title: The Risks of Incident and Recurrent Clostridium difficile-Associated Diarrhea in Chronic Kidney Disease and End-Stage Kidney Disease Patients: A Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  The objective of this systematic review and meta-analysis was to assess the risks of incident and recurrent Clostridium difficile-associated diarrhea in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) requiring dialysis.
  
  
  METHODS
  A literature search was performed from inception to February 2015. Studies that reported relative risks, odds ratios, or hazard ratios comparing the risks of C. difficile-associated diarrhea in patients with CKD or ESRD versus those without CKD or ESRD were included. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random-effect, generic inverse variance method.
  
  
  RESULTS
  Twenty studies (nine case-control, seven cohort, and four cross-sectional studies with 162,218,041 patients) were included in the meta-analysis. Pooled RRs of C. difficile-associated diarrhea in patients with CKD and ESRD were 1.95 (95% CI 1.81-2.10) and 2.63 (95% CI 2.04-3.38), respectively. When meta-analysis was limited only to cohort and case-control studies with confounder-adjusted analysis, the pooled RRs of C. difficile-associated diarrhea in patients with CKD and ESRD were 1.89 (95% CI 1.75-2.05) and 2.50 (95% CI 1.49-4.17), respectively. The pooled RR of recurrent C. difficile-associated diarrhea in patients with CKD was 2.61 (95% CI 1.53-4.44). Data on the risk of recurrent C. difficile-associated diarrhea were limited.
  
  
  CONCLUSIONS
  This meta-analysis demonstrates significantly increased risks of incident and recurrent C. difficile-associated diarrhea in patients with CKD. Furthermore, the magnitude of increased risk of C. difficile-associated diarrhea in ESRD patients is even higher.
authors.affiliation: Department of Internal Medicine, University of Minnesota, Minneapolis, MN, USA.
authors.forename: Parkpoom
authors.initials: P
authors.lastname: Phatharacharukul
authors.affiliation: Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
authors.forename: Charat
authors.initials: C
authors.lastname: Thongprayoon
authors.affiliation: Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. wcheungpasitporn@gmail.com.
authors.forename: Wisit
authors.identifier: http://orcid.org/0000-0001-9954-9711
authors.initials: W
authors.lastname: Cheungpasitporn
authors.affiliation: SUNY Upstate Medical University, Syracuse, NY, USA.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Edmonds
authors.affiliation: Division of Infectious Disease, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
authors.forename: Pailin
authors.initials: P
authors.lastname: Mahaparn
authors.affiliation: Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
authors.forename: Jackrapong
authors.initials: J
authors.lastname: Bruminhent
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D016022:Case-Control Studies; D016360:Clostridioides difficile / Q000187:drug effects / Q000472:pathogenicity*; D015897:Comorbidity; D004359:Drug Therapy, Combination; D004761:Enterocolitis, Pseudomembranous / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D008297:Male; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D006435:Renal Dialysis / Q000379:methods; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D018570:Risk Assessment
chemical_list: D000900:Anti-Bacterial Agents
keywords: C. diff infection; C. difficile; Chronic kidney disease; Clostridium difficile; Clostridium difficile-associated colitis; Dialysis; Diarrhea; End-stage kidney disease; Infection; Infectious disease; Meta-analysis