Anti-Inflammatory Approach in Chronic Dialysis Patients with SARS-CoV-2: ATA or PMMA Dialyzers?

INTRODUCTION: High-flux hemodialysis membranes may modulate the cytokine storm of SARS-CoV-2, but their impact on chronic hemodialysis (CHD) patients is unknown. The aim of the study was the evaluation of asymmetric cellulose triacetate (ATA) and polymethylmethacrylate (PMMA) dialyzers on inflammatory markers and clinical outcomes in CHD patients with SARS-CoV-2. METHODS: A prospective, observational study on CHD patients with SARS-CoV-2 was carried out. Patients were enrolled from March 2020 to May 2021. Pre- and postdialysis C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6) were determined at each session. Patients who underwent on-line hemodiafiltration (OLHDF) with a PMMA dialyzer were compared with those treated with OLHDF with a ATA dialyzer. The primary endpoint was the differences in the reduction ratio per session (RR) of CRP, PCT, IL-6, and IL-6 RR >25%. RESULTS: We consecutively enrolled 74 CHD patients with COVID-19, 48 were treated with ATA membrane, and 26 with PMMA. Median IL-6 RR was higher in the ATA group compared to PMMA (17.08%, IQR -9.0 to 40.0 vs. 2.95%, IQR -34.63 to 27.32). Median CRP RR was 7.77% (IQR 2.47-13.77) in the ATA group versus 4.8% (IQR -2.65 to 11.38) in the PMMA group (p = 0.0017). Median PCT-RR% was 77.38% (IQR 70.92-82.97) in ATA group versus 54.59% (IQR 42.62-63.16) in the PMMA group (p < 0.0001). A multiple logistic regression analysis with IL-6 RR >25% as the outcome including the membrane employed, pre-dialysis IL-6, CRP, PCT, and ferritin showed that ATA led to a higher probability to reach the outcome (OR 1.891, 95% CI 1.273-2.840, p = 0.0018) while higher CRP favors the risk of lower IL-6 RR values (OR 0.910, 95% CI 0.868-0.949, p ≤ 0.0001). CONCLUSIONS: In SARS-CoV-2 CHD patients treated with OLHDF, ATA showed a better anti-inflammatory profile, regarding IL-6 RR, compared to PMMA.

Prevalence, clinical course and outcomes of COVID-19 in peritoneal dialysis (PD) patients: a single-center experience.

INTRODUCTION: There are limited data on the effects of COVID-19 on peritoneal dialysis (PD) patients. This study aimed to describe the impact of COVID-19 on the PD population. METHODS: A monocentric retrospective observational study was conducted on 146 consecutive PD patients followed from January 2020 to March 2022 at the University Hospital of Modena, Italy. RESULTS: Twenty-seven (18.4%) PD patients experienced 29 episodes of SARS-CoV-2 infection, corresponding to an incidence rate of 0.16 episodes/patient-year. Median age of COVID-19 patients was 60.4 (interquartile range [IQR] 50.2-66.5) years. In unvaccinated patients (n. 9), COVID-19 was always symptomatic and manifested with fever (100%) and cough (77.7%). COVID-19 caused hospital admission of three (33.3%) patients and two (22.2%) died of septic shock. COVID-19 was symptomatic in 83.3% of vaccinated subjects (n.18) and manifested with fever (61.1%) and cough (55.6%). Hospital admission occurred in 27.8% of the subjects but all were discharged home. Median SARS-CoV-2 shedding was 32 and 26 days in the unvaccinated and vaccinated groups, respectively. At the end of the follow-up, COVID-19 triggered the shift from PD to HD in two subjects without affecting the residual renal function of the remaining patients. Overall, COVID-19 caused an excess death of 22.2%. COVID-19 vaccination refusal accounted for only 1.6% in this cohort of patients. CONCLUSION: COVID-19 incident rate was 0.16 episodes/patient-year in the PD population. About one-third of the patients were hospitalized for severe infection. Fatal outcome occurred in two (7.4%) unvaccinated patients. A low vaccination refusal rate was observed in this population.

Interleukin-6 and Outcome of Chronic Hemodialysis Patients with SARS-CoV-2 Pneumonia.

Background and Objectives: Chronic hemodialysis (CHD) patients are at increased risk of SARS-CoV-2 infection and the related complications and mortality of COVID-19 due to the high rate of comorbidities combined with advanced age. This observational study investigated the clinical manifestations of SARS-CoV-2 infection in CHD and the risk factors for patients' death. Materials and Methods: The study included 26 CHD patients with SARS-CoV-2 pneumonia detected by positive RT-PCR on nasopharyngeal swabs and high-resolution computed tomography at hospital admission, aged 71 + 5.9 years, 14 of which (53.8%) were male, 20 (77%) under hemodiafiltration, and 6 (23%) on standard hemodialysis, with a median follow-up of 30 days. Results: Simple logistic regression analysis revealed that the factors associated with a higher risk of death were older age (OR: 1.133; 95%CI: 1.028-1.326, p = 0.0057), IL-6 levels at admission (OR: 1.014; 95%CI: 1.004-1.028, p = 0.0053), and C-reactive protein (OR: 1.424; 95%CI: 1.158-2.044, p < 0.0001). In the multiple logistic regression model, circulating IL-6 values at admission remained the only significant prognosticator of death. The ROC curve indicated the discriminatory cut-off value of 38.20 pg/mL of blood IL-6 for predicting death in chronic hemodialysis patients with SARS-CoV-2 pneumonia (sensitivity: 100%; specificity: 78%; AUC: 0.8750; p = 0.0027). Conclusions: This study identified a threshold of IL-6 levels at hospital admission for death risk in CHD patients with SARS-CoV-2 pneumonia. This might represent a valuable outcome predictor, feasibly better than other clinical, radiological, or laboratory parameters and preceding the IL-6 peak, which is unpredictable.

Weekly Rapid Antigen Test Screening for COVID-19 in Patients on Hemodialysis.

BACKGROUND/AIM: COVID-19 is a concerning issue among in-center hemodialysis (HD) patients. To prevent COVID-19 diffusion in our HD facility, weekly rapid nasal antigen test screening was performed for all asymptomatic patients on chronic HD. This study aimed to assess the performance of weekly rapid antigen test in detecting SARS-CoV-2 infection among asymptomatic patients receiving HD. PATIENTS AND METHODS: A retrospective analysis was conducted in HD patients who underwent rapid antigen test screening from December 2021 to March 2022. The diagnosis of COVID-19 with rapid antigen test was always confirmed by reverse transcriptase-polymerase chain reaction (RT-PCR). RESULTS: During the observational period, 1,748 rapid antigen tests were performed in 220 HD patients. Mean age was 68.4±14.6 years. Fifteen (8.5%) patients resulted positive for SARS-CoV-2 infection using rapid antigen tests. The diagnosis was subsequently confirmed in 14 (93.3%) patients by RT-PCR. During the same period, 12 (5.4%) symptomatic patients, regularly screened with weekly rapid antigen test, resulted positive for SARS-CoV-2 infection using RT-PCR. Overall, weekly rapid antigen test screening identified 14 out of 26 (53.8%) COVID-19 cases and showed a positive predictive value of 93%. CONCLUSION: Weekly antigen test screening of asymptomatic patients on chronic HD detected around half of the COVID-19 cases in our population.

Ethical challenges in managing unvaccinated patients receiving chronic in-centre haemodialysis.

Insufficient vaccine coverage and dominance of the more transmissible severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants are the leading causes of the continued spread of coronavirus disease 2019 (COVID-19) worldwide. To curb the surge in infections, COVID-19 vaccination has been advocated as a priority measure, especially for frail populations and people at high risk of exposure. Patients on in-centre maintenance haemodialysis (HD) embody both conditions. They are at high risk of severe COVID-19 consequences due to their advanced age and weakened immune system and carry an increased risk of SARS-CoV-2 transmission within shared dialysis rooms and public vehicles. Vaccination of the entire HD population is therefore the most effective strategy to protect patients from the dire consequences of COVID-19. Unfortunately, a minority of patients still express COVID-19 vaccine hesitancy. The management of this group of patients, who have the full right to HD treatment, poses demanding problems from a patient safety perspective. The placement of unvaccinated patients within the dialysis room and the protection of all vaccinated patients are some of the most urgent problems the nephrologist faces during the COVID-19 pandemic. In light of these COVID-19-driven changes, an ethical reflection on the management of unvaccinated patients appears crucial to act responsibly and contribute to the health promotion of dialysis patients.

COVID-19 Rapid Antigen Test Screening in Patients on Hemodialysis.

Introduction: Patients receiving in-center hemodialysis are extremely vulnerable to COVID-19. It is unclear if routine screening of asymptomatic hemodialysis patients is an effective strategy to prevent COVID-19 outbreaks within the dialysis unit. Methods: We conducted a retrospective analysis of in-center hemodialysis patients who underwent bimonthly COVID-19 rapid antigen test screening from February 15th to December 26th, 2021. Nasal rapid antigen testing was performed in all asymptomatic patients. All rapid antigen-positive tests were confirmed by RT-PCR nasopharyngeal swab. Besides universal rapid antigen screening, RT-PCR testing was conducted in all symptomatic patients and contacts of COVID-19 subjects. Results: Overall, 4079 rapid antigen tests were performed in 277 hemodialysis patients on chronic hemodialysis with a mean age of 68.4 ± 14.6 years. Thirty-eight (0.9%) rapid antigen tests resulted positive. Only five (13.8%) positive-rapid antigen tests were also positive by RT-PCR testing. During the same period, 219 patients regularly screened by rapid antigen tests bimonthly underwent 442 RT-PCR nasopharyngeal swabs for clinical reasons. RT-PCR testing yielded a positive result in 13 (5.9%) patients. The time elapsed between PCR and the negative-rapid antigen test was 7.7 ± 4.6 days (range 1.8-13.9 days). At the end of the follow-up, 6.4% of the population on in-center hemodialysis contracted COVID-19, and routine rapid antigen tests detected only 5 out of 18 (27.7%) COVID-19 cases. No outbreaks of COVID-19 were identified within the dialysis unit. Conclusion: Bimonthly rapid antigen screening led to the early diagnosis of COVID-19 in less than one-third of cases. The short incubation period of the new SARS-CoV-2 variants makes bimonthly test screening inadequate for an early diagnosis of COVID-19. More frequent tests are probably necessary to improve the utility of COVID-19 nasal rapid antigen test in patients on hemodialysis.

Anti-Inflammatory Approach in Chronic Dialysis Patients with SARS-CoV-2: ATA or PMMA Dialyzers?

BACKGROUND AND AIMS High flux haemodialysis membranes may modulate the cytokine storm of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), but their impact in chronic haemodialysis (CHD) patients is not assessed [1, 2]. The aim of the study was the evaluation of asymmetric cellulose triacetate (ATA) and polymethylmethacrylate (PMMA) dialyzers on inflammatory markers in CHD patients with SARS-CoV-2. METHOD A prospective, observational study on CHD patients (age ≥18 years) affected by SARS-CoV-2 was carried out. Patients were enrolled from March 2020 to May 2021 and dialysis was performed at S. Orsola University Hospital (Bologna, Italy) Dialysis Unit. Mechanical ventilation at diagnosis was exclusion criteria. Pre- and post-dialysis C-reactive protein (CRP), procalcitonin (PCT) and interleukin-6 (IL-6) were determined at each session and corrected for haemoconcentration during the complete SARS-CoV-2 period. Patients who underwent online haemodiafiltration (OLHDF) with PMMA dialyzer (Filtryzer BG-U™, Toray, surface area 2.1 m2 cut-off 20 kDa, KUF 43 mL/h/mmHg) were compared with those who underwent OLHDF with ATA dialyzer (SolaceaTM Nipro, surface area 2.1 m2 cut-off 45 kDa, KUF 72 mL/h/mmHg). The primary endpoint was to assess the differences in the reduction ratio/session (RR) of CRP, PCT and IL-6. RESULTS A total of 74 patients were enrolled, 48 were treated with ATA and 26 were with PMMA (420 versus 191 dialysis sessions). The main results are shown in Table 1. Median IL-6RR% was higher for ATA [17.08%, interquartile range (IQR) −9.0 to 40.0 versus 2.95%, IQR −34.63 to 27.32]. CRP and PCT showed higher RR with ATA in comparison to PMMA. When IL-6RR > 25% was the dependent variable in the multiple logistic regression analysis only ATA showed a significant correlation [odds ratio (OR) 1.891, 95% confidence interval (95% CI) 1.273–2.840, P = .0018) while higher CRP favoured the risk of lower IL6RR (OR 0.9101, 95% CI 0.868–0.949, P < 0.0001) (Table 2). CONCLUSION In SARS-CoV-2 CHD patients treated with OLHDF, ATA showed a better anti-inflammatory profile than PMMA, in particular regarding IL-6 RR.Table 1. Clinical features and outcomes of ATA versus PMMA. Standard deviation (SD), Interquartile range (IQR)ATA (48)PMMA (26)PAge, years, mean (SD)67.67 (15.48)69.46 (16.37).6421Male, n (%)34 (71)17 (66).7930HD age, months, median (SD)47.00 (13.75–89.75)27.50 (14.25–71.50).3653Charlson Comorbidity Index, median (IQR)4.00 (3.00–5.00)5 (3.00 –7.25).2549Arteriovenous Fistula, n (%)39 (81)14 (54).0166Central venous catheter, n (%)9 (9)12 (46)Interstitial pneumonia, n (%)29 (60)20 (77).2008Pre-HD IL-6 pg/mL, median (IQR)14.50 (5.75–41.43)13.90 (5.80–34.10).6386IL-6 RR%, median (IQR)17.08 (−9.0–40.0)2.95 (−34.63–27.32)<0.001IL-6 RR% based on pre-dialysis IL-6 level (median, IQR) 1st tertile23.55 (−8.96–47.40)3.72 (−51.66–30.08).0013 2nd tertile16.69 (−9.79–39.39)2.18 (−24.03–25.95).0405 3rd tertile12.99 (−8.73–35.75)1.14 (−34.70–31.33).0501CRP RR%, median (IQR)7.77 (2.47–13.77)4.80 (−2.65–11.38).0017PCT RR%, median (IQR)77.38 (70.92–82.97)54.59 (42.62–63.16)<0.0001Variables at diagnosis, median (IQR) IL6 pg/mL20.30 (9.10–62.10)22.60 (9.80–56.35).8763 CRP mg/dL3.88 (0.77–143.70)3.30 (0.33–9.98).4134 PCT pg/mL1.60 (0.72–2.77)0.95 (0.53–1.48).0388Death, n (%)8 (17)5 (19).7604Table 2. Multiple logistic regression with IL-6 RR > 25% as outcome. Odds Ratio (OR), Confidence interval (CI)OR95% CIpATA1.8911.273–2.840.0018IL-6 pre-HD1.0031.001–1.007.0123CRP pre-HD0.91010.8682–0.9496< 0.0001PCT pre-HD0.95280.8644–1.008.2270Ferritin1.0000.9998–1.000.7697

Reactogenicity of MRNA-1273 Vaccine in Patients on Haemodialysis

BACKGROUND AND AIMS mRNA-1273 vaccine (previously known as vaccine Moderna) has shown 94.1% efficacy at preventing COVID-19 illness in the general population. Vaccine-related adverse events (AEs) were usually mild or moderate in intensity and resolved within a few days. Nevertheless, the fear of developing AEs led some patients on haemodialysis to deny vaccination or additional booster doses. No studies have been conducted to evaluate the reactogenicity of the mRNA-1273 vaccine in dialysis patients. To inform public health and clinical practice, we investigated the safety of the mRNA-1273 vaccine in a cohort of patients on haemodialysis. METHOD We conducted a retrospective analysis of in-centre haemodialysis patients without a prior COVID-19 diagnosis who underwent mRNA-1273 vaccine from 1 March to 30 April 2021. mRNA-1273 vaccine was performed in all patients without signs of ongoing infection or COVID-19 who provided written consent from 24 March to 30 April 2021. AEs occurring after the first and the second doses were collected and classified as local or systemic. RESULTS Overall, 126 patients on chronic maintenance dialysis were vaccinated with two doses of mRNA-1273 vaccine. Mean age was 68 (IQR, 54.7–76) years and 53.6% of patients were aged ≥65 years (Table 1). AEs occurred in 57.9% and 61.9% of patients after the first dose and second dose, respectively. The most common AEs were injection-site pain (61.9%), erythema (4.8%), itching (4.8%), swelling (16.7%), axillary swelling/tenderness (2.4%), fever (17.5%) headache (7.9%), fatigue (23.8%), myalgia (17.5%), arthralgia (12.7%), dyspnoea (2.4%), nausea/vomiting (7.1%), diarrhoea (5.6%), shivers (4%) and vertigo (1.6%).Table 1. Demographic and clinical characteristics of haemodialysis patients who underwent RNA-1273 vaccine administrationBasal characteristicsAll patients(n = 126) Age (year)68 (54.7–6) (range)19–92 ≥ 65 years71 (56.3) Males, n (%)71 (56.31) Ethnic origin, n. (%)  Caucasian110 (87.3) African15 (11.9) Hispanic1 (0.8)Etiology of ESRD, n. (%)  Nephrosclerosis54 (42.9) Glomerulonephritis26 (20.6) Diabetes14 (11.1) ADPKD4 (3.2) Nephrotoxic4 (3.2) Pyelonephritis4 (3.2) Interstitial3 (2.4) HIVAN2 (1.6) Others10 (7.9) NA5 (4)HD treatment schedule, n (%)  3 times per week115 (91.2) 2 times per week7 (5.5) 4 times per week4 (3.1)Infectious disease, n. (%)  HBV3 (2.3) HCV3 (2.3) HIV2 (1.5)Time elapsed from the first to the second dose of vaccine, day28 (28–28)Follow-up, day68 (66–70) ESRD, end-stage renal disease;HBV, hepatitis B virus;HCV, hepatitis C virus. The rates of local AEs were similar after the first and second doses (P = .8), whereas systemic AEs occurred more frequently after the second dose (P = .001). Fever (P = .03), fatigue (P = .02) and nausea/vomiting (P = .03) were significantly more frequent after the second dose of the vaccine (Figure 1). Analysis of the data detected statistically significant differences in duration of axillary swelling/tenderness (P = .07) and diarrhoea (P = .02) between the first and second. In both cases, these symptoms lasted longer after the second dose of the vaccine. There were no age-related differences in the rate of AEs between older (≥65 years) and younger participants (18–64 years). Lastly, we noted a lower rate of AEs in hemodialysis patients after the first dose (57.9% versus 84.2%) and second doses (61.9% versus 88.6%) compared to the general population.FIGURE 1: Number of patients who experienced AEs after the two doses. CONCLUSION RNA-1273 vaccine was associated with the development of transient AEs after the first (57.9%) and second doses (61.9%) in patients on haemodialysis. Systemic AEs were more common after the second dose than the first dose of vaccine. The duration of AEs lasted for a few days, without any apparent consequences. These data confirm the safety of the RNA-1273 vaccine in haemodialysis patients and support the promotion of COVID-19 vaccination in h sitant patients.

Covid-19 in Patients on Peritoneal Dialysis: A Case-Series

BACKGROUND AND AIMS A great amount of information has been divulged on the epidemiology and outcome of coronavirus disease 2019 (COVID-19) in patients with ESRD. The majority of the studies have been conducted in patients on maintenance hemodialysis (HD) and kidney transplant recipients. Unfortunately, few studies focused on the outcome of peritoneal dialysis (PD) patients. Information regarding this subset of the population has been extrapolated from aggregated data including a higher percentage of HD patients. As a result, the impact of COVID-19 is indefinite in patients receiving PD. We conducted a study to better understand how patients on PD have been affected by COVID-19. METHOD We conducted a single-center retrospective analysis of 141 PD patients followed at the University Hospital of Modena, Italy from 1 March 2020 to 31 December 2021. The diagnosis of COVID-19 was performed through nasopharyngeal swab RT–PCR testing. Duration of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) shedding measured the time elapsed from diagnosis of COVID-19 to one or two (if available) negative nasopharyngeal PCR tests. Median and interquartile range or mean and standard deviation were used for continuous variables and percentage for categorical variables. A P-value <0.05 was considered statistically significant. RESULTS During the pandemic, 18 out of 141 (12.7%) patients receiving PD dialysis contracted COVID-19. Median age was 60 (50.2–66.5) years with a predominance of males (72.2%) The percentage of patients on APD accounted for 33.3%. The infection was symptomatic in out of 18 (94.4%) patients. Fever (94.4%) and cough (55.6%) were the most common symptoms. Viral shedding, traced with nasopharyngeal swabs lasted 26 (14.5–3.5) days. Two patients were inactive on the waiting list for kidney transplantation for a mean of 43 ± 1.4 days. COVID-19 caused hospital admission of seven (38.9%) patients. During hospitalization two (11.1%) patients switched from PD to HD for ultrafiltration failure and inadequate solute clearance and two (11.1%) died for septic shock with multiorgan failure. In our cohort of patients, excess death due to COVID-19 was 22.2%. Half of the patients contracted the infection before the availability of SARS-CoV-2 vaccine. There were no statistically significant differences between vaccinated and unvaccinated patients in terms of symptoms, viral shedding and hospital admission or (Table 1). We underline that COVID-19 was fatal only in two unvaccinated patients.Table 1. Demographic and clinical characteristics of patients on PD with COVID-19VariablesAllpatientsUnvaccinated patientsVaccinated patientsP-value(n. 18)(n. 9)(n. 9)Age, years60 (50.2–66.5)54 (52–65)62 (39–73)0.96Male, n. (%)13 (72.2)8 (88.8)5 (55.5)0.29Dialysis vintage, years0.9 (0.7–2.4)1.2 (0.5–2.9)0.94 (0.7–2)0.85CAPD, n. (%)6 (33.3)2 (33.3)4 (44.4)0.6Immunosuppressive therapy6 (33.3)1 (16.7)5 (55.5)0.13Etiology of ESRD0.59 Hypertensive nephropathy6 (33.3)4 (44.4)2 (22.2) Diabetic nephropathy3 (16.7)2 (22.2)1 (11.1) IgA nephropathy2 (11.1)1 (11.1)1 (11.1) Lupus nephritis2 (11.1)0 (0)2 (22.2) Others5 (27.8)2 (22.2)3 (33.3)Comorbidities  Diabetes6 (33.3)3 (33.3)3 (33.3)1  CVD7 (38.9)4 (44.4)3 (33.3)1 Obesity5 (27.8)2 (22.2)3 (33.3)1  Cancer3 (16.7)2 (22.2)1 (11.1)1Symptoms  Cough10 (55.6)7 (77.7)3 (33.3)0.15  Fever17(94.4)9 (100)8 (88.8)1  Dyspnea6 (33.3)3 (33.3)3 (33.3)1Asymptomatic, n. (%)1 (5.6)0 (0)1 (11.1)1Viral shedding, day26 (14.5–33.5)26 (15–35)27.5 (11.5–33)0.51Switch to HD2 (11.1)1 (11.1)1 (11.1)1Hospitalization, n. (%)7 (38.9)3 (33.3)4 (44.4)1Death, n. (%)2 (11.1)2 (22.2)0 (0)0.47 CONCLUSION This study reports the monocentric experience of a large PD center during the COVID-19 pandemic. COVID-19 was symptomatic in the majority of patients and led to hospitalization of about 40% of the patients. The rate of symptoms, viral shedding and hospital admission was similar between vaccinated and unvaccinated patients. Two unvaccin ted patients died for the severe consequence of COVID-19.

Which criteria should we use to end isolation in hemodialysis patients with COVID-19?

Safe and timely discontinuation of quarantine of in-center hemodialysis (HD) patients with a previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a challenging issue for the nephrological community because current guidelines for ending isolation do not mention dialysis patients. To prevent potentially fatal outbreaks of coronavirus disease 2019 (COVID-19), a cautionary approach has been adopted by most dialysis units. The criteria for ending the isolation in the HD population generally coincide with those recommended for immunocompromised people. Thus, a test-based strategy relying on two consecutive negative reverse transcriptase-polymerase chain reaction (RT-PCR) nasopharyngeal swabs has been adopted to terminate quarantine. This strategy has the disadvantage of prolonging isolation as RT-PCR positivity does not equate to SARS-CoV-2 infectivity. Consequentially, prolonged positivity of SARS-CoV-2 results in excessive workload for the HD staff who must face an increasing number of COVID-19 patients requiring isolation. This condition leads also to serious implications for the patients and their households including work productivity loss, postponement of health-care appointments and an increased risk of COVID-19 reinfection. To counteract this problem, other diagnostic tests should be used to provide the best care to HD patients. Recent results seem to encourage the use of RT-PCR cycle threshold (Ct) values and rapid antigen tests given their better correlation with cell culture for SARS-CoV-2 than RT-PCR testing. Here, we provide an overview of the current scientific evidence on the tests used to verify the infectiousness of the virus in order to stimulate the nephrological community to adopt a streamlined and pragmatic procedure to end isolation in COVID-19 patients on HD.

Reactogenicity of COVID-19 vaccine in hemodialysis patients: a single-center retrospective study.

Introduction: Some hemodialysis patients are reluctant to undergo COVID-19 vaccination for the fear of developing adverse events (AEs). The aim of this study was to verify the safety of the mRNA-1273 vaccine in hemodialysis patients. Methods: We conducted a retrospective analysis of in-center hemodialysis patients who underwent mRNA-1273 vaccine from March 1st to April 30th, 2021. All AEs occurring after the first and the second doses were collected and classified as local or systemic. Results: Overall, 126 patients on chronic maintenance dialysis without a prior COVID-19 diagnosis were vaccinated with two doses of mRNA-1273 vaccine. Mean age was 68 (IQR, 54,7-76) years and 53.6% of patients were aged ≥65 years. During the observational period of 68 (IQR, 66-70) days, AEs occurred in 57.9% and 61.9% of patients after the first dose and second dose, respectively. The most common AEs were: injection-site pain (61.9%), erythema (4.8%), itching (4.8%), swelling (16.7%), axillary swelling/tenderness (2.4%), fever (17.5%) headache (7.9%), fatigue (23.8%), myalgia (17.5%), arthralgia (12.7%), dyspnoea (2.4%), nausea/vomiting (7.1%), diarrhoea (5.6%), shivers (4%) and vertigo (1.6%). The rates of local AEs were similar after the first and second doses (P=0.8), whereas systemic AEs occurred more frequently after the second dose (P=0.001). Fever (P=0.03), fatigue (P=0.02) and nausea/vomiting (P=0.03) were significantly more frequent after the second dose of the vaccine. There were no age-related differences in the rate of AEs. Overall, vaccine-related AEs in hemodialysis patients seem to be lower than in the general population. Conclusion: The RNA-1273 vaccine was associated with the development of transient AEs after the first and second doses in patients on chronic maintenance hemodialysis. They were mostly local, whereas systemic AEs were more prevalent after the second dose. Overall, all AEs lasted for a few days, without any apparent sequelae.

Awaiting a cure for COVID-19: therapeutic approach in patients with different severity levels of COVID-19.

COVID-19 is an unpredictable infectious disease caused by SARS-CoV-2. The development of effective anti-COVID-19 vaccines has enormously minimized the risk of severe illness in most immunocompetent patients. However, unvaccinated patients and non-responders to the COVID-19 vaccine are at risk of shortand long-term consequences. In these patients, the outcome of COVID-19 relies on an interplay of multiple factors including age, immunocompetence, comorbidities, inflammatory response triggered by the virus as well as the virulence of SARS-CoV-2 variants. Generally, COVID-19 is asymptomatic or mildly symptomatic in young people, but it may manifest with respiratory insufficiency requiring mechanical ventilation in certain susceptible groups of patients. Furthermore, severe SARS-CoV-2 infection induces multiorgan failure syndrome by affecting liver, kidney heart and nervous system. Since December 2019, multiple drugs have been tested to treat COVID-19, but only a few have been proven effective to mitigate the course of the disease that continues to cause death and comorbidity worldwide. Current treatment of COVID-19 patients is essentially based on the administration of supportive oxygen therapy and the use of specific drugs such as steroids, anticoagulants, antivirals, anti-SARS-CoV-2 antibodies and immunomodulators. However, the rapid spread of new variants and the release of new data coming from the numerous ongoing clinical trials have created the conditions for maintaining a continuous updating of the therapeutic management of COVID-19 patients. Furthermore, we believe that a well-established therapeutic strategy along with the continuum of medical care for all patients with COVID-19 is pivotal to improving disease outcomes and restoring healthcare care fragmentation caused by the pandemic. This narrative review, focusing on the therapeutic management of COVID-19 patients, aimed to provide an overview of current therapies for (i) asymptomatic or mildly/moderate symptomatic patients, (ii) hospitalized patients requiring low-flow oxygen, (iii) high-flow oxygen and (iv) mechanical ventilation.

Sickle Cell Trait and SARS-CoV-2-Induced Rhabdomyolysis: A Case Report.

BACKGROUND Rhabdomyolysis is a syndrome characterized by muscle necrosis and the subsequent release of intracellular muscle constituents into the bloodstream. Although the specific cause is frequently evident from the history or from the immediate events, such as a trauma, extraordinary physical exertion, or a recent infection, sometimes there are hidden risk factors that have to be identified. For instance, individuals with sickle cell trait (SCT) have been reported to be at increased risk for rare conditions, including rhabdomyolysis. Moreover, there have been a few case reports of SARS-CoV-2 infection-related rhabdomyolysis. CASE REPORT We present a case of a patient affected by unknown SCT and admitted with SARS-CoV-2 pneumonia, who suffered non-traumatic non-exertional rhabdomyolysis leading to acute kidney injury (AKI), requiring acute hemodialysis (HD). The patients underwent 13 dialysis session, of which 12 were carried out using an HFR-Supra H dialyzer. He underwent kidney biopsy, where rhabdomyolysis injury was ascertained. No viral traces were found on kidney biopsy samples. The muscle biopsy showed the presence of an "open nucleolus" in the muscle cell, which was consistent with virus-infected cells. After 40 days in the hospital, his serum creatinine was 1.62 mg/dL and CPK and Myoglobin were 188 U/L and 168 ng/mL, respectively; therefore, the patient was discharged. CONCLUSIONS SARS-CoV-2 infection resulted in severe rhabdomyolysis with AKI requiring acute HD. Since SARS-CoV-2 infection can trigger sickle-related complications like rhabdomyolysis, the presence of SCT needs to be ascertained in African patients.

Safety of Intradialytic Bamlanivimab/Etesevimab Administration in Two COVID-19 Dialysis Outpatients.

Chronic hemodialysis patients are at high risk of severe COVID-19 disease and death related to the infection. Anti-spike monoclonal antibodies administration reduces risk of disease progression and hospitalization in high-risk subjects but no clear data on end-stage renal disease are available. We report 2 cases of Bamlanivimab/Etesevimab administration to two not hospitalized chronic hemodialysis patients with SARS-CoV2 infection. Since they are large molecules (human immunoglobulin G1) with molecular weight of 146,000 Da, administration was conducted during the second hour of the dialysis session with no adverse reaction. Conclusions: Intradialytic administration of Bamlanivimab/Etesevimab could be considered safe and may allow adequate clinical observation time without hospital-stay prolongation.