Outcomes of Covid-19 Infection among Hospitalized Patients by Their Stage of Chronic Kidney Disease

INTRODUCTION: Chronic kidney disease (CKD) is an important risk factor for severe COVID-19 disease associated with increased intensive care unit (ICU) admission and mortality. Studies demonstrate an increased mortality rate among advancing CKD stages in patients without COVID-19 infection. However, it is unknown whether a graded association exists between the stages of CKD and COVID-19 mortality. We aim to compare the rates of ICU admission, mechanical ventilation (MV), and survival amongst COVID-19 patients with Stage IIIb -V CKD. METHOD(S): We conducted a retrospective cohort study on non-dialysis adults with Stages IIIb, IV, and V CKD without previous renal transplant hospitalized for COVID-19 infection in a community hospital. Patients were categorized into two groups, Stage IIIb CKD and Stages IV&V CKD, based on their pre-admission glomerular filtration rate (GFR 30-44ml/ min vs < 30ml/min). The primary endpoints were rates of ICU admission, MV, non-invasive mechanical ventilation (NIMV), and survival. The Mann-Whitney U test for continuous variables and the chi-square test for categorical variables were used for analysis. RESULT(S): We screened 228 patients and 153 met the inclusion criteria. Baseline demographics were distributed equally between the two groups. There were statistically significant differences in the ICU admission rate (45.2% vs 25.3%,p-0.01), MV rate (37.1% vs 16.5%,p-0.004) and NIMV rate (50% vs 28.6%,p-0.007) in patients with Stage IIIb versus Stages IV&V CKD respectively. However, there was no significant difference in the survival rates (79.1% vs 67.7%,p-0.1128) between the two groups. CONCLUSION(S): The association between reduced baseline eGFR and increased risk of severe COVID-19 infection has been established with multiple studies evaluating the prognostic impact of pre-existing CKD in patients with COVID-19. Our study illustrates the greater incidence of adverse outcomes, such as ICU admission rate, MV rate, and NIMV rate, in patients with Stages IV&V CKD versus Stage IIIb CKD. With recent guidelines recommending management of COVID-19 infection based on the presence of risk factors, these results will aid in risk stratification among CKD patients with COVID-19, and encourage future prospective studies to explore disease-modifying treatments for the vulnerable CKD population.

Hyperglycemia in Covid-19 Infection without Diabetes Mellitus: Association with Inflammatory Markers

INTRODUCTION: New onset hyperglycemia is common in patients with severe Covid-19 infection. Cytokine storm due to Covid-19 infection is an important etiology for new-onset hyperglycemia, but factors like direct SARS-CoV-2 induced pancreatic beta-cell failure have also been postulated to play a role. We assessed the validity of the cytokine-induced hyperglycemia hypothesis by evaluating the association between inflammatory markers and new onset hyperglycemia in non-diabetic patients with Covid-19 infection. METHOD(S): We conducted a retrospective case-control study on adults without diabetes mellitus hospitalized for Covid-19 infection. The serum levels of glucose and inflammatory markers at presentation before initiation of corticosteroid were collected. Hyperglycemia was defined as glucose levels >=140mg/dL. CRP >=100mg/L, ferritin >=530ng/ mL, LDH>=590U/L, and D-dimer >=0.5mg/L were considered elevated. We used Chi-square test for categorical variables, Mann Whitney U test for continuous variables, and calculated the logistic regression for hyperglycemia. RESULT(S): Of the 520 patients screened, 248 met the inclusion criteria. Baseline demographics were equally distributed between the two groups. There were no statistically significant differences between serum inflammatory markers except LDH in patients with or without new-onset hyperglycemia [CRP(58.1%vs.65.6%,p-0.29), ferritin (48.4%vs.34.9%, p-0.14),D-dimer (37.1%vs.37.1%,p-0.76) & LDH (19.4%vs11.8%,p-0.02)]. However, Logistic regression analysis showed no difference in LDH levels between the two groups (OR-1.623,p-0.256). Additional analysis showed significantly higher mortality (24.2%vs.9.1%,p-0.001;OR-2.528,p-0.024) and length of stay(8.89 vs 6.69,p-0.026) in patients with hyperglycemia. CONCLUSION(S): Our pilot study showed no association between inflammatory marker levels and new-onset hyperglycemia in non-diabetic patients with Covid-19 infection, thus questioning the validity of the Covid-19 cytokine storm-induced stress hyperglycemia hypothesis. Our study also showed that new-onset hyperglycemia is an independent risk factor for higher mortality and length of stay. In light of the findings of our small single-center study, it becomes imperative to undertake a larger prospective study to understand the mechanism of SARS-CoV-2 infectioninduced hyperglycemia.

Can Inflammatory Markers be used as an Early predictor for Mechanical ventilation in COVID-19 patients with Stages IIIb-V Chronic Kidney Disease?

Background. The clinical use of inflammatory markers soared during the COVID-19 pandemic. Though studies have shown C-reactive protein (CRP) to predict mechanical ventilation (MV) in patients with COVID-19, its utility is unknown in patients with chronic kidney disease (CKD), who have elevated baseline CRP levels due to chronic inflammation and reduced renal clearance of inflammatory cytokines. Our aim was to assess the association of inflammatory markers like CRP, ferritin, LDH, D dimer, and MV rate in patients with stages IIIb-V CKD and COVID-19. Methods. We conducted a cross-sectional study on inpatients in a community hospital from 12/1/19 to 1/1/22 with COVID-19 and stages IIIb-V CKD without a previous renal transplant. Primary endpoints were invasive MV(IMV) rates, noninvasive MV(NIMV) rates, and no MV. Statistical analyses used unpaired t-test for continuous variables and chi-square analysis for categorical variables. Cutoffs for variables were CRP 100 mg/L, ferritin 530ng/ml, D-dimer 0.5mg/L and LDH 590 U/L. Univariate analysis and Area under curve (AUC-ROC) between the covariates and outcomes were computed. Results. 290 patients were screened, and 118 patients met inclusion criteria. CRP, D dimer, and ferritin were significantly different among the three groups. On univariate analysis for IMV, CRP had an OR 5.44;ferritin, OR 2.8;LDH, OR 7.7;D-dimer, OR 3.9, WBC count, OR 4.2 (p< 0.05). Admission CRP level was 0.747 for the IMV group (AUC-ROC, sensitivity 80.8%, specificity 50%) and 0.663 for the NIMV group (AUC-ROC, sensitivity 69.2%, specificity 53%) Conclusion. Our results illustrate a positive correlation between CRP, ferritin, and D-dimer levels and MV and NIMV rates. The ROC demonstrates a good sensitivity for CRP levels in detectingMVthereby emphasizing the utility of these biomarkers as good predictive markers in COVID-19 patients with CKD. With increasing use of inflammatory markers to prognosticate disease severity in COVID, the applicability of these markers in different populations should be investigated. A similar pattern of elevated inflammatory markers predicting the rate of MV was found in patients with stages IIIb-V CKD. This may be because of the greater magnitude of increased inflammation due to COVID-19 itself compared with increased inflammation due to CKD alone.