Urinary tract infections in patients with renal insufficiency and dialysis - epidemiology, pathogenesis, clinical symptoms, diagnosis and treatment

Jürgen E Scherberich, Reinhard Fünfstück, Kurt G Naber, Jürgen E Scherberich, Reinhard Fünfstück, Kurt G Naber

Abstract

Epidemiological studies show an increasing number of patients worldwide suffering from chronic kidney diseases (CKD), which are associated with a risk for progression to end-stage kidney disease (ESKD). CKD patients stage 2-5, patients with regular chronic dialysis treatment (hemo- or peritoneal dialysis), and patients suffering from kidney allograft dysfunction are at high risk to develop infections, e.g. urinary tract infections (UTI) and/or sepsis (urosepsis). These groups show metabolic disturbance, chronic inflammation, and impaired immunocompetence. Escherichia coli is still the most common pathogen in UTI. A wide variety of other pathogens may be involved in UTI. Urological interventions, catheterization, as well as repeated courses of antibiotics contribute to an increased challenge of antimicrobial resistance. The diagnosis of UTI in CKD is based on standard clinical and laboratory criteria. Pyuria (≥10 leucocytes/µl) is more often observed in patients with oligoanuria and low bacterial colony counts. The treatment strategies for this population are based on the same principles as in patients with normal renal function. However, drugs cleared by the kidney or by dialysis membranes need dose adjustment. Antimicrobials with potential systemic toxicity and nephrotoxicity should be administered with caution.

Keywords: antibiotic therapy; bacterial interstitial nephritis; chronic renal failure; end-stage kidney disease; microbial resistance; pyelonephritis; pyuria; renal replacement therapy; risk profiles; urinary tract infection.

Conflict of interest statement

JS declares that he has no competing interests. RF reports consulting fees within the last two years (2019, 2020) from Novartis Pharma GmbH and Boehringer. KN reports personal consulting fees within the last two years (2019, 2020) from Adamed, Biomerieux, Bionorica, Eumedica, Hermes, Immunotek, Janssen, Klosterfrau, Medice, OM Pharma.

Copyright © 2021 Scherberich et al.

Figures

Table 1. Staging system for chronic kidney…
Table 1. Staging system for chronic kidney disease, K/DOQI, KDIGO [1]
Table 2. Incidence rates of various kidney…
Table 2. Incidence rates of various kidney diseases with potential progression to end-stage kidney disease; results of the German Dialysis Registry for the years 2000 and 2004 [2]
Table 3. Immunological factors contributing to UTI…
Table 3. Immunological factors contributing to UTI in chronic renal failure, following kidney transplantation and in chronic dialysis patients
Table 4. Selected natural (intrinsic) defensins involved…
Table 4. Selected natural (intrinsic) defensins involved to overcome UTI
Table 5. Recommendations for routine and advanced…
Table 5. Recommendations for routine and advanced diagnostics of UTI in patients with CKD
Table 6. Antimicrobial agents for treatment of…
Table 6. Antimicrobial agents for treatment of UTI: Dosing requirements in patients with chronic renal failure [71], [72]
Table 7. Dialysance of antimicrobial agents in…
Table 7. Dialysance of antimicrobial agents in patients undergoing hemodialysis treatment [79], [74]

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