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Background: For C19 to infect epithelia, serine proteases cleave the spike protein to enhance its binding to ACE2 and entry into the epithelia. Since viral replication highjacks components of the renin-angiotensin system, investigators speculate that hypertension (HTN) is a risk factor for severe infection;however, it is uncertain whether high BP at presentation is a risk factor for mortality in C19 infection. Thus, we tested whether BP at presentation portends mortality in C19 positive (+) vs. negative (-) hospitalized patients. Methods: Clinical/laboratory data from C19(+) and (-) hospitalized patients at Stony Brook Hospital (SBH) from March 2020 to July 2020 were included. The initial systolic BP (SBP) categorized patients into normotensive (SBP 90-139 mm Hg), stage 1 HTN (SBP 140-159 mm Hg) and stage 2 HTN (>160 mm Hg). Subjects with a mean arterial BP (MABP) <65 (hypotensive) were excluded and the remaining cohort was re-categorized into tertiles (T) of MABP (65-85 [T1], 86-97 [T2] and ≥98 [T3]). Results: 4436 patients were admitted to SBH and 1591 diagnosed with and 2845 without C19. Mortality of C19(+) was 4.5-fold greater than C19(-) patients. Though the diagnosis of HTN was more prevalent among C19(+) (629/1591;39.53%) vs. (-) (1014/2845;35.64%;p<0.05) patients, the average presenting SBP and MABP was significantly lower in the C19(+) cohort (p<0.05). After excluding hypotensive patients, the mortality of stage 1 (33/271;12.18%) and/or stage 2 (24/150;16.00%) SBP cohorts did not differ from the normotensives (133/1112;11.95%) in C19(+) patients. A similar finding was noted in the C19(-) patients. T2 tertile of MABP had the lowest mortality among C19(+) patients (56/562;9.96%) and the T1 and T3 tertile of MABP had greater mortality at 15.31% (81/529) and 12.75% (58/455), respectively, than T2 (p<0.05). No difference in mortality was noted across the MABP tertiles of C19(-) cohort. Two multivariate (MV) regressions models evaluating mortality were studied each comparing T1 vs T2 or T2 vs. T3. In T1 vs T2 age, gender, albumin and T1 MABP significantly contributed to mortality while in T2 vs T3 age, gender, and first respiratory rate predicted mortality. Conclusions: Univariate analysis of MABP suggests mortality is greater in T1 and T3 cohorts compared to T2;however, MV analysis implies that a low MABP (T1), but not high MABP (T3) is a significant predictor of mortality in C19 infection.
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Background: Several reports of serum sodium (Na) abnormalities have been reported in patients hospitalized with COVID-19. However, the association of Na abnormalities with hospital outcomes have not been well-described in patients with COVID-19 (C19 +v. especially in comparison to those who tested negative (C19 -). Methods: This is a retrospective analysis of the first surge of COVID-19 (C-19) in patients who presented to our ED from December 2019 -June 2020, with a systemic viral illness. There were 5,289 patients from the Covid19 data set, 1,703 COVID+ patients and 3,586 Covid-patients. Based on a nasal swab PCR patients were divided into two groups: C19 + and C19 -. Na levels at the time of hospitalization were used to divide patients into three groups: hyponatremia(hypoN) (<135), normonatremia (normoN)(135-145) and hypernatremia(hyperN)(>145). In C-19 patients, hypoN and hyperN were compared to normoN using multivariable (MV) models adjusting for comorbidities to calculate odds/ risk (O/R) ratios for outcomes. Results: C19 + patients, had significant increased incidence of HypoN (26.7% vs 16.2%;);and HyperN (4.2% vs 1.3%) compared to C19 -ve (Figure 1). Non MV analysis, among C19 + patients, found both HypoN and HyperN were significantly associated with mortality compared to normoN. HypoN (compared to normoN) was also associated with higher admission rate to the ICU, acute respiratory distress syndrome (ARDS), and intubation.(Figure 2a;2b) Conclusions: Among patients admitted with acute viral illness, Na abnormalities on admission were more prevalent in patients with COVID-19 + compared to those who tested negative. COVID-19 + patients with abnormal admission Na concentrations had increased mortality when compared to Cov -patients. Covid + patients had increased morbidity measured by admission to the ICU, need for intubation, and ARDS. Abnormalities in sodium metabolism predicts a poorer result in Covid-19 care.
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Background: Acute kidney injury (AKI) is a common complication of patients hospitalized with coronavirus disease 2019 (COVID-19), however, the epidemiological studies are limited by single or few centers and short duration. How the incidence of COVID-19-associated AKI has changed over the last 18 months since start of the pandemic is not known. Methods: We used the N3C enclave to collect data from 42 centers from all geographical regions of the United States of patients hospitalized with COVID-19 from December 2019 to May 2021. Unique patient visit occurrence ID data across various hospitalizations for each center was harmonized to uniformly collect information on serum creatinine (SCr), acute dialysis, end-stage kidney disease (ESKD) and transplantation. From a total of 127,223 patients hospitalized with COVID-19, 3,662 patients with preexisting ESKD and 20,090 with < 2 measures of SCr were excluded. AKI and AKI stages were defined by KDIGO criteria. Baseline SCr was defined from the outpatient values before hospitalization when available or lowest inpatient value if not available. We analyzed how the incidence of in-hospital AKI changed over time (every 4-month period). Mann-Kendall Test was used to test for monotonic trends of the AKI incidence. Results: Of the 103,471 patients hospitalized with COVID-19, 31,634 (30.6%) were diagnosed with AKI (mean age 63.3 years, 43.7% female, 32.4% non-white, and 19.5% Hispanic). 14,129 (13.7%) patients were diagnosed with AKI-1, 7,996 (7.7%) had AKI-2 and 9,509 (9.2%) patients had AKI-3 (6,285 [6.1%] without dialysis and 3,224 [3.1%] with dialysis). The incidence of 'all AKI' decreased from 38.8% in Dec 2019-March 2020 to 26.2% in March-May 2021 (p-value for trend = 0.086) and the incidence of AKI-3 declined from 15.5% to 6.5% (p = 0.086). Conclusions: This is the largest and most nationally representative cohort of patients hospitalized with COVID-19 with the highest number of cases of AKI and of AKI-3 reported thus far. The incidence of COVID-19-associated AKI has shown a nonstatistically significant decline during the past 18 months of the pandemic.
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Background: Acute kidney injury (AKI) is a hallmark of hospitalized patients with Coronavirus Disease 2019 (COVID-19) and associated with in-hospital mortality. Recent data suggests glomerular filtration rate (GFR) continues to decline after discharge in COVID-19 AKI survivors, but there are very few reports describing the long-term postdischarge outcomes. Methods: This is an ongoing prospective study of 161 survivors of KDIGO stage 2 or 3 AKI who were admitted at Stony Brook Medicine (SBM) for COVID-19 between March-June 2020. 'CKD' was defined as patient's final outpatient serum creatinine (SCr) value remaining >10% or 50% above baseline (defined as the lowest SCr during hospitalization) and final GFR < 60 ml/min/1.73m2. CKD was divided into 'incident' and 'progressive' based on baseline CKD status. We also investigated the readmission rate with and without AKI and post-discharge mortality. A comparison cohort of 66 AKI survivors concurrently admitted to SBM who tested negative for COVID-19 were also analyzed for all outcomes. Results: COVID-19 AKI survivors were more likely to be non-White, Hispanic, have a lower prevalence of baseline CKD and greater severity of illness (mechanical ventilation, acute respiratory distress syndrome, vasopressor use and greater length of hospital stay) during hospitalization compared to COVID-19 negative survivors (p ≤ 0.01). COVID-19 negative AKI survivors were more likely to have re-hospitalization (p =0.03), although no difference was noted in re-hospitalization with AKI among the 2 groups. 29 out of 161 (18%) of COVID-19 positive AKI survivors died after their discharge from COVID hospitalization as compared to only 1 out of 66 patients (1.5%) of the COVID-19 negative AKI survivors (p<0.001). 42 (26.1%) of COVID-19 positive and 17 (25.8%) of the COVID-19 negative patients had a SCr and eGFR measure > 90 days after discharge. COVID-19 positive AKI survivors (11.9-19.0%) had no difference in the rate of incident or progressive CKD compared with COVID-19 negative AKI survivors (17.6%). Conclusions: COVID-19 positive survivors of Stage 2 or 3 in-hospital AKI were more likely to have greater severity of illness during hospitalization and greater postdischarge mortality compared to COVID-19 negative AKI survivors. We did not find a difference in the rates of incident or progressive CKD at 10 months follow-up.
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Background: The risks of administering Angiotensin II Receptor Blockers for hypertension in hospitalized patients infected with SARS-CoV-2 remains debated. To date, there are no prospective studies evaluating outcomes with the use of ARBs in patients with hypertension and COVID 19. Methods: We conducted a single-center prospective feasibility study to ascertain the safety and efficacy of losartan in patients with COVID-19 and HTN. Inclusion criteria are patients with age ≥ 18yr, PCR confirmed SARS-CoV-2, BP>130/80, and required FiO2 ≥ 0.25 to maintain SpO2 > 92%. These patients were started and titrated on losartan 25mg daily to reach BP goal of <130/80. The vital signs, FiO2 requirements, LFTs, inflammatory markers, serum creatinine and K+ were monitored until discharge, with weekly evaluation of symptoms post-discharge. Results: 250 patients were screened from April 22 to May 18, 2020, and 16 patients enrolled. Average time to enrollment was 5.5 days, with varying degrees of acuity. 6 patients were removed from the study (see Table 1). Eight patients completed the minimum 7 days of losartan while in the hospital 6/8 patients demonstrated no deterioration of SaO2/FiO2 ratio, SaO2/FiO2 compared on day 1 (201.1 ± 108.1) and day 7 (252.3 ± 148.4), and 2/8 patients improved to room air on day 7. Among all patients, inflammatory markers were not significantly changed from admission to peak values (Table 1). Conclusions: This study has demonstrated that patients admitted with COVID 19 and hypertension who completed 7 days of Losartan showed no significant deterioration in oxygenation/worsening of inflammatory markers, thereby providing the rationale for a RCT with the use of losartan versus nonRAAS blockade in COVID-19.
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Background: SARS-CoV-2 uses the angiotensin converting enzyme (ACE) receptor for cell entry leading to COVID-19. The use of ACE Inhibitors (ACEIs) and Angiotensin II Receptor Blockers (ARBs) in hypertensive COVID-19 patients remains unclear. Since hypertension is a major comorbidity in COVID19, evaluating the efficacy versus adverse outcomes with the use of ACEI or ARB in patients with COVID-19 is essential. Methods: In this retrospective single-center study, we analyzed electronic medical record data on 300 patients admitted with COVID-19 disease. Data collection included comorbidities, medications, vital signs, and laboratory values (on admission and during hospitalization). Outcomes included inflammatory burden (calculated using composite scores for multiple markers of inflammation), AKI, admission to the intensive care unit (ICU), need for mechanical ventilation, and mortality. For multivariate analyses, generalized linear model (continuous outcomes) and logistic regression (dichotomous outcomes) were used. Results: Of the 300 patients, 80 patients (26.7%) had history of ACEI or ARB use prior to admission, with 61.3% (49/80) of these patients continuing the medications during hospitalization. Outpatient users of ACEI or ARB had a higher burden of comorbid disease and increased rates of admission and in-hospital AKI in the descriptive analysis, but not on multivariate analysis (after adjusting for multiple covariates). Continuation of ACEI or ARB inpatient was associated with lower peak C-reactive protein (CRP) levels, peak inflammation score, ICU admission and mortality in the univariate analysis. On multivariate analysis, continuation of these agents during hospitalization predicted lower ICU admissions (OR=0.25, 0.08-0.81, p=0.02), peak CRP (-6.9 ± 3.1 mg/dl, p=0.03) and peak inflammatory score (-2.3 ± 1.1, p=0.04) as compared to their discontinuation. Conclusions: In hospitalized patients with COVID-19, the use of ACEI or ARBs as an outpatient was not associated with adverse outcomes despite greater comorbid illness in users. The continued use of these medications during hospitalization was also not associated with adverse events, rather it predicted fewer ICU admissions and decreased inflammatory burden.
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Background: AKI is a major predictor of mortality in patients with coronavirus disease 2019 (COVID-19). Data regarding association of renal dysfunction (AKI, hematuria and proteinuria) at the time of admission with hospital outcomes is limited. Methods: In this retrospective single-center study, we analyzed electronic medical record data on 300 patients admitted with COVID-19. Data collection included history of comorbidities, medications, vital signs, and admission and peak laboratory values. Outcomes included inflammatory burden (calculated using composite scores for multiple markers of inflammation), AKI during hospitalization, admission to the intensive care unit (ICU), need for invasive mechanical ventilation, mortality and length of stay. For multivariate analyses, generalized linear model (continuous outcomes) and logistic regression (dichotomous outcomes) were used. Machine learning algorithms (XGBoost classifier with 3-fold crossvalidation) were performed to develop a predictive model for in-hospital AKI. Results: No significant associations between admission AKI and hospital outcomes were observed. Admission proteinuria was associated with increases in in-hospital AKI, ICU admission, death, peak inflammation score, and length of stay on descriptive analysis;however, on multivariate analysis (after adjusting for multiple covariates), only in-hospital AKI remained statistically significant (OR=4.71, 1.28-17.38, p=0.02). Admission hematuria was associated with increases in in-hospital AKI, ICU admission, invasive mechanical ventilation, and death on descriptive analysis;and on multivariate analysis it still predicted increased rates of ICU admissions (OR=4.56, 1.12-18.64, p=0.03), invasive mechanical ventilation (OR=8.79, 2.09-37.00, p=0.003), and death (OR=18.03, 2.84-114.57, p=0.002). Using machine learning algorithms, an area under the receiver operating curve (AUROC) of 87.4% with an accuracy of 87.6% was obtained for predicting in-hospital AKI using only admission data. Conclusions: In patients with COVID-19, admission hematuria and proteinuria are associated with adverse hospital outcomes, and admission data can be used to predict AKI during hospitalization.