Symptomatic Renal Infarct Secondary to COVID-19 Infection and Concomitantly Positive Antiphospholipid Antibody

COVID-19 infection predisposes patients to a hypercoagulable state. The clinical significance of concomitantly positive antiphospholipid antibodies as a risk factor for thrombus formation is unknown. We report a case of renal infarct secondary to COVID-19 infection with mildly elevated antiphospholipid antibodies. A 71-year- old woman with a history of hypertension, supraventricular tachycardia, resected carcinoid tumor in remission, COVID-19 infection (20 days prior), presented to the hospital with acute onset severe left lower quadrant pain radiating to the left flank for one day. She reported a fever of 101 F. Vital signs were normal in the emergency room. Physical exam showed left costovertebral angle tenderness, otherwise benign abdomen with no guarding or rigidity. Laboratory findings showed normal liver function tests, mildly elevated creatinine at 1.1 mg/dl (baseline 0.8 mg/dl), and leukocytosis (14.2 K/ul). Urinalysis showed no evidence of proteinuria or microscopic hematuria. CT scan of the abdomen demonstrated a large area of patchy hypoattenuation involving the upper pole and interpolar region of the left kidney with adjacent perinephric inflammation representing a sequela of an infarct. Hypercoagulable workup including HIV, hepatitis, ANA, ANCA, complements, B2 glycoprotein, homocysteine, factor V Leiden, anti-thrombin III, protein C, protein S were done. All tests resulted negative except for mildly elevated anticardiolipin antibody, IgM 12.90 MPL (normal 0.00-12.49 MPL). Holter monitor was negative for atrial fibrillation. An echocardiogram did not show any thrombus. Considering her negative tests, renal infarct was believed to be secondary to a hypercoagulable state from COVID-19 infection. Antiphospholipid antibodies repeated 3 months after this admission were mildly elevated. Renal infarction was treated with a heparin infusion and was subsequently transitioned to apixaban. Acute kidney injury resolved with intravenous fluid resuscitation. At a 3-month follow-up, her renal function remained stable with a resolution of symptoms. Renal artery infarct is a possible thrombotic complication of COVID -19. Role of lupus anticoagulant antibodies in increasing this risk warrants further studies.

Continuous renal replacement therapy (CRRT) in COVID-19 patients

INTRODUCTION: Since the first reported cases in Wuhan, China, COVID-19 has been caused more than six hundred thousand deaths worldwide. Approximately 30% of ICU admissions develops Acute Kidney Injury (AKI) and 20 % of patients admitted to ICU required Renal Replacement Therapy. At University of Mississippi Medical Center (UMMC), we followed our first group of COVID-19 adult patients (> 18 years old) that required CRRT for the subsequent 28 days after the initiation of CRRT. Main goal of the study was to determine if CRRT was associated with changes on hemodynamic parameters and identify phenotypes with potential different outcomes. METHODS: Data collected of consecutive patients who were admitted with the diagnosis of COVID-19 at UMMC that required CRRT from April 2020 and follow for 28 days. RESULTS: Out of our first 12 patients with COVID-19, 6/12 (50%) died at 28 days, 8/12 (66%) developed AKI, and 4/12 (33%) were patients already on dialysis (ESKD). Among the survivors at 28 days 5/6 were AKI patients and 1/6 was an ESKD patients. 3/4 of ESKD patients survived at day 28. Among the AKI patients, the most common presentation was AKI in the setting of multiorgan failure and vasopressor requirement. CRRT was implemented in 8/12 patients who were on high dose vasoactive meds with improvement in hemodynamics at 48 hours in 6/8 of them. CRRT was started on 10/12 patients already on mechanical ventilation. Among AKI survivors 3/5 were able to come off RRT and 2/5 remains on dialysis at day 28, both patients remain on mechanical ventilation. CONCLUSIONS: Based on this short case series and recognizing the limitation of the small number of patients, we conclude that the implementation of CRRT in COVID-19 patients is part of the supportive armamentarium and may avoid imminent death. Among the patients who require CRRT, we consider appropriate to classify them in the following clusters 1) AKI patients in the setting of hemodynamic compromise 2) ESKD patients with severe disease 3) ESKD patient without severe respiratory disease and 4) Others (Rhabdomyolysis, acute glomerulonephritis, etc.).The goal of phenotype distribution is to match the approach and modality of therapy with potential outcomes and hospital logistics (availability of resources, health care workers) in the setting of a potential health crisis.

COVID-19 in kidney transplant recipients

Background: Coronavirus disease 2019 (COVID-19) is caused by Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2). Kidney transplant recipients are at a higher risk for complications due to comorbid conditions and concurrent immunosuppression. We like to describe a small cohort of kidney transplant recipients with COVID-19 Methods: A single-center, retrospective observational cohort study describing short term outcomes of COVID-19 infection in kidney transplant recipients. Results: A total of 8 kidney transplant recipients were diagnosed with COVID-19 with a mean age of 58 yrs (26-78), predominantly African American (7/8), mean durationfrom transplant 3.5 yrs (1.5-11 yrs). All patients have HTN (8/8), half the patients have Diabetes mellitus-2 (4/8). Common presenting symptoms are fever and shortness of breath. 6/8 patients required hospitalization. 8/8 patients were managed with a reduction of immunosuppression, primarily by decreasing the dose or holding the anti-proliferative agent. 1/8 patients died, 4/6 discharged from hospital, 1/6 still admitted to the hospital with respiratory failure. 5/6 patients required supplemental oxygen. 2/6 patients required ICU stay and 1/6 required mechanical ventilation and renal replacement therapy. 3/6 hospitalized patients received hydroxychloroquine/ Azithromycin combination and 1/6 received Remdesivir. Median hospital stay is 5 days with a mean of 9 days. The patient who required mechanical ventilation and renal replacement is the only recipient who died from COVID-19 at our transplant center. Conclusions: COVID-19 is a novel infection primarily presenting with fever and shortness of breath. The course of illness appears to be severe with the majority of patients requiring supplemental oxygen and a third of hospital admitted patients required ICU stay. Reduction of immunosuppression appears to be helpful, however, no control group available. COVID-19 affected population is predominantly African American (7/8) and older recipients with age > 50 yrs (7/8).