Haematological profile abnormalities; and its relationship with severity and outcome of COVID-19 infection.

Background: Corona virus disease (Covid-19) caused by corona virus (SARS Cov-2) has affected millions of people around the world. Many diagnostic modalities have been tested but the blood complete picture remains the initial and most easily accessible investigation in Covid-19. Objectives: The objective of this study was to find out the haematological abnormalities in relation to Covid-19 severity and outcome. Methods: This cross-sectional study was carried out from April 2020 to July 2020. One--hundred and fifty polymerase chain reaction (PCR) confirmed Covid-19 patients were inducted by random sampling. Haematological profile at admission was recorded. Data thus obtained was analyzed with respect to Covid-19 severity and outcome. The data was entered and analyzed using Statistical Package for Social Sciences (SPSS) version 19. Results: Out of a total of 150 patients included in the study, 77(51.3%) patients had mild disease at the time of admission, 42 (28%) had moderate disease while 31 (20.7%) had critical disease at the time of admission. Medians (interquartile range) of total leucocyte count (TLC), neutrophils, lymphocytes, neutrophils to lymphocytes ratio (NLR), platelets to lymphocytes ratio (PLR), neutrophils to monocyte ratio (NMR), monocyte to lymphocyte ratio (MLR) were 8.11 (IQR=4.88), 5.95 (IQR=4.58), 1.66 (IQR=1.10), 3.48 (IQR=4.20), 146.24 (IQR=130.75), 18.87 (IQR=14.07), 0.16 (IQR=0.13). Median NLR was higher in patients with critical illness 11.23 (IQR=10.70) as compared to those with stable 2.51 (IQR=1.77) and moderate 3.22 (IQR=3.60) disease (p< 0.000). Similarly TLC (p< 0.000), neutrophils (p< 0.000), lymphocytes (p< 0.000), NLR (p< 0.000), PLR (p< 0.000, p=0.001), MLR (p< 0.000), NMR (p< 0.000) had significant relationship with the severity and outcome of Covid-19 infection. Conclusion: Many haematological parameters are significantly different and can be used to predict the severity and outcome of Covid-19 infection.

Kidney Transplantation From Deceased Donors With Vaccine-induced Immune Thrombocytopenia and Thrombosis: An Updated Analysis of the UK Experience.

BACKGROUND: The emergence and attendant mortality of vaccine-induced immune thrombocytopenia and thrombosis (VITT) as a consequence of vaccination against severe acute respiratory syndrome coronavirus 2 have resulted in some patients with VITT being considered as deceased organ donors. Outcomes after kidney transplantation in this context are poorly described. Because the disease seems to be mediated by antiplatelet factor 4 antibodies, there is a theoretical risk of transmission via passenger leukocytes within the allograft. METHODS: We analyzed the experience of kidney transplantation from donors with VITT in the United Kingdom between January and June 2021. We followed-up all recipients of kidney-only transplants from donors with VITT to detect major postoperative complications or features of disease transmission and assess graft survival and function. RESULTS: There were 16 kidney donors and 30 single kidney transplant recipients in our study period. Of 11 preimplantation biopsies, 4 showed widespread glomerular microthrombi. After a median of 5 mo, patient and graft survival were 97% and 90%, respectively. The median 3-mo estimated glomerular filtration rate was 51 mL/min/1.73 m 2 . Two recipients had detectable antiplatelet factor 4 antibodies but no evidence of clinical disease after transplantation. Major hemorrhagic complications occurred in 3 recipients, all of whom had independent risk factors for bleeding, resulting in the loss of 2 grafts. The involvement of VITT could not be completely excluded in one of these cases. CONCLUSIONS: The UK experience to date shows that favorable outcomes are possible after kidney transplantation from donors with VITT but highlights the need for ongoing vigilance for donor-related complications in these patients.

Prevalence and Biochemical Associations of Fever in Adults With Reverse Transcription Polymerase Chain Reaction Proven Coronavirus Disease Presenting at Tertiary Care Hospitals in Rawalpindi.

Background Clinically most apparent symptoms of COVID-19 include fever and cough, which in some patients show a worsening trend but are completely non-apparent in patients who present with an asymptomatic course of the disease. The aim of this study was to identify clinical and biochemical differences among polymerase chain reaction (PCR) positive patients who are either febrile or afebrile. Methods This study was conducted in Rawalpindi Medical University and Allied Hospitals between September and December 2020. All patients who tested positive for reverse transcription polymerase chain reaction (RT-PCR) COVID-19 were included in the study. After evaluation of 146 patients, 100 were selected, and with a response rate of 97%, a total of 97 patients were included in the final analysis. Depending on the presence of fever, the participants were divided into two groups. Both groups were then compared for baselines vitals and laboratory investigations. Data was entered and analyzed in SPSS v23.0 (IBM Inc., Armonk, New York). Results Among the 97 patients, 66 (68%) of the participants were male, and 31 (32%) were females. The mean age of the study participants was 45.23±18.08 years. Fever was present in 39 (40.2%) of the participants. When compared with patients with no fever, the patients with fever had greater severity of disease (p<0.001), higher heart rate (p<0.001), decreased oxygen saturation (p<0.001). Among the laboratory investigations, the fever group had a greater tendency of having deranged alanine aminotransferase (ALT) (70.82±29.23 vs. 32.83±16.22, p=0.010), Lymphocytes (1.56±0.54 vs. 2.12±0.94, p=0.003) and serum total bilirubin (1.06±0.36 vs. 0.55±0.21, p=0.009). Based on multiple regression analysis, the presence of fever is a predictor of derangement in ALT (OR=1.034, CI=1.001-1.068 p=0.025) and total bilirubin (OR=4.38, CI=2.14-6.78, p=0.021). Conclusion Fever may not be present among all patients presenting with COVID-19 infection, but those who have a fever have a greater risk of having deranged liver function tests. Hence, it is important to monitor liver function tests (LFTs) in COVID-19 patients presenting with fever.

Correlation of biochemical profile at admission with severity and outcome of COVID-19.

BACKGROUND: COVID-19 was detected in China in December 2019. The rapid dissemination and novelty of the disease resulted in an epidemic. This study aimed to identify biochemical parameters at admission that can be used to categorize severity and outcome of COVID -19 infection. MATERIALS AND METHODS: This cross-sectional study was conducted at Allied Hospitals of RMU from April 2020 to July 2020. It included 128 randomly selected confirmed COVID-19 patients. At admission, biochemical profile (total bilirubin, alanine aminotransferases {ALT}, aspartate aminotransferases {AST}, urea, creatinine, uric acid, sodium, potassium, and chloride were correlated with severity and outcome of COVID-19 by employing t-tests and ANOVA where required. Cut-off values to predict disease severity and outcome were calculated using ROC curve. RESULTS: The study comprised 46.1% non-severe, 29.7% severe, and 24.2% critical COVID-19 patients. 84.4% patients improved and 15.6% expired. Urea was increased in critical disease patients (p < 0.000). Higher ALT (p 0.030) and AST (p 0.004) levels were noted in severe and critical disease. Sodium (p 0.001) and chloride (p 0.026) were decreased in critical disease. Patients who expired had increased urea (p 0.000), ALT (p 0.040) and AST (p 0.002). At admission, urea >42.7 mg (sensitivity of 64.7%, specificity of 87.5%), AST >43.5 IU/L (64% sensitivity, 60% specificity), and sodium <136.9 mmol/L (sensitivity of 70.6%, specificity of 71.2%) predicted critical COVID-19 infection. CONCLUSION: At admission, increased urea, AST, and ALT along with decreased sodium can help in identifying COVID-19 patients with severe illness and poor outcome.

The management of dialysis access thrombosis during the COVID-19 pandemic.

BACKGROUND: Maintaining patent access is essential for haemodialysis dependent end stage renal failure patients. The COVID-19 pandemic has significantly affected surgical and interventional radiology services worldwide. We aimed to review the impact COVID-19 has caused to the management of acute dialysis access thrombosis. METHODS: We conducted a single centre retrospective review of outcomes of patients with arteriovenous fistula and arteriovenous graft thrombosis between March and May 2020, which coincided with the first peak of the COVID-19 pandemic in London, and a similar period in the previous year, March-May 2019. Outcomes in both cohorts of patients were compared, including attempts at salvage, salvage success, 1-month patency rates after salvage and subsequent surgery on the same access. We also analysed the use of tunnelled haemodialysis lines (THL), either due to failed salvage attempts or when salvage was not attempted. RESULTS: There was a similar incidence of access thrombosis in both periods (26 cases in 2019, 38 in 2020). There were 601 patients dialysing via an arteriovenous fistula or graft in 2019, and 568 patients in 2020. Access salvage, when attempted, had similar success rates and 1-month patency (salvage success 74% vs 80%, p = 0.39; 1-month patency 55% vs 62%, p = 0.69). The proportion of patients where access salvage was not attempted and a THL inserted was significantly higher in 2020 compared to 2019 (32% vs 4%, p = 0.007). There were more patients who subsequently had surgery to salvage or revise the same access in 2019 compared to 2020 (62% vs 13%, p < 0.001). CONCLUSIONS: During the peak of the COVID-19 pandemic, there were fewer attempts at access salvage. This was a conscious decision due to increased pressure on the healthcare system, access to emergency interventional radiology or operative theatres and the perceived risk/benefit ratio of access salvage. The long-term effects of this change in practice remain unknown.

Outcomes of Renal Transplant Recipients With SARS-CoV-2 Infection in the Eye of the Storm: A Comparative Study With Waitlisted Patients.

BACKGROUND: Patients with chronic kidney disease stage 5 and those on immunosuppression are particularly vulnerable and are shielded as per public health strategy. We present our experience of coronavirus disease 2019 (COVID-19) transplant patients in one of the most affected parts of the UK with direct comparison to waitlisted patients. METHODS: A single-center prospective study of symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive waitlisted and transplant patients was undertaken to compare these groups and assess clinical outcomes. RESULTS: A total of 60 consecutive symptomatic SARS-CoV-2 positive patients were identified with 32 active waitlisted patients and 28 functioning renal transplants. Demographics were similar. The incidence of symptomatic COVID-19 in the waitlisted group was 9.9% compared to 1.9% in renal transplant patients (P < 0.001). Immunosuppression did not influence initial symptomology. Fifteen percent of patients in the waitlisted and 32% in the transplant groups died (P = 0.726). Mortality as proportion of total waitlisted (321 patients) and transplant population (1434 patients) of our centre was 1.5% and 0.6% (P < 0.001), respectively. C-reactive protein (CRP) at 48 h and peak CRP were associated with mortality in both groups while quick sequential organ failure assessment score at 48 h (P = 0.036) was associated with mortality for transplant patients. CONCLUSIONS: Incidence of COVID-19 is higher in the waitlisted population but transplant patients have more severe disease, reflected by higher mortality. CRP at 48 h can be used as a predictive tool. In the absence of effective treatments, the current strategy of shielding is arguably the most important factor in protecting patients while resuming transplantation.

Mortality Rates in Transplant Recipients and Transplantation Candidates in a High-prevalence COVID-19 Environment.

BACKGROUND: The risk of COVID-19 infection in transplant recipients (TRs) is unknown. Patients on dialysis may be exposed to greater risk of infection due to an inability to isolate. Consideration of these competing risks is important before restarting suspended transplant programs. This study compared outcomes in kidney and kidney/pancreas TRs with those on the waiting list, following admission with COVID-19 in a high-prevalence region. METHODS: Audit data from all 6 London transplant centers were amalgamated. Demographic and laboratory data were collected and outcomes included mortality, intensive care (ITU) admission, and ventilation. Adult patients who had undergone a kidney or kidney/pancreas transplant, and those active on the transplant waiting list at the start of the pandemic were included. RESULTS: One hundred twenty-one TRs and 52 waiting list patients (WL) were admitted to hospital with COVID-19. Thirty-six TR died (30%), while 14 WL patients died (27% P = 0.71). There was no difference in rates of admission to ITU or ventilation. Twenty-four percent of TR required renal replacement therapy, and 12% lost their grafts. Lymphocyte nadir and D-dimer peak showed no difference in those who did and did not die. No other comorbidities or demographic factors were associated with mortality, except for age (odds ratio of 4.3 [95% CI 1.8-10.2] for mortality if aged over 60 y) in TR. CONCLUSIONS: TRs and waiting list patients have similar mortality rates after hospital admission with COVID-19. Mortality was higher in older TRs. These data should inform decisions about transplantation in the COVID era.

Experience of SARS-CoV-2 infection in two kidney transplant recipients living with HIV-1 infection.

There is still no consensus on the optimal management of COVID-19 within the general population due to the emerging evidence base. High-risk groups, including kidney transplant recipients living with HIV present unique additional challenges. Here we discuss two kidney transplant recipients living with HIV with SARS-CoV-2 infection and their clinical course, and review the existing literature for this subset of challenging patients.