Immunocompromised Patients And Kidney Infections: Challenges In Diagnosis And Management

Kidney infections can cause serious health problems in immunocompromised patients.¹ This is because they have a weak immune system, which reduces their ability to respond to infections.² Recurrent infections cause serious damage to the kidneys and may even lead to kidney failure.³ It is important to diagnose and treat kidney infections in immunocompromised patients at the right time to prevent potential complications.

What happens when you are immunocompromised?

When you are immunocompromised, your immune system is unable to fight against infections like a healthy individual would. The immune system cannot detect any foreign cells, hence it makes the person more susceptible to infections. The immunocompromised state is either temporary or permanent.⁴ 

Causes of immunocompromise

Immunocompromised states occur due to some underlying medical conditions or certain drugs. The main causes include:

1. Diseases conditions 

• AIDS
• Rheumatoid arthritis
• Lupus
• Type 1 diabetes 
• Lymphoma 
• Leukemia

2. Drugs

• Corticosteroids like prednisolone⁴
• Biologics and disease-modifying antirheumatic drugs(DMARDS):
  • These are drugs used in the treatment of rheumatoid arthritis. Biologics include drugs like rituximab and tocilizumab, and disease-modifying antirheumatic drugs include drugs such as methotrexate and sulfasalazine
• Drugs used after bone marrow and organ transplantation like prednisone, azathioprine, and cyclosporine⁵

3. Smoking

4. Old age

Kidney infections in immunocompromised patients

A kidney infection is generally a urinary tract infection that moves from the urethra or the bladder to the kidneys.^1,3 It is also known as pyelonephritis. 

Immunocompromised patients have a higher risk of getting kidney infections. If the infection is not managed properly, it can lead to kidney damage, other health problems, and even death. 

Causes of kidney infections 

Kidney infections are mostly caused by bacteria that enter the urethra and travel through the urinary tract to reach the kidneys. It can also be caused by viruses but this is rare in healthy individuals. Bacteria from any other infections can also enter your kidneys through the blood.³

Bacteria responsible for kidney infections include:¹

• E.coli 
• Enterobacter
• Proteus mirabilis
• Staphylococcus

Signs and symptoms of kidney infections

Signs and symptoms of kidney infections include:^1,3

• Fever
• Burning sensation while urinating
• Pain during urination
• Pain in groin and back side
• Pus in urine
• Blood in urine
• Bad odour in urine
• Increased tendency to urinate
• Urgency to urinate
• Nausea and vomiting

Risk in immunocompromised patients 

Having medical conditions that weaken the immune system can increase your chances of getting kidney infections. This includes diseases like aids and diabetes. Urinary tract infections occur in diabetics usually in the sixth decade of their life, more commonly affecting males.⁶ 

Drugs used in the treatment of autoimmune diseases and those taken after organ transplantation also make patients susceptible to kidney infections. 

What are the complications in immunocompromised patients?

Kidney infections when left untreated lead to many complications, especially in patients with weakened immune systems. These can be life-threatening in many cases.

Complications include:¹

Renal papillary necrosis

Conditions like diabetes can lead to renal papillary necrosis. It is characterized by the reduced functioning of the kidneys, which results in kidney failure.⁷ 

Emphysematous pyelonephritis

It is a condition where the destruction of the kidney tissue causes the accumulation of gas in the kidneys. This is also seen mostly in patients with untreated diabetes mellitus.

Diagnosis and potential challenges 

Infections in immunocompromised individuals are usually challenging to diagnose. They develop due to unusual bacteria and present with atypical symptoms. Also, they occur concurrently along with other infections. 

Most patients have some underlying medical conditions along with the infection, which makes the diagnosis of the infection difficult from the signs and symptoms alone. Hence, many diagnostic tests are required in order to identify the infection.⁸

What are the atypical presentations in immunocompromised patients?

Kidney infections in immunocompromised patients present with many unusual and atypical symptoms. 

1. Usual symptoms are not present in many patients. The infection may present as fever alone with no signs of swelling or redness of the skin
2. The immune system takes a longer time to eliminate the infection completely. This happens due to decreased ability of the body to fight against infections
3. The infection progresses quickly. This is due to a decrease in the white blood cells in the blood that fight against infections. Fever can rapidly elevate to sepsis and even cause death of the patient. Intravenous antibiotics are given to the patient as soon as any sign of fever is noticed

Delayed or missed diagnosis

Diagnosis of kidney infections using antibody testing is impossible in immunocompromised patients as they do not have sufficient antibodies in the body to produce a response. Also, these patients more likely develop infections where the pathogens cannot be detected through normal clinical diagnostic methods. 

The standard diagnostic tests like a biopsy and fine needle aspiration cannot be used in immunocompromised individuals as they are highly susceptible to secondary infections from such procedures.

All these challenges delay the diagnosis of kidney infections in immunocompromised patients.⁸

Significance of thorough evaluation and differential diagnosis

It is important to identify kidney infections at the earliest in immunocompromised individuals. This is because infections quickly progress in these patients. Fever can easily change to sepsis, septic shock, and even death.⁹ 

What are the challenges in management?

Kidney infections are usually managed with antibiotics. However, a compromised immune system cannot be managed using medications as it has reduced fighting capacity. It takes a longer time to completely eliminate the infection from the body. 

Drugs used in the treatment of kidney infections are:¹

1. Trimethoprim
2. Sulfamethoxazole
3. Augmentin or amoxicillin 
4. Ciprofloxacin
5. Ceftriaxone

The drugs are usually taken in pill form during a urinary infection. But, due to the rapid progression of the disease in immunocompromised patients, an intravenous injection of antibiotics is required at the earliest signs of fever. 

Limited treatment options 

Limited diagnostic procedures make it difficult to identify the type of kidney infection. Repeated use of antibiotics for the infection leads to antibiotic resistance. Patients are highly susceptible to infections after surgical treatments.¹⁰

Treatment failure and chances of recurrent infections

In some cases, the impaired immune system does not respond to normal antibiotic therapy due to the presence of multiresistant bacteria in the body. Healing is noticeably delayed and infection remains for a long time due to the weak immune system and reduced immune response. There is an increased risk of infections after surgical procedures. Coinfections occur when the body cannot ward off the multiresistant bacteria.^8,10

Collaborative efforts in management 

A multidisciplinary approach is required to treat kidney infections in immunocompromised patients. This includes a team of physicians, practitioners, nurses, social workers, dieticians, pharmacists, and other healthcare workers. This approach helps in early detection and intervention of the infection and slows down the progression of the disease. 

Type 2 diabetics have an increased chance of getting chronic kidney disease, which should be detected early to prevent its progression to kidney failure and requirement for a kidney transplant. The multidisciplinary team approach can help in preventing the disease from progressing by each member of the team intervening at an early stage of the disease.¹¹ 

FAQs

What is an immunocompromised state?

An individual is said to be immunocompromised when the immune system is weak and is unable to fight against infections like in a normal individual.

How long does the infection last when you are immunocompromised?

It takes a longer time to completely eliminate the infection from the body. This is because of a weakened immune system which is unable to fight the infection unlike a normal individual.

Does the infection go away with normal antibiotics?

Most kidney infections can be treated with antibiotics taken as pill form. Intravenous injection of antibiotics is, however, required in immunocompromised patients at the first sign of an infection to prevent rapid progression of the infection. Antibiotic resistance occurs with recurrent infections due to the presence of multiresistant bacteria. 

Summary

Immunocompromised patients are at a higher risk of getting kidney infections due to their weakened immune systems. Kidney infections in such patients typically present with fever that rapidly progresses to serious symptoms if left untreated. It is important to diagnose and manage the infection at the right time.

Diagnosis of kidney infections in immunocompromised patients is often challenging due to the presence of unusual bacteria, atypical symptoms, and coinfections. Timely management of the infection is necessary to prevent chances of sepsis and shock. A multidisciplinary team can efficiently manage the infection at an early stage and prevent its further progression.