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136 Updates in Hemodialysis

Infectious disease is one of the main complications in the patients on long-term hemodialysis. Various clinical features, including multiple comorbidities, frequent hospitalization, and immunosuppression, rendered these patients susceptible to nosocomial infections. Further‐ more, hemodialysis frequently results in chronic wasting, inflammation, uremia and gastro‐ intestinal disturbances, all of which contribute to the increasing frailty of the patient. In their weakened state, these patients are susceptible to infectious complications such as aspiration pneumonia. In this section, we discuss these aspects of hemodialysis based on the recent our clinical observations.

#### **1.1. Background of infectious disease in maintenance hemodialysis patients**

Infectious diseases are significant causes of morbidity and mortality among patients with endstage renal disease (ESRD), which is ranked as the second leading cause of death in Japanese maintenance hemodialysis (MHD) patients, following cardiovascular diseases. An increased susceptibility to infections has been ascribed partly to old age, a high prevalence of diabetes, defective phagocytic function of granulocytes, and frequent exposure to potential infectious risk factors during the hemodialysis therapy including endotoxin [1]. Anemia and malnutri‐ tion also contribute to the immune-compromised status of MHD patients. In addition, MHD patients are suffering from protein-energy wasting (PEW), making them susceptible to sarcopenia due to increased muscle protein degradation. Malnutrition causes impaired immune function and poor wound healing.

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In addition, MHD patients usually have problems other than infections, such as cardiovascular or muscle-skeletal disorders. These patients are frequently hospitalized for surgical proce‐ dures or reasons other than infection, where they were treated with various kinds of antibiotics over a long period. These typical clinical courses undergone by MHD patients are known to influence the clinical characteristics and microbiological features of pneumonia.
