ABSTRACT
Introduction: Collapsing glomerulopathy (CG) is an aggressive subtype of focal segmental glomerulosclerosis, associated with poor renal outcomes. Risk factors for CG include HIV infection, APOL1 high-risk genotypes, and CG has also recently been reported in patients with COVID-19. We report a case of CG with acute kidney injury (AKI) in a patient with a high risk APOL1 genotype, who had renal recovery after prednisone treatment. Case Description: A 43-year-old male with no past medical history presented with fever, myalgia, hemoptysis, vomiting, and diarrhea of 2 weeks duration. Initial exam was remarkable for temperature 103 degrees Fahrenheit, SpO2 95% on room air, and inspiratory crepitations without peripheral edema. Labs were notable for serum creatinine 2.6 mg/dL (unknown baseline), peak creatine kinase 4037 U/L, and urine protein creatinine ratio 19 g/g without RBCs. Chest CT was consistent with multilobar pneumonia. SARS-CoV2 PCR was repeatedly negative but COVID-19 spike and nucleocapsid IgG were positive. Extensive serologic workup for causes of glomerulonephritis and nephrotic syndrome was negative. He was empirically treated with antibiotics for pneumonia but cultures remained negative. Bronchoscopy revealed no evidence of alveolar hemorrhage. His renal function worsened, requiring hemodialysis. Kidney biopsy revealed collapsing glomerulopathy associated with thrombotic microangiopathy, few myoglobin casts suggestive of rhabdomyolysis, and acute tubular injury. Prednisone was initiated at 1mg/kg daily and tapered over 2 months. Lisinopril was initiated for proteinuria. After 5 months, serum creatinine was 1.3 mg/dL and urine protein creatinine ratio improved to 0.6g/g. Genetic testing revealed APOL1 G1/G1 genotype. Discussion(s): In this patient, SARS-CoV2 PCR was likely negative because he presented weeks after symptom onset but the clinical course and serologic evidence of prior SARS-CoV-2 infection supports the diagnosis of COVID-19 associated CG in the setting of APOL1 high-risk G1/G1. Proposed mechanisms of COVID-19-related CG include increased cytokines, that upregulate podocyte expression of toxic APOL1 variants and AKI with tubular injury is often found. Our patient improved with steroid treatment but the treatment of COVID-19 associated CG requires further study.
ABSTRACT
Background: To offset resource constraints that limited the capability to deliver hemodialysis (HD) during the COVID-19 surge, nephrologists in New York City (NYC) rapidly incorporated peritoneal dialysis (PD) for the treatment of acute kidney injury (AKI), which was rarely used in the United States. This study aims to compare the in-hospital all-cause mortality between AKI patients who received PD versus HD during the COVID-19 pandemic. Methods: In a retrospective observational study, we collected data on 259 patients with AKI who required kidney replacement therapy (KRT) in four medical centers of NYC during the Spring 2020. Patients who had ever received PD were included in the PD group (n=93), and patients who only received intermittent HD or continuous KRT were included in the HD group (n=166). Kaplan-Meier survival curves, log-rank test and Cox regression were used to compare survival between PD and HD groups. Results: For the entire cohort, the mean age was 61±11 years;31% were women;96% had confirmed COVID-19. Median follow up was 21 days (IQR 12-30). Mortality was lower in PD group compared to HD group (43% vs. 60%, p=0.01). Time-dependent analyses showed that PD group was at a lower risk for mortality compared to HD group (p<0.001 for Log-rank test;Figure). After adjusting for age, sex, BMI, comorbidities, oxygenation on admission, mechanical ventilation, prone positioning, steroid use and C-reactive protein, the PD group remained to have a lower risk of mortality compared to the HD group with a HR of 0.45 (95% CI: 0.27-0.77, p=0.003). Conclusions: Compared to HD, the use of PD for the treatment of AKI was associated with lower mortality in this cohort of patients treated during the COVID-19 pandemic in the Spring of 2020. Our findings demonstrate that rapid implementation of PD for the treatment of AKI was feasible and may be lifesaving.
ABSTRACT
Introduction: In developed countries such as the United States, intermittent hemodialysis (iHD) or continuous renal replacement therapy (CRRT) are the primary mode of renal replacement therapy (RRT) for the management of AKI. However, during the COVID-19 pandemic, the ability to provide HD in our hospital system was overwhelmed due to the surge in the number of patients with AKI requiring RRT combined with severe personnel shortages related to illness. Studies have shown no difference in clinical outcomes between HD and PD for AKI. We describe our rapid adoption of an acute PD program during the COVID-19 surge. Case Description: At Montefiore Medical Center (MMC), in Bronx, NY, the first patient with COVID-19 was admitted on March 11, 2020. As the number of patients with AKI rose, we initiated an acute PD program starting on March 25th. As of April 13th, there were 2,015 patients with COVID-19 admitted to MMC. From April 1st to April 22nd, 30 patients were initiated on PD with the help of surgery and interventional radiology who placed Tenckhoff catheters at bedside and under fluoroscopy, respectively. Of those 30 patients, 14 died, 8 were discharged, and 8 were still hospitalized as of May 14, 2020. Of the 8 patients discharged, 3 were still on PD and 5 had renal recovery (all were able to stop dialysis and 4 returned to baseline creatinine). Of the 8 patients still hospitalized, 4 patients were switched to iHD (3 due to fluid retention and 1 due to PD catheter malfunction), and 4 patients had renal recovery and were able to stop dialysis. Challenges to this program included lack of nurse training, difficulty securing supplies and irregular therapy provision and underdosing due to staffing shortages. Patients on medical wards received more frequent exchanges and did not have significant volume overload and metabolic derangements like those patients requiring intensive care. Discussion: Despite challenges, we demonstrate the feasibility of acute PD as an alternative to HD in patients with COVID-19-associated AKI. In this single-center experience, we found that acute PD was more effective for stable patients on the wards than for patients with severe illness requiring intensive care.
ABSTRACT
Background: People living with HIV (PLWH) have an increased burden of kidney disease and unique factors that may place them at increased risk for acute kidney injury (AKI) in the setting of COVID-19. The aim of our study was to characterize the incidence, risk factors and outcomes of AKI among hospitalized PLWH with COVID-19. Methods: We performed a retrospective study of adult PLWH hospitalized with laboratory-confirmed COVID-19 in a large healthcare system in Bronx, New York from March 10-May 11, 2020. Data collected included demographics, comorbidities, antiretroviral therapy (ART), initial laboratory data, and preadmission CD4 count and HIV viral load. AKI was defined and staged using KDIGO criteria. Fisher and Wilcoxon tests compared differences in those with and without AKI. Results: During the study period, 77 PLWH were hospitalized with COVID-19. The majority were Black or Hispanic, 50% were men, 53% had hypertension, 31% diabetes mellitus, 22% chronic kidney disease (CKD) and 14% end-stage kidney disease (ESKD). Mean CD4 count was 470 cells/uL and 83% had a suppressed HIV viral load (<40 copies/ mL). After excluding 11 with ESKD, AKI incidence was 50%. Those with AKI were older [63 (SD 9) vs 55 (SD 13) years, p=0.005], more were black (56% vs 37%, p=0.01) and more had CKD (42% vs 9%, p<0.0001) compared to those without AKI. There were no significant differences in CD4 count, HIV viral load, or use of tenofovir-containing ART between those with and without AKI. By AKI severity, 11/33 (33%) were stage 1, 4/33 (12%) stage 2 and 18/33 (55%) stage 3. Mechanical ventilation (33% vs 0%, p=0.0004) and in-hospital mortality (42% vs 3%, p=0.0002) were more common in those with AKI. Of 6 patients who required renal replacement therapy, 4 died and 2 remained RRT dependent. Admission white blood cell count, neutrophil/lymphocyte ratio, D-dimer, ferritin, C-reactive protein and lactate dehydrogenase levels were significantly higher in those with AKI. Conclusions: The incidence of AKI in PLWH hospitalized with COVID-19 was high and associated with poor outcomes. We did not identify HIV-specific risk factors for AKI in the setting of COVID-19. Admission inflammatory markers may be predictive of AKI in PLWH with COVID-19.