ABSTRACT
Background: COVID-19 infected more than 1.6 million Americans (0.48%) and more than 15,000 of the 500,000 (3%) Americans with chronic kidney disease treated by dialysis. The Rogosin Institute operates nine dialysis centers in New York City (NYC), the epicenter of the COVID-19 US Public Health Emergency (PHE). We followed guidance from the Centers for Disease Control and Prevention and the New York State Department of Health throughout the PHE. We screened all patients and staff for signs and symptoms of COVID-19 by measuring temperature and inquiring about symptoms on presentation to our dialysis centers. Infected patients who did not require hospitalization were treated in our centers on a dedicated shift by dedicated staff. We used a symptom-based approach to discontinuing isolation. Methods: We created a COVID-19 tool in REDCap to track the spread of Coronavirus. We surveyed our Electronic Health Record weekly using a direct data connection and automated scripting to identify patients infected with COVID-19. We reviewed demographic and clinical data for each infected patient. We used descriptive statistics to analyze our population of infected patients. Results: On February 28, 2020, 1,559 patients received dialysis at our centers. By May 11, 241 (15.5%) had been infected. Our mortality rate was 22.8% compared to general populations in NYC (10-12%), US (6.0%) and worldwide (6.5%) and rates for dialysis patients reported between 7-20%. We had a disproportionate occurrence of COVID-19 among residents of Brooklyn (49% of infections, 44% of patients) and Queens (29%;25%). Most of the infected patients were male (53%) and Black (51%). Common co-morbidities included hypertension (98%), diabetes mellitus (60%), heart failure (25%) and coronary artery disease (25%). Common outpatient medications included statins (64%) ACE inhibitors/ARBs (80%) and calcium channel blockers (63%). Fever was the only common presenting symptom (94% of patients). A significant proportion (12%) of patients were in the hospital within 14 days prior to diagnosis of COVID-19 infection. Conclusions: COVID-19 infection was common and associated with high mortality rate in our NYC population of dialysis patients despite adherence to governmental guidelines for control of disease spread. We hypothesize community spread was common in our patients residing in the epicenter of the US COVID-19 PHE.
ABSTRACT
Background: Minimal data exists regarding effect of palliative dialysis on clinical outcomes and quality measure. Frail, elderly patients may find thrice weekly, 3-5 hour hemodialysis treatments burdensome. Numerous barriers exist to providing palliative dialysis, including quality standards set by the ESRD Quality Incentive Program (QIP). This study shows the impact of reduction in dialysis frequency and time on quality standards and hospice utilization in the seriously ill elderly. Methods: A retrospective chart review was performed on four deceased patients who received palliative dialysis in one ambulatory dialysis center. Quality standards reviewed included: dialysis adequacy (Kt/V), metabolic control, nutrition, hemoglobin and ultrafiltration rate. Clinical outcomes were also reviewed. Results: All four patients were elderly with reduced functionality, heavy symptom burden and difficulty tolerating regular hemodialysis sessions. Patients were decreased to three hour hemodialysis sessions twice weekly. Despite decreased treatment time and frequency, most quality measures did not differ from baseline. Duration of palliative dialysis ranged from 2-11 weeks. Most patients tolerated palliative dialysis, remained free of hospitalization, successfully transitioned to hospice and did not experience serious clinical issues. Lack of negative impact on quality measurements were attributed to patients poor oral intake, loss of body mass and minimal weight gains between dialysis sessions. Patients were observed to have a better quality of life and better utilization of time with family. Conclusions: Palliative care, incorporating the patient and family, appears to be a good option for patients and families who are not ready to withdraw from dialysis. Palliative dialysis allows patients a slower transition to end-of-life care with more support and proper preparation in line with patients' wishes. In addition, with our recent experiences with covid 19 infections, this practice might be a possible option for someone with serious illness, hoping to avoid unwanted hospitalization and aggressive medical treatment. Goals of care conversation, timely plan of care for transition of care and close monitoring of patients are essential for palliative dialysis.
ABSTRACT
Background: Procalcitonin is a widely used test to distinguish bacterial infections from viral infections, but its level is influenced by kidney function. The normal range of procalcitonin levels in end-stage renal disease (ESRD) patients on hemodialysis (HD) is not well established. In this study, we evaluated the relationship between Procalcitonin and inflammatory markers and outcomes in ESRD outpatients on HD. Methods: We recruited 71 ESRD outpatients on HD from October 1st 2019 to December 15th 2019 and measured their procalcitonin levels prior to dialysis. We evaluated whether procalcitonin levels were associated with clinical characteristics, laboratory parameters, and future hospitalizations and infections. Results: In this cohort, the median procalcitonin level was 0.38 ng/mL with an interquartile range of 0.23 ng/mL and 0.54 ng/mL. The distribution of procalcitonin values are found in Fig. 1A. African Americans had a significantly higher procalcitonin level than non-African Americans (P=0.02, Wilcoxon rank sum test). ESRD outpatients who had hypertension, diabetes mellitus, or HIV did not have significantly higher procalcitonin levels than those who did not (P> 0.05). Procalcitonin levels were positively correlated with CRP (r=0.57, P<0.001) (Fig. 1B) and negatively correlated with albumin (r=-0.28, P=0.02) (Fig. 1C). Procalcitonin levels were not correlated with Kt/V, white blood cell count, and ferritin levels (P>0.05). ESRD outpatients who developed infections or who were hospitalized did not have significantly higher initial procalcitonin levels than those who did not (P>0.05). Conclusions: Procalcitonin levels are correlated with inflammatory markers such as CRP and albumin, suggesting its potential use to identify ESRD on HD at high risk for complications, especially in the era of COVID-19. (Figure Presented).