Clostridium Difficile-Associated Diarrhea and Chronic Renal Insufficiency

Khurshid Yousuf, MD, Mohammad G. Saklayen, MD, Ronald J. Markert, PhD, Christopher J. Barde, MD, And Narasimh Gopalswamy, MD


South Med J. 2002;95(7) 

In This Article

Abstract and Introduction

Background: Clostridium difficile-associated diarrhea (CDAD) is a common cause of mortality and morbidity in hospitalized patients. Some case reports have implicated renal failure as a risk factor for CDAD. The aim of this study was to assess whether chronic renal insufficiency is a risk factor for CDAD and whether it increases mortality and morbidity.
Method: We reviewed charts of 385 patients with diarrhea for CDAD, chronic renal insufficiency, mortality, and recurrence of CDAD.
Results: Seventy-seven patients had infection due to C difficile. There was no difference in the chronic renal insufficiency, mortality, and other comorbid conditions between patients who had C difficile infection and those who did not. The patients with CDAD and chronic renal insufficiency had significantly higher mortality and recurrence of CDAD than patients without chronic renal insufficiency.
Conclusions: Chronic renal insufficiency is not a risk factor for CDAD, but its presence with CDAD increases mortality and recurrence of CDAD.

Clostridium difficile is a gram-positive, spore-bearing anaerobic bacterium first described by Hall and O'Toole[1] in 1935, but its clinical identity as Clostridium difficile-associated diarrhea (CDAD) was not recognized until the late 1970s.[2] It is estimated that 3 million new cases of diarrhea and colitis are caused by C difficile in the United States annually. Clostridium difficile- associated diarrhea is one of the leading causes of nosocomial enteric infections.[3,4,5] It affects as many as 10% of patients hospitalized for more than 2 days. Clostridium difficile is one of the major causes of morbidity and mortality among elderly debilitated patients.

The most common predisposing factor for clostridial colitis is the use of antibiotics such as ampicillin, amoxicillin, cephalosporins, and clindamycin.[5,6] Increasing age, gastrointestinal surgery, malnutrition, use of laxatives/antacids/stool softeners, and gastrointestinal procedures have also been found to increase the risk of clostridial colitis.[6,7,8]

One of us (M.G.S.) sent a questionnaire to many nephrologists in the United States seeking their opinion regarding chronic renal failure as a possible risk factor for CDAD. Most of those who responded do suspect chronic renal failure to be a risk factor. From our observation of increased mortality in a few patients who had clostridial colitis and chronic renal failure, we suspected that chronic renal insufficiency might increase morbidity and mortality in such patients. The aim of this study was to assess whether chronic renal insufficiency is an additional risk factor for CDAD and whether mortality and morbidity increase from coexisting chronic renal insufficiency.


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