Barriers and facilitators to emotional well-being and healthcare engagement in COVID-19: A qualitative study among patients with kidney disease and their caregivers

Background: Patients with chronic kidney disease (CKD) have disproportionately faced poor health outcomes during the coronavirus disease-19 (COVID-19) pandemic. Barriers and facilitators to patients' and caregivers' emotional well-being and healthcare engagement have not been deeply described, leaving a gap in interventions during future crisis settings. Methods: We conducted a qualitative study among patients with CKD (stages 4-5), kidney failure, kidney transplantation, and their caregivers. Interviews were guided by Leventhal's Model of Self-Regulation that emphasized individual interpretations and emotional responses to health threats as determining factors of health behaviors. Interviews were audio-taped, transcribed, and analyzed thematically. Results: Twenty-eight patients (median age 63, self-reported race: White 57%, Black 18%, Asian 1%, others 14%) and 14 caregivers were interviewed over six months. Barriers and facilitators related to patients' emotional well-being included 1) negative emotional responses (feelings of increased vulnerability, anxiety, social isolation, and depression);2) coping behaviors (adaptive coping via self-preservation and emotion regulation;maladaptive coping via alcohol and unhealthy eating);3) and the need for caregiver support for daily tasks. Barriers and facilitators to healthcare engagement included: 1) continued trust in the medical community ( I put my faith in [my doctor's] knowledge);and 2) technology (telehealth was a facilitator to access for some but inadequate for multidisciplinary care [my] transplant evaluation was stoppedwe could not go to the cardiologist). Caregivers reported higher burden compared to before the pandemic. Conclusions: Patients and caregivers widely reported negative emotional reactions to enforced pandemic-related social isolation. Coping efforts were partially successful. Telehealth provided adequate access to kidney health services for some but was insufficient for those requiring multidisciplinary care. Lessons learned from the COVID-19 pandemic suggest that patients with kidney disease may benefit from psychosocial and multi-modal structural support to offset social isolation, reduce caregiver burden, and bolster access to multidisciplinary care during future crisis settings.

Outcomes of ESKD patients hospitalized with COVID-19

Background: Patients with ESKD have a dysregulated immune system and a higher annual mortality rate compared with the general population. We aimed to describe the clinical characteristics and compare the outcomes of patients with and without ESKD, among those hospitalized with COVID-19 disease. Methods: We reviewed the health records for all patients hospitalized with Covid-19 between March 1, 2020 and April 27, 2020 from 13 hospitals in New York. Patients < 18 years or admitted to inpatient obstetrics service were excluded. ESKD diagnosis was defined using ICD-10 code and manual adjudication. Patients were followed up through May 27, 2020. Results: Of 10,482 patients admitted with COVID-19, 419 (4.0%) had ESKD. Among patients with ESKD, 408 (97.4%) were on hemodialysis and 11 (2.6%) were on peritoneal dialysis. When comparing baseline characteristics of the two groups, patients with ESKD were older, were predominately of Black race, and had greater proportions of comorbid conditions. The primary outcome was that patients with ESKD had a higher odds of in-hospital death than those without ESKD (rates, 31.7% vs 25.4%;OR 1.4, 95% CI 1.1 - 1.7). After adjusting for age, sex, race/ethnicity, the odds ofin-hospital death remained higher in the ESKD group (adjusted OR 1.5, 95% CI 1.2 - 1.8). The ESKD group did not have a significantly higher odds of needing mechanical ventilation than the non-ESKD group in both the crude analysis and after adjustment for age, sex, race/ ethnicity. The odds of having a length of stay of >;7 days was higher in the ESKD group compared to the non-ESKD group, in both the crude analysis and the adjusted analysis (OR 1.62, 95% CI 1.3 - 2.1;adjusted OR 1.6, 95% CI 1.3 - 2.1). The independent predictors for death for non ESKD patients were age, male gender, cancer, CHF, elevated BUN, low albumin and being on a ventilator. The independent predictors of death for ESKD patients were age, lymphopenia, low albumin and being on a ventilator. Black race was associated with lower risk of death. Conclusions: ESKD patients had a higher rate of mortality compared to non-ESKD patients hospitalized with COVID-19. Black race was associated with a lower risk of death among ESKD patients compared to white patients.

AKI in patients hospitalized with COVID-19

Background: The rate of AKI associated with patients hospitalized with Covid-19, and associated outcomes are not well understood. Methods: We reviewed the health records for all patients hospitalized with Covid-19 between March 1, and April 5, 2020, at 13 hospitals in metropolitan New York. Patients younger than 18 years of age, with ESKD or with a kidney transplant were excluded. AKI was defined according to KDIGO criteria. The primary outcome was the development of AKI. Secondary outcomes included need for RRT and hospital disposition, i.e., discharge or death. The RRT modalities offered to patients with AKI in our health system were intermittent HD or CRRT. All patients were followed up through April 12th, 2020. We additionally analyzed urine results including urine electrolytes and urinalysis with automated microscopy that were obtained within 24 hours before or 48 hours after the initial development of AKI. Results: Of 5,449 patients admitted with Covid-19, AKI developed in 1,993 (36.6%). The peak stages of AKI were stage 1 in 46.5%, stage 2 in 22.4% and stage 3 in 31.1%. Of these, 14.3% required renal replacement therapy (RRT). AKI was primarily seen in Covid-19 patients with respiratory failure, with 89.7% of patients on mechanical ventilation developing AKI compared to 21.7% of non-ventilated patients. 276/285 (96.8%) of patients requiring RRT were on ventilators. Of patients who required ventilation and developed AKI, 52.2% had the onset of AKI within 24 hours of intubation(Figure and Table). Risk factors for AKI included older age, diabetes mellitus, cardiovascular disease, black race, hypertension and need for ventilation and vasopressor medications. Among patients with AKI, 1136 died (57%), 519 (26%) were discharged and 338 (17%) were still hospitalized. Conclusions: AKI occurs frequently among patients with Covid-19 disease. It occurs early and in temporal association with respiratory failure and is associated with a poor prognosis. (Figure Presented).