Background and Objectives
To determine the incidence rates and mortality of liver abscess in ESRD patients on dialysis.
Design, Setting, Participants, & Measurements
Using Taiwan’s National Health Insurance Research Database, we collected data from all ESRD patients who initiated dialysis between 2000 and 2006. Patients were followed until death, end of dialysis, or December 31, 2008. Predictors of liver abscess and mortality were identified using Cox models.
Of the 53,249 incident dialysis patients identified, 447 were diagnosed as having liver abscesses during the follow-up period (224/100,000 person-years). The cumulative incidence rate of liver abscess was 0.3%, 1.1%, and 1.5% at 1 year, 5 years, and 7 years, respectively. Elderly patients and patients on peritoneal dialysis had higher incidence rates. The baseline comorbidities of diabetes mellitus, polycystic kidney disease, malignancy, chronic liver disease, biliary tract disease, or alcoholism predicted development of liver abscess. Overall in-hospital mortality was 10.1%.
Citation: Hong C-S, Chung K-M, Huang P-C, Wang J-J, Yang C-M, Chu C-C, et al. (2014) Epidemiology and Mortality of Liver Abscess in End-Stage Renal Disease Dialysis Patients: Taiwan National Cohort Study. PLoS ONE 9(2): e88078. doi:10.1371/journal.pone.0088078
Editor: Li-Min Huang, National Taiwan University Hospital, Taiwan
Received: July 29, 2013; Accepted: January 4, 2014; Published: February 14, 2014
Copyright: © 2014 Hong et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This study was supported by grants CMFHR10242 from Chi Mei Hospital and NHRI-NHIRD-99182 from the National Health Research Institutes in Taiwan. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Liver abscess is associated with significant morbidity, mortality, and increased consumption of healthcare resources –. Several studies – report the incidence of liver abscess to be 1.1–3.3 per 100,000 person-years in general Western populations. Liver abscess, which is highly endemic in Taiwan, has an incidence of 11.5–17.5 per 100,000 person-years . Additionally, renal failure is a significant risk factor for liver abscess .
The precise incidence of liver abscess has not been investigated in end-stage renal disease (ESRD) dialysis patients. ESRD patients are known to be at increased risk of infectious diseases , , and associated with high mortality , . Liver abscess is the most common extra-renal abscess among this population . One study from a general population  reported that patients with renal disease had three times the risk of liver abscess compared to general population. Yang et al.  reported in a hospital-based study using retrospective chart review, that 27 of 20,676 admitted patients with ESRD had liver abscess. However, no any longitudinal cohort study have investigated the precise incidence of liver abscess in ESRD dialysis patients.
Although the global prevalence and incidence of ESRD dialysis patients has recently increased markedly , , there are no published epidemiological data on subject of increased risked of liver abscess using a national cohort of dialysis patients. Nearly half of ESRD patients have DM. In addition, they are characteristically older in age and at increased risk of infectious diseases. We hypothesized that this patient population would have a high incidence of liver abscess. To find out, we used a national cohort longitudinal follow-up design to calculate the incidence of this disease in ESRD patients receiving dialysis. We trapped a large data set, Taiwan’s National Health Insurance Research Database (NHIRD), to perform a nationwide investigation of the epidemiology, incidence, and mortality of liver abscess in ESRD dialysis patients.
For this study, we retrieved ambulatory care claims, all inpatient claims, and the updated registry for all ESRD patients receiving dialysis from 1998 to 2008. Data was collected from Taiwan’s NHIRD provided by Taiwan’s National Health Insurance (NHI), a compulsory universal health insurance program which has covered the healthcare costs of all of Taiwan’s residents except of prison inmates since 1995. The program requires all medical institutions to use standard computerized claim documents for reimbursement of medical expenses. Patients with end-stage renal disease (ESRD) are eligible for every type of renal replacement therapy without any charge, and all their expenses are covered by NHI. The NHIRD contains nearly all (99%) inpatient and outpatient medical benefit claims for the 23 million residents of Taiwan, and has been used extensively in various studies –. This database provides a great deal of information, including gender, birth date, dates of admission and discharge, the medical institutions providing the services, the ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) diagnostic and procedure codes (up to five each), and encrypted outcomes. NHIRD is released with de-identified secondary data for public research purposes. All personal identification information on files connected with the present study was scrambled using surrogate identification numbers to ensure patient confidentiality. The Bureau of National Health Insurance approves the application (NHRI-NHIRD-99182), and the institutional review board of Chi-Mei Medical Center waived the need for approval.
Patient Selection and Definition
This longitudinal cohort study selected adult ESRD patients (≥18 years old) on maintenance dialysis who began renal replacement therapy between January 1, 2000, and December 31, 2006. ESRD patients on maintenance dialysis were defined as having undergone dialysis for more than 90 days. Patients who had undergone renal transplantation before beginning dialysis were excluded. Patients were followed-up from the first reported date of dialysis to the date of death, end of dialysis, or December 31, 2008. The data of 53,249 incident dialysis patients were analyzed.
We linked study subjects to their inpatient claim data to identify the first episode of liver abscess. Cases were selected by using the following criteria: the 3 primary discharge diagnoses included liver abscess (ICD-9-CM 572.0). A total of 447 patients were diagnosed with liver abscess during the follow-up period.
Demographic and Comorbid Variables
We linked to the diagnostic codes through the inpatient and outpatient claims databases of the NHIRD. We collected survival status, date of death, patient demographics, and baseline comorbidities. Baseline comorbidities, which were diabetes mellitus (DM), polycystic kidney disease (PCKD), malignancy, chronic liver disease (CLD), biliary tract disease, and alcoholism, are important factors affecting episodes of liver abscess –,  and were assessed at the start of dialysis.
The incidence of newly diagnosed liver abscess was expressed as the number of cases of liver abscess per 100,000 person-years. Parametric Pearson’s chi square test was used to compare each variable in the groups of patients with and without liver abscess. Age was entered as a categorical variable (18–44, 45–64, and 65 years or older). Significance was set at p<0.05. The cumulative proportion of patients with liver abscess and of survivors after liver abscess were calculated using the Kaplan-Meier method. The log rank test was used to analyze significance. Cox proportional hazards models were used to identify the risk factors of liver abscess and mortality after liver abscess. Hazard ratios (HRs) and 95% confidence intervals (CIs) were derived from Cox proportional hazards models. Cox models met the assumption of proportionality of risks. To adjust for potential confounding in the relationship between comorbidities and the risk of mortality, multivariate analyses were used to model to all-cause mortality. The Statistical Package for Social Sciences for Windows 17.0 (SPSS Inc; Chicago, IL, USA) was used for all statistical analyses.
Demographics and Clinical Characteristics
A total 53249 adult incident dialysis patients were enrolled in this study. Of these patients, 447 patients (224/100,000 person-years) had liver abscess during the follow-up period (Table 1). Elderly patients had higher incidence of liver abscesses. Only 0.5% of the patients 18–44 years old and 0.9% of those ≥65 years old had liver abscess (p = 0.003). Patients with liver abscess tended to have more comorbidities than those without it. Many more patients with liver abscess than without it had DM, PCKD, malignancy, CLD, biliary tract disease, and alcoholism. Mean in-hospital stays was 22.74±17.56 days. During the study period, there were 211 and 18,612 deaths in patients with and without liver abscess group, respectively.
Cumulative Incidence and Risk Factors for Liver Abscess
The cumulative incidence rates of liver abscess in ESRD dialysis patients were 0.3% at one year, 0.7% at three years, 1.1% at five years, and 1.5% at seven years (Figure 1). After multivariate adjustment, no significant difference was found between male and female patients (Table 2). Patients ≥65 years had more than twice the incidence of liver abscess than those 18–44 years old (HR 2.33, 95% CI: 1.64–3.32). Patients on hemodialysis (HD) had a lower rate of liver abscess than those on peritoneal dialysis (PD) (HR 0.66, 95% CI: 0.46–0.93). Additionally, the following predicted a higher incidence of liver abscess: DM (HR 1.72, 95% CI: 1.41–2.09), PCKD (HR 1.99, 95% CI: 1.09–3.64), malignancy (HR 1.81, 95% CI: 1.32–2.49), CLD (HR 1.76, 95% CI: 1.44–2.17), biliary tract disease (HR 4.21, 95% CI: 2.36–7.51) or alcoholism (HR 2.617, 95% CI: 1.28–5.37).
Cumulative Survival Rate and Risk Factors for All-cause-mortality
Overall in-hospital mortality of liver abscess was 10.14% (Figure 2). Survival curves after liver abscess were stratified by those with and without liver abscess. For the control group (patients without liver abscess), patients’ age, sex, mode of dialysis and comorbidities were matched to the liver abscess group. Patients with DM had a 64% higher risk of long-term death after liver abscess (HR 1.64, 95% CI: 1.19–2.25) than those without DM (Table 3). Additionally, having CLD was also associated with significantly higher long-term mortality after liver abscess (HR 1.62, 95% CI: 1.17–2.25).
For the control group (patients without liver abscess), patients’ age, sex, mode of dialysis and comorbidities were matched to the liver abscess group.
This study represents the first nationwide population-based epidemiological study to investigate the incidence of liver abscess in chronic dialysis patients. ESRD patients receiving dialysis had a significantly higher incidence of liver abscess than general population. In addition to the well-known risk factors of liver abscess, this study was the first to report both peritoneal dialysis and polycystic kidney disease to be important risk factors for liver abscess in ESRD dialysis patients.
ESRD patients receiving dialysis have a significantly higher incidence of liver abscess. Previous studies – report an annual incidence of liver abscess to be about 1.1–3.3 per 100,000 person-years in general populations in Denmark, Canada, and the United States (Table 4). In Taiwan, Tsai et al.  reported that incidence to be 17.59 per 100,000 person-years. Klebsiella pneumoniae liver abscess is an endemic health problem in the East Asia and is emerging as a global disease . In Taiwan, Klebsiella pneumoniae is the primary pathogen and DM is a major predisposing factor of liver abscess . Renal disease is also a strong risk factor of liver abscess. Neutrophil dysfunction and the risk of infection are higher in ESRD dialysis patients than in the general population , . This study found that ESRD patients receiving dialysis to have much higher incidence of liver abscess, around 224 per 100,000 person-years. Diabetic nephropathy is the leading cause of ESRD, accounting for 40–50% of patients on maintenance dialysis . Therefore, it is no surprise that the incidence of liver abscess was found to be high among chronic dialysis patients.
Besides the well-known risk factors in general population, this study found PCKD and PD to be as significant risk factors for liver abscess among ESRD dialysis patients. One study reported that 83% of PCKD between the ages of 15 and 46 years have hepatic cysts , entities associated with significant risk for liver abscess formation , . Patients with PCKD in this study had nearly twice the risk of liver abscess than those without it. Dialysis modality was found to be an important risk factor. The most frequent infective complication of PD is peritonitis. Because intra-abdominal infection like bowel leakage or peritonitis is a major cause of liver abscess formation, it is reasonable to speculate that patients on PD have a higher risk of liver abscess than those on HD. Further studies are needed at next step to evaluate the mechanism underlying the development of liver abscess in PD patients based on the result of this study.
The in-hospital mortality in ESRD in this study (10.14%) was similar to that in the general Taiwanese population (10.9%) reported by Tsai et al. . Because liver abscess is mostly an acute illness, the determinant factors for short-term mortality are always the severity of the acute illness and immediate therapy. In Taiwan, medical resource is very popular and sound. The medical expensed for patients with ESRD are covered by the National Health Insurance program. Drainage of liver abscess can be performed in most hospitals in Taiwan, especially for patients found to be refractory to antibiotic treatment. Thus, the average short term mortality rate between patient with and without ESRD is similar. Yang et al. , performing a study in a referral hospital (National Taiwan University Hospital) for the most seriously ill patients in Taiwan, reported that the mortality rate for liver abscess among ESRD patients to be 33.3%, much higher than the result reported in the current study based on nationwide and representative data. Thus, it is reasonable to speculate that in-hospital mortality due to liver abscess among ESRD patients would probably be high if acute treatment is performed in referral hospitals reserved for seriously ill patients.
Although the in-hospital death from liver abscess is most often acute, long-term mortality in our study population was often related to their ESRD status and baseline comorbidities, mostly DM and CLD. This study found DM to be an independent predictor of long-term mortality from liver abscess in ESRD dialysis patients. ESRD dialysis patients with DM generally have multiple comorbidities and have a higher risk of death –. Taiwan is an endemic area of chronic hepatitis because of a high prevalence of virus hepatitis B and C infection. Only few previous studies showed that the CLD to be an independent predictor of mortality. Liu et al. used United States Renal Data System to demonstrate liver disease is independent predictors of mortality (Relative risk 1.21, 95%CI: 1.15–1.27) . Chien et al. further used Taiwan National Health Insurance Database  to report a high prevalence rate of liver cirrhosis among ESRD patients, and showed that liver cirrhosis is an important predictor of mortality in dialysis patients (HR 1.472, 95% CI: 1.329–1.634). ESRD patients with PCKD is a different disease entity from those without PCKD, who also frequently have DM, hypertension, glomerulonephritis and cardiovascular disease. ESRD patients with PCKD on dialysis have a significantly longer survival rate than those without PCKD –. We further analyzed the differences between ESRD patients with and without PCKD in our database. We also found that patients with PCKD tended to have less comorbidities than those without it. Only 13.2%, 16.5%, and 13.2% of patients with PCKD had DM, coronary artery disease, and heart failure, respectively. However, 49.7%, 23.5%, and 25.7% of patients without PCKD had DM, coronary artery disease, and heart failure, respectively. Perrone et al. , using data from the United States Renal Data System, found a lower mortality rate in PCKD dialysis patients than in nondiabetic dialysis patients. Zeier et al.  presumed that such an improvement may be a result of better hemoglobin levels on cardiac function.
This study has several limitations. First, similar to other studies using administrative data, our study has the problem of unmeasured confounders. Second, the comorbidities were identified based on claims data and ICD-9-CM diagnosis codes, some of which might have been incorrect. Third, our study lacked specific data on nutritional status, microbiology and biochemical data, as well as socioeconomic characteristics. The lack of microbiological data limited the interpretation of the impact of these findings in the settings. Finally, it is better to obtain more information when comparing ESRD patients with liver abscess to patients with liver abscess but no ESRD. However, our database (NHRI-NHIRD-99182) only included ESRD patients receiving dialysis, but no non-ESRD subjects for comparison. Thus, we were unable to use the current database to compare ESRD patients with liver abscess to patients with liver abscess but without ESRD.
In conclusion, there is a high incidence of liver abscess in ESRD dialysis patients, especially patients ≥ 65 years, receiving PD, and those with a history of DM, PCKD, malignancy, CLD, biliary tract disease, or alcoholism. More attention should be paid to awareness of liver abscess when treating these high-risk patients.
Conceived and designed the experiments: CSH KMC C.C. Chien. Performed the experiments: CSH KMC JJW C.C. Chu C.C. Chio C.C. Chien. Analyzed the data: CSH KMC JJW PCH CMY FLC C.C. Chu C.C. Chio C.C. Chien. Contributed reagents/materials/analysis tools: C.C. Chien. Wrote the paper: CSH C.C. Chien.
- 1. Hansen PS, Schønheyder HC (1998) Pyogenic hepatic abscess. A 10-year population-based retrospective study. APMIS 106: 396–402.
- 2. Mølle I, Thulstrup AM, Vilstrup H, Sørensen HT (2001) Increased risk and case fatality rate of pyogenic liver abscess in patients with liver cirrhosis: a nationwide study in Denmark. Gut 48: 260–263.
- 3. Kaplan GG, Gregson DB, Laupland KB (2004) Population-based study of the epidemiology of and the risk factors for pyogenic liver abscess. Clin Gastroenterol Hepatol 2: 1032–1038.
- 4. Meddings L, Myers RP, Hubbard J, Shaheen AA, Laupland KB, et al. (2010) A population-based study of pyogenic liver abscesses in the United States: incidence, mortality, and temporal trends. Am J Gastroenterol 105: 117–124.
- 5. Tsai FC, Huang YT, Chang LY, Wang JT (2008) Pyogenic liver abscess as endemic disease, Taiwan. Emerg Infect Dis 14: 1592–1600.
- 6. Chonchol M (2006) Neutrophil dysfunction and infection risk in end-stage renal disease. Semin Dial 19: 291–296.
- 7. Vanholder R, Ringoir S (1993) Infectious morbidity and defects of phagocytic function in end-stage renal disease: a review. J Am Soc Nephrol 3: 1541–1554.
- 8. Gabriel R (1984) Morbidity and mortality of long-term haemodialysis: a review. J R Soc Med 77: 595–601.
- 9. Collins AJ, Foley RN, Gilbertson DT, Chen SC (2009) The state of chronic kidney disease, ESRD, and morbidity and mortality in the first year of dialysis. Clin J Am Soc Nephrol (Suppl 1): S5–S11.
- 10. Chuang FR, Lee CH, Chen JB, Cheng YF, Yang BY (2002) Extra-renal abscess in chronic hemodialysis patients. Ren Fail 24: 511–521.
- 11. Yang YF, Wang HJ, Kan WC, Kuo HL, Huang CC (2006) Pyogenic liver abscess in ESRD patients undergoing maintenance dialysis therapy. Am J Kidney Dis 47: 856–861.
- 12. United States Renal Data System (2009) Excerpts from the USRDS 2009 annual data report: atlas of end-stage renal disease in the United States. Available: http://www.usrds.org. Accessed 2011 August 25.
- 13. Yang WC, Hwang SJ (2008) Taiwan Society of Nephrology (2008) Incidence, prevalence and mortality trends of dialysis end-stage renal disease in Taiwan from 1990 to 2001: the impact of national health insurance. Nephrol Dial Transplant 23: 3977–3982.
- 14. Chen HA, Wang JJ, Chou CT, Chien CC, Chu CC, et al. (2011) Predictors of longterm mortality in patients with and without systemic lupus erythematosus on maintenance dialysis: a comparative study. J Rheumatol 38: 2390–2394.
- 15. Chien CC, Yen CS, Wang JJ, Chen HA, Chou MT, et al. (2012) Reverse epidemiology of hypertension-mortality associations in hemodialysis patients: a long-term population-based study. Am J Hypertens 25: 900–906.
- 16. Chien CC, Wang JJ, Sun YM, Sun DP, Sheu MJ, et al. (2012) Long-term survival and predictors for mortality among dialysis patients in an endemic area for chronic liver disease: a national cohort study in Taiwan. BMC Nephrol 13: 43.
- 17. Chou MT, Wang JJ, Sun YM, Sheu MJ, Chu CC, et al. (2013) Epidemiology and mortality among dialysis patients with acute coronary syndrome: Taiwan National Cohort Study. Int J Cardiol 167: 2719–2723.
- 18. Siu LK, Yeh KM, Lin JC, Fung CP, Chang FY (2012) Klebsiella pneumoniae liver abscess: a new invasive syndrome. Lancet Infect Dis 12: 881–887.
- 19. Bae KT, Zhu F, Chapman AB, Torres VE, Grantham JJ, et al. (2006) Magnetic resonance imaging evaluation of hepatic cysts in early autosomal-dominant polycystic kidney disease: the Consortium for Radiologic Imaging Studies of Polycystic Kidney Disease cohort. Clin J Am Soc Nephrol 1: 64–69.
- 20. Telenti A, Torres VE, Gross JB Jr, Van Scoy RE, Brown ML, et al. (1990) Hepatic cyst infection in autosomal dominant polycystic kidney disease. Mayo Clin Proc 65: 933–942.
- 21. Cigarrán S, Neches C, Lamas JM, García-Trio G, Alonso M, et al. (2008) A case report of a pyogenic liver abscess caused by Fusobacterium nucleatum in a patient with autosomal dominant polycystic kidney disease undergoing hemodialysis. Ther Apher Dial 12: 91–95.
- 22. Lee KT, Wong SR, Sheen PC (2001) Pyogenic liver abscess: an audit of 10 years’ experience and analysis of risk factors. Dig Surg 18: 459–465.
- 23. Chen SC, Lee YT, Lai KC, Cheng KS, Jeng LB, et al. (2006) Risk factors for developing metastatic infection from pyogenic liver abscesses. Swiss Med Wkly 136: 119–126.
- 24. United States Renal Data System (2010) Excerpts from the USRDS 2009 annual data report: Atlas of end-stage renal disease in the United States. Am J Kidney Dis (Suppl 1): S1–S420.
- 25. Wolfe RA, Gaylin DS, Port FK, Held PJ, Wood CL (1992) Using USRDS generated mortality tables to compare local ESRD mortality rates to national rates. Kidney Int 42: 991–996.
- 26. United States Renal Data System (2006) Excerpts from the USRDS 2005 annual data report: Atlas of end-stage renal disease in the United States. Am J Kidney Dis (Suppl 1): S1–S286.
- 27. Tien KJ, Lin ZZ, Chio CC, Wang JJ, Chu CC, et al. (2013) Epidemiology and Mortality of New-Onset Diabetes Mellitus After Dialysis: Taiwan national cohort study. Diabetes Care 36: 3027–3032.
- 28. Liu J, Huang Z, Gilbertson DT, Foley RN, Collins AJ (2010) An improved comorbidity index for outcome analyses among dialysis patients. Kidney Int 77: 141–151.
- 29. Lee PW, Chien CC, Yang WC, Wang JJ, Lin CC (2013) Epidemiology and mortality in dialysis patients with and without polycystic kidney disease: a national study in Taiwan. J Nephrol 26: 755–762.
- 30. Perrone RD, Ruthazer R, Terrin NC (2001) Survival after end-stage renal disease in autosomal dominant polycystic kidney disease: contribution of extrarenal complications to mortality. Am J Kidney Dis 38: 777–784.
- 31. Zeier M, Jones E, Ritz E (1996) Autosomal dominant polycystic kidney disease–the patient on renal replacement therapy. Nephrol Dial Transplant 11 Suppl 618–20.