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OBJECTIVE: Patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) require immunosuppressive therapy for disease control and relapse prevention and may be at risk for severe coronavirus disease 2019 (COVID-19). The study objective was to analyse risk factors and outcomes of COVID-19 in well-characterized AAV patients. METHOD: Data were retrieved from March 2020 to May 2021 from medical records of AAV cohorts in Stockholm and Uppsala, Sweden. COVID-19 was confirmed by positive PCR test or by ELISA. Severe COVID-19 was defined as need for non-invasive ventilation, intensive care unit care, and/or death. Age, gender, ANCA antibody type, ongoing immunosuppressive medication, and estimated glomerular filtration rate were recorded. RESULTS: The cohort comprised 310 AAV patients, of whom 29 (9%) were diagnosed with COVID-19. Four deaths were attributed to COVID-19. Fifteen patients (52%) were on prednisolone in the COVID-19 group and 130 (46%) in the non-COVID group, with significantly higher doses in COVID-19 patients (p < 0.01). Ongoing induction therapy was more prevalent in the COVID-19 group (p < 0.01). Severe COVID-19 was diagnosed in 9/29 (31%). Significant risk factors for severe COVID-19 were impaired kidney function (p = 0.01) and more intense immunosuppressive therapy (p = 0.02), with a trend for age (p = 0.07). Maintenance therapy with rituximab was not associated with severe COVID-19. CONCLUSIONS: Our findings highlight risks and suggest that more attention should be given to optimal AAV treatment in a pandemic situation. They also emphasize the need for continued shielding, mitigation strategies, and effective vaccination of AAV patients.
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Background:Patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) require immunosuppressive therapy for disease control and reduction of disease relapse and may be at risk for complications during Sars-CoV-2 (COVID-19) infection.Objectives:To analyze the consequences of COVID-19 in a large cohort of AAV patients regarding occurrence, need of hospitalization, treatment at the intensive care units (ICU), or death.Methods:Data were retrieved from March 2020 to mid-January 2021 from medical records from the AAV cohort (n=233). Patients diagnosed with granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA) or eosinophilic granulomatosis with polyangiitis (EGPA) were included. Data included age, gender, diagnosis, ongoing immunosuppressive medication at onset of COVID-19 or at last follow-up in non-COVID individuals. Renal involvement (ever) and estimated glomerular filtration rate (eGFR) were included. COVID-19 was confirmed either by a positive PCR test in the upper airways or by serology. Severe COVID-19 was defined as need of non-invasive ventilation, ICU care, and/or death.Results:The cohort comprised of 172 patients with GPA, 50 with MPA and 11 with EGPA. There were 121 females (52%). During the study period, 20 patients (8.6%) were diagnosed with COVID-19. The median age at data retrieval in all patients was 68 years (21-93), in the COVID-19 group 63 (29-93) and 68.5 (21-90) years in the non-COVID patients.Fourty-three patients in all (18%) were hospitalized during the study period of which 11 (4.7%) due to COVID-19 infection. In all, 8 deaths occurred of which 3 were related to COVID-19.At data retrieval, 110 (47%) patients were on prednisolone treatment, 10/20 (50%) in the COVID-19 group and 100 (47%) in the non-COVID-19 group (p=0.5), with significantly higher doses in COVID-19 patients (p<0.001). In patients hospitalized with COVID-19, 6/11 (54.5%) were on prednisolone, median dose 5 mg/day (0-50). In the total group 112 (48%) were on disease modifying anti-rheumatic drugs (DMARD) and 64 (27.5%) on rituximab as maintenance therapy. Eight patients were on induction treatment with either cyclophosphamide or rituximab.Of the 20 COVID-19 cases, 8 had severe COVID-19. Of these, 2 were inactive without immunosuppressive treatment, 4 had stable disease with prednisolone (5-7.5 mg/day) in combination with DMARDs, and 2 were active treated with high dose prednisolone (25-50 mg/day) in combination with cyclophosphamide and rituximab (n=1) or rituximab (n=1).A higher proportion of patients had active AAV (p=0.03) in the severe COVID-19 then in the non-COVID group (10/213 patients).In the group with the severe COVID-19, 1/8 (12%) patient had rituximab as maintenance therapy, compared to 61/213 (28.6%) in the group of non-COVID-19 patients (p=0.5).Renal involvement (ever) was present in 144 patients (62%), in 6 patients (30%) with COVID- 19, from which 5 (62%) were in the group of severe COVID-19 patients. Median eGFR did not differ between severe COVID-19 and remaining patients with renal involvement independently of COVID-19 infection.Conclusion:We found a high rate of severe COVID-19 infection in our cohort of AAV patients which indicates risk for serious complications, especially in patients with active disease and intense immunosuppressive therapy. Maintenance therapy with rituximab did not seem to increase the risk for severe COVID-19. The findings stress the need for continued shielding and early vaccination in AAV patients.Disclosure of Interests:None declared
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BACKGROUND AND AIMS: Research regarding COVID-19 and acute kidney injury (AKI) in older adults is scarce. We evaluated the risk factors and outcomes of AKI in hospitalized older adults with and without COVID-19. METHOD: Observational study of patients admitted to two geriatric clinics in the Stockholm Region of Sweden during the first wave of the COVID-19 pandemic from March 1st to June 15th 2020. The difference in incidence, risk factors and adverse outcomes for AKI between patients with or without COVID-19 were examined. Odds ratios (ORs) for AKI were obtained from logistic regressions. The hazard ratios (HRs) for the risk of in-hospital death were calculated from Cox proportional hazard regression models. RESULTS: We analyzed 316 older patients hospitalized for COVID-19 and 876 patients for non-COVID-19 diagnoses. The mean age was 8369 years, 57% were women, and mean baseline kidney function as depicted by estimated glomerular filtration rate (eGFR) was 62623 ml/min/1.73m2. AKI occurred in 92 (29%) of patients with COVID-19 vs. 159 (18%) without COVID-19. The severity of AKI was significantly worse in patients with COVID-19 compared with non-COVID patients. The odds for developing AKI were higher in patients with COVID-19 (adjusted OR, 1.70;95% CI, 1.04-2.76), low baseline kidney function [4.19 (2.48-7.05), for eGFR 30 ≥ <60 ml/min/1.73m2, and 20.3 (9.95-41.3) for eGFR <30ml/min/1.73m2], and higher C-reactive protein (CRP) level (OR 1.81(1.11-2.95)). The risk of in-hospital death was highest in patients with COVID-19 and AKI [adjusted HR 23.5, 95% CI (8.75-63.0)], followed by COVID-19 without AKI [9.10 (3.52-23.6)] and by patients without COVID-19 and with AKI [6.38 (2.28-17.9)] after adjusting for patient demographics, vital signs, baseline kidney function and medications and using non-COVID patients with no AKI as reference. CONCLUSION: Geriatric patients hospitalized with COVID-19 had a higher incidence of AKI compared with patients hospitalized with other diagnoses. AKI and COVID-19 were associated with in-hospital death. Optimal management of AKI may improve the outcome of COVID-19 in geriatric patients.
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Introduction: Acute kidney injury (AKI), albuminuria and hematuria are common and increase mortality in Covid-19 in addition to viral pneumonia, hypercoagulability and hyperinflammation. We present short-term outcomes of 21 Covid-19 patients with AKI and CRRT and the clinical course of 40 chronic hemodialysis (HD) patients with Covid-19. Case Description: Twenty-one non-CKD Covid-19 infected patients with AKI required mechanical ventilation and CRRT at the ICU, 20 were males, average age was 59.7 years (y), average BMI 29 kg/m2, 33 % had diabetes. The typical scenario was a normal/slightly elevated creatinine level at admission, normalizing after iv fluids, but rising creatinine from day 3-4 and start of CRRT on day 8 (median). Urine analysis was available in eight patients, of which seven had albuminuria and/or hematuria. So far eight patients (38 %) have died. Dialysis has been discontinued in nine patients (43 %), median time 17 days in dialysis (range 1-35 days), follow up of 1-4 weeks. Patients 3-4 weeks after CRRT discontinuation have a creatinine level of 50-161 μmol/L (ref < 90-100 μmol/L). Four patients are still dialysis dependent (median time in dialysis 7-22 days). Forty out of 520 patients on chronic HD in Stockholm had symptomatic Covid-19 in March-April 2020, of these 24 patients (60 %) required hospitalization, 16 patients (40%) did not. Nine patients died (22,5 %), of whom eight were men. The average age (78 y) was significantly higher (p = 0.003) and median time in dialysis (11.5 y) was longer (p = 0.01) in the non-survivors compared to the survivors. CRP at admission was significantly higher in the non-survivors (p=0.0003), but there were no differences regarding prior cardiovascular disease or diabetes (56 vs 55 %). Only three patients had a BMI > 30 kg/m2. Among survivors, the number of patients with ACE inhibitor/ARB treatment did not differ from non-survivors (p = 0.08), 13 out of 15 patients continued their treatment, without more serious disease. Discussion: The AKI mortality in Covid-19 with CRRT is high, but a substantial number of patients have survived and recovered kidney function although follow-up for long-term CKD prognosis is important. Fewer chronic HD patients than expected suffered severe disease, however patients older than 70 y in combination with longer time (> 10 y) in HD and high CRP at admission were at a higher risk of dying from symptomatic Covid-19.