Research Article: Previously-initiated hemodialysis as prognostic factor for in-hospital mortality in pneumonia patients with stage 5 chronic kidney disease: Retrospective database study of Japanese hospitals

Date Published: February 28, 2019

Publisher: Public Library of Science

Author(s): Daisuke Takada, Susumu Kunisawa, Kiyohide Fushimi, Yuichi Imanaka, Wisit Cheungpasitporn.


Some clinicians keep patients in stage 5 chronic kidney disease (CKD) without hemodialysis for a while. This study investigated whether previously-initiated hemodialysis in stage 5 CKD patients may become a prognostic factor for in-hospital mortality due to pneumonia.

Patient data were obtained from the multi-institutional diagnosis procedure combination database between April 1, 2012 and March 31, 2016. The patients had records of pneumonia as both trigger and major diagnoses and records of end stage renal disease (ESRD) or stage 5 CKD as a comorbidity or other diagnoses on admission and aged 18 years or older. The following factors were adjusted: age, sex, body mass index, Barthel index, orientation disturbance, arterial oxygen saturation, systolic blood pressure, C-reactive protein level or the extent of consolidation on chest radiography, ambulance use, hospitalization within 90 days, and comorbidities upon admission. The primary outcome measure was all-cause in-hospital mortality obtained via multivariable logistic regression analysis using four Models. Model 1 involved complete case analysis with overlapping; one hospitalization per patient was counted as one. Model 2 involved a complete case analysis without overlapping; only the first hospitalization per patient was counted. Model 3 involved multilevel analysis clustered by hospital codes. Model 4 was created after multiple imputation for lacking adjusted factors.

A total of 907 hospitals and 7,726 patients were identified. Hemodialysis was significantly associated with lower in-hospital mortality in all models (odds ratio [OR] = 0.68, 95% confidence interval [CI]: 0.54–0.87 in Model 1; OR = 0.71, 95% CI: 0.55–0.91 in Model 2; OR = 0.67, 95% CI: 0.52–0.86 in Model 3; and OR = 0.68, 95% CI: 0.54–0.87 in Model 4).

Previously-initiated hemodialysis may be an independent prognostic factor for in-hospital mortality in pneumonia patients with end-stage renal disease. This should be borne in mind when considering the time of initiation of dialysis.

Partial Text

End-stage renal disease (ESRD) is one of the leading causes of morbidity and mortality worldwide [1]. The prevalence of ESRD and use of renal replacement therapies (RRTs) such as hemodialysis are expected to increase rapidly, and the number of patients who need RRT will more than double to approximately 5.4 million by 2030 [1]. Some countries, including Japan, have high prevalence of RRT [2]. Furthermore, it is of great concern that the mortality rate due to infection among patients with initiated dialysis has increased year after year [3, 4], and another paper reported that death from pneumonia comprised 46.1% of all infectious disease deaths among dialysis patients in Japan [5].

A total of 907 hospitals and 8,412 patients with ESRD who were admitted due to pneumonia were identified from the DPC database. We excluded patients who were on peritoneal dialysis (n = 314), those who received renal transplant (n = 75), those older than 95 years (n = 66), and whose LOS was less than 3 days (n = 231). Moreover, patients with missing data were not included (n = 2,433). Thus, 5,293 patients were finally included in the complete case analysis (Fig 1). Missing pattern table are shown in S1 Fig.

This multicenter study showed that previously initiated hemodialysis was associated with low in-hospital mortality among patients with stage 5 CKD who were admitted due to pneumonia, after adjusting for relevant confounding factors such as the severity of pneumonia and activities of daily living. The good effect of hemodialysis was similar among the four models.

In conclusion, our findings suggest that previously-initiated hemodialysis is an independent prognostic factor for in-hospital mortality in pneumonia patients with ESRD. This should be borne in mind when considering the time when dialysis was initiated. There is also a need for further studies; if possible, randomized control trials with reduced selection bias should be conducted to explore it further.




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