The Characteristics, Dynamics, and the Risk of Death in COVID-19 Positive Dialysis Patients in London, UK.

Background: Patients on dialysis with frequent comorbidities, advanced age, and frailty, who visit treatment facilities frequently, are perhaps more prone to SARS-CoV-2 infection and related death-the risk factors and dynamics of which are unknown. The aim of this study was to investigate the hospital outcomes in patients on dialysis infected with SARS-CoV-2. Methods: Data on 224 patients on hemodialysis between February 29, 2020 and May 15, 2020 with confirmed SARS-CoV-2 were analyzed for outcomes and potential risk factors for death, using a competing risk-regression model assessed by subdistribution hazards ratio (SHR). Results: Crude data analyses suggest an overall case-fatality ratio of 23% (95% CI, 17% to 28%) overall, but that varies across age groups from 11% (95% CI, 0.9% to 9.2%) in patients ≤50 years old and 32% (95% CI, 17% to 48%) in patients >80 years; with 60% of deaths occurring in the first 15 days and 80% within 21 days, indicating a rapid deterioration toward death after admission. Almost 90% of surviving patients were discharged within 28 days. Death was more likely than hospital discharge in patients who were more frail (WHO performance status, 3-4; SHR, 2.16 [95% CI, 1.25 to 3.74]; P=0.006), had ischemic heart disease (SHR, 2.28 [95% CI, 1.32 to 3.94]; P=0.003), cerebrovascular disease (SHR, 2.11 [95% CI, 1.20 to 3.72]; P=0.01), smoking history (SHR, 2.69 [95% CI, 1.33 to 5.45]; P=0.006), patients who were hospitalized (SHR, 10.26 [95% CI, 3.10 to 33.94]; P<0.001), and patients with high CRP (SHR, 1.35 [95% CI, 1.10 to 1.67]) and a high neutrophil:lymphocyte ratio (SHR, 1.03 [95% CI, 1.01 to 1.04], P<0.001). Our data did not support differences in the risk of death associated with sex, ethnicity, dialysis vintage, or other comorbidities. However, comparison with the entire dialysis population attending these hospitals, in which 13% were affected, revealed that patients who were non-White (62% versus 52% in all patients, P=0.001) and those with diabetes (54% versus 22%, P<0.001) were disproportionately affected. Conclusions: This report discusses the outcomes of a large cohort of patients on dialysis. We found SARS-CoV-2 infection affected more patients with diabetes and those who were non-White, with a high case-fatality ratio, which increased significantly with age, frailty, smoking, increasing CRP, and neutrophil:lymphocyte ratio at presentation.

'It gives you the skills of how you can cope': Exploring the self-reported experience of patients receiving in-centre haemodialysis on participating in chosen art activities.

BACKGROUND: Increasing numbers of patients are receiving dialysis, particularly in high-income countries. Patients receiving haemodialysis often experience fatigue, anxiety, depression and boredom. It is suggested that arts activities could have a therapeutic effect. OBJECTIVE: This study aimed to explore patients' perspectives of participating while on dialysis in chosen arts and creative living activities provided by tutors at the bedside. DESIGN: Qualitative semi-structured interviews in the interpretive tradition were conducted, with thematic analysis. SETTING AND PARTICIPANTS: Fifteen patients of different ages, genders and ethnicities who participated in an arts activity while receiving haemodialysis in an inner-city dialysis unit in England were included in this study. RESULTS: Participants reported positive experiences of engaging in art activities. Their views on the value of the activities were grouped into five themes: diversion from receiving haemodialysis, a sense of achievement, contribution to a more positive self-identity, increased confidence and motivation and a therapeutic talking relationship. Participants suggested that patient peer promotion of the activities could increase uptake, with patient choice of activity seen as important. CONCLUSIONS: Participation in a chosen arts activity while receiving haemodialysis was perceived by patients to have positive psychosocial effects. We theorize three potential explanatory mechanisms for these effects: That the experience of participating in the activities engendered positive psychological states of 'being in the flow'; enhanced self-esteem to add to personal coping mechanisms; and offered additional facets to the patient's identity that countered the stigmatizing effect of receiving dialysis. PATIENT OR PUBLIC CONTRIBUTION: Patients and public representatives advised on the design, research methods and tools.

Kidney transplantation and patients who decline SARS-CoV-2 vaccination: an ethical framework.

As SARS-CoV-2 vaccines have started to be rolled out, a key question facing transplant units has been whether listing for transplantation should be contingent on recipients having received a vaccine. We aimed to provide an ethical framework when considering potential transplant candidates who decline vaccination. We convened a working group comprising transplant professionals, lay members and patients and undertook a literature review and consensus process. This group's work was also informed by discussions in two hospital clinical ethics committees. We have reviewed arguments for and against mandating vaccination prior to listing for kidney transplantation and considered some practical difficulties which may be associated with a policy of mandated vaccination. Rather than requiring that all patients must receive the SARS-CoV-2 vaccine prior to transplant listing, we recommend considering vaccination status as one of a number of SARS-CoV-2-related risk factors in relation to transplant listing. Transplant units should engage in individualised risk-benefit discussions with patients, avoid the language of mandated treatments and strongly encourage uptake of the vaccine in all patient groups, using tailor-made educational initiatives.

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.

COVID-19 infection in kidney transplant recipients.

By 21 March 2020 infections related to the novel coronavirus SARS-CoV-2 had affected people from 177 countries and caused 11,252 reported deaths worldwide. Little is known about risk, presentation and outcomes of SARS-CoV-2 (COVID-19) infection in kidney transplantation recipients, who may be at high-risk due to long-term immunosuppression, comorbidity and residual chronic kidney disease. Whilst COVID-19 is predominantly a respiratory disease, in severe cases it can cause kidney and multi-organ failure. It is unknown if immunocompromised hosts are at higher risk of more severe systemic disease. Therefore, we report on seven cases of COVID-19 in kidney transplant recipients (median age 54 (range 45-69), three females, from a cohort of 2082 managed transplant follow-up patients) over a six-week period in three south London hospitals. Two of seven patients presented within three months of transplantation. Overall, two were managed on an out-patient basis, but the remaining five required hospital admission, four in intensive care units. All patients displayed respiratory symptoms and fever. Other common clinical features included hypoxia, chest crepitation, lymphopenia and high C-reactive protein. Very high D dimer, ferritin and troponin levels occurred in severe cases and likely prognostic. Immunosuppression was modified in six of seven patients. Three patients with severe disease were diabetic. During a three week follow up one patient recovered, and one patient died. Thus, our findings suggest COVID-19 infection in kidney transplant patients may be severe, requiring intensive care admission. The symptoms are predominantly respiratory and associated with fever. Most patients had their immunosuppression reduced and were treated with supportive therapy.