The growing economic burden of diabetic kidney disease

Diabetes, a cardinal cause of chronic kidney disease, is the most common cause of end-stage renal disease. In the Medicare program, non-dialysis-requiring chronic kidney disease, diabetes, and congestive heart failure account for close to two thirds of all costs, and 4.2% of individuals with diabetes and chronic kidney disease account for 13.4% of expenditures. Diabetes is present in approximately 60% of new dialysis patients in the United States, and although the prevalence of renal replacement therapy remains comparatively low, rising prevalence rates may have substantial economic implications, especially when one considers that renal replacement therapy accounts for about 6% of current Medicare expenditures. Among dialysis patients, the presence of diabetes is associated with expenditures that are approximately 27% higher than in patients without diabetes. Interventions that successfully prevent the development or progression of both conditions have the potential to substantially reduce global health care costs.     

Modern nephrology--new methods, new treatments and still numerous difficult challenges

In the current decade, 2001 to 2010, the number of patients undergoing renal replacement therapy worldwide will increase from 1.5 to 2.5 mln. This requires considerable financial input, thus limiting treatment access in 90% to the inhabitants of North America, Europe and Japan, that constitutes less than 20% of the world's population. It is presumed that about 1 mln people die every year, a death rate which could be avoidable, were the proper funds for renal replacement therapy obtained. Over the last five years, Poland has joined the elite group of countries fully covering the needs in this respect. Modern nephrology gradually focuses on reducing the incidence of end-stage renal disease, through more effective treatment of diabetes, glomerulonephritis and polycystic kidney disease. Reducing morbidity and mortality rates in dialysis treatment and post-kidney transplant follow-up is another key issue. This overview discusses the modern options and perspectives to face those challenges.     

Renal replacement therapy for patients with diabetes mellitus in Hong Kong

Diabetes mellitus is becoming the most common cause of end-stage renal failure in Hong Kong. This review is based on data from the Hong Kong Renal Registry from 1995 through 2000. As of March 31, 2000, a total of 1026 patients with diabetes mellitus were on renal replacement therapy. A total of 809 patients had diabetic nephropathy as primary disease and 217 had diabetes mellitus as comorbidity. The prevalence of renal replacement therapy for patients with diabetes mellitus was 151 per million population. For the year ending March 31, 2000, there were 342 new patients with diabetes mellitus requiring renal replacement therapy. Of all the patients on renal replacement therapy, 23% were diabetic. The patients with diabetes mellitus were older (median age, 63 years), and had a higher incidence of hypertension (85%), ischemic heart disease (24%), cerebrovascular disease (9%), and peripheral vascular disease (3%). The modes of renal replacement therapy for patients with diabetes mellitus were peritoneal dialysis (81%), hemodialysis (9%), and transplant (10%). The annual crude mortality rate of patients with diabetes mellitus was 16% (peritoneal dialysis, 17%; hemodialysis, 18%; transplant, 1%) compared with 6% for patients without diabetes mellitus (peritoneal dialysis, 8%; hemodialysis, 12%; transplant, 1%). The major causes of death were cardiovascular disease (33%), infection (28%), and cerebrovascular event (8%). The 1-and 5-year survival rates of dibetic patient were 89% and 32% for peritoneal dialysis, 73% and 26% for hemodialysis, and 94% and 87% for transplant, respectively. The 1-and 5-year graft survival rates were 88% and 82% (death not censored), and 91% and 91% (death censored), respectively.     

Renal replacement therapy in Slovenia: 2003 annual report

The total number of end-stage renal disease patients treated by renal replacement therapy increased from 1584 on 31 December 2002 to 1661 on 31 December 2003 (4.9% increase). Of these patients, 70.5% were treated by hemodialysis, 7.0% by peritoneal dialysis and 22.5% had a functioning renal graft. The patients were treated at 18 dialysis centers and one transplant center. The number of prevalent patients treated by renal replacement therapy per million of the population (p.m.p.) was 846 at the end of 2003. The number of incident (new) patients in 2003 was 131 p.m.p. The gross mortality rate of dialysis patients was stable through the years of the study and reached 11.8% in 2003. 57.6% of new patients starting hemodialysis were > or = 65 years old and 23.2% were diabetics. Epoetin therapy was prescribed to 89.8% of dialysis patients. The number of patients positive for hepatitis B or hepatitis C viruses is stable and low (3.1% of all dialysis patients).     

Renal disease and the mouth

Oral manifestations of renal disease are common. They may present as unique signs of multi-system disease affecting the kidneys (such as vasculitis), or as common oral pathologies found at an increased prevalence in patients with end-stage renal disease. Despite more oral and dental disease in patients on renal replacement therapy, attendance at dental clinics is infrequent, and physician awareness of the problem is low. In our short review, aimed at renal, transplant, and general physicians, we discuss the link between clinical changes in the mouth and multi-systemic disease involving the kidney. We suggest a standardized approach to oral examination to increase diagnostic yield and discuss common oral complications in patients on dialysis or successfully transplanted. Finally, we suggest potential treatments for oral disease that nephrologists might safely institute.     

Dialysis patients refusing kidney transplantation: data from the Slovenian Renal Replacement Therapy Registry

Kidney transplantation is considered the best renal replacement therapy (RRT) for patients with end-stage renal disease; nevertheless, some dialysis patients refuse to be transplanted. The aim of our registry-based, cross-sectional study was to compare kidney transplant candidates to dialysis patients refusing transplantation. Data were collected from the Slovenian Renal Replacement Therapy Registry database, as of 31 December 2008. Demographic and some RRT data were compared between the groups. There were 1448 dialysis patients, of whom 1343 were treated by hemodialysis and 105 by peritoneal dialysis (PD); 132 (9%) were on the waiting list for transplantation, 208 (14%) were preparing for enrollment (altogether 340 [23%] dialysis patients were kidney transplant candidates); 200 (13.7%) patients were reported to refuse transplantation, all ≤ 65 years of age; 345 (24%) were not enrolled due to medical contraindications, 482 (33%) due to age, and 82 (6%) due to other or unknown reasons. No significant difference was found in age, gender, or presence of diabetes between kidney transplant candidates vs. patients refusing transplantation (mean age 50.5 ± 13.9 vs. 51.3 ± 9.6 years, males 61% vs. 63%, diabetics 18% vs. 17%). The proportion of patients ≤ 65 years old who were refusing transplantation was 28% (187/661) for hemodialysis and 17% (13/79) for PD patients (P = 0.03). There is a considerable group of dialysis patients in Slovenia refusing kidney transplantation. Compared to the kidney transplant candidates, they are similar in age, gender and prevalence of diabetes. Patients treated by peritoneal dialysis refuse kidney transplantation less often than hemodialysis patients.     

Comparison of the course to end-stage renal disease of Type 1 (insulin-dependent) and Type 2 (non-insulin-dependent) diabetic nephropathy

Summary Is the course leading to diabetic end-stage renal disease similar for Type 1 (insulin-dependent) and Type 2 (non-insulin-dependent) diabetes mellitus? We identified all diabetic end-stage renal disease patients starting renal replacement therapy from 1989 to 1991 in two urban counties in Texas. Three ethnic/racial groups were enrolled: Mexican Americans, non-Hispanic Whites, African Americans. Patients were interviewed and their medical records, both inpatient and out-patient, were abstracted for relevant diagnostic and therapeutic information. We attempted to obtain records as far back as the onset of diabetes or hypertension and from all physicians who had cared for the patient. An historical algorithm was used to determine diabetic type. Of the patients enrolled, 91 were Type 1 and 438 were Type 2 diabetic patients. Type 1 diabetic patients had higher mean glucose levels in the first 10 years of diabetes (16.3 vs 11.4 mmol/l) but lower systolic blood pressures (148 vs 157 mmHg). The duration of diabetes prior to end-stage renal disease was longer for Type 1 than Type 2 patients (22 vs 17 years). Type 1 diabetic patients were more likely to have other microvascular complications (retinopathy, neuropathy, gastroparesis), less likely to have coronary disease (myocardial infarction and congestive heart failure), and had similar rates of stroke and vascular surgery procedures (carotid endarterectomy, coronary artery bypass surgery, aortofemoral bypass). Type 1 and Type 2 diabetic patients were just as likely to have a first degree relative with hypertension (60.5 vs 65.5%). The late manifestations of end-stage renal disease were similar between the two groups (kidney size, proteinuria, slope of the inverse of creatinine, laboratory data prior to end-stage renal disease, reasons for starting dialysis). The course to end-stage renal disease may be different for Type 1 and Type 2 diabetes, with hyperglycaemia playing a more dominant role in Type 1 and hypertension playing a more dominant role for Type 2. The Type 1/Type 2 differences in patterns of other diabetic complications add weight to this hypothesis. However, the late course of the renal disease and the end result on the kidney is very similar.     

The timing of dialysis and kidney transplantation in type 1 diabetes

Despite significant improvements in the treatment of diabetic nephropathy over the last 20 years, patients with type 1 diabetes are at high risk of developing end-stage renal disease (ESRD) and high mortality once ESRD develops. The timing of dialysis initiation has occurred earlier over the years, but a recent study has led to a re-evaluation of that approach. People with type 1 diabetes treated with pre-dialysis (pre-emptive) transplantation have a lower death rate than people with type 1 diabetes treated with dialysis. Living donor kidney transplantation is possible before starting dialysis and is associated with better kidney and patient outcomes as compared to transplantation while on dialysis. Multiple barriers remain that prevent people with type 1 diabetes from enjoying the reduced risk of death afforded by a pre-emptive kidney transplant, including lack of knowledge by primary care physicians, endocrinologists and nephrologists, late referral for transplantation, patient and family misconceptions about timing of transplantation and who can be a donor. New data on both the optimal time to initiate dialysis or to pursue transplantation will be reviewed.     

Considerations in the optimal preparation of patients for dialysis

Every year, more than 110,000 Americans are newly diagnosed with end-stage renal disease and in the overwhelming majority, maintenance dialysis therapy is initiated. However, most patients, having received no predialysis nephrology care or dietary counseling, are inadequately prepared for starting treatment; furthermore, the majority of patients do not have a functioning permanent dialysis access. Annualized mortality in the USA in the first 3 months after starting dialysis treatment is approximately 45%; this high rate is possibly in part due to inadequate preparation for renal replacement therapy. Data from the Dialysis Outcomes and Practice Patterns study suggest that similar challenges exist in many parts of the world. Implementation of strategies that mitigate the risk of adverse consequences when starting dialysis are urgently needed. In this Review we present a step-by-step approach to tackling inadequate patient preparation, which includes identifying individuals with chronic kidney disease (CKD) who are most likely to need dialysis in the future, referring patients for education, timely placement of dialysis access and timely initiation of dialysis therapy. Treatment with dialysis might not be appropriate for some patients with progressive CKD; these individuals can be optimally managed with nondialytic, maximum conservative management.     

Long-term outcome of kidney transplantation in patients with hepatitis C virus infection

BACKGROUND/AIMS: The impact of HCV (hepatitis C virus) infection on the long-term outcome of kidney transplant patients is controversial. METHODOLOGY: Eighty-four renal allograft recipients who were seronegative for hepatitis B surface antigen and had been screened for antibody to hepatitis C virus (anti-HCV) were included. The outcome and survival were compared between anti-HCV-positive (n = 30, group 1) and anti-HCV-negative (n = 54, group 2) kidney transplant patients. Group 1 patients were further compared to 52 anti-HCV-positive end-stage renal disease patients (group 3) who were on chronic dialysis. RESULTS: Group 1 patients had a higher prevalence of chronic hepatitis than group 2 and group 3 patients did (67% vs. 2% and 31%). Liver-related complications and deaths between group 1 and group 2, and group 1 and group 3 patients were not significantly different. The comparisons of the long-term survival between these groups showed no significant differences, despite group 3 patients had a higher overall mortality rate. Cox regression analysis confirmed that age more than 45 years was the only independent factor that affected survival in anti-HCV-positive end-stage renal disease patients with or without kidney transplantation. CONCLUSIONS: HCV infection is not a contraindication to kidney transplantation. For anti-HCV-positive end stage renal disease patients, survival is better in younger patients, and is not influenced by kidney transplantation or continuing dialysis.     

Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization

BACKGROUND: Chronic kidney disease is the primary cause of end-stage renal disease in the United States. The purpose of this study was to understand the natural history of chronic kidney disease with regard to progression to renal replacement therapy (transplant or dialysis) and death in a representative patient population. METHODS: In 1996 we identified 27 998 patients in our health plan who had estimated glomerular filtration rates of less than 90 mL/min per 1.73 m(2) on 2 separate measurements at least 90 days apart. We followed up patients from the index date of the first glomerular filtration rates of less than 90 mL/min per 1.73 m(2) until renal replacement therapy, death, disenrollment from the health plan, or June 30, 2001. We extracted from the computerized medical records the prevalence of the following comorbidities at the index date and end point: hypertension, diabetes mellitus, coronary artery disease, congestive heart failure, hyperlipidemia, and renal anemia. RESULTS: Our data showed that the rate of renal replacement therapy over the 5-year observation period was 1.1%, 1.3%, and 19.9%, respectively, for the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) stages 2, 3, and 4, but that the mortality rate was 19.5%, 24.3%, and 45.7%. Thus, death was far more common than dialysis at all stages. In addition, congestive heart failure, coronary artery disease, diabetes, and anemia were more prevalent in the patients who died but hypertension prevalence was similar across all stages. CONCLUSION: Our data suggest that efforts to reduce mortality in this population should be focused on treatment and prevention of coronary artery disease, congestive heart failure, diabetes mellitus, and anemia.     

Nierenerkrankungen bei HIV-Infektion unter HAART

The introduction of highly active antiretroviral therapy (HAART) has dramatically changed the clinical course of human immunodeficiency virus (HIV) infection. With increasing life spans of HIV-infected individuals, treatment of chronic cardiovascular, liver, and kidney disease has become increasingly important in preventing morbidity and mortality in these patients. Renal disease is a common complication in HIV-infected patients. The causes and spectrum of kidney disease in these individuals is extensive and includes end-stage renal disease. Moreover, the classic risk factors for renal disease, such as hypertension and diabetes, increase with the longevity of HIV-infected patients. Renal replacement therapy for these patients has become routine in many dialysis centers, and HIV infection is no longer an absolute contraindication for renal transplantation. In the future, nephrologists will be involved more frequently in the treatment of HIV-infected patients.     

Meldung von Patienten zur Transplantation

Kidney transplantation is in most cases the first choice for renal replacement procedures for advanced chronic and end-stage renal failure and is clearly superior to chronic dialysis treatment with respect to long-term survival. As far back as 1999 Wolfe et al. reported that the long-term mortality (>18?months) of recipients of a kidney transplant from deceased donors was reduced by 68% compared to dialysis patients remaining on the waiting list for a kidney transplant. In the immediate postoperative period the mortality of transplantation patients initially increases compared to waiting list patients but as early as 244?days after transplantation this effect turns to the opposite so that the cumulative mortality after transplantation is lower than for dialysis patients. The best form of transplantation is a preemptive (living) transplantation because this is coupled with the best survival of both transplants and patients. This is independent of age, underlying disease and ethnicity etc. On the basis of these results and due to a general increase in dialysis patients in recent years the number of waiting list patients for kidney transplants continuously rose before a plateau was reached in the last 2?years. Even if individual studies could repeatedly show an advantage of kidney transplantation, the individual factors associated with a large or small advantage for transplantation have so far been insufficiently described. Furthermore, there are currently few data on how the relative advantage of transplantation compared to dialysis changes in the course of time. This is even more important with respect to the fact that dialysis patients are becoming older and have more comorbidities and the simultaneous increase in waiting time for kidney transplantation due to the lack of organs.     

Ambulatory blood pressure and the kidney

During the last few years there has been a renewed interest in blood-pressure-induced kidney damage, due to a progressive increase in the incidence and prevalence of hyipertension and vascular diseases as a cause of end-stage renal disease (ESRD). The need to prevent ESRD demands continued efforts to achieve the early identification of persons with hypertension who are at risk and to provide them with effective antihypertensive therapy. Ambulatory blood pressure monitoring (ABPM) has been used successfully to assess blood pressure values and identify risk markers for cardiovascular diseases. A logical approach would be to use it also to identify those for ESRD. For hypertensive and type 1 diabetics ABPM data usually have a stronger correlation to the presence and magnitude of microalbuminuria than do routine office blood pressure measurements. The best Pearson correlation coefficients for relationship between ambulatory blood pressure values and urinary excretion of albumin were obtained with nocturnal blood pressure regardless of whether systolic, diastolic or mean blood pressure were considered. Moreover, high percentages of non-dippers have been found among subjects with renal failure, subjects undergoing dialysis (haemofiltration, peritoneal dialysis, continuous ambulatory peritoneal dialysis (CAPD), subjects with renovascular hypertension and with cystic kidney disease, subjects who have had a kidney transplant and subjects with cyclosporine-induced hypertension. Finally, ABPM seems to be prognostic for development of proteinuria in some refractory hypertensives. Whether higher nocturnal blood pressure values and the non-dipping pattern constitute a cause or are consequences of renal disease should be addressed in prospective studies. Assessment of nocturnal blood pressure seems to be an important tool in the management of patients with hypertensive-related renal disease and of patients who are susceptible to developing it.     

Challenges of valve surgeries in post-renal transplant patients

Renal transplantation remains a mainstay of therapy for the end-stage renal disease. Cardiac disease has a high prevalence in this patient population. Cardiovascular disease remains the leading cause of death among kidney transplantation patients. The cardiac disease accounts for 43% of all-cause mortality among dialysis patients and for ≈38% of all-cause mortality after transplantation. In this article, we review the factors and outcomes associated with valve surgeries in renal transplant recipients and evaluate the strategy for open heart surgery after renal transplantation performed.     

Kidney Transplantation as Primary Therapy for End-Stage Renal Disease: A National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQI?) Conference

Background and objectives: Kidney transplantation is the most desired and cost-effective modality of renal replacement therapy for patients with irreversible chronic kidney failure (end-stage renal disease, stage 5 chronic kidney disease). Despite emerging evidence that the best outcomes accrue to patients who receive a transplant early in the course of renal replacement therapy, only 2.5% of incident patients with end-stage renal disease undergo transplantation as their initial modality of treatment, a figure largely unchanged for at least a decade.Design, setting, participants, & measurements: The National Kidney Foundation convened a Kidney Disease Outcomes Quality Initiative (KDOQI) conference in Washington, DC, March 19 through 20, 2007, to examine the issue. Fifty-two participants representing transplant centers, dialysis providers, and payers were divided into three work groups to address the impact of early transplantation on the chronic kidney disease paradigm, educational needs of patients and professionals, and finances of renal replacement therapy.Results: Participants explored the benefits of early transplantation on costs and outcomes, identified current barriers (at multiple levels) that impede access to early transplantation, and recommended specific interventions to overcome those barriers.Conclusions: With implementation of early education, referral to a transplant center coincident with creation of vascular access, timely transplant evaluation, and identification of potential living donors, early transplantation can be an option for substantially more patients with chronic kidney disease.Transplantation was the first successful modality of renal replacement therapy (RRT) for irreversible chronic kidney disease (CKD; stage 5); however, its broad applicability has been limited by immunologic rejection, adverse effects of immunosuppressant agents, and a relative shortage of available organs. After implementation of Medicare funding for RRT in 1972, long-term dialysis rapidly evolved as first-line treatment. In 1978, Rennie (1) summarized the prevailing situation: “Even although it offers a much better quality of life while it works, a transplant in most cases (of kidney failure) can be considered only a temporary respite from the basic form of treatment, which is dialysis.” Despite many remarkable advances during the past three decades, with transplantation now viewed unequivocally as offering the best survival and quality of life for candidates across all demographic groups, current practice remains that described by Rennie (2). Notwithstanding strong evidence that transplantation is most successful when implemented before onset of long-term dialysis, only 2.5% of patients with end-stage renal disease undergo transplantation as initial RRT (3–5).This persistent finding has been subject to numerous explanations, often subjective and speculative, and thus far not amenable to remedy. In response to this conundrum, the National Kidney Foundation (NKF) convened a conference to address the issue of early transplantation within its Kidney Disease Outcomes Quality Initiative (KDOQI) framework, held in Washington, DC, March 19 through 20, 2007. Fifty-two participants representing transplant centers, dialysis providers, and payers were divided into three working groups. The first (work group 1) addressed the issue of how optimally to position kidney transplantation within the current CKD staging and treatment paradigms (6). Work group 2’s task was to formulate recommendations regarding educational and training implications required to promote early transplantation. Finally, given the critical importance of fiscal issues in RRT, work group 3 evaluated how finances might impede access to transplantation for patients with CKD and was charged with formulating potential remedies. This article is a summary of the deliberations, findings, and recommendations of these three work groups.The first challenge for the conference was to determine the focus of deliberations: Was preemptive (before the onset of dialysis) or early (performed within the first 6 to 12 mo after initiation of dialysis) transplantation to be the primary concern? It was noted that both terms (preemptive and early) are adjectives that refer to the timing of transplantation and impart urgency to the process. Current data indicate recipient and allograft survival benefits for patients who receive a transplant within the first year of RRT; with each additional year of dialysis therapy, survival is compromised (7). Whether there are additional advantages associated with true preemptive transplantation, after correction for multiple interrelated risk factors, is less certain (8,9). Even so, it seems that patients and payers benefit from preemptive transplantation by avoiding medical complications and costs associated with initiation of dialysis, vascular access, and loss of employment; therefore, the participants chose to emphasize preemptive transplantation as the ideal, with the understanding that the unpredictability of advanced CKD and the shortage of organs from deceased donors necessitates that the next best option for many candidates will be transplantation as early in the course of RRT as possible.     

Percutaneous coronary intervention as a bridge to renal transplantation in a patient with end-stage renal disease--a case report

Renal transplantation is one of the preferred modes of replacement therapy in patients with end-stage renal disease. Cardiovascular disease remains the leading cause of morbidity and mortality in patients with end-stage renal disease and renal transplant recipients. The authors describe a patient with end-stage renal disease who developed unstable angina before renal transplantation. Emergent cardiac catheterization and percutaneous coronary intervention served as a bridge to his successful renal transplantation without complications.     

高龄终末期肾脏病患者肾脏替代治疗时机和治疗方式的选择

高龄(≥80岁)终末期肾脏病(ESRD)患者人数不断增加,年龄是透析患者生存率的独立危险因素,有关高龄ESRD患者治疗时机与治疗方式选择的报道较少。本文从保守治疗与肾脏替代治疗对高龄患者生存率的差异、透析时机对患者生活质量及预后的影响、肾脏替代治疗方式的选择、血液透析和腹膜透析治疗效果和并发症的差异等方面总结了国内外的相关文献报道,以期为高龄ESRD患者的治疗决策提供参考。     

Hepatitis C virus and kidney disease

Hepatitis C virus (HCV) infection remains frequent in patients on renal replacement therapy and has an adverse impact on survival in infected patients on chronic hemodialysis as well as renal transplant (RT) recipients. Nosocomial spread of HCV within dialysis units continues to occur. HCV is also implicated in the pathogenesis of renal dysfunction often mediated by cryoglobulins leading to chronic kidney disease as well as impairing renal allograft function. The role of antiviral therapy for hepatitis C in patients with renal failure remains unclear. Monotherapy with conventional interferon (IFN) for chronic hepatitis C is probably more effective in dialysis than in non-uraemic patients but tolerance is lower. Limited data only are available about monotherapy with pegylated interferon and combination therapy (pegylated IFN plus ribavirin) for chronic HCV in the dialysis population. Clinical experience with antiviral therapy for acute HCV in dialysis population is encouraging. Interferon remains contraindicated post-RT because of concerns about precipitating graft dysfunction. Sustained viral responses obtained by antiviral therapy in renal transplant candidates are durable after renal transplantation and may reduce HCV-related complications after RT (post-transplant diabetes mellitus, HCV-related glomerulonephritis, and chronic allograft nephropathy).     

Epidemiology of Acute Infections among Patients with Chronic Kidney Disease

The objectives of this review were (1) to review recent literature on the rates, risk factors, and outcomes of infections in patients who had chronic kidney disease (CKD) and did or did not require renal replacement therapy; (2) to review literature on the efficacy and use of selected vaccines for patients with CKD; and (3) to outline a research framework for examining key issues regarding infections in patients with CKD. Infection-related hospitalizations contribute substantially to excess morbidity and mortality in patients with ESRD, and infection is the second leading cause of death in this population. Patients who have CKD and do not require renal replacement therapy seem to be at higher risk for infection compared with patients without CKD; however, data about patients who have CKD and do not require dialysis therapy are very limited. Numerous factors potentially predispose patients with CKD to infection: advanced age, presence of coexisting illnesses, vaccine hyporesponsiveness, immunosuppressive therapy, uremia, dialysis access, and the dialysis procedure. Targeted vaccination seems to have variable efficacy in the setting of CKD and is generally underused in this population. In conclusion, infection is a primary issue when caring for patients who receive maintenance dialysis. Very limited data exist about the rates, risk factors, and outcomes of infection in patients who have CKD and do not require dialysis. Future research is needed to delineate accurately the epidemiology of infections in these populations and to develop effective preventive strategies across the spectrum of CKD severity.Recent data have reinforced the growing public health burden of chronic kidney disease (CKD). Between 1999 and 2004, an estimated 13% of the US adult population had CKD as compared with 10% in 1988 through 1994 (1). In 2005, approximately 485,000 people received renal replacement therapy, 340,000 of whom were receiving maintenance dialysis (2). It is currently projected that there will be approximately 710,000 prevalent end-stage renal disease (ESRD) patients by the year 2015 (3). The importance of this information on the changing epidemiology of kidney disease is that the advanced stages of CKD and ESRD (stage 5 CKD requiring renal replacement therapy) are associated with a marked increase in the risk for all-cause and cardiovascular morbidity and mortality (2,4). For patients who have ESRD and initiate maintenance dialysis, the overall 1-yr mortality rate is 20%, and the 5-yr mortality rate exceeds 60% (2). Importantly, there is a graded, increased risk in the annual incidence of all-cause mortality with declining glomerular filtration rate (GFR) among patients with mild to moderate CKD (4). Of interest, acute infections (bacterial, viral, and fungal) contribute substantially to the high rates of hospitalization and mortality in patients with ESRD (2). Limited existing data suggest that annual mortality rates in the dialysis population are increased by 10-fold for pneumonia and 100-fold for sepsis compared with the general population (5,6). Even less is known about the role of infections among patients with mild to moderate CKD.In this review, we examine the risks and associated complications of acute infections in patients with CKD and ESRD and discuss a proposed framework for addressing existing knowledge gaps in this area. For the purposes of this review, CKD refers to patients who are not receiving renal replacement therapy (i.e., dialysis or transplant), and ESRD refers to patients who have stage 5 CKD and are receiving maintenance dialysis (hemodialysis or peritoneal dialysis). Although the physiologic effects of kidney dysfunction are a continuum, a distinction between CKD requiring compared with not requiring dialysis therapy is made because the population characteristics and risk factors for infection differ in these populations, and outcomes among patients who receive dialysis are affected by both the underlying kidney disease and the dialysis therapy. The kidney transplant population is a separate subgroup of patients with ESRD, with unique risk factors for infection, and is not discussed in this review.For this review, we searched PubMed for relevant articles using the following keywords: “infection” “chronic kidney disease,” “end-stage renal disease,” “chronic renal failure,” “dialysis,” “vaccination,” “influenza vaccine,” “hepatitis B vaccine,” and “pneumococcal vaccine” through December 31, 2007. On the basis of a review of the titles and the abstracts of identified articles, articles were selected for full review. In addition, references from reviewed articles were hand searched for additional articles. Included in this review are the articles that we considered to be informative and relevant to the epidemiology of infections and efficacy of vaccinations in the setting of kidney disease.