Diagnostic and Therapeutic Particularities of Sepsis in Hemodialysis Patients

Background: Sepsis is a leading cause of morbidity and mortality among patients receiving maintenance hemodialysis (HD), reflecting a unique combination of immunologic dysfunction, comorbidities, and healthcare-related exposures. Despite advances in dialysis technology and infection control, outcomes for septic HD patients remain disproportionately poor. Objective: This review aims to synthesize current evidence on the epidemiology, risk factors, diagnostic challenges, and treatment considerations of sepsis in HD patients, highlighting persistent vulnerabilities and areas for clinical improvement. Methods: A structured narrative review was conducted, focusing on high-quality cohort studies, surveillance data, and pharmacologic analyses published over the past two decades. The literature search was performed using PubMed, Web of Science, and Google Scholar. A total of 37 studies were included in the final synthesis. Key themes were organized around epidemiologic trends, infection sources, risk modifiers, treatment outcomes, and antimicrobial considerations in the dialysis population. Results: The review found that sepsis in HD patients is multifactorial and systemic. Diabetes, advanced age, and central venous catheters remain strong risk factors, while a substantial proportion of infections arise from non-access-related sources. Mortality rates remain high, often due to delays in recognition, inappropriate empiric therapy, and challenges in antimicrobial dosing. Pharmacokinetic alterations in renal replacement therapy complicate treatment, requiring individualized approaches. Despite variations in infection rates across centers, systemic vulnerabilities-rather than dialysis modality alone-drive outcomes. Conclusions: Sepsis in hemodialysis patients is not solely a hardware-related complication but reflects deeper systemic and immunologic challenges. Improving outcomes will require earlier recognition, tailored antimicrobial strategies, standardized infection control protocols, and broader attention to patient-specific risk factors. Future research should focus on ESRD-adapted sepsis diagnostics and interventional models to reduce infection-related mortality in this high-risk group.