CHRONIC BACK PAIN IN CKD PATIENTS WHO ARE ON MAINTANENCE HEMODIALYSIS .

 

Infective spondylodiscitis is a rare disease. 

Infective spondylodiscitis should be considered in hemodialysis patients who present with prolonged back pain with or without fever. Non-contrast MRI is an appropriate diagnostic tool for this condition. Vascular access infection increases the risk for infective spondylodiscitis in hemodialysis patients. 

A review of the literature indicated that the common risk factors for infective spondylodiscitis are intravenous drug use, uncontrolled or poorly controlled DM, complications from catheter-associated infections, infective endocarditis, prior spinal surgery, and immunocompromised status.

Patients on maintenance HD are exposed to additional risks due to the need for repetitive puncture of the arteriovenous shunt, long-term indwelling of a central venous catheter or Gore-Tex graft, and contamination of the dialysate storage or distribution system .

We report 2  cases of infective spondylodiscitis in chronic kidney disease patients who are on maintenance hemodialysis .

Both of them have AV fistula as vascular access for hemodialysis.

Intially they had central venous line in internal jugular vein for initial one month and later AV fistula was created .

FIRST CASE : 

32 yr old male who was on maintanence hemodialysis since one year , was complaining of recurrent low backache since 6 months ,which was stabbing type in lumbar area and non radiating. Present throughout the day and aggrevated by bending and daily activities and relieved by rest . Associated with intermittent fever spikes .

Initially thought to be renal osteodystrophy . But later due to severe pain and pain aggrevating on movement ,and intermittent fever .

MRI LS spine with whole spine screening was done ,which revealed Infective spondylitis involving L3-L4 , along with paravertebral collections .

https://saisurya100.blogspot.com/2021/10/32-yr-old-man-with-ckd-on-mhd-with.html?m=1

SECOND CASE : 

45 year old male who was diagnosed with diabetes 13 years ago .

6  months ago he  noticed swelling of legs which was insidious in onset and gradually progressive , for which he went to local doctor and took medication for 4 days,later  he developed swelling all over body( hands, legs, scrotum, abdomen , face) and had  shortness of breath on exertion for which he consulted our hospital and was diagnosed as renal failure and started intially on diuretics and later on maintanence hemodialysis .

 5 months back he complained of lower back pain which was sudden in onset and gradually progressive in nature which was throbbing type and non radiating ,  and patient is not able to sit , getting up from chair and not able to sit cross legged , present through out the day, no relieving factors , aggaravated by sitting standing, not associated with fever, trauma 

• Abdomen distension since 4 months ,and on diagnostic tapping revealed hemorrhagic ascitis 

1/09/2021 therapeutic ascitic tap was done and nearly 500- 600 ml was drained which was pinkish red in colour and sent for microbiology, pathological, biochemical investigations was done .

Ascitic fluid pcv and hemoglobin was done which was low to differentiate hemorrhagic ascitis vs hemo-peritoneum .

https://saichennuru.blogspot.com/2021/09/45-year-old-male-patient-with-back-pain.html?m=1

Third case report 

https://nikhithapulipeta130.blogspot.com/2022/02/50ym-follow-up-case.html

This is case review which describes the clinical course, risk factors, and outcomes of adult patients on maintenance hemodialysis who presented with infective spondylodiscitis at a single medical center in Taiwan : 

Study was conducted by retrospective review of the records of patients who were admitted for infective spondylodiscitis between January 2005 and July 2015 in a tertiary medical center in Taiwan.

S - All included patients were adults on maintenance HD who received treatment for infective spondylodiscitis in our hospital.

We excluded patients with post-operative spinal infection, tuberculous spondylodiscitis and relapse pyogenic spondylodiscitis. 

We finally included 18 cases.

RESULTS :

There were 18 cases (mean age: 64.9 ± 10.8 years) over more than 10 years. The average hemodialysis duration was 72.8 ± 87.5 months, and 8 patients (44.4%) started hemodialysis within 1 year prior to infective spondylodiscitis. Four patients (22.2%) had vascular access infection-associated spondylodiscitis. 

The lumbar region was the most common location of infection (77.8%), 44.4% of patients developed abscesses, and Staphylococci were the most common pathogen (38.9%). The mortality rate was 16.7%, all due to sepsis.

 Thirty-three percent of the survivors had recurrent infective spondylodiscitis within 1 year. Infective spondylodiscitis should be considered in hemodialysis patients who present with prolonged back pain with or without fever. Non-contrast MRI is an appropriate diagnostic tool for this condition. Vascular access infection increases the risk for infective spondylodiscitis in hemodialysis patients

The United States Renal Data System (USRDS) 2015 annual report reported that septicemia and other infections contributed to 12% of deaths in ESRD patients.1 Bone and joint infections accounted for 1.7% of infection-related hospitalizations in patients receiving in-center dialysis. 

The lumbar level was the most common site of infection (14 patients, 77.8%); 2 patients (11.1%) had involvement of the cervical spine and 2 patients (11.1%) had involvement of the thoracic spine. Eight patients (44.4%) had complicated abscess formation over the epidural space (75%), psoas muscle (37.5%), and paraspinal area (12.5%).

Staphylococci were the most common pathogens (7 patients, 38.9%) and coagulase-negative staphylococcus, Coag(−) Staphylococcus, was the major pathogen in cases with vascular access-related infective spondylodiscitis. 

All patients received antibiotic treatment, and the average treatment duration of survivors was 51.9 ± 36.1 days. Most of the cases used vancomycin or teicoplanin plus ceftriaxone or extended-spectrum penicillin/β-lactamase inhibitor or carbapenem as initial antibiotics (Table 3). The aim of empiric treatment was to cover Staphylococci and Gram-negative bacilli.

Ten patients (55.6%) received surgical intervention and 1 patient (5.6%) received CT-guided drainage. The indication of surgical intervention in those cases were spinal instability, abscess drainage for poor controlled infection and progressive neurologic deficits. The methods of operation included laminectomy, discectomy, and debridement of the infected spine in all cases. 

The mean (±SD) hospital stay was 59.1 ± 38.4 days for survivors and 22.3 ± 3.9 days for non-survivors.

The overall mortality rate was 16.7%, and all 3 deaths were due to sepsis. Among survivors, 5 patients (33.3%) had recurrent infective spondylodiscitis within 1 year. 

In conclusion, infective spondylodiscitis should be considered in HD patients present with back pain or fever of unknown origin. The initial evaluations include detailed neurologic examinations, laboratory blood tests and spine plain film. Elevated WBC, CRP, and ESR are helpful for the diagnosis. MRI without contrast is an appropriate diagnostic tool for infective spondylodiscitis in HD patients. The recommended empiric antibiotics are vancomycin or teicoplanin plus one kind of anti-Gram negative bacilli agent. 

Patients will receive antibiotics for at least 4–6 weeks. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6014531/#!po=27.3810