ABSTRACT
Background. Coronavirus Disease 2019 (COVID-19) is associated with an increased incidence of pulmonary embolism (PE). Both conditions increase hospital complications and mortality, especially when exhibited concurrently. Unfortunately, both conditions may present similarly, and physicians often have a difficult time finding clinical indicators to suggest pursuing further evaluation of a PE during a COVID-19 infection. Methods. Using a multi-center facility database, we conducted a retrospective analysis of 3,675 COVID-19 patients at Methodist Health System from March 2020 to December 2020. COVID-19 infection was determined via molecular PCR testing and PE was determined by computed tomography (CT) scan with angiography. Patient demographics and laboratory values were determined by a manual review of patient charts. Chi-Square test was used to analyze observed variables. Odds ratios were calculated for variables with a statistically significant difference (p < 0.05). Results. Of the 3,675 patients diagnosed with COVID-19, 150 (4.1%) were diagnosed with PE. Elevated D-dimer level had a statistically significant association with increased rate of PE (OR 0.1988, 95% CI 0.0727 - 0.5438, p < 0.001). Factors such as elevated C-reactive protein (p = 0.61), IL-6 (p = 0.26), smoking history (p = 0.70), age over 65 (p=0.54), BMI over 25 (p = 0.42), and history of chronic kidney disease (p = 0.16) did not show a significant association with PE incidence. Of note, patients with PE during admission were seen to have an increased incidence of intubation (OR 0.40, 95% CI 0.2660 - 0.6029, p < 0.001). Conclusion. Our study suggests that COVID-19 patients with elevated D-dimer have higher odds of having a PE. This study also suggests that COVID-19 patients that develop a PE during hospitalization are more likely to require intubation.
ABSTRACT
Purpose: To evaluate the knowledge, attitude, and practices (KAP) of patients who have undergone kidney and/or liver solid organ transplants (SOTs) during the COVID-19 pandemic. Method(s): This single institution cross-sectional study was conducted on patients who underwent a liver and/or kidney transplantation between June 01, 2020, and June 30, 2021 at Methodist Dallas Medical Center, Dallas, Texas, USA. A KAP questionnaire of 26 questions assessing KAP regarding COVID-19 was designed and sent to 1,053 SOT recipients. A score of 70% or higher was deemed to be sufficient for each corresponding category. Statistical significance amongst parameters was determined using Chi-Square test or Fisher's exact test. Result(s): A total of 238 out of 1,053 (22.6%) SOT patients responded to the survey questionnaire. Socio-demographic and clinical characteristics breakdown can be seen in Figure Attached. Those who scored sufficiently in knowledge were more likely to score higher in the practices portion of the survey (OR 4.25, 95% CI 1.59-11.38, p < 0.01). Those above 61 years of age were less likely to score higher than those between 41-60 years of age (OR 0.46, 95% CI 0.23-0.93, p = 0.0314). Combined liver and kidney transplant patients were more likely to score higher than liver only transplant patients (OR 4.84, 95% CI 1.01-23.24, p < 0.05). Patients on triple immunosuppression were more likely to adhere to sufficient COVID-19 practices than those who were not on triple immunosuppression (OR 4.07, 95% CI 1.99-8.33, p < 0.001). Conclusion(s): In this study we observed correlations between practice scores and knowledge, age, type of SOT, and use of triple immunosuppression. This information will better help medical workers, public health officials, and health education programs target areas of improvement to improve overall safety of this vulnerable population against COVID-19. (Table Presented).
ABSTRACT
Introduction: Renal arterial thrombosis and infarction is an under-recognized condition due to its rarity and ability to mimic other disease processes. It can lead to secondary hypertension, acute kidney injury, and chronic kidney disease. Clinical manifestations include nausea, vomiting, flank pain, and sudden elevations in blood pressure. Here, we present a case of a patient with previous normal kidney function presenting with a severe AKI due to an acute renal arterial thrombus. Case Description: A 58-year-old woman with previously normal kidney function (baseline Cr of 0.8 mg/dL) presented with complaints of nausea and vomiting and was found to have a stage 3 AKI with a creatinine of 4.65 mg/dL. Her creatinine level continued to rise, peaking at 8.5 mg/dL, despite volume expansion. Her urinalysis showed moderate blood and moderate protein. Her FeNa was calculated to be 6.5% and the P/creatinine was found to be 4.56 grams. Renal ultrasound revealed right renal atrophy and a normal appearing left kidney. She remained non-oliguric with good urine output and initially did not meet requirements for renal replacement therapy. Due to the unknown etiology of her AKI, a left kidney biopsy was performed which revealed fulminant acute cortical necrosis. Subsequently, an MRA revealed complete occlusion of the left renal artery. No angioplasty or stent placement was performed, and she eventually required renal replacement therapy. Hypercoagulable testing revealed protein S deficiency. Other serologic work up was negative. She was tested multiple times for COVID19 infection during her hospital stay and each test was negative. Discussion: The majority of renal thromboembolisms originate as emboli from the heart. Much less commonly, thrombi may form in the renal arteries themselves, especially in those with a hypercoagulable state such as this patient. In light of the recent global COVID19 pandemic, renal artery thromboembolism has gained increased recognition and prevalence. As such, our patient tested negative multiple times for COVID19 as a potential explanation for her hypercoagulable state. Acute renal artery thrombosis should be considered as an explanation for AKI of unknown etiology, especially in those who have underlying risk factors. In the appropriate context, imaging studies should be obtained promptly to prevent permanent kidney injury.
ABSTRACT
Introduction: Lupus nephritis is a well-described entity. The simultaneous presence of ANCA abs is rare and is related to poor prognosis. Positive patients usually have MPOANCA. We present a case of biopsy-proven Class IV/V Lupus nephritis with PR3-ANCA and decreased ADAMTS 13 activity in an AA man. Case Description: This 46-year-old AA man with no known past medical history presented to the ED for two weeks of SOB, leg, and scrotal swelling. He denies any associated symptoms. He denies using any other OTC medications and illegal drugs. On exam, vital signs were stable. He had 2+ pitting edema in LE bilaterally, scrotal and penile edema. Other systems were unremarkable. Labs were significant for Hg 5.1, Platelets 106, K 6.9, CO2 9, BUN 78, Cr 10.2, and Albumin 2.4. UA showed dysmorphic RBCs and proteinuria, and Urine protein/creatinine of 9. COVID-19 testing was negative. HIV1&2, RPR titer, hepatitis panel, rheumatoid factor, ASO screen were all negative. Renal U/S showed normal-sized kidneys and no hydronephrosis. ANA, ANA titer, and anti-dsDNA returned elevated at >10,1:640 and 9.9IU, respectively. PR3-ANCA was also positive, but MPO-ANCA negative. C3 and C4 at 0.4g/L and 0.14g/L, respectively. ADAMTS-13 activity decreased to 40%. The rest of the work-up was negative. Kidney biopsy confirmed lupus nephritis, Class IV, and V, with ∼50% cellular crescents. Moderate to advanced interstitial fibrosis and tubular atrophy ∼50%. EM showed two globally sclerotic glomeruli. IF showed a full-house with IgG, IgA, C3, C1q, kappa, and lambda. Unfortunately, kidney function did not recover, and hemodialysis was started, and he was treated with MMF, Methylprednisolone, and with plasma exchange. Discussion: ANCA positivity, although not common, is a well-described entity but not understood in lupus nephritis patients. Most of these patients present with MPO-ANCA rather than PR3-ANCA. This subset of patients usually presents clinically differently with distinct histopathological features. Long-term follow-up in these patients is also needed to better understand this disease process in lupus nephritis patients.