ABSTRACT
Background: End stage kidney disease (ESKD) patients are particularly susceptible to poor outcomes from Covid-19 infection (C19). Vaccination has been the cornerstone of mortality prevention. We examine the efficacy of C19 vaccine in ESKD patients. Method(s): All patients dialyzed at Emory dialysis centers from December 1, 2020 until February 2022 represent the study population. Date of completed vaccines series was recorded. Confirmed C19 cases were also registered. Time from vaccination to C19 and from C19 to death was recorded. Mortality risk was compared between vaccinated and unvaccinated patients. Patients that received vaccination after an episode of C19 were excluded from the analysis (n=89). Result(s): 935 patients received maintenance dialysis during the study period. 68% completed 2 doses of C19 vaccine. 46% of vaccinated patients received a booster dose after 294 days (IQR: 251-273) of completing the primary vaccination series. Non-vaccinated patients were younger (55 vs 60y/o), with shorter dialysis vintage (1.0 vs 2.8 years). The proportion of home and in-center dialysis was similar among vaccinated and unvaccinated patients. The prevalence of diabetes, CHF, PVD, COPD, atrial fibrillation, and previous transplants was also similar. 71 vaccinated patients died during follow up (11%) after 196 days (IQR 122-290), compared to 70 in the non-vaccinated group (24%) after 86 days (IQR 39-166), p<0.001. Adjusting for age, dialysis vintage, diabetes and CHF, ESKD vaccinated patients had a 78% reduction in mortality risk (A). 73 vaccinated patients (11%) acquired C19 after 250 days (IQR 150-288) compared to 48 unvaccinated patients (16%) who acquired C19 after 64 days (IQR 30-215), p<0.001. The mortality odds ratio after C19 infection was 3.9 [CI: 1.3-11.9] for unvaccinated patients 30 days post infection, 4.7 [CI: 1.7-14.2] at 60 days and 4.1 [CI: 1.6-11.5] at 90 days (B). Conclusion(s): Vaccination against C-19 infection resulted in a 78% reduction of mortality risk in patients receiving dialysis. Non-vaccinated patients diagnosed with C19 had higher mortality rates than vaccinated patients (OR 4.1 at 90 days post infection).
ABSTRACT
Vaccination is a critical strategy to prevent COVID-19. We describe the effects of a vaccine drive implemented in Emory Dialysis centers on COVID-19 vaccine uptake, infection rates and outcomes. Emory Dialysis, serving an urban population, conducted a COVID-19 vaccination drive (i.e. vaccine education and onsite vaccine administration) across its 4 dialysis centers (~750 patients) from March—April 2021. Monthly COVID-infection and vaccination rates were tracked from March 2020—September 2021. We assessed the effect of the drive on the COVID-19 vaccine uptake, infection rates and outcomes including hospitalizations and 30-day mortality. Patients were included if they were diagnosed with COVID-19, 14 days after the vaccination drive (to reflect fully vaccinated status). Patients were stratified by vaccination status and descriptive statistics were performed. From March 2020–April 2021, monthly COVID-19 infection rates were 0.41—4.97% and vaccination rates were 0–6%. From May–September 2021 (post-vaccination drive), the monthly COVID-19 infection rates ranged from 0–2.50% and vaccination rates were 67.4–76.1%. In the post-vaccination period, 34 patients were diagnosed with COVID-19;26 were fully vaccinated and 8 were unvaccinated. Among the 34 patients, the median age was 57 years [interquartile range (IQR) 47–73], 29% were female and 79.4% were Black. Compared to unvaccinated group, the vaccinated group was older (62 years [IQR 50-73] vs. 50 years [IQR 41-60], p=0.06), and had a higher prevalence of cardiovascular disease (46.2% vs. 25.0%, p=0.62);otherwise, patient characteristics were similar between the groups. Twelve patients (48.1%) in the vaccinated group vs. 6 patients (75.0%) in the unvaccinated group were hospitalized for COVID-infection (p=0.26). Three patients (11.5%) in the vaccinated group vs. 2 patients (25%) in the unvaccinated group (p=0.35) died within 30-days of COVID-19 diagnosis. Providing vaccinations at dialysis centers may improve COVID-19 vaccine uptake and outcomes. Studies evaluating the long-term effects of vaccination programs in dialysis centers are needed.
ABSTRACT
Background: ESKD patients on dialysis have been significantly affected by the COVID pandemic. By now, a substantial number of patients have survived the disease. We display graphically the temporary changes in dialysis parameters of patients that have survived COVID-19 infection. Methods: All patients receiving hemodialysis at Emory dialysis centers diagnosed with COVID-19 infection between 3/1/20 to 1/31/21 who survived for at least 3 months were identified. The date of COVID-19 diagnosis was used to time-reference dialysis parameters including duration of hemodialysis, weight, ultrafiltration, mean arterial pressure pre-dialysis, hemoglobin, albumin, calcium, phosphorus, potassium, serum bicarbonate, absolute lymphocyte count and Kt/V. The temporary behavior of these parameters is presented graphically. Data manipulation, analysis and graphical display was performed using R-software and tidyverse package. Results: 96 patients were identified. 82% were African-American with a median age of 64y/o. 52% were male and 60% were diabetics, The median time on dialysis was 2.5 years. All studied parameters showed a significant deviation from baseline measurements obtained in the 60 days prior to the diagnosis of COVID-19. The parameter with the least amount of change was Kt/V. In the subsequent 2 months after diagnosis, all of the parameters studied returned to baseline except for Potassium, that remained below premorbid levels 2 months after the COVID-19 diagnosis. These changes are presented in Figure 1. Conclusions: COVID-19 infection has a significant impact on hemodialysis parameters as presented in figure 1. The temporary variation of the most common parameters associated with COVID-19 infection presented in this study can be used as reference for patients, dieticians, and nephrologists caring for ESKD affected by COVID-19. (Figure Presented) .
ABSTRACT
Background: Vitamin D insufficiency and deficiency are common abnormalities and high risk groups include kidney disease patients and African-Americans. Recommendations on the evaluation of vitamin D levels in CKD and ESKD are ambiguous due to a lack of studies examining epidemiology and treatment. The COVID-19 pandemic has disproportionately affected minorities and has highlighted the need for evidence as studies have examined vitamin D deficiency as a risk factor for COVID-19 complications. We present a case series examining the prevalence of vitamin D deficiency in a predominantly African-American hemodialysis patient population. Methods: Retrospective chart review of all in-center hemodialysis patients at Emory Dialysis in Atlanta, GA. Data extracted from Sep to Nov 2020. We excluded any patients on home therapies. Serum 25(OH)vitamin D concentration total was analyzed. We defined vitamin D insufficiency as 20-29.9 ng/mL and vitamin D deficiency as a level<20 ng/ml. Results: Patients receiving in-center hemodialysis(n=615). Average length of time on dialysis was 5 years and average age was 59.4 years. Patients were 52.5% male(n=323). 91.5%(n=563) of patients were African-American. Mean calcium level for all patients was 8.73 mg/dL and PTH level of 554 pg/mL. Mean vitamin D in all patients was 26.32 ng/mL. 98%(n=603) of patients had a vitamin D level available. All patients with vitamin D level<30 ng/mL=412(68.3%) and all patients with vitamin D level<20 ng/ mL=244(40.5%). African-American patients with a vitamin D level was 552. African-American patients with vitamin D level<30 ng/mL=382 (69.2%) and African-American patients with vitamin D level<20 ng/ml=229(41.5%). Mean vitamin D in African-American patients 25.7 ng/mL and non-African-American patients 32.7 ng/mL, p=0.01. Conclusions: In comparison to others such as the DIVINE trial, we present a larger and more diverse cohort. In our study, African-Americans had a statistically significant lower vitamin D level. A case for replacing 25(OH) vitamin D even in ESKD patients is based on the action of vitamin D beyond mineral metabolism, especially with regard to autocrine regulation of immune function. Future directions include examining effects of treatment on PTH and study of vitamin D deficient patients' risks for adverse events like COVID-19 infection.
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Background: Acute kidney injury (AKI) is a complication that has been described among severely ill patients with COVID-19 and may be more common in those with underlying chronic kidney disease (CKD). Some patients with AKI require renal replacement therapy (RRT), including continuous RRT (CRRT). During the COVID-19 pandemic, some US areas experienced CRRT supply shortages. We sought to describe the percent of hospitalized COVID-19 patients who developed AKI or needed RRT to inform patient care and resource planning. Methods: We searched for studies in the literature and public health investigations that described CKD, AKI, and/or RRT in COVID-19 patients from January 2020 onward. Studies were excluded if no CKD, AKI, or RRT information was provided. We abstracted counts of hospitalized COVID-19 patients, including those admitted to intensive care units (ICU) who developed AKI, underwent RRT, and/or had CKD. Data were pooled across cohorts by geographic region with available data (US, China, or United Kingdom [UK]). We compared proportions using Chi-square tests. Results: A total of 311 studies were identified;23 studies (US n=11;China n=11;UK n=1) that described kidney disease and/or kidney-related outcomes in hospitalized COVID-19 patients were included. Underlying CKD prevalence was higher in US cohorts (10.3%) compared with China (2.5%) or UK (1.5%) (p< 0.0001). AKI was markedly higher among hospitalized (31.3% vs. 6.4%;p < 0 .001) and ICU patients (55.4% vs. 18.2%;p< 0.0001) in the US compared to China. The percent of ICU patients requiring RRT in the US (16.8%) was significantly different from that reported in China (12.5%) and the UK (23.9%) (p< 0.0001). Limitations include differences in CKD and RRT definitions across studies. Conclusion: AKI is a frequent outcome among US COVID-19 patients, affecting almost one third of hospitalized and more than half of ICU patients. AKI was reported more frequently in the US than China. The percent of ICU patients who received RRT was higher in the US and UK than in China. Understanding the occurrence of kidney-related outcomes among patients with COVID-19 including the impact of underlying CKD and regional practice variations is essential for healthcare systems to successfully plan for RRT needs during the pandemic.
ABSTRACT
Background: Effective dialysis care during the C19 pandemic has required implemetation of new policies and procedures to ensure adequate care, to avoid contagion in dialysis centers and to minimize unnecesary expossure to medical personnel. Methods: Emory dialysis program provides dialysis care for ~ 750 patients in 4 hemodialysis centers and 3 home dialysis locations in the metro Atlanta area. The first cases of C19 in Georgia were reported on March 2, 2020 and plans to contain the spreading of the disease were implemented in our dialysis units, including mask use, triaging of patients and personnel based on symptoms, telemedicine rounds, cohorting of C19+ patients in a single shift in a designated unit, and physical isolation of nursing home residents while receiving hemodialysis. This report describe the clinical outcomes related to these interventions. Results: Until May 30/2020, 106 patients had been tested (14%). 22 patients were positive for C19 (2.9%) of which 20 were on HD and 2 on PD. Five C19+ patients died (mortality 23%). Patients that tested positive were older (65±13 vs 60±13y/o), mainly African-Americans (90%) with a higher BMI (29 vs 26), more likely to be diabetics (51% vs 44%) and to reside in a Nursing Home (20 vs 10%), with higher prevalence of cardiovascular disease (45 vs 30%). Dialysis-related parameters (albumin, hemoglobin, phophorus, PTH, Kt/V and blood pressure) were similar between those that tested positive vs negative. 4% (31 patients) of our entire dialysis population resides in Nursing Homes. 12 of them have been tested and 8 were C19+ (26%). The dialysis patients that expired were older (69 vs 57y), all were African-Americans and had higher BMI (30 vs 26) and time on dialysis (12.3 vs 5.6 y) than those that survived. We did not observe an increase frequency of hospitalizations or deaths compared to previous months (Figure 1). Conclusions: In our dialysis population the incidence of C19 infection was 2.9% with 14% of patients tested. Mortality was 24%. Deceased patients were older, had a higher BMI and were on dialysis for longer time compared to those that survived. We did not observe an increase rate of hospitalizations or deaths during initial 3 months of the pandemic.
ABSTRACT
Background: Emerging data reveal disparities in the burden and severity of disease among racial and ethnic minorities in the US. Emory Dialysis consists of 4 outpatient dialysis facilities, serving an older, urban and predominantly African-American population. These facilities are in counties with the highest number of COVID-19 cases in Georgia. We describe infection control measures implemented to prevent COVID-19 transmission, and the clinical characteristics of patients with COVID-19 in the facilities. Methods: Based on CDC's recommended guidance, we implemented the following infection control procedure between February and April 2020: 1) screening;triaging all patients, and separating patients with symptoms of COVID-19;2) monitoring staff for COVID-19 symptoms;3) limiting healthcare personnel in the facilities;4) universal masking in the dialysis units;5) conducting PPE re-trainings;6) assessing facility preparedness;7) separating high risk patients (nursing home residents);and 8) cohorting patients with COVID-19 to a dedicated dialysis shift. Results: Of the 745 patients followed at the Emory dialysis facilities, 18 (2.4%) were diagnosed COVID-19 between March 25-May 7, 2020. Among the 18 patients, 17 were receiving in-center hemodialysis and 1 was on peritoneal dialysis. The median age was 66.8 years (range 43-84) and 11 (61.1%) were female. Nine (50%) were residents of a skilled nursing facility. Sixteen (88.9%) patients had a diagnosis of hypertension, 10 (55.6%) had diabetes, and 10 (55.6%) had cardiac disease. Eight patients (44.4%) required hospitalization and 4 patients (22.2%) died from COVID-19 related complications. Two patients with COVID-19 were dialyzing at adjacent dialysis stations and the timing of their symptoms suggested possible transmission in the dialysis facility. In response, education, infection control audits and PPE re-trainings were conducted to bolster infection control practices. Conclusions: In a high-risk patient dialysis population, we successfully implemented recommended infection control measures to mitigate the spread of SARS-COV-2 in our facilities. Dialysis facilities must stay vigilant and monitor for possible transmission of COVID-19. Regular audits of infection control practices remains critical.