1. A Retrospective Study of Discitis : a Life-threatening Complication of Chronic Haemodialysis
De Silva S T¹, Qurban S², Farrington K³
¹Consultant Physician, Teaching Hospital, Kandy,
formerly Clinical Fellow in Nephrology,
²Senior House Officer, and
³Consultant Nephrologist
Department of Renal Medicine, Lister Hospital, Stevenage, UK

2. Infection & Haemodialysis
Infection is the 2nd commonest cause of death in haemodialysis patients
Discitis is rare but potentially life-threatening
Discitis is an infection in an inter-vertebral disc in the spine
Disc space infection is an infection of the intervertebral disc, that begins in one of the continguous end plates, and spreads to the disc secondarily.

3. Study Design Retrospective analysis of all episodes of discitis
All patients on chronic haemodialysis from
3 Haemodialysis Centres attached to Renal Department, Lister Hospital, Stevenage, UK
Using RenalPlus - database of all patients treated since inception of Unit
Data from Renal Plus, a large data base of all patients treated at the Centre since its inception.

4. Objectives of Study Determine patient characteristics
Determine outcome & prognosis

5. Results Total number of patients studied - 809
(on haemodialysis for >3 months)
Fistula 2/3 & Line 1/3
10 radiologically proven episodes in 10 patients
incidence %
8 male
Average age 71.3 years
(range 57 – 83)
Silastic cuffed catheters are tunneled through the skin and inserted into the jugular or subclavian vein. Age at time of episode

6. Haemodialysis (range 0.85 – 1.37)
Average duration on all modes of dialysis -
43 months (range 14 – 96)
Average duration on haemodialysis -
35.4 months (range 8 – 96)
Access – 5 fistula
5 lines
Dialysis adequacy (Kt/V) –
(range 0.85 – 1.37)
All data at time of episode

7. Symptoms at Presentation
Backache / neck pain 8
Fever 4
Rigors 4
Shoulder pain 2
Paraplegia 2
Dysphagia 1
Sensory level 1
Severe back pain that began insidiously was characteristic. The back pain was constant and there was no history of trauma. There was a lack of systemic symptoms ie fever in most, with neurological signs present in only 4 patients.

8. Symptoms at Presentation
All 4 with neurology had fever/rigors & back/neck pain

9. Co-morbidity Commonest underlying renal disease was Diabetes Mellitus
Commonest co-morbidity was Ischaemic Heart Disease
(in 2)
None were on immuno-suppressants
Mixed bag for underlying disease with analgesic, renovascular, glom-neph, renovascular, amyloid, PCKD & unknown being other causes.

10. Previous Infections on Dialysis
Line infections in 4 patients
Staph aureus 3
CNS* 1
Average time before discitis episode was 22 months
Fistula infection in 1 (Staph aureus)
Time before discitis episode was 11 months
PD peritonitis in 2 (organism unknown)
Average time before discitis episode was 31 months
*Coagulase Negative Staphylococci

11. Subsequent Infections
1 each of
- no further infections
- neutropenic sepsis ?origin (12 months)
- Enterococcus line infection (21 months)
- VRE* line infection (7 months)
- MSSA** endocarditis (16 months)
*Vancomycin Resistent Enterococci
**Methycillin Sensitive Staph aureus

12. Investigations
The laboratory study may be misleading, normal white blood cell counts are common, radiographs often show no abnormalities early in the course of the illness, and even more sensitive diagnostic tests such as bone scans may not become positive for a week. When the diagnosis is suspected, the MRI now seems to be the most reliable early confirmatory test, while elevations of the erythrocyte sedimentation rate are a valuable screening test.

13. Investigations MRI proven discitis - in ALL Blood cultures -
negative in 3
MSSA¹ in 3
MRSA², CNS³, VRE* & Enterobacter in 1 each
Fistula swab MSSA* - in 1
(BC negative)
¹Methycillin Sensitive Staph aureus
²Methycillin Resistent Staph aureus
³Coagulase Negative Staphylococci
*Vancomycin Resistent Enterococci

14. Associated Diagnoses 4/10 had associated abscess 1 had osteomyelitis
(paravertebral, extradural, epidural & retro-pharyngeal)
1 had osteomyelitis
(lumbar)
1 had aortic valve endocarditis

15. Treatment Vancomycin + Fusidic acid 2/10
Vancomycin + Ciprofloxacin 2/10
Combinations /10
(of Vancomycin, Flucloxacillin, Ceftazidine, Teicoplanin, Amoxycillin, Linezolid)
Single agent 2/10
(Co-amoxyclav, Clindamycin)

16. Outcome Mean duration of treatment was 6 weeks 5 patients died
5 patients recovered with NO neurological sequelae

17. Conclusions I
Discitis must be suspected in haemodialysis patients presenting with backache & fever, even when neurological symptoms are absent
Patients tend to be male, elderly & diabetic
Patients are more likely to be line dependant & poorly dialysed

18. Conclusions II CRP was a good marker of infection
MRI was the best technique for diagnosis
MSSA was the commonest infecting organism
Prolonged course of antibiotic therapy was required

19. Conclusions III Discitis was fatal in half the study population
High degree of suspicion and early diagnosis with MRI are vital to prevent fatalities in the future

20. Relevance of Study Incidence of CKD increasing in Sri Lanka
More patients likely to reach ESRD in future
Most ESRD patients on chronic haemodialysis

21. Relevance of Study
Rare but potentially life-threatening complications of chronic haemodialysis must be suspected early
This study was done to increase awareness of one such complication - discitis

22. References
Troidle L, Eisen T, Pacelli L, Finkelstein F. Complications associated with the development of bacteremia with Staphylococcus aureus. Hemodialysis International 2007; 11 (1): 72–75.
Marella D, Punnaiah C, Hasan M, Saqib M, Habte-Gabr P, Eyassu F. Report of 2 Cases of Vertebral Osteomyelitis/Discitis Caused by Enterococcus faecalis in Dialysis Patients. Infectious Diseases in Clinical Practice 2007; 15(3):
Harris S A C, Brown E A. Patients surviving more than 10 years on haemodialysis.
The natural history of the complications of treatment. Nephrology Dialysis Transplantation 1998; 13: 1226–1233
Kikuchi S, Muro K, Yoh K, Iwabuchi S, Tomida C, Yamaguchi N, Kobayashi M, Nagase S, Aoyagi K, Koyama A. Two cases of psoas abscess with discitis by methicillin-resistant Staphylococcus aureus as a complication of femoral-vein catheterization for haemodialysis. Nephrology Dialysis Transplantation 1999; 14: 1279–1281
Philipneri M, Ziyad A A, Kamal A, Gellens M E, Bastani B. Routine Replacement of Tunneled, Cuffed, Hemodialysis Catheters Eliminates Paraspinal/Vertebral Infections in Patients with Catheter-Associated Bacteremia. American Journal of Nephrology 2003;23:
Tsuchiya K, Yamaoka K, Tanaka K, Sasaki T. Bacterial Spondylodiscitis in the Patients With Hemodialysis. Spine 2004; 29(22):