Patients With Vitiligo, End-Stage Renal Disease Face Greater Risk of Infection

Patients with end-stage renal disease (ESRD) and vitiligo receiving dialysis may be at a greater risk of infection with bacteremia, cellulitis, and herpes zoster, according to findings from a retrospective cohort study.¹

Leveraging data for more than 1.5 million patients with ESRD in the United States Renal Data System, study results showed .04% of the cohort had a vitiligo diagnosis, further highlighting significant associations with race/ethnicity, gender, tobacco use, alcohol dependency, and hepatitis C, as well as an increased risk of several infections.¹

A condition in which the skin loses its pigmentation, vitiligo occurs when the immune system destroys melanocytes producing melanin that gives skin its color. It is estimated to affect about 1% of the global population and although vitiligo is generally considered a cosmetic condition, it has been linked to a predisposition to other autoimmune conditions impacting the immune system. Although this mechanism is not fully understood, the potential for increased susceptibility to infection merits further exploration.²

“Based on the characteristic pathogenesis of vitiligo, it is reasonable to hypothesize that vitiligo, as a comorbidity in patients with ESRD undergoing dialysis, may lead to an increased risk of infections compared to the general population, potentially due to epidermal barrier dysfunction,” wrote investigators.¹ “However, there is a lack of research examining the correlation between vitiligo and infection risk in patients on dialysis.”

To address this gap and research, Wendy Bollag, PhD, professor in the department of physiology at the Medical College of Georgia at Augusta University, and a team of investigators conducted a series of retrospective analyses for patients with ESRD in the United States Renal Data System who initiated dialysis between 2004 and 2019. They further queried the system for patients with a diagnosis of vitiligo to determine whether vitiligo serves as an independent risk factor for bacteremia, septicemia, cellulitis, herpes zoster, and conjunctivitis in this patient population.¹

Funded by the National Institute of Diabetes and Digestive and Kidney Diseases, the United States Renal Data System is a national data system that collects, analyzes, and distributes demographic and CMS medical claim information about chronic kidney disease (CKD) and ESRD in the United States.¹

Patients < 18 years, > 100 years of age, or had missing or unknown data on age, race, sex, ethnicity, access type, or dialysis type, were excluded from the present study. Patients with ESRD with a diagnosis of vitiligo were identified using ICD-9 and ICD-10 codes. Infectious outcomes of interest included bacteremia, cellulitis, conjunctivitis, herpes zoster, and septicemia, identified using ICD-9 and ICD-10 codes from hospital, detailed, and physician/supplier claims.¹

A total of 1,526,270 individuals with ESRD meeting the inclusion and exclusion criteria were identified and included in the study. Among the cohort, the average age was 63.5 (Standard deviation [SD], 14.9) years and the majority of patients were White (66%) and male (57.2%). Nearly all (99.9%) patients were on hemodialysis and 80.8% had a catheter for their access type, while .04% had a vitiligo diagnosis.¹

Multivariable logistic regression modeling indicated female sex, Black compared to White race, Hispanic ethnicity, hepatitis C infection, and tobacco use were associated with a greater risk of vitiligo (all P <.001), whereas increasing age (P = .0024) and catheter, versus arteriovenous fistula, and access type were associated with a decreased risk (P <.001).¹

After controlling for demographics and clinical covariates, investigators noted vitiligo was significantly associated with an increased risk of bacteremia (adjusted risk ratio [aRR], 1.20; 95% Confidence interval [CI], 1.05-1.37; P = .0063), cellulitis (aRR, 1.15; 95% CI, 1.03-1.28; P = .0129), and herpes zoster (aRR, 1.51; 95% CI, 1.14-1.99; P = .0040). However, this association was not significant for conjunctivitis (aRR, 1.13; 95% CI, 0.67-1.90; P = .6593) or septicemia (aRR, 1.08; 95% CI, 0.98-1.18; P = .1169).¹

Investigators pointed out the study’s reliance on the United States Renal Data System dataset presents several inherent limitations, including the use of billing codes to determine patients’ diagnoses rather than clinical data, instances of inaccurate or missed codes within the dataset, and the potential for bias among patients with lighter skin types. Still, investigators suggested these limitations are at least partially mitigated by the large size of the dataset and the substantial statistical power it offers.¹

“Overall, these findings highlight the importance of physician surveillance for infection in ESRD patients with vitiligo, although further research, preferably prospectively, is clearly warranted,” investigators concluded.¹

References:

1. Shah P, Hanson M, Waller JL, et al. The Assessment of Infection Risk in Patients with Vitiligo Undergoing Dialysis for End-Stage Renal Disease: A Retrospective Cohort Study. Pathogens. 2024; 13(1):94. https://doi.org/10.3390/pathogens13010094
2. Cleveland Clinic. Vitiligo. Diseases & Conditions. November 23, 2022. Accessed January 30, 2024. https://my.clevelandclinic.org/health/diseases/12419-vitiligo