The changing pattern of COVID-19 infection in hemodialysis and peritoneal dialysis patients.

INTRODUCTION: Following the first wave of COVID-19 there have been several variants. We wished to review the number and severity of infections with the different variants in a population of hemodialysis (HD) and peritoneal dialysis (PD) patients. METHODS: We reviewed the outcomes and results in HD and PD patients testing positive for COVID-19 between March 2020 and August 2022. RESULTS: Seven hundred and ninety-five cases of COVID-19 were recorded in 710 dialysis patients. More HD patients than PD contracted wild type (21.4% vs. 6.8%), delta (23.3% vs 6.3%), and omicron (27.7% vs. 14.7%), all p < 0.01, but no difference with alpha (4.6% vs. 6.3%) or beta variants (5.7% vs. 6.85%). Hospitalization and death were greatest for alpha followed by wild type, beta, delta, and omicron (60.6% vs. 57% vs. 47.5% vs. 21.2% vs. 19.3%), respectively, p < 0.001. C reactive protein progressively increased from outpatient management to hospitalization to hospitalization with critical care or death (14 (4-30) vs. 41 (18-101) vs. 94 (47-168) mg/L, p < 0.001. Despite previous infection and vaccination 85 (12%) patients had two or more infections with COVID-19. CONCLUSION: Disease severity declined and survival improved as the virus mutated from wild-type and alpha to beta, delta, and omicron variants. Whether this related to reduction in viral virulence, vaccination, natural acquired immunity, or introduction of pharmacological treatments remains to be determined. Government lockdowns and enhanced infection control measures reduced the percentage of HD patients contracting alpha and beta variants to that of PD. Vaccination and prior infection did not prevent reinfection.

Increased risk of dialysis circuit clotting in hemodialysis patients with COVID-19 is associated with elevated FVIII, fibrinogen and D-dimers.

INTRODUCTION: Severe COVID-19 infections increase the risk of thrombotic events and Intensive Care Units reported increased extracorporeal circuit clotting (ECC) in COVID-19 patients with acute kidney injury. We wished to determine whether hemodialysis (HD) patients with COVID-19 also have increased risk of circuit clotting. METHODS: We reviewed coagulation studies and HD records, 4 weeks before and after COVID-19 polymerase chain reaction detection in HD patients between April 2020 and June 2021. FINDINGS: Sixty-eight (33.5%) of 203 HD patients with COVID-19, 65% male, mean age 64.9 ± 15.3 years, experienced some circuit clotting, and no clotting recorded prior to positive test results. In those who experienced ECC, prothrombin, activated partial thromboplastin or thrombin times were not different, whereas median factor VIII (273 [168-419] vs. 166 [139-225] IU/dl, p < 0.001), D-dimers (2654 [1381-6019] vs. 1351 [786-2334] ng/ml, p < 0.05), and fibrinogen (5.6 ± 1.4 vs. 4.9 ± 1.4 g/L, p < 0.05) were greater. Antithrombin (94 [83-112] vs. 89 [84-103] IU/dl), protein C (102 [80-130] vs. 86 [76-106] IU/dl), protein S (65 [61-75] vs. 65 [52-79] IU/dl) and platelet counts (193 [138-243] vs. 174 [138-229] × 109 /L) did not differ. On multivariable logistic analysis, circuit clotting was associated with log factor VIII (odds ratio [OR] 14.8 (95% confidence limits [95% CL] 1.12-19.6), p = 0.041), fibrinogen (OR 1.57 [95% CL 1.14-21.7], p = 0.006) and log D dimer (OR 4.8 [95% CL 1.16-12.5], p = 0.028). DISCUSSION: Extracorporeal circuit clotting was increased within 4 weeks of testing positive for COVID-19. Clotting was associated with increased factor VIII, fibrinogen and D-dimer, suggesting that the risk of circuit clotting was related to the inflammatory response to COVID-19.

Survey of food offered to United Kingdom haemodialysis patients attending for dialysis sessions in main dialysis centres and satellite units and international comparison.

Background: Haemodialysis (HD) patients are at increased risk of frailty, sarcopenia and protein energy wasting, all associated with increased mortality. Most of the dialysis day is taken up with travelling to and from dialysis centres and dialysis treatment. The International Society of Nutrition and Metabolism (ISNM) recommend that meals or supplements should be part of standard clinical practice when patients attending for dialysis. Results: We surveyed adult UK centres to determine the provision of food to dialysis patients in the United Kingdom (UK). A hot meal was provided by six (8.7%) of the 69 UK adult units, although 16 (23.2%) main centres would potentially provide meals to a restricted number of malnourished patients. Forty-seven (68.1%) centres provided sandwiches, although this was restricted in eight main centres, and 26.2% of units did not provide sandwiches to patients in their satellite dialysis centres. Biscuits were the only nutrition routinely offered in 15 (21.7%) of the main dialysis units, 41.3% of satellite units. Meals were more likely to be offered in Northern Ireland and Scotland compared to England, and 38% of the main dialysis units in England, and 58% of their satellite centres did not routinely offer patients a sandwich compared to none or one centre in Wales, Scotland and Northern Ireland. Conclusions: Despite an increasing older, more frail dialysis population in the UK, food provision for dialysis patients has reduced, particularly in England, with < 10% of centres routinely offering hot food, and > 50% of dialysis units now only offering biscuits to their satellite dialysis patients.

Spread of Covid-19 in hemodialysis centres; the effects of ventilation and communal transport.

AIMS: Hemodialysis (HD) patients are at increased risk of respiratory infections, due to increased use of communal travel, waiting areas, close proximity to others when dialysing, and contact with healthcare personnel. We wished to determine the major factors associated with transmission of COVID-19 within dialysis centres. METHODS: We compared the differences in the number of COVID-19 infections in patients and staff in 5 dialysis centres during the 1st COVID-19 pandemic between March and June 2020, and analyzed differences between centres. Isolation policies and infection control practices were identical between centres. RESULTS: 224 (30.3%) patients tested positive for COVID-19, by reverse transcriptase polymerase chain reaction, ranging from 4.8% (centre 1 size 55 patients) to 41.5% (centre 5-248 patients) p = 0.007. Communal transport had a significant effect; with 160 of 452 (35.4%) patients using communal testing positive compared to 22.2% of those not using communal transport (X214.5, p < 0.001). Staff sickness varied; 35 of 36 (97.3% centre 5) dialysis staff contracting COVID-19, compared to 60% from centre 4 (189 patients 30 staff) (p < 0.001). Whereas centre 5 had no natural ventilation, and fan assisted ventilation did not meet standards for air changes and air circulation, centre 4 met ventilation standards. CONCLUSIONS: Although there are many potential risk factors accounting for the increased risk of COVID-19 infection in hemodialysis patients, we found that differences in communal transport for patients and ventilation between centres was a major contributor accounting for the differences in patients testing positive for COVID-19 and staff sickness rates. This has important practical applications for designing kidney dialysis centres.

The effect of prescribing vitamin D analogues and serum vitamin D status on both contracting COVID-19 and clinical outcomes in kidney dialysis patients'.

AIMS: Vitamin D plays a role in innate immune system activation, and deficiency increases susceptibility to respiratory infections and disease severity including COVID-19. We determined whether vitamin D levels and medications were associated with contracting COVID-19, and disease severity defined by hospitalisation and dialysis patient mortality. METHODS: We reviewed serum vitamin D levels, and prescription of cholecalciferol and alfacalcidol along with corresponding medical records of adult dialysis patients from a United Kingdom tertiary centre between March 2020 and May 2021. COVID-19 infection was determined by polymerase chain reaction (PCR) results. RESULTS: 362 (35%) of 1035 dialysis patients tested PCR positive for COVID-19. COVID-19 positive patients had lower native median vitamin D (65 (39-95) versus 74 (40.5-101) nmol/L (p = .009) despite greater prescription of cholecalciferol (median 20 000 (20000-20 000) versus 20 000 (0-20 000) IU/week), p < .001, but lower prescription of alfacalcidol 0 (0-3.0) versus 2.0 (0.-5.0) ug/week, p < .001. On multivariate logistic regression COVID-19 infection was associated with haemodialysis versus peritoneal dialysis (p < .001), cholecalciferol dose (p < .001) and negatively with alfacalcidol (p < .001). However, serum vitamin D levels and alfacalcidol dosages were not significantly different for those requiring hospitalisation compared to those managed at home, although those who died were prescribed lower alfacalcidol dosages. CONCLUSION: Dialysis patients who contracted COVID-19 had lower levels of native vitamin D prior to COVID-19 and were prescribed lower dosages of alfacalcidol. However, there was no association between vitamin D status and disease severity. This retrospective observational analysis supports a potential role for vitamin D and susceptibility to COVID-19 infection in dialysis patients.

The effect of SARS-Co-V2 infection on prothrombotic and anticoagulant factors in dialysis patients.

BACKGROUND: Patients with COVID-19 infection are at increased risk of thrombosis. We wished to determine whether this was is due to an increase in prothrombotic or reduction in anticoagulant factors and whether heparin would be an appropriate anticoagulant. METHODS: We measured routine coagulation and prothrombotic factors in dialysis patients after a positive COVID-19 test between March 2020 -April 2021. RESULTS: Routine coagulation tests were measured in 227 dialysis patients, 148 males (65.2%), median age 67.5 (53.8-77.0) years. The international normalized ratio was prolonged in 11.5%, activated partial thromboplastin time in 48.5%, thrombin time in 57%. Factor VIII was increased in 59.1%, fibrinogen 73.8%, and D-dimer 95.5%. Protein C was reduced in 15.3%, protein S 28%, and antithrombin (AT) in 12.1%. Two patients were Lupus anticoagulant positive, and two Factor VLeiden positive. Factor VIII levels increased with clinical disease; outpatients 159 (136-179) IU/dl, hospitalized but not ventilated 228 (167-311) IU, ventilated 432 (368-488) IU/dl (p < 0.01). Overall 75% had an AT level ≥ 88 IU/dl (reference range 79-106), but only 11.7% of non-hospitalized patients compared to 45% of those who died, p < 0.01, fibrinogen, D-dimers, and protein S or C did not differ with clinical disease severity, whether patients required hospital admission or not and between survivors and those who died. CONCLUSION: COVID-19 dialysis patients have increased levels of fibrinogen and D-Dimers, but only factor VIII levels in the clotting profile increased with clinical disease severity increasing systemic hypercoagulability. AT concentrations are maintained and as such should not compromise anticoagulation with heparins.

Short-Term Immunogenicity Profiles and Predictors for Suboptimal Immune Responses in Patients with End-Stage Kidney Disease Immunized with Inactivated SARS-CoV-2 Vaccine.

INTRODUCTION: Patients with end-stage kidney disease (ESKD) are at risk of severe coronavirus disease and mortality. Immunogenicity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) inactivated whole-virus vaccine in patients with ESKD has never been explored. METHODS: We conducted a prospective cohort study of 60 patients with ESKD and 30 healthy controls. All participants received two doses of an inactivated whole-virus SARS-CoV-2 vaccine (Sinovac Biotech Ltd) 4 weeks apart. SARS-CoV-2-specific humoral and cell-mediated immune responses were investigated and referenced with healthy controls. RESULTS: After two doses, an anti-receptor-binding domain immunoglobulin G of 50 AU/ml or greater was present in 53 of 60 patients (88%) in the ESKD group and all participants (100%) in the control group (P = 0.05). The percentage of patients with ESKD and controls with neutralizing antibodies of 35% threshold or greater was 58% and 88%, respectively (P = 0.01). Furthermore, the proportion of patients with ESKD and S1-specific T cell response was comparable with controls (82% vs. 77%, P = 0.45). Old age, high ferritin level, and low absolute lymphocyte count were independently associated with poor humoral immune responses. CONCLUSIONS: Patients with ESKD could develop similar SARS-CoV-2-specific cell-mediated immune responses compared to healthy controls, although suboptimal humoral immune responses were observed following two doses of SARS-CoV-2 vaccination. Therefore, patients with ESKD and the abovementioned factors are at risk of generating inadequate humoral immune responses, and a vaccine strategy to elicit greater immunogenicity among these relatively immunocompromised patients is warranted. (Thai Clinical Trials Registry, TCTR20210226002).

Continuous renal replacement therapy under special conditions like sepsis, burn, cardiac failure, neurotrauma, and liver failure.

Continuous renal replacement therapy (CRRT) in sepsis does have a role in removing excessive fluid, and also role in removal of mediators although not proven today, and to allow fluid space in order to feed. In these conditions, continuous renal replacement therapy can improve morbidity but never mortality so far. Regarding sepsis, timing has become a more important issue after decades and is currently more discussed than dosing. Rationale of blood purification has evolved a lot in the last years regarding sepsis with the discovery of many types of sorbent allowing ideas from science fiction to become reality in 2021. Undoubtedly, COVID-19 has reactivated the interest of blood purification in sepsis but also in COVID-19. Burn is even more dependent about removal of excessive fluid as compared to sepsis. Regarding cardiac failure, ultrafiltration can improve the quality of life and morbidity when diuretics are becoming inefficient but can never improve mortality. Regarding brain injury, CRRTs have several advantages as compared to intermittent hemodialysis. In liver failure, there have been no randomized controlled trials to examine whether single-pass albumin dialysis offers advantages over standard supportive care, and there is always the cost of albumin.

Telemedicine in the Satellite Dialysis Unit: Is It Feasible and Safe?

Telemedicine has gained popularity during the recent COVID-19 pandemic. Regular and timely physician review is an essential component of care for the maintenance of hemodialysis patients. While it is widely acknowledged that telemedicine cannot fully replace the role of physical review in this group of patients with organ failure, it can perhaps reduce the reliance on physical review or serve as a filter and triage in determining which patient requires actual physical review. The use of technology in any healthcare setting should always align with existing clinical workflow and protocols. We discuss the safety and quality aspects of this new concept applied to the satellite dialysis unit.

Recommendations for the prevention, mitigation and containment of the emerging SARS-CoV-2 (COVID-19) pandemic in haemodialysis centres.

COVID-19, a disease caused by a novel coronavirus, is a major global human threat that has turned into a pandemic. This novel coronavirus has specifically high morbidity in the elderly and in comorbid populations. Uraemic patients on dialysis combine an intrinsic fragility and a very frequent burden of comorbidities with a specific setting in which many patients are repeatedly treated in the same area (haemodialysis centres). Moreover, if infected, the intensity of dialysis requiring specialized resources and staff is further complicated by requirements for isolation, control and prevention, putting healthcare systems under exceptional additional strain. Therefore, all measures to slow if not to eradicate the pandemic and to control unmanageably high incidence rates must be taken very seriously. The aim of the present review of the European Dialysis (EUDIAL) Working Group of ERA-EDTA is to provide recommendations for the prevention, mitigation and containment in haemodialysis centres of the emerging COVID-19 pandemic. The management of patients on dialysis affected by COVID-19 must be carried out according to strict protocols to minimize the risk for other patients and personnel taking care of these patients. Measures of prevention, protection, screening, isolation and distribution have been shown to be efficient in similar settings. They are essential in the management of the pandemic and should be taken in the early stages of the disease.