Int J Med Sci 2022; 19(3):416-424. doi:10.7150/ijms.69577 This issue


Challenge of evolving Klebsiella pneumoniae infection in patients on hemodialysis: from the classic strain to the carbapenem-resistant hypervirulent one

Shuai Zhou1,2*, GuangWei Ren2*, YuKun Liu3, XiaoMing Liu2, LiHong Zhang2, ShuFeng Xu4, Tao Wang2✉

1. Graduate School of HeBei Medical University, No.361 East Zhongshan Boulevard, ShiJiaZhuang 050011, P.R. China.
2. Department of Nephrology, the First Hospital of HeBei Medical University, No.89 East DongGang Road, ShiJiaZhuang 050030, P.R. China.
3. Faculty of Nursing, HuaXin College of Hebei Geology University, No.69 BeiHuanGang Road, ShiJiaZhuang 050702, P.R. China.
4. Department of Respiratory Diseases, the First Municipal Hospital of QinHuangDao city, No.258 WenHua Road, QinHuangDao 066099, P.R. China.
*Equal contributions as first author.

This is an open access article distributed under the terms of the Creative Commons Attribution License ( See for full terms and conditions.
Zhou S, Ren G, Liu Y, Liu X, Zhang L, Xu S, Wang T. Challenge of evolving Klebsiella pneumoniae infection in patients on hemodialysis: from the classic strain to the carbapenem-resistant hypervirulent one. Int J Med Sci 2022; 19(3):416-424. doi:10.7150/ijms.69577. Available from

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Graphic abstract

Loss of renal function may render hemodialysis patients more susceptible to infectious diseases, which is the second of all-causes mortality in this population. In addition to infection caused by the classic Klebsiella pneumoniae (cKp), however, hemodialysis staffs are now facing new challenge with growing prevalence of the carbapenem-resistant Kp (CR-Kp) and hypervirulent Kp (hvKp) as they are respectively associated with increased drug-resistance and virulence. We therefore chose to share our recent experience in treating severe infections either caused (cKp, CR-Kp, hvKp) or complicated (CR-hvKp) by these strains in hemodialysis patients. Based upon yet beyond published works, we further came up with the detection of intracranial lesion, novel diagnostic approach using unique biomarkers followed by selection of appropriate antibiotics, management of metastasic abscesses and bracing for the most lethal scenario in the order of cKp, CR-Kp, hvKp and CR-hvKp, respectively. Since reports of complicated hvKp infection in hemodialysis patients were rare, we also discussed in details this clinical entity focusing on its epidemiology, mechanism of increased virulence and involvement of the arteriovenous fistula as insidious source of persistent septicemia. By covering the full spectrum of clinically relevant Kp stains specifically from the viewpoint of nephrology, our work had highlighted the importance of infection control in uremic state and vice versa. As such, it may greatly raise the awareness of dialysis staffs against the challenge of evolving Klebsiella pneumoniae infection in hemodialysis patients and expeditiously reach a higher degree of readiness which was proved to be the key determinant of ultimate survival.

Keywords: hypervirulent Klebsiella pneumoniae, carbapenem-resistant, maintenance hemodialysis, antibiotic, arteriovenous fistula