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Therapeutic Apheresis and Dialysis 2014; 18(4):326–333 doi: 10.1111/1744-9987.12143 © 2013 The Authors Therapeutic Apheresis and Dialysis © 2013 International Society for Apheresis
Serum Creatinine and Albumin Decline Predict the Contraction of Nosocomial Aspiration Pneumonia in Patients Undergoing Hemodialysis Hitoshi Minakuchi, Shu Wakino, Koichi Hayashi, Hajime Inamoto, and Hiroshi Itoh Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
Abstract: Aspiration pneumonia (AP) is prevalent in older adults and the hemodialysis (HD) population has been getting older. Therefore, it is speculated that increasing number of HD patients would suffer from AP. However, the clinical aspects of AP in HD patients have not been elucidated. Consecutive HD patients with nosocomial AP hospitalized in our university hospital from April 2007 to December 2008 were recruited. Their clinical characteristics, risk factors for contraction, and the fatality of AP and treatment options were described. Nineteen out of 356 hospitalized HD patients had AP and 8 out of 19 AP patients died, indicating the incidence rate and fatality rate were 5.34% and 42.1%, respectively. Multiple regression analysis revealed that the risk factors for contracting AP included age, body mass index, serum creatinine levels (Cre) and the
monthly decline rate of Cre. It also revealed that serum albumin (Alb) and basal total cholesterol levels, the decline rate of Alb and Cre levels, and the duration of AP were independent risk factors for fatality. Survivors were most often treated with tube feeding. Both contraction rate and fatality of nosocomial AP were high among HD patients. Both the malnutrition as well as the decline rate for nutrition and muscle volume indicated by falls in Alb and Cre, respectively, had clinical relevance in AP. Maintaining nutritional state by tube feeding and muscle volume seems to be the mainstay for the prevention and the treatment of AP in HD patients. Key Words: Aspiration pneumonia, Hemodialysis, Infection, Nosocomial pneumonia, Nutrition, Protein energy wasting.
The leading cause of death of hemodialysis (HD) patients after congestive heart failure is infectious disease. HD patients are particularly predisposed to infection. In addition, patients undergoing dialysis are in a protein-energy wasting state (PEW), in which patients are susceptible to sarcopenia due to the increased muscle protein degradation. Malnutrition causes impaired immune function and poor wound healing. Several mechanisms are involved in this condition, including activation of oxidative stress, inflammatory response, and the dialysis measure itself. Regarding infectious diseases, it has been reported that approximately 20% of infectious deaths in end-stage renal disease (ESRD) are attributed to pneumonia. Mortality of pulmonary infection in HD patients has been reported to be 14 to 16 times higher than in the general population (1). An increased
susceptibility to infections has been ascribed partly to old age, a high prevalence of diabetes, defective phagocytic function of granulocytes, and frequent exposure to potential infectious risk factors during the normal course of dialysis therapy (2). Among pneumonia infections, aspiration pneumonia (AP) should be emphasized in the recent increase in the aged HD population because, in general, aged patients are susceptible to AP due to swallowing dysfunction. The reasons for dysphagia in aged patients consist of neurological dysfunction due to cerebral infarction, cognitive deficit, and muscle weakness. Since HD patients are susceptible to sarcopenia and malnutrition, these changes predict the risk of development of AP. However, there have been no reports demonstrating the clinical relationship between malnutrition and contraction of AP. In this report, we surveyed nosocomial AP in HD patients at a university hospital and identified risk factors.We found that decreased rates of albumin and creatinine—which could be indicators for malnutrition and loss of muscle mass after the occurrence
Received January 2013; revised August 2013. Address correspondence and reprint requests to Dr Shu Wakino, MD, Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan. Email: [email protected]
326
Aspiration Pneumonia in Hemodialysis of pneumonia—were identified as independent risk factors for fatality from AP. In describing the clinical course of our patients, we stress that nutritional care is important to prevent AP in nosocomial situations in HD patients. PATIENTS AND METHODS Patients This research was conducted retrospectively at Keio University Hospital in Japan, from April 2007 to December 2008. A total of 335 consecutive patients undergoing HD who needed hospitalization were recruited, and 19 patients with AP were selected. All the studies were conducted after obtaining informed consent from each participant. Diagnosis of nosocomial pneumonia We checked past medical records and surveyed results of sputum culture examinations obtained from all patients suspected of having an upper respiratory infection. This investigation aimed to elucidate the clinical picture of the patients under chronic dialysis therapy. Immune-compromised patients, due to cancer chemotherapy or malnutrition by surgical procedure and not because of renal insufficiency alone, were excluded. The patients with acute renal failure who had just begun HD were also excluded from the further analysis. Specimens were obtained twice from each patient to confirm the diagnosis. The diagnosis of infectious pneumonia combines clinical, laboratory microbiological data, and confirmatory chest radiographic findings. A compatible clinical picture included fever, cough and/or auscultatory findings such as rales and/or evidence of pulmonary consolidation. Sputum specimens were washed, Gram-stained, and cultured quantitatively. Since the purpose of this study is to survey the related organisms for pneumonia in HD patients, all the organisms present in the specimen when the patients were clinically diagnosed with pneumonia were regarded as pathogens. Therefore, in some cases, several organisms were related to pneumonia. Diagnosis of AP The diagnostic criteria of AP are advocated by a pulmonary disease swallowing research group, and both definite and probable AP cases detailed below were included in our study. Definite cases satisfy one of these two criteria: (i) pneumonia after direct observation of aspiration, and (ii) pneumonia with aspiration substances in the trachea. The criteria for probable AP cases are: (i) that the pneumonia does © 2013 The Authors Therapeutic Apheresis and Dialysis © 2013 International Society for Apheresis
327
not satisfy one of the abovementioned two criteria for definite cases; and (ii) that it fulfills one of these conditions: (i) old or acute cerebral infarction, (ii) degenerative neurological diseases or neuromuscular disease, (iii) disturbance of consciousness or severe dementia, (iv) digestive disease that can be the cause of vomiting or reflux esophagitis including postgastrectomy, (v) oral, pharyngeal or mediasternal tumor and trancheoesophageal fistula, (vi) tracheotomy, (vii) tubal feeding from nasal tube, or (viii) other basal diseases that can be the cause of swallowing function disorders. The diagnostic criteria of pneumonia are satisfied if the following are true: (i) pneumonia image in chest radiography or computed tomography (CT); and (ii) two out of four requirements are met, which are: (i) fever greater than 37.5°C, (ii) high level of C-reactive protein, (iii) number of peripheral leukocytes more than 9000/μL, and (iv) respiratory tract symptoms such as expectoration. Information on gender, HD vintage, primary disease, comorbidity, cause of hospitalization, pathogenic bacteria, nutrition administration, and antibiotics were analyzed as well as age. We reviewed the laboratory test results from three separate events: at admission, onset of pneumonia, and 2 weeks after the onset of pneumonia. For the choice of antibiotics, we examined sputum cultures and selected antibiotics with reference to the guideline, which recommends penicillin with β-lactamase inhibitor for first choice and cephalosporins of third generation or carbapenem with clindamycin for the next choice. We could check the results of sputum culture 2 or 3 days after the onset, and decided the de-escalation or escalation of antibiotics, considering the clinical course. To conduct the clinical study, the authors adhered to the Declaration of Helsinki and this study protocol was approved by the Ethical Committee of Keio University. Analysis of risk factors for contraction of and fatality from AP Predialysis blood samples were drawn immediately before the initiation of dialysis on the first day during the first weekly session. First, we examined several parameters related to AP and the difference in these values between the 19 affected and 316 unaffected patients with AP. Values examined included age, dialysis vintage, body mass index (BMI), number of lymphocytes, hemoglobin, plasma levels of total protein, albumin, blood urea nitrogen (BUN), creatinine, total cholesterol, calcium, glutamicoxaloacetic transaminase (GOT), glutamic-pyruvic transaminase (GPT), and the monthly change rate of serum levels of creatinine.
Ther Apher Dial, Vol. 18, No. 4, 2014
328
H Minakuchi et al.
Furthermore, we performed logistic regression analysis by using variables significantly different between the patients with and without AP, and determined the risk factors for contraction rate of AP. Next, we compared several parameters at the onset of AP between 11 living and eight deceased patients with AP. Parameters we used included age, dialysis vintage, BMI, the number of lymphocytes, hemoglobin, plasma levels of total protein, albumin, creatinine, total cholesterol, calcium, phosphate, and the monthly change rate of serum levels of creatinine. Logistic regression analysis was performed by using variables significantly different between the living and deceased cases, and the risk factors for AP mortality were determined. We further analyzed whether factors related to the clinical course after the onset of AP pose more risk factors for fatality. Therefore, we performed logistic regression analysis by using the monthly decline rate of serum levels of albumin and creatinine as well as the duration of AP. Statistics Discrete variables were expressed as counts (percentage) and continuous variables as mean ± SD. We first described the baseline characteristics of the study participants and then evaluated the association between the fatality or incidence rate and variables. The Mann–Whitney test was used for the analysis of parameters between the cases of AP and the controls, and between the living and deceased cases. Using the statistically significant parameters, multiple logistic
TABLE 1.
#1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14 #15 #16 #17 #18 #19
regression analysis was performed to analyze the risk factors. Fisher’s exact probability test was used for the analysis of the relationship between antibiotics or pathogenic bacteria and fatality. A statistically significant level of P < 0.05 was used. The statistical analyses were performed using StatView J-4.5 statistical software (Abacus Concepts, Piscataway, NJ, USA). RESULTS The clinical characteristics of nosocomial AP in HD patients We enrolled a total of 356 patients hospitalized at Keio University hospital from April 2007 to December 2008. The incidence rate of AP was 5.34% (N = 19, Table 1). Mean age was 76.8 ± 1.74 years old, and 13 out of 19 patients were male. The mean duration of dialysis period was 35.8 ± 7.8 months. Mean BMI of patients was 18.4 ± 0.519 (kg/m2). These data suggest that this complication was one of the problems in thin and aged patients shortly after initiation of HD. Eight patients were diabetic (42.1%) (Table 2). Since we focused on nosocomial AP, various causes for hospitalization other than pulmonary complications are listed in Table 1, including peripheral artery disease (PAD), cerebrovascular disease, and heart failure. The direct causes for AP of each case are also listed.These were classified into three categories: (i) malnutrition due to long-term diet prohibition or appetite loss (14 cases), (ii) cerebrovascular
List of patients, nutrition management, and prognosis
Cause of hospitalization
Putative causative factors for aspiration
Nutrition management means and timing (start after hospitalization)
Outcome
SAH Stroke Stroke Stroke Sick sinus syndrome Heart failure Acute MI Pneumonia Pneumonia Renal Abscess PAD PAD PAD PAD Shunt failure Shunt failure Gastric ulcer Galbladder polyp Ileus
Appetite loss Dysphagia Loss of consciousness Dysphagia Appetite loss Appetite loss Long term diet prohibition Neurological disease Appetite loss Appetite loss GI bleeding, long term diet prohibition Appetite loss narcotics Appetite loss narcotics Appetite loss narcotics Cerebrovascular accident Appetite loss Long term diet prohibition Long term diet prohibition Long term diet prohibition
Oral intake 8 days Tube feeding 14 days IVH 6 days and tube feeding 14 days Tube feeding 10 days Oral intake 11days Tube feeding 8 days Tube feeding 13 days Oral intake 7 days Oral intake 14 days Tube feeding 9 days Oral intake 12 days Failure in tube feeding and IVH 19 days IVH 8 days Oral intake 15 days and IVH 24 days Tube feeding 7 days and IVH 31 days IVH 10 days IVH 13 days IVH 5 days IVH 10 days
Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Dead Dead Dead Dead Dead Dead Dead Dead
IVH, intravenous hyperalimentation; MI, myocardial infarction; PAD, peripheral artery disease; SAH, subarachnoid hemorrhage.
Ther Apher Dial, Vol. 18, No. 4, 2014
© 2013 The Authors Therapeutic Apheresis and Dialysis © 2013 International Society for Apheresis
Aspiration Pneumonia in Hemodialysis TABLE 2.
329
The comparison of various parameters between hemodialysis (HD) patients with and without aspiration pneumonia (AP)
Parameters Age HD duration (months) BMI Number of lymphocytes (/mm3) Hemoglobin (g/dL) Total protein (mg/dL) Albumin (mg/dL) Creatinine (mg/dL) Total cholesterol (mg/dL) Calcium (mg/dL) Phosphate (mg/dL) GOT (IU/L) GPT (IU/L) Decline rate in creatinine for a month (mg/dL/month) HD time (hour/week) Kt/V
Affected patients
Unaffected patients
P
76.8 ± 1.74 35.8 ± 7.08 18.4 ± 0.519 655 ± 50.4 9.3 ± 0.27 6.2 ± 0.14 2.9 ± 0.09 6.7 ± 0.34 146 ± 8.76 9.0 ± 0.19 4.5 ± 0.27 27 ± 5.3 14 ± 3.1 0.51 ± 0.13
62.4 ± 2.94 108.5 ± 24.7 21.4 ± 0.583 881 ± 72.4 9.8 ± 0.25 6.5 ± 0.16 3.6 ± 0.13 9.7 ± 0.42 165 ± 6.68 9.1 ± 0.13 4.7 ± 0.26 15 ± 1.3 9.9 ± 0.97 0.15 ± 0.072
0.0001 0.0001 0.0001 0.0385 0.194 0.137
Therapeutic Apheresis and Dialysis 2014; 18(4):326–333 doi: 10.1111/1744-9987.12143 © 2013 The Authors Therapeutic Apheresis and Dialysis © 2013 International Society for Apheresis
Serum Creatinine and Albumin Decline Predict the Contraction of Nosocomial Aspiration Pneumonia in Patients Undergoing Hemodialysis Hitoshi Minakuchi, Shu Wakino, Koichi Hayashi, Hajime Inamoto, and Hiroshi Itoh Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan
Abstract: Aspiration pneumonia (AP) is prevalent in older adults and the hemodialysis (HD) population has been getting older. Therefore, it is speculated that increasing number of HD patients would suffer from AP. However, the clinical aspects of AP in HD patients have not been elucidated. Consecutive HD patients with nosocomial AP hospitalized in our university hospital from April 2007 to December 2008 were recruited. Their clinical characteristics, risk factors for contraction, and the fatality of AP and treatment options were described. Nineteen out of 356 hospitalized HD patients had AP and 8 out of 19 AP patients died, indicating the incidence rate and fatality rate were 5.34% and 42.1%, respectively. Multiple regression analysis revealed that the risk factors for contracting AP included age, body mass index, serum creatinine levels (Cre) and the
monthly decline rate of Cre. It also revealed that serum albumin (Alb) and basal total cholesterol levels, the decline rate of Alb and Cre levels, and the duration of AP were independent risk factors for fatality. Survivors were most often treated with tube feeding. Both contraction rate and fatality of nosocomial AP were high among HD patients. Both the malnutrition as well as the decline rate for nutrition and muscle volume indicated by falls in Alb and Cre, respectively, had clinical relevance in AP. Maintaining nutritional state by tube feeding and muscle volume seems to be the mainstay for the prevention and the treatment of AP in HD patients. Key Words: Aspiration pneumonia, Hemodialysis, Infection, Nosocomial pneumonia, Nutrition, Protein energy wasting.
The leading cause of death of hemodialysis (HD) patients after congestive heart failure is infectious disease. HD patients are particularly predisposed to infection. In addition, patients undergoing dialysis are in a protein-energy wasting state (PEW), in which patients are susceptible to sarcopenia due to the increased muscle protein degradation. Malnutrition causes impaired immune function and poor wound healing. Several mechanisms are involved in this condition, including activation of oxidative stress, inflammatory response, and the dialysis measure itself. Regarding infectious diseases, it has been reported that approximately 20% of infectious deaths in end-stage renal disease (ESRD) are attributed to pneumonia. Mortality of pulmonary infection in HD patients has been reported to be 14 to 16 times higher than in the general population (1). An increased
susceptibility to infections has been ascribed partly to old age, a high prevalence of diabetes, defective phagocytic function of granulocytes, and frequent exposure to potential infectious risk factors during the normal course of dialysis therapy (2). Among pneumonia infections, aspiration pneumonia (AP) should be emphasized in the recent increase in the aged HD population because, in general, aged patients are susceptible to AP due to swallowing dysfunction. The reasons for dysphagia in aged patients consist of neurological dysfunction due to cerebral infarction, cognitive deficit, and muscle weakness. Since HD patients are susceptible to sarcopenia and malnutrition, these changes predict the risk of development of AP. However, there have been no reports demonstrating the clinical relationship between malnutrition and contraction of AP. In this report, we surveyed nosocomial AP in HD patients at a university hospital and identified risk factors.We found that decreased rates of albumin and creatinine—which could be indicators for malnutrition and loss of muscle mass after the occurrence
Received January 2013; revised August 2013. Address correspondence and reprint requests to Dr Shu Wakino, MD, Department of Internal Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan. Email: [email protected]
326
Aspiration Pneumonia in Hemodialysis of pneumonia—were identified as independent risk factors for fatality from AP. In describing the clinical course of our patients, we stress that nutritional care is important to prevent AP in nosocomial situations in HD patients. PATIENTS AND METHODS Patients This research was conducted retrospectively at Keio University Hospital in Japan, from April 2007 to December 2008. A total of 335 consecutive patients undergoing HD who needed hospitalization were recruited, and 19 patients with AP were selected. All the studies were conducted after obtaining informed consent from each participant. Diagnosis of nosocomial pneumonia We checked past medical records and surveyed results of sputum culture examinations obtained from all patients suspected of having an upper respiratory infection. This investigation aimed to elucidate the clinical picture of the patients under chronic dialysis therapy. Immune-compromised patients, due to cancer chemotherapy or malnutrition by surgical procedure and not because of renal insufficiency alone, were excluded. The patients with acute renal failure who had just begun HD were also excluded from the further analysis. Specimens were obtained twice from each patient to confirm the diagnosis. The diagnosis of infectious pneumonia combines clinical, laboratory microbiological data, and confirmatory chest radiographic findings. A compatible clinical picture included fever, cough and/or auscultatory findings such as rales and/or evidence of pulmonary consolidation. Sputum specimens were washed, Gram-stained, and cultured quantitatively. Since the purpose of this study is to survey the related organisms for pneumonia in HD patients, all the organisms present in the specimen when the patients were clinically diagnosed with pneumonia were regarded as pathogens. Therefore, in some cases, several organisms were related to pneumonia. Diagnosis of AP The diagnostic criteria of AP are advocated by a pulmonary disease swallowing research group, and both definite and probable AP cases detailed below were included in our study. Definite cases satisfy one of these two criteria: (i) pneumonia after direct observation of aspiration, and (ii) pneumonia with aspiration substances in the trachea. The criteria for probable AP cases are: (i) that the pneumonia does © 2013 The Authors Therapeutic Apheresis and Dialysis © 2013 International Society for Apheresis
327
not satisfy one of the abovementioned two criteria for definite cases; and (ii) that it fulfills one of these conditions: (i) old or acute cerebral infarction, (ii) degenerative neurological diseases or neuromuscular disease, (iii) disturbance of consciousness or severe dementia, (iv) digestive disease that can be the cause of vomiting or reflux esophagitis including postgastrectomy, (v) oral, pharyngeal or mediasternal tumor and trancheoesophageal fistula, (vi) tracheotomy, (vii) tubal feeding from nasal tube, or (viii) other basal diseases that can be the cause of swallowing function disorders. The diagnostic criteria of pneumonia are satisfied if the following are true: (i) pneumonia image in chest radiography or computed tomography (CT); and (ii) two out of four requirements are met, which are: (i) fever greater than 37.5°C, (ii) high level of C-reactive protein, (iii) number of peripheral leukocytes more than 9000/μL, and (iv) respiratory tract symptoms such as expectoration. Information on gender, HD vintage, primary disease, comorbidity, cause of hospitalization, pathogenic bacteria, nutrition administration, and antibiotics were analyzed as well as age. We reviewed the laboratory test results from three separate events: at admission, onset of pneumonia, and 2 weeks after the onset of pneumonia. For the choice of antibiotics, we examined sputum cultures and selected antibiotics with reference to the guideline, which recommends penicillin with β-lactamase inhibitor for first choice and cephalosporins of third generation or carbapenem with clindamycin for the next choice. We could check the results of sputum culture 2 or 3 days after the onset, and decided the de-escalation or escalation of antibiotics, considering the clinical course. To conduct the clinical study, the authors adhered to the Declaration of Helsinki and this study protocol was approved by the Ethical Committee of Keio University. Analysis of risk factors for contraction of and fatality from AP Predialysis blood samples were drawn immediately before the initiation of dialysis on the first day during the first weekly session. First, we examined several parameters related to AP and the difference in these values between the 19 affected and 316 unaffected patients with AP. Values examined included age, dialysis vintage, body mass index (BMI), number of lymphocytes, hemoglobin, plasma levels of total protein, albumin, blood urea nitrogen (BUN), creatinine, total cholesterol, calcium, glutamicoxaloacetic transaminase (GOT), glutamic-pyruvic transaminase (GPT), and the monthly change rate of serum levels of creatinine.
Ther Apher Dial, Vol. 18, No. 4, 2014
328
H Minakuchi et al.
Furthermore, we performed logistic regression analysis by using variables significantly different between the patients with and without AP, and determined the risk factors for contraction rate of AP. Next, we compared several parameters at the onset of AP between 11 living and eight deceased patients with AP. Parameters we used included age, dialysis vintage, BMI, the number of lymphocytes, hemoglobin, plasma levels of total protein, albumin, creatinine, total cholesterol, calcium, phosphate, and the monthly change rate of serum levels of creatinine. Logistic regression analysis was performed by using variables significantly different between the living and deceased cases, and the risk factors for AP mortality were determined. We further analyzed whether factors related to the clinical course after the onset of AP pose more risk factors for fatality. Therefore, we performed logistic regression analysis by using the monthly decline rate of serum levels of albumin and creatinine as well as the duration of AP. Statistics Discrete variables were expressed as counts (percentage) and continuous variables as mean ± SD. We first described the baseline characteristics of the study participants and then evaluated the association between the fatality or incidence rate and variables. The Mann–Whitney test was used for the analysis of parameters between the cases of AP and the controls, and between the living and deceased cases. Using the statistically significant parameters, multiple logistic
TABLE 1.
#1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14 #15 #16 #17 #18 #19
regression analysis was performed to analyze the risk factors. Fisher’s exact probability test was used for the analysis of the relationship between antibiotics or pathogenic bacteria and fatality. A statistically significant level of P < 0.05 was used. The statistical analyses were performed using StatView J-4.5 statistical software (Abacus Concepts, Piscataway, NJ, USA). RESULTS The clinical characteristics of nosocomial AP in HD patients We enrolled a total of 356 patients hospitalized at Keio University hospital from April 2007 to December 2008. The incidence rate of AP was 5.34% (N = 19, Table 1). Mean age was 76.8 ± 1.74 years old, and 13 out of 19 patients were male. The mean duration of dialysis period was 35.8 ± 7.8 months. Mean BMI of patients was 18.4 ± 0.519 (kg/m2). These data suggest that this complication was one of the problems in thin and aged patients shortly after initiation of HD. Eight patients were diabetic (42.1%) (Table 2). Since we focused on nosocomial AP, various causes for hospitalization other than pulmonary complications are listed in Table 1, including peripheral artery disease (PAD), cerebrovascular disease, and heart failure. The direct causes for AP of each case are also listed.These were classified into three categories: (i) malnutrition due to long-term diet prohibition or appetite loss (14 cases), (ii) cerebrovascular
List of patients, nutrition management, and prognosis
Cause of hospitalization
Putative causative factors for aspiration
Nutrition management means and timing (start after hospitalization)
Outcome
SAH Stroke Stroke Stroke Sick sinus syndrome Heart failure Acute MI Pneumonia Pneumonia Renal Abscess PAD PAD PAD PAD Shunt failure Shunt failure Gastric ulcer Galbladder polyp Ileus
Appetite loss Dysphagia Loss of consciousness Dysphagia Appetite loss Appetite loss Long term diet prohibition Neurological disease Appetite loss Appetite loss GI bleeding, long term diet prohibition Appetite loss narcotics Appetite loss narcotics Appetite loss narcotics Cerebrovascular accident Appetite loss Long term diet prohibition Long term diet prohibition Long term diet prohibition
Oral intake 8 days Tube feeding 14 days IVH 6 days and tube feeding 14 days Tube feeding 10 days Oral intake 11days Tube feeding 8 days Tube feeding 13 days Oral intake 7 days Oral intake 14 days Tube feeding 9 days Oral intake 12 days Failure in tube feeding and IVH 19 days IVH 8 days Oral intake 15 days and IVH 24 days Tube feeding 7 days and IVH 31 days IVH 10 days IVH 13 days IVH 5 days IVH 10 days
Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Dead Dead Dead Dead Dead Dead Dead Dead
IVH, intravenous hyperalimentation; MI, myocardial infarction; PAD, peripheral artery disease; SAH, subarachnoid hemorrhage.
Ther Apher Dial, Vol. 18, No. 4, 2014
© 2013 The Authors Therapeutic Apheresis and Dialysis © 2013 International Society for Apheresis
Aspiration Pneumonia in Hemodialysis TABLE 2.
329
The comparison of various parameters between hemodialysis (HD) patients with and without aspiration pneumonia (AP)
Parameters Age HD duration (months) BMI Number of lymphocytes (/mm3) Hemoglobin (g/dL) Total protein (mg/dL) Albumin (mg/dL) Creatinine (mg/dL) Total cholesterol (mg/dL) Calcium (mg/dL) Phosphate (mg/dL) GOT (IU/L) GPT (IU/L) Decline rate in creatinine for a month (mg/dL/month) HD time (hour/week) Kt/V
Affected patients
Unaffected patients
P
76.8 ± 1.74 35.8 ± 7.08 18.4 ± 0.519 655 ± 50.4 9.3 ± 0.27 6.2 ± 0.14 2.9 ± 0.09 6.7 ± 0.34 146 ± 8.76 9.0 ± 0.19 4.5 ± 0.27 27 ± 5.3 14 ± 3.1 0.51 ± 0.13
62.4 ± 2.94 108.5 ± 24.7 21.4 ± 0.583 881 ± 72.4 9.8 ± 0.25 6.5 ± 0.16 3.6 ± 0.13 9.7 ± 0.42 165 ± 6.68 9.1 ± 0.13 4.7 ± 0.26 15 ± 1.3 9.9 ± 0.97 0.15 ± 0.072
0.0001 0.0001 0.0001 0.0385 0.194 0.137
