ABSTRACT
Background: The incidence of AKI in COVID 19 is very variable across the world. In New York City it was as high as 36% in a large series in early 2020. However, the incidence of AKI during the second surge between Oct of 2020 to early 2021 is unknown. In this study, we compared these two COVID-19 periods for the incidence of AKI amongst hospitalized patients. Methods: This was a multi-center, retrospective cohort study of patients hospitalized with COVID-19 between March 1st and July 16th 2020 (n=1,719), and between October 15th 2020 and February 28th 2021(n=997) in two NYC public hospitals, (total n= 2,716). Patients < 18 years, with End Stage Kidney Disease or a kidney transplant were excluded. Chi-squared test and Fisher's exact test were used to compare the clinical characteristics of the patients. A p-value less than 0.05 was considered statistically significant. Results: The baseline clinical characteristics and demographics of the two surges were similar. The incidence of AKI as defined by KDIGO criteria, during admission decreased from 28.7% in the first surge to 18.6% in the second surge (p<0.0001). This trend was seen both at encounter level too as shown below. For laboratory characteristics, more patients with hypernatremia and with peak CRP > 50 (Ref range: <50) presented in the first surge than the second surge (p<0.0001). No differences in the peak potassium and peak D-Dimer, or ICU admission rates were seen between two surges. However, significantly more AKI patients in the first surge were on mechanical ventilation as compared to the second surge (p=0.0196). Conclusions: To our knowledge this is the first comparison reported between rates of AKI in hospitalized patients with COVID-19 during two different surge periods. The difference may be related to less severe disease during the second surge, though ICU admission rate was the same. Better care established by the time of the second surge and improved therapeutics such as early use of anti-viral agents, corticosteroids, and anticoagulation may have contributed to better outcomes. Improvement in care of COVID-19 in the second surge may have contributed to a decline in the incidence of AKI. Future studies are needed to see if this trend towards lower AKI incidence continues.
ABSTRACT
Background: We are an inner-city hospital in New York that had a surge of patients diagnosed with COVID-19. Many of these patients had acute kidney injury (AKI) and required renal replacement therapy (RRT). NYC Health + Hospitals/Kings County has 40 adult intensive care unit (ICU) beds. ICU capacity expanded to a potential of 150 beds during the COVID-19 surge. The surge included patients transferred from other NY innercity hospitals for critical care and RRT. Sequential obstacles were faced in providing hemodialysis (HD) to this expanded pool of AKI patients. Additional machines, supplies, staffing and organization were helpful. Clinicians noted that COVID-19 complications included hypercoaguability and we observed an increased frequency of clotting of hemodialysis catheters (HDC). Methods: We examined the percentage COVID-19 tested renal failure patients with clotting of HDC access during the period March 1, 2020 to May 15, 2020. We collected data on 146 patients during the above period who had HD. We then compared those who were COVID-19+ positive confirmed by testing to those who were not COVID-19+ by testing. HDC clotting was identified by the use of alteplase. We compared our findings of the two groups to historical controls during a similar time period prior to the COVID-19 surge, between January 1 to February 29, 2020. Results: We had 3,665 admissions between March 1 and May 15, 2020, of which 1,075 patients had a confirmed COVID + test during the admission. Of these, 773 patients were noted to have AKI from diagnosis codes in the electronic medical record. Of the146 patients who needed HD (including patients with AKI and CKD) 97 were COVID-19+ and 49 were negative. HDC clotting identified by the use of alteplase was noted in 27% of those who were COVID-19 + compared to 10% of those who were COVID-19 negative. (P value= 0.02 by Chi-square using SPSS Version 24). The percentage of patients with clotting of catheters in the non-COVID-19 group was comparable to historical controls. Conclusions: Significantly more COVID-19+ patients had HD catheter clotting compared to non-COVID-19 patients. Increased clotting was noted as a barrier to providing optimal HD therapy. For this and other reasons, we initiated an urgent start acute peritoneal dialysis program to mitigate the challenges in delivering HD to COVID-19 patients.
ABSTRACT
Background: HD units are clustered close contact environments where prolonged and repeated exposure to blood borne pathogens occurs. Weeks into the CoVID-19 pandemic, wide disparities in rates of death and exposure of staff and patients amongst HD units in the same zip code of an epicenter in New York regions emerged. Methods: Random HD units surveyed as to when and what infection control measures they implemented. Direct input into RedCap and SAS 9.0 analysis of the data conducted. Results: 15 HD units (average census 18-240) responded. Survey compiled exposure rates from 3/1/20 - 4/30/20. The 1st reported case of CoVID-19 by a facility was 3/2/20. Most facilities reported outbreaks (4-30 cases per facility) by 3/21/20. Missed HD sessions due to CoVID varied from 2-100, hospital stays for such patients varied from 2-20 days and death rates from 0-15 per facility. 4 of 15 facilities reported deaths of family members of exposed patients and impediments in logistics of single person transportation forcing carpooling. Home dialysis programs reported minimal deaths and exposures. 20% of facilities had no infection preventionist and 26% no patient educator. Reported waiting area cleaning and hand sanitizer refill rates ranged from 1-5 times per day. 20% of the facilities have < 6 feet distance between patients. Implementation of infection control practices such as wearing of masks by patients varied widely amongst units. Some started March 1st-March 16th, some later due to mixed messages of its importance. Lack of personal protective equipment (PPE)(in 13% of facilities), staff, and housekeeping shortages (6.7-13.3%) compounded the problems. Positive CoVID results had 1-10 staff members infected per facility with sick call rates from 7-30 days, and no staff death. 46% of the HD units don't belong to the CDC coalition. Conclusions: Maintenance of strict hand hygiene, proper air flow, repeated environmental surface cleansing, availability of PPE, and patient and staff education remain the corner stone in preventing infections from spreading. Lack of leadership support and failing to share best practices between dialysis units in the US remains prohibitive but must be encouraged and standardized.