COVID-19 Infection in Dialysis Patients: Efficacy of Vaccination

Background: End stage kidney disease (ESKD) patients are particularly susceptible to poor outcomes from Covid-19 infection (C19). Vaccination has been the cornerstone of mortality prevention. We examine the efficacy of C19 vaccine in ESKD patients. Method(s): All patients dialyzed at Emory dialysis centers from December 1, 2020 until February 2022 represent the study population. Date of completed vaccines series was recorded. Confirmed C19 cases were also registered. Time from vaccination to C19 and from C19 to death was recorded. Mortality risk was compared between vaccinated and unvaccinated patients. Patients that received vaccination after an episode of C19 were excluded from the analysis (n=89). Result(s): 935 patients received maintenance dialysis during the study period. 68% completed 2 doses of C19 vaccine. 46% of vaccinated patients received a booster dose after 294 days (IQR: 251-273) of completing the primary vaccination series. Non-vaccinated patients were younger (55 vs 60y/o), with shorter dialysis vintage (1.0 vs 2.8 years). The proportion of home and in-center dialysis was similar among vaccinated and unvaccinated patients. The prevalence of diabetes, CHF, PVD, COPD, atrial fibrillation, and previous transplants was also similar. 71 vaccinated patients died during follow up (11%) after 196 days (IQR 122-290), compared to 70 in the non-vaccinated group (24%) after 86 days (IQR 39-166), p<0.001. Adjusting for age, dialysis vintage, diabetes and CHF, ESKD vaccinated patients had a 78% reduction in mortality risk (A). 73 vaccinated patients (11%) acquired C19 after 250 days (IQR 150-288) compared to 48 unvaccinated patients (16%) who acquired C19 after 64 days (IQR 30-215), p<0.001. The mortality odds ratio after C19 infection was 3.9 [CI: 1.3-11.9] for unvaccinated patients 30 days post infection, 4.7 [CI: 1.7-14.2] at 60 days and 4.1 [CI: 1.6-11.5] at 90 days (B). Conclusion(s): Vaccination against C-19 infection resulted in a 78% reduction of mortality risk in patients receiving dialysis. Non-vaccinated patients diagnosed with C19 had higher mortality rates than vaccinated patients (OR 4.1 at 90 days post infection).

Effect of COVID-19 Vaccination Drive on COVID-19 Outcomes in Urban Dialysis Centers

Vaccination is a critical strategy to prevent COVID-19. We describe the effects of a vaccine drive implemented in Emory Dialysis centers on COVID-19 vaccine uptake, infection rates and outcomes. Emory Dialysis, serving an urban population, conducted a COVID-19 vaccination drive (i.e. vaccine education and onsite vaccine administration) across its 4 dialysis centers (~750 patients) from March—April 2021. Monthly COVID-infection and vaccination rates were tracked from March 2020—September 2021. We assessed the effect of the drive on the COVID-19 vaccine uptake, infection rates and outcomes including hospitalizations and 30-day mortality. Patients were included if they were diagnosed with COVID-19, 14 days after the vaccination drive (to reflect fully vaccinated status). Patients were stratified by vaccination status and descriptive statistics were performed. From March 2020–April 2021, monthly COVID-19 infection rates were 0.41—4.97% and vaccination rates were 0–6%. From May–September 2021 (post-vaccination drive), the monthly COVID-19 infection rates ranged from 0–2.50% and vaccination rates were 67.4–76.1%. In the post-vaccination period, 34 patients were diagnosed with COVID-19;26 were fully vaccinated and 8 were unvaccinated. Among the 34 patients, the median age was 57 years [interquartile range (IQR) 47–73], 29% were female and 79.4% were Black. Compared to unvaccinated group, the vaccinated group was older (62 years [IQR 50-73] vs. 50 years [IQR 41-60], p=0.06), and had a higher prevalence of cardiovascular disease (46.2% vs. 25.0%, p=0.62);otherwise, patient characteristics were similar between the groups. Twelve patients (48.1%) in the vaccinated group vs. 6 patients (75.0%) in the unvaccinated group were hospitalized for COVID-infection (p=0.26). Three patients (11.5%) in the vaccinated group vs. 2 patients (25%) in the unvaccinated group (p=0.35) died within 30-days of COVID-19 diagnosis. Providing vaccinations at dialysis centers may improve COVID-19 vaccine uptake and outcomes. Studies evaluating the long-term effects of vaccination programs in dialysis centers are needed.

Temporary changes in hemodialysis parameters in patients affected by COVID-19 infection: A visual guide

Background: ESKD patients on dialysis have been significantly affected by the COVID pandemic. By now, a substantial number of patients have survived the disease. We display graphically the temporary changes in dialysis parameters of patients that have survived COVID-19 infection. Methods: All patients receiving hemodialysis at Emory dialysis centers diagnosed with COVID-19 infection between 3/1/20 to 1/31/21 who survived for at least 3 months were identified. The date of COVID-19 diagnosis was used to time-reference dialysis parameters including duration of hemodialysis, weight, ultrafiltration, mean arterial pressure pre-dialysis, hemoglobin, albumin, calcium, phosphorus, potassium, serum bicarbonate, absolute lymphocyte count and Kt/V. The temporary behavior of these parameters is presented graphically. Data manipulation, analysis and graphical display was performed using R-software and tidyverse package. Results: 96 patients were identified. 82% were African-American with a median age of 64y/o. 52% were male and 60% were diabetics, The median time on dialysis was 2.5 years. All studied parameters showed a significant deviation from baseline measurements obtained in the 60 days prior to the diagnosis of COVID-19. The parameter with the least amount of change was Kt/V. In the subsequent 2 months after diagnosis, all of the parameters studied returned to baseline except for Potassium, that remained below premorbid levels 2 months after the COVID-19 diagnosis. These changes are presented in Figure 1. Conclusions: COVID-19 infection has a significant impact on hemodialysis parameters as presented in figure 1. The temporary variation of the most common parameters associated with COVID-19 infection presented in this study can be used as reference for patients, dieticians, and nephrologists caring for ESKD affected by COVID-19. (Figure Presented) .

Hospital-acquired AKI in COVID-19 has a similar prognosis with or without prior community-acquired AKI

Background: Recent meta-analyses suggest that Hospital Acquired AKI (HA) has a worse prognosis than Community Acquired AKI (CA). The effect of prior CA on HA in COVID-19 is largely unknown. COVID-19 case series that use lowest hospital creatinine (Cr) rather than outpatient baseline Cr may underestimate CA incidence. Methods: Excluding ESKD and hospital transfers, COVID-19 PCR confirmed cases admitted to 4 hospitals between 3/01/20 & 5/31/20 had data collected through 7/31/20 including readmissions. Baseline Cr was adjudicated by manual review from 6 months prior until 5 months post admission. AKI and renal recovery were scored using KDIGO staging. CA is AKI with the highest Cr on admission, rising Cr from admission, or RRT in 48 hrs of admission. HA is AKIs occurring after >48 hrs. HA with CA (HA+CA) is AKI occurring in CA patients after renal recovery for > 48 hrs. Results: AKI was present in 402 of 706 patients with COVID-19. HA+CA occurred in 63. Patients with HA+CA were older, had more comorbidities, lower eGFR, and lower admission albumin than patients with HA. Laboratory markers of COVID severity were similar in patients with HA or HA+CA and much worse than CA. Outcomes, including stage of AKI, renal recovery, ICU parameters, and mortality were similar in HA and HA+CA and much better in CA. Conclusions: In COVID-19, HA + CA occurs in older patients with more comorbidities than HA but shares similar adverse disease markers and poor outcomes. We hypothesize that among older patients who recover from CA, those with severe disease markers are at risk for HA+CA.

Increased markers of disease severity in COVID-19 patients with hospital-acquired vs. Community-Acquired AKI

Background: The etiology of AKI in COVID-19 correlates strongly with age, comorbidities, and laboratory markers of disease severity. Outpatients with COVID-19 have different exposures that may cause AKI than hospitalized patients;thus, the etiology of AKI occurring before hospitalization [community-acquired AKI (CA)] may differ from those with hospital-acquired AKI (HA). Methods: Excluding ESKD and hospital transfers, all COVID-19 PCR-confirmed cases admitted to 4 hospitals from 3/01/20 to 5/31/20 had data collected electronically through 7/31/20 including readmissions. Baseline C-EPI eGFR was determined by chart review for the period of 6 months prior to 5 months post-admission. AKI and recovery from AKI were scored using KDIGO staging. CA was defined as AKI with the highest level of creatinine (Cr) on admission, rising Cr on admission, or RRT started within 48 hours of admission without a subsequent AKI event after recovery. All AKI occurring > 48 hours was considered HA. To test which laboratory values correlated with CA or HA, we used a model adjusted for demographics, BMI, Elixhauser comorbidity index (ECI), and CKD stage. Results: The table shows patients with HA and CA had similar demographics with only the ECI differing significantly. CA had less severe AKI, improved recovery to baseline, and lower mortality than HA. The lower mortality in CA was directly related to the lower stage of AKI. Within a given stage of AKI, mortality was not different between CA and HA. Recovery of renal function was significantly better in CA stage 1 vs. HA (8% vs. 26%, p = 0.001) but was not different for stage 2 or 3. In an adjusted model, higher maximum dimers, ALT, AST, Bili, BNP, lactic acid, CRP, ferritin, LDH, neutrophils, troponin and lower minimum lymphocyte count were significantly associated with HA compared with CA. In contrast, on admission, only higher BNP, higher CRP, lower CPK and higher total CO2 were associated with HA versus CA. Conclusions: Compared to patients with CA, patients with HA had higher stages of AKI that correlated with higher mortality. They also had worsened recovery from stage 1 AKI and increased markers of COVID severity (except for CPK) in-hospital and on admission. We propose that factors other than COVID-19 disease severity led to CA, with volume and rhabdomyolysis as possible contributors.

Prevalence of vitamin D deficiency in a predominantly African-American hemodialysis patient population

Background: Vitamin D insufficiency and deficiency are common abnormalities and high risk groups include kidney disease patients and African-Americans. Recommendations on the evaluation of vitamin D levels in CKD and ESKD are ambiguous due to a lack of studies examining epidemiology and treatment. The COVID-19 pandemic has disproportionately affected minorities and has highlighted the need for evidence as studies have examined vitamin D deficiency as a risk factor for COVID-19 complications. We present a case series examining the prevalence of vitamin D deficiency in a predominantly African-American hemodialysis patient population. Methods: Retrospective chart review of all in-center hemodialysis patients at Emory Dialysis in Atlanta, GA. Data extracted from Sep to Nov 2020. We excluded any patients on home therapies. Serum 25(OH)vitamin D concentration total was analyzed. We defined vitamin D insufficiency as 20-29.9 ng/mL and vitamin D deficiency as a level<20 ng/ml. Results: Patients receiving in-center hemodialysis(n=615). Average length of time on dialysis was 5 years and average age was 59.4 years. Patients were 52.5% male(n=323). 91.5%(n=563) of patients were African-American. Mean calcium level for all patients was 8.73 mg/dL and PTH level of 554 pg/mL. Mean vitamin D in all patients was 26.32 ng/mL. 98%(n=603) of patients had a vitamin D level available. All patients with vitamin D level<30 ng/mL=412(68.3%) and all patients with vitamin D level<20 ng/ mL=244(40.5%). African-American patients with a vitamin D level was 552. African-American patients with vitamin D level<30 ng/mL=382 (69.2%) and African-American patients with vitamin D level<20 ng/ml=229(41.5%). Mean vitamin D in African-American patients 25.7 ng/mL and non-African-American patients 32.7 ng/mL, p=0.01. Conclusions: In comparison to others such as the DIVINE trial, we present a larger and more diverse cohort. In our study, African-Americans had a statistically significant lower vitamin D level. A case for replacing 25(OH) vitamin D even in ESKD patients is based on the action of vitamin D beyond mineral metabolism, especially with regard to autocrine regulation of immune function. Future directions include examining effects of treatment on PTH and study of vitamin D deficient patients' risks for adverse events like COVID-19 infection.

Treatment access and adherence during social preventive and mandatory isolation in argentinian patients with spondylarthritis

Background: Access to high-cost treatments is especially limited in low-resource countries. This issue is becoming stronger today given the health and economic crisis caused by the SARS-CoV2 pandemic. There are no reports in our country on limitations to access and adherence to treatment in patients with Spondyloarthritis (SpA) during social preventive and mandatory isolation. Objectives: Evaluate access and adherence to treatment in patients with Spondyloarthritis during social preventive and mandatory isolation. Methods: Patients with axial spondyloarthritis (axSpA) radiological (r-axSpA), non-radiological (nr-axSpA) and peripheral spondyloarthritis (pSpA), according to ASAS criteria and psoriatic arthritis (PsA) according to CASPAR criteria, were included. Sociodemographic data, comorbidities, disease activity and treatments were collected at baseline. Data on treatment discontinuation, medical attention for suspected COVID-19 disease, RT-qPCR for SARS-CoV-2 detection and outcome of COVID-19 disease were collected from April to September 2020. Numerical variables were summarized as means and standard deviations (SD) or as medians and interquartiles 25-75 (IQ 25-75). Results: 320 patients were included, 55% were male, with a mean age of 50 years (SD 13), 21.6% had diagnosis of r-axSpA, 6.9% nr-axSpA, 6.9% pSpA, and 64.7% PsA. Disease duration was 11 (IQ 5-16) years and activity parameters were as follow: BASDAI 3.65 (SD 3), BASFI 3 (1.5-9), PASI 0.3 (0-7), BSA 0.2 (0-6). 14 (4.4%) patients with COVID-19 disease were reported, 10 were confirmed by positive RT-qPCR and 4 by symptoms and history of close contact with SARS patients. 4 (28.6%) received anti TNF (3 adalimumab, 1 certolizumab), 4 (28.6%) anti IL17 (3 secukinumab and 1 ixekizumab), 8 (57%) methotrexate (MTX) and 2 (14%) leflunomide (LF). Among the 320 patients included, 59 (18.4%) discontinued at least one treatment during follow-up. The discontinued medications were: adalimumab (16), MTX (15), secukinumab (9), etanercept (6), certolizumab(4), ustekinumab (3), NSAIDs (2), apremilast (1), golimumab (1), ixekuzumab (1), LF (1), MTX plus LF (1). The main reason for treatment discontinuation was drug shortage: 36 (62%), followed by patient's decision: 12 (21%) and medical indication: 11 (17%). Of the 36 patients who discontinued due to shortage, 11 received adalimumab, 8 secukinumab, 5 MTX, 3 etanercept, 3 certolizumab, 3 ustekinumab, 2 NSAIDs and 1 golimumab. Conclusion: In our Argentinian cohort of patients with SpA, drug shortage was the main reason for treatment discontinuation. The SARS-CoV2 pandemic exposed limitations to access to treatment for patients with SpA.

Incidence and severity of COVID-19 in patients with spondyloarthritis in argentina: experience in a country with strict isolation

Background: There are limited data worldwide on the behavior of SARSCOV2 in patients with Spondyloarthritis (SpA). Objectives: To describe the incidence and severity of COVID-19 disease in patients with SpA in Argentina. Methods: Patients with axial spondyloarthritis (AxSpA) radiological (EA) and non-radiological (AxSpA-nr) and peripheral spondyloarthritis (according to ASAS criteria) and psoriatic arthritis (PsA) (according to CASPAR criteria) were included. Sociodemographic data, comorbidities, disease activity and treatments were collected at baseline. The patients were followed up by phone or in person monthly. Data were collected from 1/4/2020 to 9/20/2020. Descriptive statistics were performed with mean and standard deviation (SD) and median and quartile 25-75 according to distribution, and the cumulative incidence (AI) of the disease was calculated. Results: 320 patients were included, of which 55% were male, with a mean age of 50 SD 13, 21.6% had a diagnosis of AS, 6.9% SpAax-nr, 6.9% SpAp, and 64.7% PsA, BASDAI 3.65 (3), BASFI 3 (1.5-9), PASI 0.3 (0-7), BSA 0.2 (0-6). Fourteen patients with a diagnosis of COVID-19 (4.4%) were reported, of which 10 diagnoses were by positive PCR and 4 by positive symptoms and close contact. 93% (13) of the cases were patients from the Province of Buenos and CABA and 1 patient from Santiago del Estero. The total IA for the country was 0.04. Of the 14 patients with COVID-19, 7 (50%) were men, 4 had a diagnosis of AS, 1 of SpAax-nr, 9 (64.3%) PsA. 100% live in urban areas, 2 (14%) have hypertension, 1 (7%) DBT, 1 (7%) COPD, 2 (14%) depression or anxiety, 11(97%) had received influenza vaccine 2020, 13 (93%), Antineumoccic 23, 14 (100%) Antineumoccic 13. Regarding the treatments: 4 (28.6%) were in treatment with anti TNF (3 with Adalimumab, 1 with certolizumab pegol), 4 (28.6%) with Anti IL17 (3 with Secukinumab, 1 with Ixekizumab), 8 (57%) with methotrexate and 2 (14%) with Leflunomide. Place of follow-up of the disease: 10 (71.4%) at home, 3 (21.4%) in the common room and 1 (7) in the intensive care unit. Treatments received for COVID-19: 1 (7%) antiretroviral, 1 (7%) antibiotic and 1 (7%) steroids. None of the patients died from COVID-19. Conclusion: An incidence of 4.4% of COVID-19 was found in this population with SpA and most of the patiend had mild symptoms and no deaths were reported. .

COVID-19 with and without pneumonia: clinical outcomes in the internal medicine ward

The clinical features of COVID-19 differ substantially upon the presence (or absence) of viral pneumonia. The aim of this article was to describe the clinical characteristics of COVID-19 patients admitted to the Internal Medicine ward, as divided into those with and without pneumonia. This single-center prospective cohort study was conducted in a tertiary teaching public hospital in Buenos Aires City named Hospital General de Agudos Carlos G. Durand. Baseline data collection was performed within 48 hours of admission and patients were followed until discharge or in-hospital death. Epidemiological, clinical, laboratory, and radiological characteristics together with treatment data were obtained from the medical records. Of the 417 included, 243 (58.3%) had pneumonia. Median age was 43 years (IQR:32-57) and 222 (53.2%) were female. The overall crude case-fatality rate was 3.8%. None of the COVID-19 patients without pneumonia developed critical disease, required invasive mechanical ventilation nor died during hospitalization. However, 7 (4%) developed severe disease during follow-up. Among patients with COVID-19 pneumonia, in-hospital mortality rate was 6.6%, severe disease developed in 81 (33.3%), critical disease in 23 (9.5%), and 22 (9.1%) were admitted to the intensive care unit. A largely good prognosis was observed among COVID-19 patients without pneumonia, still, even among this group, unfavorable clinical progression can develop and should be properly monitored. Critical illness among patients with COVID-19 pneumonia was frequent and observed rates from this cohort provide a sound characterization of COVID-19 clinical features in a major city from South America.

COVID-19 con y sin neumonía: resultados en la sala de medicina interna

The clinical features of COVID-19 differ substantially upon the presence (or absence) of viral pneumonia. The aim of this article was to describe the clinical characteristics of COVID-19 patients admitted to the Internal Medicine ward, as divided into those with and without pneumonia. This single-center prospective cohort study was conducted in a tertiary teaching public hospital in Buenos Aires City named Hospital General de Agudos Carlos G. Durand. Baseline data collection was performed within 48 hours of admission and patients were followed until discharge or in-hospital death. Epidemiological, clinical, laboratory, and radiological characteristics together with treatment data were obtained from the medical records. Of the 417 included, 243 (58.3%) had pneumonia. Median age was 43 years (IQR:32-57) and 222 (53.2%) were female. The overall crude case-fatality rate was 3.8%. None of the COVID-19 patients without pneumonia developed critical disease, required invasive mechanical ventilation nor died during hospitalization. However, 7 (4%) developed severe disease during follow-up. Among patients with COVID-19 pneumonia, in-hospital mortality rate was 6.6%, severe disease developed in 81 (33.3%), critical disease in 23 (9.5%), and 22 (9.1%) were admitted to the intensive care unit. A largely good prognosis was observed among COVID-19 patients without pneumonia, still, even among this group, unfavorable clinical progression can develop and should be properly monitored. Critical illness among patients with COVID-19 pneumonia was frequent and observed rates from this cohort provide a sound characterization of COVID-19 clinical features in a major city from South America. Las características clínicas del COVID-19 difieren sustancialmente según la presencia (o ausencia) de neumonía viral. El objetivo de este artículo fue describir las características clínicas de los pacientes con COVID-19 internados en el servicio de Clínica Médica, divididos en pacientes con y sin neumonía. Fue un estudio de cohorte prospectivo, con base en un único centro, realizado en un hospital público de la ciudad de Buenos Aires: Hospital General de Agudos Carlos G. Durand. La recolección basal de datos se realizó dentro de las 48 horas del ingreso y los pacientes fueron seguidos hasta el alta o la muerte hospitalaria. Las características epidemiológicas, clínicas, de laboratorio y radiológicas junto con los datos del tratamiento se obtuvieron de la historia clínica. De los 417 incluidos, 243 (58.3%) tenían neumonía. La mediana de edad fue de 43 años (RIC: 32-57) y 222 (53.2%) eran mujeres. La tasa global de letalidad fue del 3.8%. Ninguno de los pacientes con COVID-19 sin neumonía desarrolló enfermedad crítica, requirió ventilación mecánica invasiva ni falleció durante la hospitalización. Sin embargo, 7 (4%) desarrollaron enfermedad grave durante el seguimiento. Entre aquellos con neumonía COVID-19, la tasa de mortalidad hospitalaria fue del 6.6%, se desarrolló enfermedad grave en 81 (33.3%), enfermedad crítica en 23 (9.5%) y 22 (9.1%) fueron trasladados a la unidad de cuidados intensivos. Los pacientes con COVID-19 sin neumonía presentaron buen pronóstico;sin embargo, incluso en este grupo, se observaron algunos con progresión clínica desfavorable, por lo que se requirió seguimiento adecuado. En los pacientes con neumonía por COVID-19, el desarrollo de enfermedad crítica fue frecuente y las tasas observadas en esta cohorte proporcionan una caracterización sólida de las características clínicas de los pacientes con COVID-19 en una importante ciudad de América del Sur.

Dialysis care during the COVID-19 (C19) pandemic: A large urban academic dialysis center experience

Background: Effective dialysis care during the C19 pandemic has required implemetation of new policies and procedures to ensure adequate care, to avoid contagion in dialysis centers and to minimize unnecesary expossure to medical personnel. Methods: Emory dialysis program provides dialysis care for ~ 750 patients in 4 hemodialysis centers and 3 home dialysis locations in the metro Atlanta area. The first cases of C19 in Georgia were reported on March 2, 2020 and plans to contain the spreading of the disease were implemented in our dialysis units, including mask use, triaging of patients and personnel based on symptoms, telemedicine rounds, cohorting of C19+ patients in a single shift in a designated unit, and physical isolation of nursing home residents while receiving hemodialysis. This report describe the clinical outcomes related to these interventions. Results: Until May 30/2020, 106 patients had been tested (14%). 22 patients were positive for C19 (2.9%) of which 20 were on HD and 2 on PD. Five C19+ patients died (mortality 23%). Patients that tested positive were older (65±13 vs 60±13y/o), mainly African-Americans (90%) with a higher BMI (29 vs 26), more likely to be diabetics (51% vs 44%) and to reside in a Nursing Home (20 vs 10%), with higher prevalence of cardiovascular disease (45 vs 30%). Dialysis-related parameters (albumin, hemoglobin, phophorus, PTH, Kt/V and blood pressure) were similar between those that tested positive vs negative. 4% (31 patients) of our entire dialysis population resides in Nursing Homes. 12 of them have been tested and 8 were C19+ (26%). The dialysis patients that expired were older (69 vs 57y), all were African-Americans and had higher BMI (30 vs 26) and time on dialysis (12.3 vs 5.6 y) than those that survived. We did not observe an increase frequency of hospitalizations or deaths compared to previous months (Figure 1). Conclusions: In our dialysis population the incidence of C19 infection was 2.9% with 14% of patients tested. Mortality was 24%. Deceased patients were older, had a higher BMI and were on dialysis for longer time compared to those that survived. We did not observe an increase rate of hospitalizations or deaths during initial 3 months of the pandemic.

Outcome of hospitalized ESRD-COVID-19 (C19) infected patients

Background: Emory University affiliated hospitals serve the metro Atlanta area, where a significant number of C19 cases have ocurred. In this report we describe the outcomes of AKI and ESRD patients with confirmed C19 admitted to our health-system. Methods: All patients seen by Emory Nephrology at 2 tertiary referral and one county hospital were categorized as ESRD if they required dialysis prior to C19 infection, or AKI if they developed acute kidney injury as a result of C19 infection. Outcomes of interest included patient survival and discharge from the hospital. Admission to Intensive care unit and use of mechanical ventilation were recorded. Comorbid conditions and outpatient use of medications were analyzed. Results: From 3/1/20 to 5/26/20, 474 consecutive patients were seen in COVID-19 related consultation. 287 patients were considered PUI and eventually tested negative for C19. The remaining 187 patients were C19 positive by nasopharyngeal swab or tracheal aspirate and represent the study population for this report. There were 43 ESRD (23%) and 144 AKI (77%) patients. Age (64 vs 63 years), gender (63 vs 66% males) ethnicity (86 vs 82% African-americans) and comorbid conditions were similar in AKI and ESRD patients. AKI patients were more likely to be admitted to ICU (83 vs 35%) and to require mechanical ventilation (73 vs 20%) compared to ESRD patients (p<0.05). Figure 1 presents the outcomes based on the type of renal disease at presentation. The eGFR of AKI patients at time of admission was 50±34 ml/kg/m2. 84 AKI patients required dialysis during their hospitalization (52.5%). Conclusions: Patients with ESRD C19+ were less likely to require ICU admission or mechanical ventilation. Mortality of ESRD patients was 14% compared with 42% of AKI patients, (p<0.002). ESRD patients with C19 were also more likely to be discharged from the hospital compared to those with AKI. Despite similar demographics and comorbidities, hospitalized C19 AKI patients had worse mortality than those receiving chronic dialysis.

Quality improvement project: Examining urine sediment and microscopic findings in COVID-19 AKI patients

Background: The examination of the urine microscopy manually is common in the work-up of AKI. SARS-CoV-2 has been detected in urine samples of infected patients. There have been safety concerns about the handling of urine samples in patient under investigation and COVID-19 confirmed cases. Limitations in personal protective equipment have provided challenges. There has been limited reports of urine microscopic findings during the COVID-19 pandemic. We developed a QI project examining the urine sediment of COVID-19 AKI patients from digital pictures provided by the IRIS IQ200 Microscopy System. Methods: This QI project took place at Emory University Hospital Midtown. We retrospectively evaluated baseline characteristics, labs, and urine volume. The urinalysis and urine sediment were evaluated for each patient by digital images produced by the IRIS IQ200 Microscopy System. Results: A total of 17 African American patients with a mean age of 71±12.5 years (range, 55 to 98);64.7 % were female. Comorbidities included hypertension (94.1%), diabetes (58.8%), CAD (11.9%) and CKD (52.9%). Average serum creatinine was 3.1 mg/dL. 8 patients (47%) were oliguric;4 patients had FENa < 1%. 8 patients (47%) had 2+ proteinuria. 9 patients (52.9%) had a positive leukocyte esterase and all were nitrate negative. 8 patients (47%) had ATN with visible muddy brown casts. 6 patients (35%) had ≥ 5 rbc/hpf and 11 patients (65%) had ≥ 5 wbc/hpf. 8 patients (47%) had shock requiring vasopressor support, 8 patients (47%) required dialysis and 13 patients (76.5%) required mechanical ventilation. Conclusions: Urinalysis and urine microscopy are important in evaluation of AKI, and there is a paucity of data about findings in COVID-19 AKI patients. Without conclusive evidence of the infective potential of urine samples, it is much needed at this time to device a safe alternative to manual urine microscopic examination. Almost half of our patients had ATN and we were able to arrive at the diagnosis using digital images from this automated urine microscopy system. Use of such technology will help nephrologists safely examine urine sediments and minimize exposure to COVID-19.

Implementing COVID-19 infection control procedures in outpatient dialysis in an urban us population

Background: Emerging data reveal disparities in the burden and severity of disease among racial and ethnic minorities in the US. Emory Dialysis consists of 4 outpatient dialysis facilities, serving an older, urban and predominantly African-American population. These facilities are in counties with the highest number of COVID-19 cases in Georgia. We describe infection control measures implemented to prevent COVID-19 transmission, and the clinical characteristics of patients with COVID-19 in the facilities. Methods: Based on CDC's recommended guidance, we implemented the following infection control procedure between February and April 2020: 1) screening;triaging all patients, and separating patients with symptoms of COVID-19;2) monitoring staff for COVID-19 symptoms;3) limiting healthcare personnel in the facilities;4) universal masking in the dialysis units;5) conducting PPE re-trainings;6) assessing facility preparedness;7) separating high risk patients (nursing home residents);and 8) cohorting patients with COVID-19 to a dedicated dialysis shift. Results: Of the 745 patients followed at the Emory dialysis facilities, 18 (2.4%) were diagnosed COVID-19 between March 25-May 7, 2020. Among the 18 patients, 17 were receiving in-center hemodialysis and 1 was on peritoneal dialysis. The median age was 66.8 years (range 43-84) and 11 (61.1%) were female. Nine (50%) were residents of a skilled nursing facility. Sixteen (88.9%) patients had a diagnosis of hypertension, 10 (55.6%) had diabetes, and 10 (55.6%) had cardiac disease. Eight patients (44.4%) required hospitalization and 4 patients (22.2%) died from COVID-19 related complications. Two patients with COVID-19 were dialyzing at adjacent dialysis stations and the timing of their symptoms suggested possible transmission in the dialysis facility. In response, education, infection control audits and PPE re-trainings were conducted to bolster infection control practices. Conclusions: In a high-risk patient dialysis population, we successfully implemented recommended infection control measures to mitigate the spread of SARS-COV-2 in our facilities. Dialysis facilities must stay vigilant and monitor for possible transmission of COVID-19. Regular audits of infection control practices remains critical.