Critical Appraisal Journal

“URINARY TRACT INFECTION WITH

KLEBSIELLA PNEUMONIAE IN PATIENTS
WITH CHRONIC KIDNEY DISEASE”

“HYPONATREMIA IS ASSOCIATED WITH

FLUID IMBALANCE AND ADVERSE RENAL
OUTCOME IN CHRONIC KIDNEY DISEASE
PATIENTS TREATED WITH DIURETICS”

ANGGITA NARA SAFITRI

PKPA RSUD CENGKARENG
 “Urinary tract infection with
Klebsiella pneumoniae in Patients
with Chronic Kidney Disease”

CRITICAL APPRAISAL
• MERUPAKAN PENILAIAN ATAU EVALUASI TERHADAP JURNAL
PENELITIAN KLINIS UNTUK MEMVALIDASI PENELITIAN TERSEBUT
• METODE YANG DIGUNAKAN : JBI CHECKLIST FOR COHORT
STUDIES
• ALASAN : JURNAL PENELITIAN YANG DIGUNAKAN MENGGUNAKAN
SAMPLING LEBIH DARI 1 DATA PASIEN DENGAN MEMBANDINGKAN
PERBANDINGAN DATA KELOMPOK (2010 DAN 2016) DENGAN
PENYAKIT ATAU KONDISI TERTENTU PADA PASIEN/
RETROSPEKTIF DAN PENELITIAN INI BELUM PERNAH DILAKUKAN
OLEH PENELITI(BARU)
Jurnal yang digunakan
 Abstrak Penelitian

Tujuan : menentukan frekuensi terjadinya Urinary Tract Infection/UTI (ISK)

Klebsiella pneumonia pada pasien gagal ginjal kronis (CKD)

Metode : mengisolasi 14 sampel urin yang diambil dari pasien CKD dengan parameter
klinis, faktor yang mempengaruhi (usia, jenis kelamin, tingkat CKD, komorbiditas) dan
parameter biokimia (serum urea, kreatinin, asam urat dan elektrolit darah) terhadap
golongan antibiotik berdasarkan farmakodinamiknya

Hasil :
 ISK Klebsiella pneumonia dengan pasien CKD selama periode penelitian sejumlah
0,51% dari total pasien rawat inap di klinik peneliti
 ISK saja sejumlah 32,60% dari 100% ISK + CKD sedangkan ISK + CKD stage 4 dan
5 sejumlah 78,56% (11 pasien) dengan infeksi K. Pneumonia dan 4 dari pasien
tersebut menderita diabetes melitus tipe 2 sejumlah 28,75%
 Peningkatan kadar serum (100%), urea (85,71%), asam urat (45,45%)
 2 pasien meninggal setelah terjadinya perubahan pada kardivaskular
 Critical Appraisal Journal
1. Were the two groups similar and
recruited from the same population?

Ya
Pada desain studi/ penelitian mengisolasi
bakteri K.pneumonia pada sampel urin
pasien CKD dan untuk mengetahui
sensitivitas bakteri tersebut terhadap
antibiotik dengan pemilihan berdasarkan
inklusi dan ekslusi.

Inklusi : usia, jenis kelamin, lingkungan asal

(perkotaan/perdesaan), riwayat penyakit
diabetes, hipertensi, ISK berulang,
nefrolitiasis, glomerulonefritris, piolenefritis
Ekslusi : pernah transplantasi ginjal, TB
dengan ginjal, lupus nefritis, kehamilan,
riwayat penyakit baru-baru ini instrumentasi
urogenital, hpersensitivitas/ alergi terhadap
antibiotik yg diuji
 Critical Appraisal Journal
2. Were the exposures measured
similarly to assign people to both
exposed and unexposed groups?

Tidak
Tidak terdapat data yang menunjukkan
efektifitas golongan antibiotik karena peneliti
hanya menggunakan perbandingan data
tahun 2010 dan 2016
 Critical Appraisal Journal
3. Was the exposure measured in a
valid and reliable way?

Ya
Peneliti telah memenuhi standar prosedur
untuk kerentanan antibiotik dari obat diuji
dalam M02, M07 dan M100 dengan
suplemen di M100 S25 (januari 2015)
yang mencakup data tambahan untuk
seleksi antibiotik, interprestasi kualitas,
dan kontrol yang diperlukan untuk
praktek klinis
 Critical Appraisal Journal
4. Were confounding factors
identified?

Ya
Faktor :
 Usia : 3 pasien (50-60tahun), 3 pasien
lain >60 tahun
 Jenis kelamin : 4 pasien pria dan 1 pasien
wanita
 Lingkungan/ tempat tinggal: 4 pasien
tinggal diperkotaan dan 2 pasien tinggal
dipedesaan
 Critical Appraisal Journal
5. Were strategies to deal with
confounding factors stated?

Ya
Peneliti mengolah data dengan menggunakan
X2 dan t-test, dan regresi logistik untuk
penerapan dari model prodiktif
 Critical Appraisal Journal
6. Were the groups/participants free
of the outcome at the start of the
study (or at the moment of
exposure)?

Ya
Peneliti menggunakan retrospektif data
 Pasien yang dipilih adalah pasien CKD
dengan pemeriksaan lab untuk
menentukan serum kreatinin, urea, asam
urat dan proteinuria sehingga dapat
dikatakan partisipan tidak masuk dalam
outcome atau harapan peneliti
 Sensitivitas antibiotik : pada sampel urin
yang diambil belum pernah dilakukan uji
sensitivitas banteri (pertama kali)
 Critical Appraisal Journal
7. Were the outcomes measured in a
valid and reliable way?

Ya
 Peneliti mengukur dan menghitung nilai
laju filtrasi glumerolus (GFR) dan
mengkategorikan sesuai dengan tingkatan
berdasarkan KDOQI (Kidney Disease
Outcomes Quality)
 Peneliti memenuhi standar dalam
prosedur pengujian sensitivitas antibiotik
sesuai dengan M02, M07 and M100
with the supplement in M100 S25
(January 2015) mencakup a data untuk
seleksi obat.
 Critical Appraisal Journal
8. Was the follow up time reported
and sufficient to be long enough for
outcomes to occur?

Tidak
Tidak terdapat data yang menunjukkan
rentang waktu / intervensi pada penelitian
karena peneliti hanya menggunakan
perbandingan data tahun 2010 dan 2016
 Critical Appraisal Journal
9. Was follow up complete, and if
not, were the reasons to loss to
follow up described and explored?

Tidak
Tidak ada pasien yang di follow up karena
peneliti tidak melakukan pengujian terapi
pada pasien sehingga tidak ada data yang
diperoleh misalnya persentase jumlah pasien
yang putus obat atau lupa minum obat dan
tidak ada data pasien yang dieliminiasi
selama penelitian berlangsung
 Critical Appraisal Journal
10. Were strategies to address
incomplete follow up utilized?

Tidak
Tidak ada pasien yang di follow up karena
peneliti memilih data pasien yang sudah ada
dan tidak ada data pasien yang dieliminiasi
selama penelitian berlangsung
 Critical Appraisal Journal
11. Was appropriate statistical
analysis used?

Ya
Pada penelitian ini diperoleh perbedaan
signifikan pada parameter yang diuji dengan
Chi-square, t-test dan SPSS
Dimana apabila p value ≤0,05 dinilai terjadi
perubahan signifikan pada data
Sedangkan perbedaan antar kelompok diuji
menggunakan X2, t-studi, regresi logistik
 “Hyponatremia is Associated with Fluid
Imbalance and Adverse Renal Outcome in
Chronic Kidney Disease Patients Treated with
Diuretics”

CRITICAL APPRAISAL
• MERUPAKAN PENILAIAN ATAU EVALUASI TERHADAP JURNAL
PENELITIAN KLINIS UNTUK MEMVALIDASI PENELITIAN TERSEBUT
• METODE YANG DIGUNAKAN : JBI CHECKLIST FOR COHORT
STUDIES
• ALASAN : JURNAL PENELITIAN YANG DIGUNAKAN MENGGUNAKAN
SAMPLING LEBIH DARI 1 DATA PASIEN DENGAN DATA KELOMPOK
(2002 DAN 2009) DENGAN PENYAKIT ATAU KONDISI TERTENTU
PADA PASIEN/ RETROSPEKTIF DAN PENELITIAN INI BELUM
PERNAH DILAKUKAN OLEH PENELITI/BARU (2010)
Jurnal yang digunakan
 Abstrak Penelitian

Tujuan : untuk menentukan apakah penggunaan diuretik dan hiponatremia terkait

berhubungan dengan ketidakseimbangan cairan dan dapat diprediksi hasil klinis yang
merugikan, termasuk hasil ginjal, pada pasien dengan CKD

Metode : 5.047 (11 Nov dan 30 Jun 2009) dipilih pasien melalui program perawatan
CKD terintegrasi di 2 rumah sakit afiliasi Universitas Kedokteran Kaohsiung di Taiwan
Selatan dan diamati sampai 31 Juli 2010

Hasil :
 Adanya korelasi positif dengan hiponatremia tetapi tidak dengan diuretik tiazid
 Pada pengguna diuretik, setelah rata-rata tindak lanjut 1070 hari, kejadian RRT
lebih tinggi pada Na <135 mEq/L, yaitu 113 (62,4%)
 Persentase Na <135 mEq/L pada non-pengguna diuretik adalah 17,3%
 Na <132mEq/L dikaitkan dengan risiko RRT yang lebih tinggi sedangkan Na >143
mEq/L dikaitkan dengan risiko yang lebih tinggi untuk semua penyebab kematian
(Na <135mEq/L, Na 135–138mEq/L, Na 138– 141mEq/L, dan Na >141mEq/L )
 Critical Appraisal Journal
1. Were the two groups similar and
recruited from the same population?

Ya
Pada desain studi/ penelitian
mengelompokkan pasien pengguna diuretik
dan pengguna diuretik non-penggunaan

Inklusi : demografis, riwayat medis,

temuan pemeriksaan, data laboratorium,
dan riwayat pengobatan
Ekslusi : pasien yang mangkir dalam
waktu 3 bulan dan pasien dengan
informasi pengobatan yang tidak lengkap
dieliminasi dari penelitian
 Critical Appraisal Journal
2. Were the exposures measured
similarly to assign people to both
exposed and unexposed groups?

Ya
Untuk mencegah variabilitas, elektrolit
termasuk natrium serum dikumpulkan 3
bulan sebelum dan sesudah pendaftaran dan
dirata-rata. Untuk mempelajari hubungan
hasil klinis dengan 2 ujung kadar natrium,
pasien dibagi menjadi 4 kelompok menurut
kadar natrium serum, dengan nilai cut-off
dari 135mEq/L, 138mEq/L, dan 141mEq/L
 Critical Appraisal Journal
3. Was the exposure measured in a
valid and reliable way?

Ya
Peneliti menggunakan standar CKD
dipentaskan menurut definisi K/DOQI dan
perkiraan laju filtrasi glomerulus (eGFR)
dihitung menggunakan persamaan 4-variabel
Modifikasi Diet pada Penyakit Ginjal
(MDRD) Study
 Critical Appraisal Journal
4. Were confounding factors
identified?

Ya
Faktor :
Usia, jenis kelamin, perkiraan laju filtrasi
glomerulus (eGFR), DM, penyakit
kardiovaskular, tekanan darah rata-rata,
hemoglobin terglikasi, hemoglobin, albumin,
kolesterol, rasio protein-ke-kreatinin urin,
Protein C-reaktif, indeks massa tubuh,
angiotensin-converting enzyme
inhibitor/angiotensin II receptor blocker,
agen antihipertensi, obat antidiabetes oral,
statin, perawatan CKD terpadu dan penyebab
penyakit ginjal
 Critical Appraisal Journal
5. Were strategies to deal with
confounding factors stated?

Ya
Peneliti mengolah data dengan menggunakan
perangkat lunak STATA 12.0 (Stata Corp
LP, College Station, TX, USA) dan Paket
Statistik untuk Ilmu Sosial, Versi 21.0
untuk Windows (SPSS Inc., Chicago, IL,
USA)
 Critical Appraisal Journal
6. Were the groups/participants free
of the outcome at the start of the
study (or at the moment of
exposure)?

Ya
Peneliti memilih pasien yang tidak dalam
kondisi perkembangan koroner akut
sindrom atau stroke akut, rawat inap
untuk penyakit oklusi arteri perifer atau
gagal jantung kongestif, dan kematian
oleh sebab-sebab ini
 Critical Appraisal Journal
7. Were the outcomes measured in a
valid and reliable way?

Ya
 Peneliti mengukur dan menghitung nilai
laju filtrasi glumerolus (GFR) dan
mengkategorikan sesuai dengan tingkatan
berdasarkan KDOQI (Kidney Disease
Outcomes Quality)
 Metode penelitian disetujui oleh
Institutional Review Board Rumah Sakit
Universitas Kedokteran Kaohsiung
(KMUH-IRB-990198)
 Critical Appraisal Journal
8. Was the follow up time reported
and sufficient to be long enough for
outcomes to occur?

Ya
Pasien discreening dari 11/11/ 2002 -
30/6/2009. Lalu dilakukan follow up sampai
tanggal 31/7/2010. Dalam jurnal disebutkan
bahwa untuk ukuran sampel yang lebih kecil
dari 2 kadar natrium serum dan durasi follow
up yang relatif singkat dapat menghasilkan
kekuatan statistik yang lebih rendah,
sehingga kekuatannya lemah dalam
menganalisis hubungan antara kematian dan
kejadian KV dan ketidakmampuan untuk
membedakan efek loop dan diuretik tiazid
 Critical Appraisal Journal
9. Was follow up complete, and if
not, were the reasons to loss to
follow up described and explored?

No
Tidak semua pasien menyelesaikan penelitian
ini sampai akhir . Sejumlah 123 pasien yang
mangkir dalam waktu 3 bulan dan 158
pasien dengan informasi pengobatan yang
tidak lengkap dieliminasi dari pertisipan.
Untuk alasan pasien yang mangkir dalam
waktu 3 bulan tidak disebutkan alasannya
dalam penelitian ini
 Critical Appraisal Journal
10. Were strategies to address
incomplete follow up utilized?

Ya
Peneliti melakukan dilakukan follow up
sampai tanggal 31/7/2010.
Partisipan/pasien akan diemilinasi apabila
mangkir dalam waktu 3 bulan dan 158
pasien dengan informasi pengobatan yang
tidak lengkap
 Critical Appraisal Journal
11. Was appropriate statistical
analysis used?

Ya
Dilakukan dengan perangkat lunak STATA
12.0 (Stata Corp LP, College Station, TX,
USA) dan Paket Statistik untuk Ilmu
Sosial, Versi 21.0 untuk Windows (SPSS
Inc., Chicago, IL, USA). Dimana apabila p
value ≤0,05 dinilai terjadi perubahan
signifikan pada data
Current Health Sciences Journal Vol. 43, No. 2, 2017 April-June

Original Paper
Urinary tract infection with Klebsiella pneumoniae
in Patients with Chronic Kidney Disease
OANA MARIANA CRISTEA1, CARMEN SILVIA AVRĂMESCU1,
MARIA BĂLĂȘOIU1, F.D. POPESCU2, FLORICA POPESCU3, M.O. AMZOIU4
1
Department of Microbiology, University of Medicine and Pharmacy of Craiova, Romania
2
Department of Allergology, ”Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
3
Department of Pharmacology, University of Medicine and Pharmacy of Craiova, Romania
4
Faculty of Pharmacy, University of Medicine and Pharmacy of Craiova, Romania

ABSTRACT: Study Motivation: After assessing electronic databases of medical scientific literature, we have
observed that the interrelation between urinary tract infections (UTIs) and chronic kidney disease (CKD) is poorly
studied, especially when UTIs are caused by Klebsiella pneumoniae (K. pneumoniae). Materials and methods: K.
pneumoniae was isolated in 14 urine samples from patients with CKD addmited in the Nephrology Department of the
County Emergency Clinical Hospital Craiova. The isolated strains were statistically analyzed in the correlation with
the different clinical and functional parameters (age, gender, CKD stage, comorbidities, biochemical parameters-
serum urea, creatinine, uric acid and blood electrolytes). The degree of K. pneumoniae susceptibility to antibiotics
from different pharmacodynamic classes was assessed. Results: UTIs with K. pneumoniae in patients with CKD in
the investigated period represented 0.51% from the total admissions in the clinic and 32.60% from cases of UTI.
Eleven patients with this type of infection (78.56%) were in stage 4 and 5 CKD, and from them 4 also had diabetes
mellitus type 2 (28.57%). We observed an increased level for serum creatinine (100%), blood urea (85.71%), and
serum uric acid (45.45%). Two patients died after installation of cardiovascular changes in CKD, at advanced ages
and in the presence of urinary infection. Multiple drug resistance occurred in 6 strains of K. pneumoniae correlated
with the degree of kidney failure, advanced age, male gender, and diabetes mellitus. Conclusions: UTI with K.
pneumoniae in patients with CKD is the second cause of urinary infection which raises problems of unfavorable
evolution of CKD and also the recurrence of UTI with multiple drug resistance in CKD, which may lead to
pharmacotherapeutical problems.

KEYWORDS: Klebsiella pneumoniae, urinary tract infection (UTI), chronic kidney disease (CKD), antibiotics,
susceptibility, multiresistance

targets of this pathogenic bacteria [1]. The

Introduction
Klebsiella pneumonia is the most relevant
human pathogen within genus Klebsiella,
causing many infections in hospitals, long-term
care facilities and communities worldwide,
including lung, urinary tract, abdominal cavity,
surgical sites and soft tissues infections, even
bacteremia [1,2]. This capsulated Gram-negative
bacterium is found in normal flora of the mouth,
skin and intestine, and it is also the third most
frequently isolated microorganism in the blood
cultures from sepsis patients [3]. A new
hypervirulent (hypermucoviscous) variant of
K. pneumoniae, determining severe and life-
threatening infections, including pyogenic liver
abscesses, endophthalmitis and meningitis, has
been described and is becoming a public health
concern [2,4,5].
It is important to underline that Klebsiella
pneumoniae is one of the most common
pathogens in nosocomial infections, and tends to
become multidrug-resistant [3]. The
hospitalized, immunocompromised patients with
significant underlying diseases are the main
underlying molecular mechanisms involved in
the pathogenesis of infections with this
microorganism are not entirely elucidated.
Endocytosis regulating protein caveolin-1 is
implicated in inflammatory responses in K.
pneumoniae infection. The Src tyrosine kinase
Lyn, involved in monocyte-related phagocytosis
through FcγR via the phosphorylation of
tyrosines in immunoreceptor tyrosine-based
activation motifs, may coordinate lipid rafts and
impact cellular function of caveolin-1. Lyn is
located in the proximity of lipid rafts and can be
translocated into the activated membrane
domains to transmit cellular signals, thus being
involved in host defense against K. pneumoniae
by regulating the phagocytosis processes and
downregulating inflammatory responses [3,6].
Lyn deficiency could accelerate and intensify
cytokine responses (such as cytokines IL-6,
tumor necrosis factor TNF-alpha) in mice
infected by K. pneumoniae. Lyn cooperating
with lipid rafts regulates inflammatory responses
in K. pneumoniae infection through the p38/NF-
κB pathway [3].

10.12865/CHSJ.43.02.06 137
Oana Mariana Cristea et al. - Urinary tract infection with Klebsiella pneumonia in Patients with Chronic Kidney Disease
Chronic kidney disease (CKD) is
increasingly recognized as a global public health
problem [7]. Patients with CKD and kidney
failure may be at hight-risk for infectious
complications, similar to patients with other
tipes of acquired immune deficiencies or those
treated with immunosuppresive drugs.
Secundary immune alterations in uremia are
multifaceted and influenced by uraemic
intoxication per se, by altered renal metabolism
of immunologically active proteins and by
specific effects of therapy [8]. Dialysis causes
additional immune abnormalities [8]. End-stage
renal disease (ESRD) is associated with
significantly increased morbidity and mortality
resulting from cardiovascular disease (CVD) and
infections, accounting for about 50% and 20%,
respectively, of the total mortality in ESRD
patients [9]. It is plausible that these
complications are linked to alterations in the
immune system functions in ESRD. Uremia is
associated with immune dysfunctions
characterized by an impaired immune response
component that contributes to the high
prevalence of infections among these patients, as
well as by a persistent immune stimulation
component resulting in inflammation that may
contribute to CVD [9,10]. Accelerated
atherosclerosis in ESRD may involve
interrelated processes, including oxidative stress,
endothelial dysfunction and vascular
calcification, in a milieu of constant low-grade
inflammation with impaired function of T cells
and neutrophils, as well as a dysregulated
cytokine network, the mainly proinflammatory
cytokines IL-6 and TNF-alpha playing key roles
in the development of Th imbalance and CVD
[11]. Chronic renal failure is a risk factor for the
development of urinary tract infections (UTIs)
due to metabolic disorders resulting in
secondary immune alterations affecting many
components of the immunity. Moreover, in
patients with chronic renal failure, UTIs occur
frequently after kidney transplantation [12].
We found few studies related to the
relationship between UTIs and CKD, by
assessing electronic databases of medical
scientific literature, and fewer studies of
uropathogenic K. pneumoniae resistance to
antibiotics in these cases. The management of
UTIs in patients with chronic renal failure has
drawn little attention [13].
We investigated the interrelation between
Klebsiella pneumoniae UTIs and CKD, by
evaluating clinical and laboratory correlations.
We also assessed antibiotic susceptibility of the
138
uropathogen. An important aim of the study is to
highlight whether CKD and chronic renal failure
can be associated with antibiotic resistance of
K. pneumoniae isolates in the UTIs.
The objectives are to determine the
frequency of UTIs with Klebsiella pneumoniae
in CKD, assessing clinical forms of the chronic
kidney disease, favorable factors, co-morbidities
and the influence of the infection on the
evolution of chronic kidney failure and the
degree of antibiotic susceptibility of
uropathogenic K. pneumoniae.
Study design
The clinical study was conducted at the
Nephrology Department and the hospital's
Bacteriology Laboratory of the County
Emergency Clinical Hospital Craiova for the
period July 1-December 31, 2016.
Laboratory screening of CKD was performed
by determining serum creatinine, urea, uric acid
and proteinuria.
CKD is defined as “Either kidney damage or
GFR of less than 60mL/min/1.73m2 of body
surface area lasting for long than 3 months”
[14].
We determined the stages of CKD based on
the GFR (Glomerular Filtration Rate) estimate
which is calculated from serum creatinine
according to the KDOQI guidelines (National
Kidney Foundation's Kidney Disease Outcomes
Quality Initiative):
Stage 1: GRF ≥ 90mL/min/1.73m2
Stage 2: GRF = 60-89mL/min/1.73m2
Stage 3: GRF = 30-59mL/min/1.73m2
Stage 4: GRF = 15-29mL/min/1.73m2
Stage 5: GRF < 15 mL/min/1.73m2or dialysis
Normal age-related decline in GFR is
~1mL/min/1.73m2/yr after 30–40 years of age.
We evaluated the risk factors (diabetes
mellitus, urolithiasis, hydronephrosis etc).
To evaluate correlations between UTIs, CKD
and antibiotic resistance of K. pneumoniae, we
assessed:
• demographic parameters of the study group:
age, gender, the environment of origin (urban,
rural);
• CKD stage by determining serum
creatinine, urea, uric acid, GFR;
• blood electrolytes determination (serum
sodium, potassium);
• state of performing or not hemodialysis;
• ultrasound examination with detection of
anatomical anomalies of the kidneys and the
presence of kidney stones;
10.12865/CHSJ.43.02.06
Current Health Sciences Journal
• patient history such as diabetes,
hypertension, recurrent UTIs, nephrolithiasis,
glomerulonephritis, pyelonephritis.
Exclusion criteria were represented by renal
transplantation, renal tuberculosis, lupus
nephritis, pregnancy, personal history of recent
urogenital instrumentation, hypersensitivity
/allergy to the tested antibiotics.
Urine cultures for patients included in the
study were carried out in the Department of
Bacteriology of the hospital laboratory, and
antibiotic susceptibility/resistance testing was
determined by antibiogram after detection of the
causative microorganism of UTIs (Klebsiella
pneumoniae).
Antibiotic susceptibility
Antibiotic susceptibility of K. pneumoniae
isolates was done by Bauer’s and Kirby’s disk
diffusion method [15]. Organisms were grown
on specific media and inoculated on Mueller
Hinton agar plates by sterile swabs and then
antibiotic disks were placed on media and
pressed gently followed by overnight incubation.
This method was done according to Clinical and
Laboratory Standards Institute (CLSI) guidelines
to determine susceptibility of UTIs causative
agents [15].
We have complied with standardized
procedures for antimicrobial susceptibility of the
drugs tested presented in M02, M07 and M100
with the supplement in M100 S25 (January
2015) that include data essential to drug
selection, quality interpretation and control
required for clinical practice [16].
In this study the antibiotic disks used for
antibiogram were:
Beta-lactams+beta-lactamase inhibitors:
Amoxicillin+Clavulanic acid (AMC),
Piperacillin+tazobactam (TPZ),
Cefoperazone+sulbactam (CES);
Cephalosporins: Cefazoline (CZ) first
generation, Cefuroxime (CXM), Cefoxitin (FOX)
and Cefaclor (CEC), second generation,
Ceftriaxone (CRO), Ceftibuten (CTB) and
Cefpodoxim (CPO), third generation, Cefepime
(FEP) fourth generation;
Carbapenems: Imipenem (IP);
Fluoroquinolones: Ciprofloxacin (CPR),
Ofloxacin (OFX), Norfloxacin (NOR);
Aminoglycosides: Gentamicin (GN),
Amikacin (AK);
Polymyxins: Colistin (CO);
Folate pathway inhibitors: Trimethoprim/
sulfamethoxazole (SXT);
Nitrofurans-Nitrofurantoin (FM);
10.12865/CHSJ.43.02.06
Vol. 43, No. 2, 2017 April-June
Phosphonic acid derivate: Fosfomicin
trometamol (FOT).
The study was retrospective, descriptive and
non-randomized.
Data obtained from patients in 2016 were
compared with similar data obtained previously
in 2010, to assess changes.
Statistical analysis
The antibiotic resistance data was recorded in
MS-Excel and the statistical analysis of the data
was performed and statistical significance
between different parameters was checked by
Chi-square test, t-test and the Statistical Package
for the Social Sciences (SPSS) 13.0 for
Windows. A p value of ≤0.05 was considered
significant. Differences between groups were
tested by use of the x2 and Student’s t test. Also
were used the logistic regressions for elaboration
of predictive model.
Results
Prevalence of Klebsiella pneumoniae
uropathogens in CKD
In the Nephrology Department between July
1 and December 31, 2010, 357 patients were
hospitalized, from which 37 (10.36%) had UTIs
with 12 cases (32.43%) with CKD and K.
pneumoniae UTI, from them 10 (27.03%) being
male and 2 (5.40 %) female patients (Table 1,2).
In 2016, in the last 6 months, of the
272 admitted patients 46 (16.91%) had UTIs,
from which 15 (32.60%) with K. pneumoniae,
8 (17.08%) men and 7 (15.22%) women
(1 women without CKD) (30.43% patients had
UTI with Klebsiella and CKD) (Table 1,2).
In both time periods the main etiology of
UTIs was Escherichia coli.
In the last 6 months of 2010, the rate of UTIs
with uropathogenic germs in CKD patients was
37 (10.36%). In the same period of the year
2016 the percentage was 16.91% (46 patients).
Compared to all patients admitted to the clinic
during this time, UTIs with K. pneumoniae in
patients with CKD accounted for 0.33% in 2010
and 0.51% in 2016 (Table 2).
There is no correlation in the prevalence of
UTIs cases in patients with CKD linked to the
hot or cold season of the year. In 2010, there
were several UTIs cases with K. pneumoniae in
August, November, and in 2016 in August,
September, November (Table 2).
139
Oana Mariana Cristea et al. - Urinary tract infection with Klebsiella pneumonia in Patients with Chronic Kidney Disease

Table 1. Distribution of patients without UTI during July-December 2010 and 2016

Month of patient without UTI hospital admission (n)

Without UTI patients
Total July August September October November December
Females without UTI 2010 151 20 17 25 30 27 32
Males without UTI 2010 169 27 26 32 26 27 31
Total without UTI 2010 320 47 43 57 56 54 63
Females without UTI 2016 118 17 14 26 14 31 16
Males without UTI 2016 108 21 13 18 16 32 8
Total without UTI 2016 226 38 27 42 30 63 24

Table 2. Distribution of patients with Klebsiella pneumonia

UTI and UTIs (total) during July-December 2010 and 2016

Total Month of patient with UTI hospital admission (n)

Urine culture
(n) July August September Octomber November December
F (2) 0 0 0 1 1 0
Urine culture Klebsiella 2010
M (10) 2 4 0 1 3
Urine culture Klebsiella 2010
12 2 4 0 2 4 0
- total
F (7) 0 2 3 1 0 1
Urine culture Klebsiella 2016
M (8) 2 2 3 1 0 0
Urine culture Klebsiella 2016
15 2 4 6 2 0 1
-total
Total uropathogenic germs
37 6 9 7 6 8 1
2010
Total uropathogenic germs
46 7 8 13 5 8 5
2016

In the 2016 evaluation, we observed that the
age of patients it’s between 50 and 82, with an
average age of 69.8 (Table 3).
Analyzing UTIs with K. pneumoniae in
patients admitted to the Nephrology Department,
it was found that it prevails at the age above
55 years, similar in the two studied periods of
time.
In 2016, from 15 cases of UTIs with K.
pneumoniae, in 14 (93.33%) the infection
occurred in the patients with CKD and in one
(6.67%) patient without CKD hospitalized for
urinary infection and kidney cyst with
nephrolithiasis.
Among patients with CKD, 6 (42.86%) were
on renal dialysis (3 males and 3 females).
Although in 2010 UTIs with K. pneumoniae
and CKD predominated in males (83.33%), in
2016 the proportion of males and females is
quite similar, with a slight predominance in
males (6→42.86% women and 8→57.14%
men).
In 2016 from the patients with CKD, 3
(21.42%) patients were in the stage 3 of kidney
failure, 3 patients (21.42%) in stage 4 and 8
(57.14%) patients in stage 5.
From the 14 cases with CKD and UTI with
K. pneumoniae, 7 (50%) had also type 2
diabetes, of which 4 (28.57%) were in stage 4
and 5 of CKD.

Table 3. Distribution of UTI and CKD patients according to age group

Age Distribution
Age groups Min and max
<=25 26 - 35 36 - 45 46 - 55 56 - 65 66 - 75 >75
(years) ages.
Number of
1 1 3 14 12 (min. 21 ages)
patients with 0 (0%) 15 (32.60%)
(2.17%) (2.17%) (6.52%) (30.44%) (26.08%) (max.83 ages)
UTI 2016
Number of 3 (20.14%)
1
patients with +1 patient (min.50 ages)
0 (0%) 0 (0%) 0 (0%) (7.14%) 4 (28.57%) 6 (42.85%)
Klebsiella UTI without CKD (max. 82 ages)
(50 ages)
2016 (7.14%)

140 10.12865/CHSJ.43.02.06
Current Health Sciences Journal Vol. 43, No. 2, 2017 April-June

Of the 14 patients with CKD and UTI, cefoperazone-sulbactam (6/7-85.71%

nephropathy without case specification was
found in 6 (42.85%) patients, nephrolithiasis in
4 (28.57%) patients, and renal cyst in one case
(7.14%).
Regarding biochemical parameters related to
kidney function, increased blood urea was
performed in 12/14 (85.71%) patients,
5/11 (45.45%) patients with increased uric acid,
elevated serum creatinine in 14/14 (100%)
patients. Proteinuria was found in 5/10 (50%) of
CKD patients.
Blood electrolytes determinations revealed a
decrease in serum sodium below normal values
in 9/14 (64.29%) patients with CKD, serum
potassium increased in 6/14 (42.86%) patients
and 1/14 (7.14%) with low serum potassium
compared to normal.
Antibiotic susceptibility
Patients with CKD are possibly more likely
to have a resistant strain.
Among the Klebsiella strains tested on eight
cephalosporins, there is a high resistance in the
first and second generation ones (10/14-71.43%
cefazoline-resistant, 3/4-75% to cefuroxime,
7/14-50% to cefoxitin, but also to 5/14-35.71%
intermediate sensitivity to cefoxitin,
8/13-61.54% resistance to ceftriaxone). From
third generation a moderate sensitivity to
ceftibuten was found where 4/7-57.14% strains
were susceptible. Unfortunately, in the cefepime
(fourth generation cephalosporin) of the 4 tested
strains 2 (50%) were resistant and 2 (50%)
sensitive intermediates. In carbapenems,
imipenem remains a reserve antibiotic with a
good sensitivity to K. pneumoniae
(10/14-71.43% susceptibiliy strains) (Table 4).
The combinations of betalactams-beta-
lactamase inhibitors demonstrated that the best
susceptibility of K. pneumoniae was to
susceptible strains) and also piperacillin-
tazobactam (7/14-50% susceptible strains)
(Table 4).
In the group of CKD many fluoroquinolones
still retain good susceptibility (9/14-64.29%
susceptible and 5/14-35.71% resistant to
ciprofloxacin, 3/3-100% susceptible to ofloxacin
and less to norfloxacin-3/7-42.86% susceptible,
4/7-57.14% resistant) (Table 4).
High sensitivity to aminoglycosides may be
explained by their reduced use in CKD due to
nephrotoxicity (5/14-35.71% to gentamicin and
11/13-84.62% to amikacin). However, the
resistance to gentamicin is still quite high
(5/14-35.71%) (Table 4).
High sensitivity has also been encountered
with colistin for injection, maybe due to reduced
use in CKD (11/11-100.00%) (Table 4).
Resistance is increased to
trimethoprim/sulfamethoxazole (13/14-92.86%)
and to nitrofurantoin (13/14-92.86% and one
strain with intermediate sensitivity) probably
due to more widespread use (Table 4).
Klebsiella spp. are only moderately inhibited by
nitrofurantoin [17].
For fosfomycin trometamol, currently used in
single-dose for cystitis, the study reveales a high
resistance with 7/14 (50%) resistant strains,
2/14 (14.29%) strains with intermediate
susceptibility and only 5/14 (35.71%)
susceptible strains (Table 4).
Of the 15 antibiotics tested in the
K. pneumoniae UTI without CKD it was
revealed resistance to ofloxacin, ciprofloxacin,
ceftriaxone, trimethoprim / sulfametoxazole and
nitrofurantoin, and susceptibility to gentamicin,
amikacin, tazobactam/piperacillin, ceftibuten,
imipenem, colistin, intermediate sensitivity to
cefoxitin, cefazoline, fosfomycin trometamol
and cefoperazone/sulbactam.

Table 4. Susceptibility patterns for Klebsiella pneumoniae isolated from urine samples of CKD patients
(N-number, %)

Disks Isolates Resistant Intermediate Susceptible

Classes of antibiotics Antibiotic used Codes
(μg) (N) N (%) N (%) N (%)
Beta-lactams
Amoxicillin+
AMC 20/10 4 3 (75) 0 (0) 1 (25)
Clavulanic acid
Beta-lactam + beta- Piperacillin+
TPZ 100/10 14 4 (28.57) 3 (21.43) 7 (50)
lacatamase inhibitors Tazobactam
Cefoperazone
CES 75/30 7 0 (0) 1 (14.29) 6 (85,71)
+sulbactam
Cefazolin 1rd
CZ 30 14 10 (71.4) 3 (21.43) 1 (7,14)
generation
Cefuroxime 2rd
Cephalosporins CXM 30 4 3 (75) 1 (25) 0 (0)
generation
Cefoxitin 2rd
FOX 30 14 7 (50) 5 (35,71) 2 (14.29)
generation

10.12865/CHSJ.43.02.06 141
Oana Mariana Cristea et al. - Urinary tract infection with Klebsiella pneumonia in Patients with Chronic Kidney Disease

Cefaclor 2rd
CEC 30 1 1 (100) 0 (0) 0 (0)
generation
Ceftriaxone 3rd
CRO 30 13 8 (61.54 ) 2 (19.23) 2 (19.23)
generation
Ceftibuten 3rd
CTB 30 7 2 (28.57) 1 (14.29 ) 4 (57.14)
generation
Cefpodoxim 3rd
CPO 30 1 1 (100) 0 (0) 0 (0)
generation
Cefepime 4rd
FEP 30 4 2 (50) 2 (50) 0 (0)
generation
Carbapenems Imipenem IP 10 14 3 (21.43) 1 (7,14) 10 (71.43)
Non-betalctams
Ciprofloxacin CPR 5 14 5(35.71) 0 (0) 9 (64.29)
Quinolones Ofloxacin OFX 5 3 0(0) 0 (0) 3 (100)
Norfloxacin NOR 10 7 4(57.14) 0 (0) 3 (42.86)
Gentamicin GN 10 14 5(35.71) 4 (28.58) 5 (35.71)
Aminoglycozides
Amikacin AK 3010 13 1(7.69) 1 (7.69) 11 (84.6)
Polymyxins Colistin CO 11 0(0) 0 (0) 11 (100)
Folate pathway Trimethoprim/S SXT/ 1.25/23
14 13 (92.86) 0 (0) 1 (7.14 )
inhibitors ulfamethoxazole TS .75
Phosphonic acid Fosfomycin
FOT 50 14 7(50) 2 (14.29 ) 5 (35.71)
derivatide trometamol
Nitrofurans Nitrofurantoin FM 300 14 13 (92.86) 1 (7.14) 0 (0)

From all strains isolated of K. pneumoniae, generation (71.43%), and 75% strains were
over 70% were resistant to trimethoprim/ resistant to cefuroxime (second generation
sulfamethoxazole (92.86%), nitrofurantoin cephalosporin) and to amoxicillin/ clavulanic
(92.86%), cefazoline, cefalosporin of first acid.
Table 5. Strains of multidrug resistant Klebsiella pneumoniae from patients with UTI and CKD

Klebsiella strains
resistant to No.
Klebsiella resistant to CKD Hemo Renal Gender
Ciprofloxacin + antibiotics Diabetes Age
other antibiotics stage dialysis affecting distribution
resistant to other tested
antibiotics (n.)
FOX/CZ/TPZ/CTB/FM/
+7 antibiotics 14 4 0 + L, C 66 M
NOR/TS
GM/FOX/CZ/TPZ/CTB/
+10 14 5 + + 0 79 M
FM/NOR/CRO/FEP/TS
GM/FOX/CZ/FOT/TPZ/
+11 FM/NOR/ 15 3 0 + L 50 M
CRO/IP/TS/CXM
GM/CZ/FOT/FM/NOR/
+9 16 4 0 + 0 76 M
CRO/TS/CXM/AMC
GM/FOX/AK/CZ/TPZ/C
+8 12 5 + 0 N 60 M
RO/IP/TS
Without
+5 FM/CPR/CRO/OFX/TS 15 0 0 L, C 60 F
CKD
L=lithiasis; C=renal cyst; N=nephropaty; M=male; F= female; n=number

Of the six ciprofloxacin resistant strains, five
were multiresistant (for 12,11,10,9,8 antibiotics),
and one strain from a CKD-free patient is
resistant to 5 antibiotics from different
pharmacodynamic classes (cephalosporins/
nitrofurans/ fluoroquinolones/ folate pathway
inhibitors) (Table 5).
Although strain number 10 is sensitive to
ciprofloxacin, it is resistant to other
8 antibiotics from 5 different pharmacodynamic
classes (Table 6). It was isolated from a female
patient aged 77 years with CKD stage 3 and
diabetes.
By analyzing the sensitivity of the six
strains, we found that they are resistant to more
than four classes of antibiotics, which makes
them fit into the group of Klebsiella
pneumoniae multiresistant strains. The presence
of multidrug resistant strains in advanced
kidney disease (stage 4 and 5) is noted. Of the
six patients with CKD, only two were on
hemodialysis (Table 5).
Regarding the age of the patients with K.
pneumoniae UTIs, three subjects were between
50 and 60 year-old (of which, one in CKD stage
3, one in stage 5, and one without CKD), and
three patients were over 65 years (with stages 4
and 5 CKD) (Table 5).
Considering gender and CKD, five patients
were men and only one woman. Four patients
were from urban environment and two from
rural environment (Table 4).

142 10.12865/CHSJ.43.02.06
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Table 6. The resistance of Klebsiella pneumoniae strains to antibiotics

and the number of classes of antibiotics

Number of
Klebsiella Number of
Antibiotic resistance classes of
strains antibiotics
antibiotics
1 FOX/CZ/TPZ/CTB/FM/CPR/NOR/TS 8 5 classes
2 GM/FOX/CZ/TPZ/CTB/FM/CPR/NOR/CRO/FEP/TS 11 6 classes
3 GM/CZ/CRO/FEP/TS 5 4 classes
4 FOT/FM/TS 3 3 classes
5. CZ/FM/CRO/TS 4 3 classes
6 FM/TS 2 2 classes
7 FOT/FM/TS 3 3 classes
8 GM/FOX/CZ/FOT/TPZ/FM/CPR/NOR/CRO/IP/TS/CXM 12 9 classes
9 FM/TS/AMC 3 3 classes
10 FOX/CZ/FOT/FM/CRO/TS/CXM/AMC 8 5 classes
11 GM/CZ/FOT/FM/CPR/NOR/CRO/TS/CXM/AMC 10 4 classes
12 FOX/CZ/FOT/FM/CRO/TS 6 6 classes
13 GM/FOX/AK/TPZ/FM/CPR/CRO/IP/TS 9 8 classes
14 FOX/CZ/FOT/FM/IP/CEC/CPO 7 4 classes
15 * FM/CPR/CRO/OFX/TS 5 4 classes
*Klebsiella pneumoniae of patient without CKD

K. pneumoniae strains were defined as or extended multidrug resistance. Thus, subjects

resistant multidrug strains following analysis of
resistance and susceptibility to antibiotics tested
for each strain. Using the median, standard
deviation and variation coefficient, limits have
been set for regrouping cases as having limited
with strains resistant to less than 8 antibiotics
were included in the first group, and if they had
strains resistant to more than 8 antibiotics were
considered with severe multidrug resistance.

Table 7. Observing-predicted frequency table for the two groups (limited and extended resistance), and risk
factors

PRO Frequency Percentage

CREA URIC DIAB HEMODI CKD URBAN/RU GENDE Multi
TEINUR UREA AGE Obser Pearson Obse Predic
TININE ACID ETES ALYSIS STAGE RAL R Resistance Predicted
IA ved Residual rved ted
EXTENDED 0 ,000 ,000 ,0% ,0%
0 1 0 0 0 0 R 60 F
LIMITED 1 1,000 ,000 100,0% 100,0%
EXTENDED 0 ,000 ,000 ,0% ,0%
0 0 0 0 3 R 69 F
LIMITED 1 1,000 ,000 100,0% 100,0%
0
EXTENDED 0 ,000 ,000 ,0% ,0%
1 0 1 1 5 R 65 M
LIMITED 1 1,000 ,000 100,0% 100,0%
1
EXTENDED 1 1,000 ,000 100,0% 100,0%
1 1 0 3 U 75 F
LIMITED 0 ,000 ,000 ,0% ,0%
EXTENDED 1 1,000 ,000 100,0% 100,0%
0 1 1 5 U 79 M
LMITED 0 ,000 ,000 ,0% ,0%
EXTENDED 1 1,000 ,000 100,0% 100,0%
3 U 50 M
LIMITED 0 ,000 ,000 ,0% ,0%
1 1 1
EXTENDED 1 1,000 ,000 100,0% 100,0%
1 1 0 66 M
LIMITED 0 ,000 ,000 ,0% ,0%
4 U
EXTENDED 1 1,000 ,000 100,0% 100,0%
76 M
LIMITED 0 ,000 ,000 ,0% ,0%

From the multivariate analysis we can see
that the common, defining elements of the
multi-resistance group are: CKD stage 3-5, male
gender, age over 70 years, urban environment,
diabetes association, high levels of creatinine,
urea and ureic acid, proteinuria. (Table 7). Each
strain of K. pneumoniae is multidrug resistant to
8 and more than 8 antibiotics (Tables 5,6). The
model used is predictive for 62.5% of
investigated cases.
The frequency of resistance for each
antibiotic from the extended multidrug
resistance group and the limited drug resistant
group was compared to determine which
antibiotic should be avoided in patients with
multidrug resistance.
Thus, in Gentamicin there are 66.4% cases of
resistance in the extended multidrug resistance
group, vs. 11% resistance in the limited
resistance group (p=0.037); FOX 83% vs. 22.2%
(p=0.007); CZ 100% vs. 44.4% (p=0.0003); TPZ

10.12865/CHSJ.43.02.06 143
Oana Mariana Cristea et al. - Urinary tract infection with Klebsiella pneumonia in Patients with Chronic Kidney Disease
66.4% vs. 0% (p=0.025); CTB 100% vs. 0% (p
<0.001); FM 100% vs. 88.8% (p=0.0006); CPR
83% vs. 11.1% (p=0.004); NOR 80% vs. 0%
(p=0.01); TS 100% vs. 88% (p=0.0006); CXM
100% vs. 0% (p <0.001).
A similar sensitivity in both groups (p> 0.05)
was found for: AK; FOT; IP; CES; CO. These
antibiotics may be used in patients with UTI and
CKD.
Noteworthy, a 77 year-old women with CKD
stage 5 with nephropathy, hemodialysis,
hypertension, heart failure and with
K. pneumoniae UTI was hospitalized twice at
interval of one month during the study period,
and the Klebsiella susceptibility changed as
follows. At the first admission, the
K. pneumoniae revealed resistance to 3/16 tested
antibiotics (nitrofurantoin, trimethoprim/
sulfamethoxazole, amoxicillin / clavulanic acid),
intermediate sensitivity to 6/16 antibiotics and
susceptibility to 7/16 antibiotics tested. At one
month interval, at the second admission
Klebsiella pneumoniae had resistance to
6/12 antibiotics, intermediate sensitivity to
1/12 antibiotics and susceptibility to
5/12 antibiotics. No susceptibility to norfloxacin,
cefoperazone/ sulbactam, cefuroxime,
amoxicillin/ clavulanic acid has been tested,
which would possibly have shown Klebsiella
resistance to these antibiotics. The patient died
by cardiopulmonary arrest two weeks after the
second hospitalization. In this patient, an
increase in the resistance of urine isolated
K. pneumoniae to the cephalosporins of first,
second and third generation was observed. There
was a change from intermediate susceptibility to
resistance for three antibiotics (cefazoline,
cefoxitin, ceftriaxone), and the sensitivity to
imipenem decreased at intermediate sensitivity.
Another patient who died was an 82 year-old
man with CKD stage 5, nephropathy, cardiac
disease and UTI with K. pneumoniae. In his
unfavorable evolution, it seems that cardiac
damage prevailed, with death due to worsening
of the renal failure and myocardial infarction.
K. pneumoniae revealed resistance to three
antibiotics (tazobactam/ piperacillin, fosfomycin
tromethanol, trimethoprim/ sulfametazazole,
from three different pharmacodynamic classes)
and intermediate sensitivity to ceftriaxone and
cefoxitin (another classes of antibiotics).
Discussions
In 2001, the European Commission presented
a “Community strategy against Antimicrobial
Resistance”. An important part of this strategy is
144
the „Council Recommendation on the prudent
use of antimicrobial agents in human medicine”.
These proposals provide a detailed set of public
health actions against antimicrobial resistance
[18].
Urinary tract infections caused by
K. pneumoniae appear to be increasing and have
become a real health problem, especially in
hospital settings. This trend should be
approached even more carefully in patients with
CKD, where urinary infection can accelerate
evolution to the final stages of renal failure,
infections being the second cause of mortality in
these patients after cardiovascular
complications.
Kidney disorders are increasing in
prevalence, affecting mostly elderly people.
Pharmacokinetics of kidney eliminated drugs is
significantly altered, and drug dosage
adjustments based on individual renal function
must be performed [19].
CKD and other chronic illness, especially
those which alter the immune system function,
such as diabetes, may increase the risk of
developing UTIs [20].
UTI involve the combination of pathogens
within urinary tract and symptoms and/or
inflammatory response to the pathogens
requiring treatment. Asymptomatic bacteriuria is
defined as isolation of a specified quantitative
count of bacteria in an appropriately collected
urine specimen from an individual without
clinical manifestations. UTIs are usually
classified by the site of infection as cystitis or
pyelonephritis [21].
The risk of developing chronic kidney
insufficiency due to UTIs without other risk
factors is low. The course and severity of UTIs
are determined by the pathogenicity of the
infective microorganism and the efficiency of
local or systemic defense mechanisms.
Virulence properties, given by adhesins, toxins
or capsule, are encoded by the genomic
structures. In kidney failure, many different
molecules (uraemic toxins, betaine, amino acids,
creatinine, urea, glucose) influence the microbial
environment. Defense factors, such as
phagocytic activity of granulocytes, defensins
and Tamm-Horsfall protein, as well as the
underlying anatomical lesions and the pre-
existing renal disease determine the severity of
UTIs and the prognosis of renal insufficiency
[22]. In the presented study, we have seen a
slightly decrease in percent, but with an increase
in absolute number of UTI cases with
K. pneumoniae after 6 years in patients with
10.12865/CHSJ.43.02.06
Current Health Sciences Journal
CKD (30.43% in 2016 as compared to 32.43%
in 2010 versus 14 patients in 2016 and
12 patients in 2010). The age of patients with
CKD and UTIs with Klebsiella admitted to the
Nephrology Department shifted towards older
age groups. This increase in the number of
third-age CKD patients maybe due to the
increase in the lifetime of the entire population,
with improved medical care for renal patients.
In a study published by Taiwanese authors in
patients with UTI and CKD with varying
degrees of renal impairment, it was found that
age, female gender, and kidney stones are
independently associated with UTI in the upper
urinary tract. This study revealed also that
patients with CKD and UTI were elderly, and
that females were prone to have more bacteriuria
and upper UTI than males. In addition, subjects
who had renal stones were more prone to have
upper UTI than other bacteriuria patients [23]. In
our study there is a higher proportion of elderly
men with UTI and CKD.
UTIs prevalence is usually higher in women,
at a younger age. Klebsiella infections are more
prevalent in older groups [24]. Other authors
mention a higher prevalence in women of the
third age, but does not specify whether the
patients had associated CKD [1,25]. A reduction
in estimated glomerular filtration rate and/or the
presence of proteinuria, are the predominant
manifestations of CKD, which is common in the
elderly population [26]. Proteinuria accelerates
the rate of decline of GFR in hypertensive,
diabetic, and non-diabetic individuals.
Proteinuria was recorded in our study in
5/10 (50%) CKD patients (stage 3-one patient,
stage 4-two patients and stage 5-two patients)
aged 65-79 year-old. In 2014 some autors have
stated that there is currently no evidence on the
relationship between proteinuria and infection
incidence independent of the glomerular
filtration rate [27].
In another study, UTIs in dialyzed kidney
patients were frequent, with Klebsiella as a
second uropathogen involved [28]. In our study,
from 14 patients with CKD, six underwent
dialysis. Of these, a multiresistant Klebsiella
was isolated in two patients.
While bacterial infections have diminished as
a cause of death in the general population, they
remain the second most common cause of death
in patients ESRD. This is largely due to the
impaired immune response in uremia which is
caused by a decreased granulocyte and
monocyte/macrophage phagocytic function, but
also a defective antigen presenting capacity of
10.12865/CHSJ.43.02.06
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antigen presenting cells and a depletion of the
antigen presenting dendritic cells. Moreover,
there is a reduction in number and antibody
producing capacity of B cells, and an increased
T cell turnover and apoptosis leading to
depletion of naive and central memory CD4+and
CD8+T cells, with an impaired cell mediated
immunity [29]. In our study, the serum urea was
above the normal range in 13/14 patients with
CKD, contributing probable to decreased
immunity, and favoring therefore K. pneumoniae
UTI.
Predialysis kidney disease appears to be
associated with increased risk of severe
infection. Whether predialysis kidney disease
increases the susceptibility to infections and
whether age modifies this association remains
unclear [30].
Complicated UTIs with relapsing Klebsiella
infections are relatively more common in
patients with diabetes [31]. Diabetes, as well as
CKD, are risk factors for recurrent UTIs by
decreasing immunity and therefore resistance to
infection.
Diabetes represents the most common cause
of chronic kidney disease. It is part of the first
category of risk factors in the progression of
CKD. Type 2 diabetes is not only a risk factor
for community-acquired UTIs, but also for
health care-associated UTIs, catheter-associated
UTI and post-renal transplant-recurrent UTIs
[32]. In addition, these patients are more prone
to have resistant pathogens as the cause of their
UTIs, including extended-spectrum β-lactamase-
positive Enterobacteriaceae, fluoroquinolone-
resistant uropathogens, carbapenem-resistant
Enterobacteriaceae, and vancomycin-resistant
Enterococci. Susceptibility to UTIs increases
with longer duration and greater severity of
diabetes. High urine glucose content and
defective host immune factors predispose to
infection. Hyperglycemia causes neutrophil
dysfunction by increasing intracellular calcium
levels and interfering with actin and, thus,
altering diapedesis and phagocytosis [32].
Various impairments in the immune system,
including humoral, cellular, and innate immunity
may contribute in the pathogenesis of UTIs in
diabetic patients. Bacteria have ability to thrive
in the presence of elevated blood sugar, and, in
addition, a hyperglycemic state negatively
affects the body’s ability to respond to
antimicrobial therapy. In our study
7/14 Klebsiella UTIs patients had type
2 diabetes as co-morbidity for CKD. The
145
Oana Mariana Cristea et al. - Urinary tract infection with Klebsiella pneumonia in Patients with Chronic Kidney Disease
association of diabetes-CKD further favors
UTIs.
In a study performed in a tropical region, K.
pneumoniae was found to the most frequent
bacterial etiological agent in UTIs, after
Escherichia coli, both isolated microorganisms
being highly resistant to ampicillin,
trimethoprim/sulfamethoxazole, doxycycline,
amoxicicline/clavulanic acid, whereas Klebsiella
demonstrated also to be highly resistant to
cefuroxime, ceftriaxone and gentamycin [33].
An Indian study, found that most of the
Klebsiella strains in UTIs were susceptible to
amikacin. In our study, K. pneumoniae isolated
from the urine of CKD patients revealed that,
from 14 strains tested, 12 were susceptible to
amikacin. Rare use of this antibiotic in our
region may explain the maintenance of
susceptibility [34]. A study in Jordan highlighted
that all isolates from the UTI of Klebsiella were
resistant to at least one antibiotic [35]. In our
study, most Klebsiella strains were resistant to
more than three antibiotics.
Tazobactam in combination with piperacillin
has an excellent clinical efficacy in various
infections [20]. Tazobactam is a promising beta-
lactamase inhibitor which has its own antibiotic
activity. In our study, if the resistance to
amoxicillin with clavulanic acid was significant,
the association of piperacillin with tazobactam
was found to be effective in the percentage of
50% and cefoperazone with sulbactam
(85.71%).
A recent Taiwanese study revealed in the last
decade a decreased susceptibility of Klebsiella
to most antibiotics, especially third generation
cephalosporins and fluoroquinolones [37].
Fluoroquinolones appear to be drugs of choice
for the treatment of pyelonephritis and cystitis in
patients with renal dysfunction. Theoretically,
ciprofloxacin would appear to be the preferred
fluoroquinolone in CKD. It is secreted as well as
filtered, and has good tissue penetration. A
broad spectrum cephalosporin such as
ceftriaxone may also be considered as an
alternative to ciprofloxacin in chronic kidney
failure, but K. pneumoniae in our study shows a
high degree of resistance to this antibiotic
(8/13-61.54% resistant strains).
Fosfomycin is increasingly used for empiric
treatment of urinary tract infection in the
absence of routine drug susceptibility testing
[38]. Fosfomycin is a phosphonic acid derivative
with antibacterial activity against a wide range
of gram-negative pathogens and some gram-
positive pathogens [24]. The antibacterial
146
spectrum of fosfomycin includes the most of the
enteric gram-negative bacteria, but with a
considerably higher MIC for Klebsiella sp [38].
In our study, a relatively large number of
K. pneumoniae is resistant to fosfomycin (50%),
probably as a consequence of its frequent use in
uncomplicated urinary tract infections.
Patients with chronic kidney failure, up to a
creatinine clearance of 20mL/min, can be
expected to have still sufficiently high urinary
concentrations of fosfomycin, and treatment of
cystitis may be justified from pharmacokinetic/
pharmacodynamic point of view. Single oral
dose therapy with fosfomicin is recommended
for treatment and prophylaxis of uncomplicated
UTIs, not only in premenopausal, but also in
post-menopausal elderly, otherwise healthy
women above 65 years of age [39]. Our study
revealed that increased use of fosfomycin
trometamol in recent years has probably led to
an increase in resistance to this antibiotic.
The death of the two patients with CKD
(14.28%) in the study group was favored by the
presence of severe kidney failure, advanced age,
CVD complications and Klebsiella pneumoniae
UTIs.
The multiple resistance to antibiotics of the
Klebsiella pneumoniae strains was correlated
with the advanced age of the patients, the
presence of diabetes in four cases, advanced
renal failure with high serum urea and creatinine
levels, and male gender.
Conclusions
Klebsiella pneumoniae strains isolated from
urine in UTI patients with CKD are the most
important uropathogenic microorganisms, after
Escherichia coli.
UTIs due to K. pneumoniae are favored by
the presence of CKD, with increased blood urea,
in turn the CKD evolution to the final stages is
accelerated by UTI.
Although the percentage of urinary infections
with K. pneumoniae is reduced in the case of
uropathogenic isolates from patients with
advanced CKD stages, isolated strains are
multiresistant in more than four classes of
antibiotics.
The treatment of UTIs caused by
K. pneumoniae with trimethoprim/
sulfamethoxazol, nitrofurantoin, first generation
of cephalosporins, and even the combination of
broad spectrum penicillin (amoxicillin) with
beta-lactamase inhibitor (clavulanic acid) has no
more favorable effect on patients with UTIs and
CKD, due to high resistance.
10.12865/CHSJ.43.02.06
Current Health Sciences Journal
UTIs with multiresistant K.pneumoniae have
a high prevalence in older subjects with CKD.
Renal insufficiency with uraemia increases the
severity of urinary infection with frequent
recurrences and worsening of kidney disease.
It appears that the aggressiveness of the
bacteria increases with the increase in antibiotic
resistance mechanisms and the degree of renal
insufficiency in CKD.
In CKD, UTI recurrences with
K. pneumoniae occur due to alterations of
immune defense mechanisms, especially with
comorbidities, such as diabetes. UTI recurrences
increase bacterial resistance to antibiotics by
selecting multiresistant strains.
The fatal progression of patients with
end-stage CKD is favored by CVD, but also
possible to Klebsiella infection and advanced
age.
For UTIs treatment in CKD patients with
high degrees of renal impairment as first choice
may be a fluoroquinolone (ciprofloxacin), and in
severe and persistent forms, piperacillin/
tazobactam or cefoperazone/ sulbactam.
Imipenem cilastatin, a carbapenem, may be
retained as a reserve antibiotic in urosepsis.
Aminoglycosides are poorly used due to
nephrotoxicity, especially in advanced CKD
stages (stages 4 and 5 of kidney failure).
This study had the approval of the local
Hospital Ethics Committee.
This study was designed to fully protect the
anonymity of patients, confidentiality of data,
respecting principles of the contemporary
version of the Declaration of Helsinki.
The limits of the study are represented by the
fact that is a retrospective study, there was a
short time period for assessment of UTIs with
K. pneumoniae in patients with CDK, and not
use the similar antibiotics for susceptibility
testing in case of relapses.
Contributors
Authors designed the study strategy,
reviewed the literature, performed the laboratory
investigations and all authors approved the final
version of the manuscript. First three authors
performed the laboratory investigations, while
the fourth author was involved in immunological
comments. Pharmacology problems have been
solved by the fifth author. The sixth author
carried out the statistical processing. This report
is independent research and the authors report no
conflicts of interest in this work.
10.12865/CHSJ.43.02.06
Vol. 43, No. 2, 2017 April-June
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 www.nature.com/scientificreports

OPEN Hyponatremia is Associated with

Fluid Imbalance and Adverse Renal
Outcome in Chronic Kidney Disease
received: 17 March 2016
accepted: 18 October 2016 Patients Treated with Diuretics
Published: 14 November 2016
Lee Moay Lim1,*, Ni-Chin Tsai1,2,*, Ming-Yen Lin1,3, Daw-Yang Hwang1, Hugo You-Hsien  Lin1,4,
Jia-Jung Lee1, Shang-Jyh Hwang1,3, Chi-Chih Hung1 & Hung-Chun Chen1,3

Chronic kidney disease (CKD) is frequently complicated with hyponatremia, probably because of fluid
overload or diuretic usage. Hyponatremia in CKD population is associated with increased mortality,
but the effect on renal outcome was unknown. We investigated whether hyponatremia is associated
with fluid status and is a prognostic indicator for adverse outcomes in a CKD cohort of 4,766 patients
with 1,009 diuretic users. We found that diuretic users had worse clinical outcomes compared with
diuretic non-users. Hyponatremia (serum sodium <135 mEq/L) was associated with excessive volume
and volume depletion, measured as total body water by bioimpedance analysis, in diuretic users, but
not in diuretic non-users. Furthermore, in Cox survival analysis, hyponatremia was associated with an
increased risk for renal replacement therapy (hazard ratio, 1.45; 95% CI, 1.13–1.85, P < 0.05) in diuretic
users, but not in diuretic non-users (P for interaction <0.05); restricted cubic spline model also showed
a similar result. Hyponatremia was not associated with all-cause mortality or cardiovascular event
whereas hypernatremia (serum sodium >141 mEq/L) was associated with an increased risk for all-cause
mortality. Thus, hyponatremia is an indicator of fluid imbalance and also a prognostic factor for renal
replacement therapy in CKD patients treated with diuretics.

Chronic kidney disease (CKD) causes dysfunction in regulating water homeostasis because of a reduced glomer-
ular filtration rate (GFR)1. Volume overload is highly prevalent in patients with CKD and a 10% to 30% increase
in extracellular fluid can be detected, even in the absence of overt edema2. The disorder in homeostasis resulted
in hypertension, electrolyte imbalance and edema. Volume overload has been associated with CKD progression
and cardiovascular disease (CVD) related morbidity or mortality3. Diuretics are essential in treating fluid bal-
ance, blood pressure control, prevention of hyperkalemia and urine amount regulation in CKD population4–6.
However, several studies have reported negative outcomes of diuretic usage on renal function, mortality, and
hospitalization in patients with heart failure7–11. In acute kidney injury (AKI), loop diuretics exert no significant
effect on renal recovery, the need for dialysis, or mortality12–15. In CKD, the long-term effect of diuretic usage in
correction of volume overload has not been thoroughly studied16.
Sodium imbalance could be secondary to diuretic usage, particularly in patients with CKD, because the ability
of kidneys to regulate dilution and concentration becomes impaired as renal disease progressing2. Hyponatremia
could be a consequence of fluid overload or a consequence of diuretic usage in these patients. Various epide-
miological studies have documented an association between hyponatremia and increased mortality from dis-
eases involving fluid overload and diuretic usage, such as congestive heart failure (CHF) and liver cirrhosis17–21.
Recently, Kovesdy et al. discovered that both lower and higher serum sodium levels are associated with higher
mortality in patients with CKD, independent of CHF and liver disease22, but renal outcome and the degree of diu-
retic usage were not reported. Due to the unique disease characteristic that are susceptible to sodium imbalance,

1
Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung
Medical University, Kaohsiung, Taiwan. 2Department of Obstetrics and Gynecology, Kaohsiung Chang Gung
Memorial Hospital, Chang Gung University, College of Medicine, Taiwan. 3Faculty of Renal Care, College of Medicine,
Kaohsiung Medical University, Kaohsiung, Taiwan. 4Department of Internal Medicine, Kaohsiung Municipal Ta-Tung
Hospital, Kaohsiung, Taiwan. *These authors contributed equally to this work. Correspondence and requests for
materials should be addressed to C.-C.H. (email: chichi@cc.kmu.edu.tw)

Scientific Reports | 6:36817 | DOI: 10.1038/srep36817 1

www.nature.com/scientificreports/

Diuretic non-users (n = 3757) Diuretic users (n = 1009) p

Demographics data
Age, yrs 61.2 ±​  14.8 64.0 ±​  13.5 <​0.001
Female, n (%) 1573 (41.9%) 500 (49.6%) <​0.001
Congestive heart failure, n (%) 303 (8.1%) 279 (27.7%) <​0.001
Diabetes mellitus, n (%) 1297 (34.5%) 661 (65.5%) <​0.001
Cardiovascular disease, n (%) 774 (20.6%) 425 (42.1%) <​0.001
Severe liver disease, n (%) 167 (4.4%) 66 (6.5%) 0.006
Body mass index, kg/m2 24.5 ±​  4.0 24.9 ±​  3.8 0.002
Total body water (male), % 54.0 ±​  5.7 55.5 ±​  8.2 0.036
Total body water (female), % 49.0 ±​  6.3 49.6 ±​  6.5 0.374
Mean blood pressure, mmHg 99.2 ±​  13.9 100.4 ±​  14.8 0.030
Integrated CKD care 2840 (75.6%) 731 (72.4%) 0.116
Causes of renal disease <​0.001
Glomerulonephritis 1617 (43%) 249 (24.7%)
Tubular interstitial disease 361 (9.6%) 36 (3.6%)
Diabetes mellitus 1115 (29.7%) 584 (57.9%)
Hypertension 399 (10.6%) 87 (8.6%)
Other 265 (7.1%) 53 (5.3%)
Laboratory values
eGFR, ml/min/1.73 m2 33.7 ±​  25.7 25.1 ±​  22.3 <​0.001
UPCR, mg/g 1026 (351–2106) 2089 (941–3715) <​0.001
Hemoglobin, g/dL 11.4 ±​  2.5 10.2 ±​  2.2 <​0.001
Albumin, g/dL 3.9 ±​  0.6 3.5 ±​  0.6 <​0.001
CRP, mg/dL 1.4 (0.4–6.5) 1.6 (0.5–6.2) 0.179
HbA1c, % 6.4 ±​  1.6 7.0 ±​  1.9 <​0.001
Outcomes
Renal replacement therapy, n (%) 949 (25.3%) 520 (51.5%) <​0.001
All-cause mortality, n (%) 561 (14.9%) 255 (25.3%) <​0.001
Cardiovascular events, n (%) 415 (11.0%) 273 (27.1%) <​0.001

Table 1.  Baseline characteristics and clinical outcomes of the diuretic users and diuretic non-users.
Abbreviations: eGFR, estimated glomerular filtration rate; CRP, C-reactive protein; UPCR, Urine protein-to-
creatinine ratio. Continuous variables are expressed as mean ±​ standard deviation or median (inter-quartile
range), and categorical variables are expressed as percentage. p <​ 0.05 indicates a significant difference between
diuretic non-user and diuretic user.

hyponatremia could be prognostic indicator in patients with CKD. Thus, the aim of our study was to determine
whether diuretic usage and the related hyponatremia are associated with fluid imbalance and are predictive of
adverse clinical outcomes, including renal outcomes, in patients with CKD.

Results
Baseline characteristics and clinical outcomes of the diuretic users and diuretic non-users. 
Table 1 showed the baseline characteristics of diuretic users and non-users which comprised of 1,009 and 3,757
respectively. The diuretic users showed higher percentage of CHF, Diabetes mellitus (DM), CVD and severe
liver disease (SLD). They exhibited a significantly higher mean blood pressure, urine protein-to creatinine ratio
(UPCR) and HbA1c level (P <​ 0.05). At the same time, lower estimated glomerular filtration rate (eGFR), serum
hemoglobin and albumin were observed in diuretic users (Table 1). However, only male diuretic users showed
higher total body water (TBW) (55.5 ±​ 8.2% vs 54.0 ±​ 5.7%). Diuretic users also showed higher percentage of
renal replacement therapy (RRT) and CVD.

Baseline characteristics of diuretic users according to serum sodium.  Table 2 showed the baseline
characteristics of diuretic users. The mean age was 64.0 ±​ 13.5 years and 49.6% were female. Diuretic users were
divided according to mean serum sodium ±​ 1 SD into 4 groups: Na <​135 mEq/L, Na 135–138 mEq/L, Na 138–
141 mEq/L, and Na >​141 mEq/L (Table 2). Diuretic users with Na <​135 mEq/L were more likely than those with
Na 138–141 mEq/L to experience CHF, DM, and CVD, have higher blood glucose levels, HbA1C and UPCR, and
have lower albumin concentrations. Diuretic usage did not differ among the Na groups (Table 2). In male diuretic
users, Na <​135 mEq/L was associated with lowest TBW.

Association between hyponatremia and total body water in diuretic users.  Table 3 showed the
variables associated with hyponatremia (Na<​135 mEq/L) in diuretic users. To understand whether hyponatremia
could be an indicator of fluid status, we measured TBW by using the bioimpedance method in 498 randomly
selected diuretic users and performed logistic regression to determine the nonlinear association between serum

Scientific Reports | 6:36817 | DOI: 10.1038/srep36817 2

www.nature.com/scientificreports/

Na (mEq/L)
All (n = 1009) <135 (n = 181) 135–138 (n = 332) 138–141 (n = 335) >141 (n = 161) p for trend
Demographics and Medical History
Age, year 64.0 ±​  13.5 65.1 ±​  11.2 63.4 ±​  13.9 62.6 ±​  14.6 66.8 ±​  12.0 0.360
Female, n (%) 500 (49.6%) 97 (53.6%) 165 (49.7%) 151 (45.1%) 87 (54.0%) 0.607
CHF, n (%) 279 (27.7%) 68 (37.6%) 91 (27.4%) 75 (22.4%) 45 (28.0%) 0.011
DM, n (%) 661 (65.5%) 138 (76.2%) 220 (66.3%) 204 (60.9%) 99 (61.5%) 0.001
CVD, n (%) 197 (19.5%) 97 (53.6%) 148 (44.6%) 119 (35.5%) 61 (37.9%) <​0.001
SLD, n (%) 66 (6.5%) 10 (5.5%) 26 (7.8%) 22 (6.6%) 8 (5.0%) 0.679
BMI, kg/m2 24.9 ±​  3.8 24.2 ±​  3.6 24.9 ±​  3.9 25.3 ±​  3.8 25.1 ±​  3.9 0.010
Total body water (male), % 55.5 ±​  8.2 54.4 ±​  9.1 55.2 ±​  7.7 55.9 ±​  8.1 57.2 ±​  8.2 0.216
Total body water (female), % 49.6 ±​  6.5 49.7 ±​  5.5 49.4 ±​  6.8 50.1 ±​  7.5 48.2 ±​  4.7 0.611
Mean BP, mmHg 100.4 ±​  14.8 99.9 ±​  14.3 100.4 ±​  14.9 101.3 ±​  14.9 98.8 ±​  14.8 0.612
Integrated CKD care 708 (70.2%) 123 (68.0%) 238 (71.7%) 235 (70.1%) 112 (69.6%) 0.278
Primary renal disease 0.015
Glomerulonephritis 249 (24.7%) 37 (20.4%) 73 (22.0%) 107 (31.9%) 43 (26.7%)
Tubular interstitial disease 36 (3.6%) 7 (3.9%) 8 (2.4%) 11 (3.3%) 10 (6.2%)
Diabetes mellitus 584 (57.9%) 115 (63.5%) 194 (58.4%) 170 (50.7%) 94 (58.4%)
Hypertension 87 (8.6%) 13 (7.2%) 34 (10.2%) 32 (9.6%) 8 (5.0)
Other 53 (5.3%) 9 (5.0%) 23 (6.9%) 15 (4.5%) 6 (3.7%)
Laboratory values
eGFR, ml/min/1.73 m2 25.1 ±​  22.3 23.2 ±​  20.5 23.6 ±​  20.9 28.5 ±​  24.9 23.1 ±​  20.7 0.537
2089 2477 2106 1870 1869
UPCR, mg/g 0.043
(941–3715) (1238–3715) (899–4399) (752–3690) (973–3709)
Hemoglobin, g/dL 10.2 ±​  2.2 9.9 ±​  2.1 10.3 ±​  2.1 10.5 ±​  2.3 10.0 ±​  2.1 0.595
Albumin, g/dL 3.5 ±​  0.6 3.4 ±​  0.6 3.5 ±​  0.6 3.6 ±​  0.6 3.6 ±​  0.6 0.003
CRP, mg/dL 1.6 (0.5–6.2) 1.74 (0.44–6.59) 1.74 (0.5–7.79) 1.44 (0.50–4.68) 1.81 (0.46–6.10) 0.468
Sodium, mEq/L 137.5 ±​  3.9 131.4 ±​  3.1 136.5 ±​  1.1 139.4 ±​  0.9 142.5 ±​  1.6 <​0.001
Potassium, mEq/L 4.3 ±​  0.6 4.3 ±​  0.6 4.3 ±​  0.6 4.3 ±​  0.7 4.3 ±​  0.7 0.362
HCO3, mg/dL 21.3 ±​  4.6 20.5 ±​  4.4 21.2 ±​  4.5 21.7 ±​  4.4 21.4 ±​  4.9 0.786
Phosphorus, mg/dL 4.7 ±​  1.3 4.7 ±​  1.4 4.8 ±​  1.3 4.5 ±​  1.2 4.7 ±​  1.2 0.476
Calcium, mg/dL 8.8 ±​  0.8 8.7 ±​  0.8 8.8 ±​  0.7 8.8 ±​  0.8 9.0 ±​  0.7 0.268
Cholesterol, mg/dL 203.9 ±​  67.8 202.4 ±​  72.0 203.4 ±​  72.5 204.9 ±​  63.5 204.6 ±​  62.3 0.729
Blood glucose, mg/dL 124.5 ±​  54.4 141.8 ±​  68.0 123.5 ±​  48.3 118.9 ±​  52.4 118.5 ±​  49.6 <​0.001
HbA1c, % 7.0 ±​  1.9 7.7 ±​  2.4 7.0 ±​  1.7 6.7 ±​  1.8 6.9 ±​  1.6 <​0.001
Medications, n (%)
Furosemide 867 (85.9%) 152 (84.0%) 294 (88.6%) 283 (84.5%) 138 (85.7%) 0.850
Thiazide 175 (17.3%) 36 (19.9%) 52 (15.7%) 59 (17.6%) 28 (17.4%) 0.760
ACEI/ARB 655 (64.9%) 118 (65.2%) 209 (63.0%) 235 (70.1%) 93 (57.8%) 0.680
Anti-HTN agents 801 (79.4%) 145 (80.1%) 274 (82.5%) 256 (76.4%) 126 (78.3%) 0.230
OAD agents 448 (44.4%) 103 (56.9%) 149 (44.9%) 124 (37.0%) 72 (44.7%) <​0.001
Statins 403 (39.9%) 74 (40.9%) 131 (39.5%) 142 (42.4%) 56 (34.8%) 0.312

Table 2.  Baseline characteristics of diuretic users according to serum sodium. Abbreviations: CHF,
congestive heart failure; DM, Diabetes mellitus; CVD, cardiovascular disease; SLD, Severe liver disease; BMI,
Body mass index; BP, blood pressure; eGFR, estimated glomerular filtration rate; CRP, C-reactive protein;
UPCR, Urine protein-to-creatinine ratio; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin
II receptor blocker; Anti-HTN, anti-hypertensive; OAD, Oral antidiabetic drug. Continuous variables are
expressed as mean ±​ standard deviation or median (inter-quartile range), and categorical variables are
expressed as number and percentage. P for trend <​ 0.05 indicates a significant trend for increasing Na levels.

sodium and TBW. Our results showed that the lowest and highest quartiles of TBW were associated with hypona-
tremia (Table 3). Age, CVD, HbA1c and BMI also showed positive correlation with hyponatremia but not thiazide
diuretics. No association between serum sodium and TBW was noted in diuretic non-users (Supplementary Table 1).
CVD, eGFR, albumin, HbA1c and BMI showed positive correlation with hyponatremia in diuretic non-users.

Association between serum sodium and clinical outcomes in diuretic users.  In diuretic users,
after a median follow-up of 1070 days, the RRT event was higher in Na <​135 mEq/L, which was 113 (62.4%)
(Table 4). In fully-adjusted competing risk Cox regression model, compared with Na 135–138 mEq/L, Na
<​135 mEq/L was associated with an adjusted HR of 1.45 (95% CI, 1.13–1.85; P <​ 0.05) for RRT, but not associ-
ated with all-cause mortality and cardiovascular events (Table 4). Na >​141 mEq/L was associated with a trend of

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Variables OR 95% CI P
Age, year 1.032 1.005 to 1.060 0.022
Male 1.094 0.771 to 1.552 0.614
DM 1.207 0.778 to 1.871 0.401
CVD 1.614 1.137 to 2.290 0.007
Total body water
 1st quartile 3.707 1.054 to 13.046 0.041
 2nd quartile 1.000 1.0
 3rd quartile 1.048 0.273 to 4.019 0.946
 4th quartile 3.589 1.049 to 12.280 0.042
eGFR, ml/min/1.73 m2 0.999 0.989 to 1.009 0.835
Hb, g/dL 0.930 0.836 to 1.034 0.179
Albumin, mg/dL 0.863 0.616 to 1.210 0.393
CRPlog 1.030 0.860 to 1.233 0.748
HbA1c, % 1.241 1.130 to 1.363 0.005
UPCR log 1.165 0.790 to 1.719 0.442
Mean BP, mmHg 1.017 0.998 to 1.037 0.083
BMI, kg/m2 0.954 0.911 to 0.999 0.047
Thiazide (vs furosemide) 0.889 0.654 to 1.173 0.289

Table 3.  Logistic regression for sodium <135 mEq/L in diuretic users. Abbreviations: as Table 1. DM,
Diabetes mellitus; CVD, cardiovascular disease; BMI, Body mass index; eGFR, estimated glomerular filtration
rate; CRP, C-reactive protein; UPCR, Urine protein-to-creatinine ratio; Adjusted for age, gender, eGFR,
diabetes mellitus, cardiovascular disease, mean blood pressure, HbA1c, hemoglobin, albumin, cholesterol, log-
transformed urine protein to creatinine ratio, log-transformed C-reactive protein, body mass index, ACEI/ARB,
anti-HTN agents, OAD agents and statins.

increased risk for RRT. When compared with Na 138–141 mEq/L, Na >​141 mEq/L had an adjusted HR of 1.59
(95% CI, 1.09–2.32; P <​ 0.05) for all-cause mortality. In analysis of serum sodium and outcomes as restricted
cubic splines, we observed that Na <​132 mEq/L was associated with a higher risk for RRT (Fig. 1) whereas Na
>​143 mEq/L was associated with a higher risk for all-cause mortality (Fig. 2).

Association between serum sodium and clinical outcomes in diuretic non-users and interac-
tion between diuretic use and serum sodium.  We studied the prognostic effect of sodium in diuretic
non-user (Supplement Table 2). The percentage of Na <​135 mEq/L in diuretic non-users was 17.3% similar to
that in diuretic users, 17.9%. Na <​135 mEq/L was associated with increased risks of RRT, all- cause mortality
and cardiovascular events in unadjusted models; however, the result became non-significant after adjustment
(Supplement Table 2). In analysis of serum sodium and outcomes as restricted cubic splines, we also did not
observe a significant association (Supplement Figures 1, 2 and 3). The interaction between diuretic use and serum
sodium for RRT was significant with a p value of 0.017 and 0.038, when serum sodium treated as a categorical
variable or a continuous variable, respectively.

Sensitivity test for the association between serum sodium and clinical outcomes.  We tested
other grouping methods as stated in the method. In diuretic users, compared with Na 135–141 mEq/L, Na
<​135 mEq/L was associated with an increased risk of RRT and Na >​141 mEq/L was associated with an increased
risk of all-cause mortality (Supplement Table 3). In analysis by restricted cubic spline model with different knots,
we also observed that Na <​132 mEq/L was associated with a higher risk for RRT (Supplement Figure 4) whereas
Na >​143 mEq/L was associated with a higher risk for all- cause mortality (Supplement Figure 5). In diuretic
non-users, serum sodium treated as a categorical variable (3 groups) or as a continuous variable with different
knots showed similar results (data not shown). The interaction between diuretic use and serum sodium for RRT
was also significant with a p value of 0.024 and 0.036, when serum sodium treated as a categorical variable or a
continuous variable, respectively (data not shown).

Discussion
We investigated the diuretic usage, clinical outcomes, and prognostic effect of serum sodium among patients in
a CKD cohort. We found that hyponatremia is associated with imbalance of TBW in diuretic users. In investi-
gating the prognostic effect of diuretic- related hyponatremia, we revealed, for the first time, that serum sodium
<​135 mEq/L is independently associated with a higher risk for RRT in diuretic users, but not in diuretic
non-users. Moreover, we also observed that serum sodium >​141 mEq/L is associated with an increased risk for
all-cause mortality.
Previous studies on the effects and outcomes of diuretic usage have mainly focus on patients with AKI or
edematous diseases other than kidney disease. Using diuretics to treat AKI provides no clear benefits in the
recovering of kidney function or preventing mortality23 other than maintaining urine output13. Moreover, diuretic
usage by critically ill patients with AKI was associated with an increased risk of death and non-recovery in renal

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Na (mEq/L)
<135 135–138 138–141 >141
Renal replacement Therapy
Event 113 (62.4%) 174 (52.4%) 148 (44.2%) 85 (52.8%)
Unadjusted HR 1.33 (1.05–1.68)* 1 (reference) 0.80 (0.63–0.98)* 1.02 (0.79–1.32)
Adjusted HR 1.45 (1.13–1.85)* 1 (reference) 1.18 (0.94–1.48) 1.22 (0.83–1.71)
All-cause mortality
Event 56 (30.9%) 86 (25.9%) 60 (17.9%) 53 (32.9%)
Unadjusted HR 1.21 (0.86–1.69) 1 (reference) 0.72 (0.52–1.00) 1.25 (0.89–1.77)
Adjusted HR 1.11 (0.79–1.58) 1 (reference) 0.87 (0.62–1.22) 1.38 (0.98–1.96)
Cardiovascular event
Event 58 (32.0%) 89 (26.8%) 76 (22.7%) 50 (31.1%)
Unadjusted HR 1.22 (0.93–1.59) 1 (reference) 0.72 (0.56–0.94)* 1.04 (0.78–1.39)
Adjusted HR 1.06 (0.80–1.40) 1 (reference) 0.92 (0.70–1.19) 1.15 (0.86–1.54)

Table 4.  Associations between serum sodium and outcomes in diuretic users. Adjusted for age, gender,
eGFR, diabetes mellitus, cardiovascular disease, mean blood pressure, HbA1c, hemoglobin, albumin,
cholesterol, log-transformed urine protein to creatinine ratio, log-transformed C-reactive protein, body mass
index, ACEI/ARB, anti-HTN agents, OAD agents, statins, integrated CKD care and causes of renal diseases.
*(p <​ 0.05) indicates a significantly different from reference group.

Figure 1.  Association between serum sodium and renal replacement therapy by restricted cubic spline
model in diuretic users.

Figure 2.  Association between serum sodium and all-cause mortality by restricted cubic spline model in
diuretic users.

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function24. Observational studies have shown that diuretic usage by patients with heart failure is associated with
reduced renal function, the progression of heart failure and increased mortality25–27. Compared with paracentesis,
diuretic usage was associated with a higher incidence of renal impairment and other complications in patients
with liver cirrhosis and ascites28. These data suggest that diuretic usage could be harmful to patients with extreme
volume changes.
Clinical trials in patients with hypertension have yielded controversial results regarding the effects of diu-
retic usage on clinical outcomes. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack
Trial (ALLHAT) reported that thiazide diuretics were not inferior to calcium channel blockers and angiotensin-
converting enzyme inhibitors in preventing all-cause mortality and were superior in preventing CVD29. The
renal outcomes of these drugs did not differ30. However, in the Avoiding Cardiovascular Events in Combination
Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) study, benazepril plus hydrochlorothi-
azide, compared with benazepril plus amlodipine, were more strongly associated with hypotension and higher
risks of the progression of CKD, cardiovascular morbidity, and mortality31. These data suggest that thiazide diu-
retics could be harmful if they cause volume depletion.
Little research has examined the association between diuretic usage and outcomes in CKD comparatively.
Diuretics have considerable therapeutic importance in treatment volume overload of CKD patients, but may
possess direct nephrotoxicity, particularly tubulointerstitial injury32 and impaired renal vaso-relaxation33. The
overuse of diuretics causes volume depletion and subsequently increased sympathetic activity34 and stimulates
the renin-angiotensin-aldosterone system34, as evidenced by animal studies. Both local renal effects and systemic
neuro-hormonal effects impair renal function. In patients with hypertension and GFR <​60 mL/min/1.73 m2, thi-
azide diuretics were not inferior to 2 other drugs in reducing end-stage renal disease in the ALLHAT study35, and
benazepril plus hydrochlorothiazide were not associated with hypotension or a higher risk of the progression of
CKD in the ACCOMPLISH study31. No previous studies investigated the impact of loop diuretics in patients with
CKD. In our study, we discovered that diuretic users (80% loop diuretics) had worse clinical outcomes. However,
the causal relationship between them could not be determined.
In patients with CKD and volume overload, diuretic usage may be a necessary evil in managing volume status.
High prevalence of volume overload in CKD patients lead to unavoidable diuretic usage. Volume status could be
measured by using the bioimpedance method36, which reflects the status of hydration quantitatively. However,
this is not routinely use in daily practice. We found hyponatremia under diuretic usage could become a clinical
parameter which indicates the increased TBW (increased fluid status despite diuretic use) or decreased TBW
(likely because of too much diuretic use). Hyponatremia with increased TBW denotes water and salt retention
because of impaired renal excretion and activation of the neuro-hormonal mechanisms37. The increased fluid
status would increase renal efferent pressure and decrease renal blood38. Our previous study had shown that fluid
overload is associated with worse renal outcome36. Conversely, hyponatremia with decreased TBW suggests vol-
ume depletion under diuretic usage,
which enhances arginine-vasopressin (AVP) and renin-angiotensin secretion39. Acute volume depletion is
well-known as a cause of acute renal injury40 and chronic volume depletion could leads to chronic tubulointersti-
tial injury and CKD41. Volume depletion also decreases renal perfusion and increases the susceptibility to anal-
gesics and nephrotoxic agents. Thus, hyponatremia indicates imbalanced volume status and could be associated
with renal function progression.
Hyponatremia could also indicate an impaired renal dilution capability in CKD patients. As CKD progresses,
renal sodium loss because of impaired tubular reabsorption and osmotic disequilibrium between the luminal
fluid and medullary interstitial impair dilution42. CKD is also associated with increased AVP secretion and exper-
imental evidence has demonstrated that AVP is critical in initiating and exacerbating renal damage43. A sustained
stimulation of vasopressin receptors induced intrarenal renin- angiotensin system activation, glomerular hyper-
filtration, and hypertrophy, causing proteinuria and glomerulosclerosis43. However, our data demonstrated that
hyponatremia in diuretic non-users was associated with lower eGFR but was not associated adverse clinical out-
comes. Besides, thiazide diuretics, which inhibit sodium transport in the distal tubule, could prevent the maximal
dilution of urine44. But we found no association between hyponatremia and thiazide diuretics in diuretic users.
These data suggest that impaired renal dilution capability could not explain the prognostic effect of hyponatremia
in diuretic users.
Hyponatremia may also reflect concurrent heart failure, which may impose additive deleterious effects on
poor renal outcomes. Fluid overload as indicated by hyponatremia could cause cardiomyocyte elongation and
dysfunction during the left ventricle remodeling45. Our data demonstrated that hyponatremia was associated with
cardiovascular disease in patients with CKD. Hoorn et al. demonstrated that hyponatremia predicts declining
creatinine clearance in patients with severe heart failure46. The concourse of hyponatremia and renal dysfunction
has been shown to be associated with heart and liver failure47. Thus, cardiorenal syndrome can cause a vicious
cycle in which deteriorating heart function accelerates the reduction in kidney function via the neurohormonal
pathways48.
Hyponatremia is an independent prognostic factor for morbidity and mortality in heart failure 19,49 and
maintenance hemodialysis17,50. Kovesdy et al. concluded that lower serum sodium (<​135.9 mEq/L) and higher
serum sodium (>​145 mEq/L) were associated with higher mortality in a large cohort of patients with non–
dialysis-dependent CKD22. In our CKD cohort, the lack of association between hyponatremia and mortality
could be attributed to the fact that renal replacement therapy could resolve the fluid overload eventually in
patients with advanced CKD51. Our data also reconfirmed the association between hypernatremia and mortality
in CKD patients. Hypernatremia (serum sodium >​145 mEq/L) was much less than hyponatremia (serum sodium
<​135 mEq/L), 3% vs 17%. Patients with hypernatremia could be associated with acute complications and death,
rather than RRT.

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Our study had several limitations. First, as an observational cohort, our ability to elucidate definite causal links
was limited. Second, total body water measured by bioelectrical impedance analysis was not equal to extracellular
fluid, though we had found a good correlation. Third, CV events were recorded in only one hospital, which might
have caused an underestimation. Fourth, variations in serum sodium levels caused by daily intake, nutritional
status, and medication use during the follow-up period could have confounded the results. However, our pur-
pose was to apply serum sodium as a prognostic factor, not a causal factor. Fifth, the smaller sample size of the
2 extreme serum sodium levels and relatively short follow-up duration could have resulted in lower statistical
power, which might account for the weak association with mortality and CV events and the inability to differen-
tiate the effects of loop and thiazide diuretics.
In conclusion, diuretic users have adverse clinical outcomes in CKD population. Hyponatremia is associated
with imbalanced TBW and is a prognostic indicator for RRT in diuretic users, but not in diuretic non-users.
Hyponatremia was not associated with all- cause mortality or cardiovascular event whereas hypernatremia was
associated with an increased risk for all-cause mortality. Therefore, the serum sodium levels of patients with CKD
who are being treated with diuretics should be routinely evaluated. Additionally, interventions other than diuret-
ics aimed at achieving optimal fluid status should be considered. Whether the mechanism behind hyponatremia
is diuretic-induced direct renal injury or neuro-hormonal activation requires further study.

Methods
Participants and Measurement.  Between November 11, 2002, and June 30, 2009, 5,047 patients who
were screened through an integrated CKD care program at 2 affiliated hospitals of Kaohsiung Medical University
in Southern Taiwan were included in the CKD cohort and followed until July 31, 2010. Integrated CKD care
program Kaohsiung for delaying dialysis (ICKD) study was designed as a prospective cohort study to investigate
the impact of an integrated CKD care program on clinical outcomes in patients with CKD stages 1–5 not on
dialysis. CKD was staged according to K/DOQI definitions and the estimated glomerular filtration rate (eGFR)
was calculated using the equation of the 4-variable Modification of Diet in Renal Disease (MDRD) Study. A total
of 123 patients who were lost to follow-up within 3 months and 158 patients with incomplete medication infor-
mation were excluded. Of the patients included, 3,659 were treated as part of the integrated care program and
1,107 received regular care. A total of 4,766 patients with CKD between stages 1 and 5 were eligible for this study.
The study protocol was approved by the Institutional Review Board of Kaohsiung Medical University Hospital
(KMUH-IRB-990198). Written informed consent was obtained from patients and all clinical investigations were
conducted according to the principles expressed in the Declaration of Helsinki.
Baseline variables included demographic features, medical history, examination findings, laboratory data,
and medication history. The demographic features were the baseline records when patients enrolled in the CKD
care program. The medical history was obtained by reviewing doctor charts. DM and hypertension were defined
according to clinical diagnoses and prescribed medications. CVD was defined as a clinical diagnosis of heart fail-
ure, acute or chronic ischemic heart disease, or cerebrovascular disease. Diuretic use was defined as loop diuretics
exceeding equivalent furosemide 39 mg per day or thiazide diuretics exceeding equivalent trichlormethiazide
3.9 mg per day for more than half of the observation period. Other medication use was also defined as treatment
for more than half of the observation period. To prevent variability, electrolytes including serum sodium were col-
lected 3 months before and after enrollment and were averaged. To study the association of clinical outcomes with
2 ends of sodium level, patients were divided into 4 groups according to serum sodium levels, with cut-off values
of 135 mEq/L, 138 mEq/L, and 141 mEq/L equal to mean −​1 standard deviation (SD), mean, and mean +​1 SD,
respectively. We also examined serum sodium as a continuous predictor using restricted cubic spline analysis52.
Bioelectrical impedance analysis measures the change in impedance of electrical signals, which travel more
rapidly through water and lean body mass than through fat body mass. The device used in this study was the
InBody 230 (Biospace Co Ltd, Korea), which uses 2 frequencies (20 k and 100 kHz). Our preliminary data demon-
strated that the first and fourth quartiles of TBW (expressed as % of body weight) were associated with adverse
clinical outcomes. Accordingly, we defined decreased TBW as the first quartile (<​25%) and increased TBW as
the fourth quartile (>​75%).

Outcomes.  Three outcomes were assessed: all-cause mortality, renal replacement therapy (RRT), and car-
diovascular events. Survival status and cause of death were ascertained in a death certificate review by using
charts and the National Death Index. Cardiovascular events were defined as the development of acute coronary
syndrome or acute stroke, hospitalization for peripheral arterial occlusion disease or congestive heart failure,
and death by these causes. The development of cardiovascular events was ascertained by reviewing charts. RRT
was defined as the initiation of hemodialysis, peritoneal dialysis, or renal transplantation and was ascertained by
reviewing charts and catastrophic illness certificate.

Statistical Analysis.  The baseline characteristics of all patients are expressed as percentages for categorical
data, in mean ±​ SD for continuous variables with approximately normal distribution, and median and inter-
quartile ranges for continuous variables with skewed distribution. The association between hyponatremia (Na
<​135 mEq/L) and clinical variables including TBW in diuretic users was evaluated using logistic regression anal-
ysis. Competing risk Cox proportional hazard analysis was used to assess the relationship between serum sodium
and clinical outcomes. The covariates were selected according to previous studies and our past publications, and
the continuous variables with skewed distributions were log-transformed to obtain normal distributions. The
adjusted covariates included age, gender, estimated glomerular filtration rate (eGFR), DM, cardiovascular disease,
mean blood pressure, glycated hemoglobin, hemoglobin, albumin, cholesterol, urine protein-to-creatinine ratio,
C-reactive protein, body mass index, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker,

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Figure 3.  Association between serum sodium and cardiovascular event by restricted cubic spline model in
diuretic users.

anti- hypertensive agents, oral anti-diabetic drug, statins, integrated CKD care and causes of renal diseases53.
Serum sodium was treated as a categorical variable with the cuf-off at 135, 138, and 141 mEq/L (the 16.6th, 50th,
and 83.3th percentile) in Table 4 and as a categorical variable with the cuf-off at 135 and 141 mEq/L (the 16.6th
and 83.3th percentile) in Supplement Table 3. Serum sodium was treated as a continuous variable with 5 knots at
130, 135, 138, 141, and 143 (the 5th, 16.6th, 50th, and 83.3th, and 95th percentile) in Figs 1, 2 and 3 and Supplement
Figures 1, 2 and 3 and as a continuous variable with 5 default knots at 130, 136, 138, 140, and 143 (the 5th,
27.5th, 50th, 72.5th, and 95th percentile) in Supplement Figures 4–6. P <​ 0.05 was considered statistically significant.
Statistical analysis was performed with STATA 12.0 software (Stata Corp LP, College Station, TX, USA) and the
Statistical Package for Social Sciences, Version 21.0 for Windows (SPSS Inc., Chicago, IL, USA).

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Author Contributions
Research idea and study design: L.M.L., N.C.T., D.Y.H., C.C.H.; Data acquisition: H.Y.H.L., J.J.L., L.M.L.; C.C.H.;
Data analysis/interpretation; L.M.L., D.Y.H., H.Y.H.L., C.C.H.; Statistical analysis: C.C.H., M.Y.L.; Supervision or
mentorship: S.J.H., H.C.C.; Each author contributed crucial intellectual content during manuscript drafting and
revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy
or integrity of any portion of the work are appropriately investigated and resolved. All authors reviewed the
manuscript. Chih-Chi Hung is responsible for the honesty, accuracy, and transparency of the report; that no
important aspects of the study were omitted; and that any discrepancies from the study as planned (and, if
relevant, registered) are explained.

Additional Information
Supplementary information accompanies this paper at http://www.nature.com/srep
Competing financial interests: The authors declare no competing financial interests.

Scientific Reports | 6:36817 | DOI: 10.1038/srep36817 9

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How to cite this article: Lim, L. M. et al. Hyponatremia is Associated with Fluid Imbalance and Adverse Renal
Outcome in Chronic Kidney Disease Patients Treated with Diuretics. Sci. Rep. 6, 36817; doi: 10.1038/srep36817
(2016).
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© The Author(s) 2016

Scientific Reports | 6:36817 | DOI: 10.1038/srep36817 10