodialysis patients with SARS-CoV-2