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

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 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 Daisuke Takada1, Susumu Kunisawa1, Kiyohide Fushimi2, Yuichi Imanaka ID1* 1 Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto City, Kyoto, Japan, 2 Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, Yushima, Bunkyo-ku, Tokyo, Japan * OPEN ACCESS Citation: Takada D, Kunisawa S, Fushimi K, Imanaka Y (2019) 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. PLoS ONE 14(2): e0213105. https://doi.org/10.1371/journal. pone.0213105 Editor: Wisit Cheungpasitporn, University of Mississippi Medical Center, UNITED STATES Received: October 23, 2018 Accepted: February 14, 2019 Published: February 28, 2019 Copyright: © 2019 Takada et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: The Japanese government has made a law “Act on the Protection of Personal Information”, which restricts the use of personal information. Our dataset includes potentially sensitive information, such as diagnosis and medical histories regarded as “Special carerequired personal information” specified by the above law. And if our dataset would be combined with other datasets, it can be linked to personal identification. Moreover, our datasets were Abstract Background 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. Methods 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 inhospital 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. Results 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% PLOS ONE | https://doi.org/10.1371/journal.pone.0213105 February 28, 2019 1 / 12 Effects of hemodialysis on the in-hospital mortality of stage 5 chronic kidney disease patints with pneumonia collected from each hospital within the bounds of the ethical procedures of academic research and the data use were limited to the researchers listed on the research plan submitted in advance to the Ethics Committee. So our data are not permitted to release publicly. The Japanese ethical guideline “Ethical Guidelines for Medical and Health Research Involving Human Subjects” has imposed these restrictions in consistency with the law “Act on the Protection of Personal Information”. Requests to access the data should be submitted to Kyoto University Graduate School of Medicine/ Faculty General Affairs Division, Research Promotion Section. Email: . kyoto-u.ac.jp. Funding: Health Sciences Research Grants from the Ministry of Health, Labour and Welfare of Japan (H27-iryo-ippan-001, 7 H30-seisaku-shitei004), and a Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science(16H02634). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. 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). Conclusion 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. Introduction 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]. To reduce infection mortalities among patients with stage 5 chronic kidney disease (CKD), including ESRD, early initiation of dialysis might be beneficial. A well-known randomized controlled trial [6] showed no significant difference in all-cause mortality, infection mortality, and infection hospitalization between two groups: patients whose estimated glomerular filtration rates (eGFRs) were 10.0 to 14.0 mL per minute, which represents the early initiation of hemodialysis, and those with eGFRs between 5.0 to 7.0 mL per minute. However, the conclusion of this trial remains controversial due to sampling bias, because about three-quarters of the screened patients were excluded from the analysis due to physician decision, cancer comorbidity, declined participation, and other reasons. Pneumonia is a frequently occurring and critical infectious disease, and mortality rates due to pneumonia are higher among patients with ESRD than among the general population [7, 8]. Ure (...truncated)