4-Organ Sofa Score as Tool to Triage Crrt Use in Covid-19 Patients during Crisis Standards of Care

INTRODUCTION: Acute kidney injury requiring renal replacement therapy (AKI-RRT) is associated with high mortality, especially in the setting of COVID-19. During the peak of the delta wave in New Mexico in late 2021, crisis standards of care were declared and strategies to ration care were explored. Our hypothesis is that a simplified SOFA score in patients with COVID-19 and AKI-RRT may predict short-term mortality. METHOD(S): We retrospectively analyzed all COVID-19 patients started on CRRT for AKI in the medical ICU at our center between April 2020 and July 2021. A 4-organ SOFA score (4OSS), with renal and neurologic sub-scores excluded, was calculated at the time of CRRT initiation. Neurologic sub-score was excluded because it is subjective, inconsistently documented, and confounded by the frequent use of sedation and paralysis in severe COVID-19. ECMO patients were included and assigned the maximum respiratory sub-score. Patients started on RRT at an outside hospital, found to be incidentally COVID-positive, or on chronic dialysis were excluded. P values were obtained using 1-sided Mann-Whitney U tests. RESULT(S): 63 total COVID-19 patients on CRRT were identified with 73% 30-day mortality and 83% in-hospital mortality. The median 4OSS was 8 in both in-hospital survivors and non-survivors with interquartile range [IQR] of 4-9 and 7-9.75, respectively (difference between groups non-significant, p = 0.075). The median 4OSS was 7 [5.5- 8.5] and 8 [7-10] in 30-day survivors and non-survivors, respectively (p = 0.018). Those with 4OSS of >=10 (n=13, 20.6%) had 100% in-hospital mortality. CONCLUSION(S): Similar to other analyses of SOFA score in COVID-19, 4OSS at CRRT initiation in patients with COVID-19 and AKI-RRT appears to have limited prognostic ability, with substantial overlap in scores between survivors and non-survivors. However, while additional multicenter studies are needed, 4OSS of >=10 may identify a group of about 20% of COVID-19 patients with AKI-RRT and mortality approaching 100%. Given the absence of a superior validated metric, a 4OSS of >=10 may be a reasonable tool for triage of CRRT in the setting of crisis standards of care and CRRT machine or supply shortages. At a minimum, 4OSS could inform goals of care discussions prior to CRRT initiation in patients with COVID-19 complicated by AKI-RRT.

COVID-19 Infection Is a Risk Factor for CKD and Glomerulonephritis

Background: The ongoing COVID19 pandemic continues to challenge healthcare systems. While COVID19 disease is associated with Acute Kidney Injury and collapsing glomerulonephritis, little is known about the potential kidney manifestations of PASC (Post-Acute Sequelae of COVID19). In this study we used TrinetX, a large health research network that aggregates data from multiple centers in the United States to analyze the effects of COVID19 on chronic kidney disease (CKD) manifestations of PASC. Method(s): We searched TrinetX for patients > 18 years old with a documented SARSCOV-2 PCR test and classified them into 2 cohorts: C19+ve (with a [+] molecular test for SARS-COV-2 or a clinical diagnosis of COVID19 disease) and C19-ve (absence of such findings). We excluded patients who had received any COVID19 vaccine. We collected demographics, comorbidities, diagnoses for up to two years after any COVID19 PCR test (index event). A 1:1 propensity score matching (PSM) using the nearest neighbor method was used to balance the 2 cohorts on age, gender, Hispanic ethnicity, black race, hypertension, diabetes, heart failure and atherosclerosis. Patients with a kidney specific diagnosis prior to their COVID19 PCR test were excluded. Result(s): We identified 2,780,780 C19+ve and 6,757,849 C19-ve patients. After PSM each group contained 2,775,418 subjects. Mean age was 40.2+/-23.1, females were 54.7%, blacks were 15.8% & 12.3% were Hispanic or Latinos. COVID19 diagnosis was a strong risk factor for CKD (Relative Risk, RR 2.474, p<0.001), nephritic, nephrotic syndrome and glomerular disorders. Conclusion(s): COVID19 disease is a major risk factor for incident CKD, nephrotic and nephritic syndrome. These findings should be confirmed in prospective studies. Whether these sequalae represent persistence of the kidney tropic SARS-COV-2 virus, vascular damage from the acute infection or a manifestation of autoimmunity can only be established through targeted mechanistic studies.

Vaccination Reduces Risk of CKD Associated With COVID-19 Disease

Background: COVID19 disease has emerged as a major risk factor of chronic health conditions, i.e. PostAcute Sequelae of COVID19 (PASC). With the emergence of more transmissible variants, the global human population will eventually be exposed to the spike protein of SARS-COV-2 either through natural infection or vaccination. It remains unknown whether vaccination may affect the kidney manifestations of PASC. Method(s): We searched TrinetX, a large health research network that aggregates data from multiple centers in the United States to analyze the effects of vaccination on CKD manifestations of PASC. We classified patients as C19+ve (with a [+] molecular test for SARS-COV-2 or a clinical diagnosis of COVID19 disease) and Vax7+ve if they had at least one dose of any COVID19 vaccine and did not have a breakthrough infection. We collected demographics, comorbidities, diagnoses for up to 2 years after any COVID19 PCR test (index event). A 1:1 propensity score matching (PSM) using the nearest neighbor method was used to balance the two cohorts on age, gender, Hispanic ethnicity, black race, hypertension, diabetes, heart failure and atherosclerosis. Patients with a kidney specific diagnosis prior to their COVID19 PCR test were excluded. Result(s): We identified 2,780,576 C19+ve and 735,966 Vax+ve patients. After PSM each group contained 736,034 subjects. Mean age was 51.5+/-21.4, females were 58.8%, blacks were 14.9% & 9.9% were Hispanic or Latinos. COVID19 vaccination was associated with reduced risk of incident CKD, unspecified kidney failure and the nephritic syndrome, but did not reduce the risk of the nephrotic syndrome or glomerulonephritis relative to COVID19 disease. Conclusion(s): Vaccination may reduce the risk of CKD associated with PASC. If confirmed in a prospective study, our findings can expand the known benefits of vaccination on the acute disease to PASC manifestations, potentially improving the uptake of the COVID19 vaccines by the population.

Vaccination rates in Europe are not associated with online media intensity

To map the public information about COVID-19 vaccines and vaccine trials in Europe, we have compiled an inventory of online communication materials from official sources (e.g., governments, public agencies, and NGOs) via directed online research. While information for the general public was abundant across Europe, we found a large variation in number, type and target audiences among countries. Little or no information was found for population groups that are typically underrepresented in vaccine clinical trials. Materials about clinical trials and trial participation were also limited.Interestingly, higher number of media materials was not reflected in higher national vaccination rates.

COVID-19 among a population of predominantly American Indian and Hispanic American kidney transplant recipients

Background: COVID-19 leads to higher mortality among organ transplant recipients when compared to the general population. Methods: In this study, 52 renal transplant recipients with COVID-19 were followed through 60 days from the date of initial diagnosis. We analyzed basic demographics, therapeutics used, and clinical outcomes among patients who survived and those who did not. Results: Of the entire cohort, 53.8% were Hispanic Whites, 38.5% American Indian, and 5.8% were non-Hispanic Whites. 48% required hospital admission and 17% died, with 15% of deaths attributed to complications secondary to COVID-19. All those who died were either American Indian or Hispanic. Comorbidities among the non-survivors included hypertension (100%), chronic kidney disease (67%), diabetes (78%), and either being overweight or obese (100%). 89% had acute kidney injury and 56% required renal replacement therapy. Gender, blood type, and panel reactive antibody prior to transplant did not correlate with disease severity. There was no improvement in mortality during the fall/winter surge compared to the spring/summer surge, though therapies improved during the pandemic. None of the patients who received monoclonal antibody progressed to severe disease or died. Conclusions: In conclusion, mortality with SARS-CoV-2 infection remains high among kidney transplant recipients, especially from ethnic minority groups. However, therapy with monoclonal antibody was associated with a reduced progression to severe disease and better outcomes. Therefore, it should be considered as a therapy in this highrisk group of patients if they satisfy the eligibility criteria listed by the Food and Drug Administration. Finally, further studies are needed to corroborate the findings from our study.

Impact of COVID-19 pandemic on crude mortality rates associated with acute kidney injury requiring continuous renal replacement therapy: A single-center study

RATIONALE Acute kidney injury requiring renal replacement therapy (AKI-RRT) in the intensive care unit (ICU) is associated with significant mortality, with short-term death rates often exceeding 50% in modern cohtorts.1 Similarly high mortality with AKI-RRT has been reported in multiple U.S. cohorts of patients with coronavirus disease 2019 (COVID-19)2-4, but none have specifically focused on the outcomes of AKI treated with continuous RRT (CRRT) in the ICU or compared the outcomes of AKI-CRRT to COVID-negative controls. METHODS We carried out a retrospective review of all patients admitted to the University of New Mexico Hospital and initiated on CRRT in January to October 2020 and compared outcomes between those with and without symptomatic COVID-19. Patients felt to be incidentally infected with COVID-19 and those with end-stage kidney disease (ESKD) were excluded. Crude death rates in AKI-CRRT patients with and without COVID-19 were compared by chisquared test. Patients discharged before 30 days were assumed alive at 30 days. RESULTSA total of 102 patients were treated with 103 CRRT treatments over the 10-month period. Of these, two felt to be incidentally infected were excluded. Ten with ESKD, including three with COVID-19, were also excluded. Of the remaining 90 with AKI-CRRT, 30 were treated for symptomatic COVID-19 starting in April 2020 and had 30-day and in-hospital mortality rates of 67.7% and 80.0%, respectively. Of the 60 COVID-19-negative patients with AKI-CRRT, the 30-day and in-hospital mortality rates were 58.3 and 63.3%, respectively (p = 0.44 and = 0.11, respectively, versus COVID-positive patients). When broken into pre-pandemic and post-pandemic groups, the 30-day and in-hospital death rates for AKI-CRRT in COVID-negative patients were 56.5% and 60.9% in January to March and 59.5% and 64.9% in April to October, respectively (p = >0.05 for both comparisons). CONCLUSIONS These data confirm the high mortality associated with AKI-CRRT in the setting of severe COVID-19. Though not statistically significant in this limited sample, the trend for higher in-hospital mortality in COVID-19 patients suggests the mortality of AKI-CRRT in this setting may be higher than other ICU patients. Notably, the mortality of AKI-CRRT in COVIDnegative patients did not significantly differ before and after the start of the pandemic. Overall, while conclusions about the independent effect of COVID-19 are limited with these unadjusted data, awareness of the high mortality of AKI-CRRT in the setting of COVID-19 may be useful in discussing prognosis and goals of care in these patients.