ABSTRACT
Background: Vaccine-triggered complications, including autoimmune diseases and minimal change disease (MCD), were reported during recent COVID-19 vaccine rollout. Anti-nephrin autoantibodies were described in nephrotic syndrome (NS) with kidney biopsy (Kbx)-proven MCD. Therefore, we examined patients with COVID-19 vaccineassociated NS for anti-nephrin autoantibodies. Methods: 5 patients presenting with nephrotic-range proteinuria 1-3 weeks after COVID-19 vaccine and a KBx were identified (3 Pfizer/BioNTech, 2 Moderna). Past medical history and lab tests including serum creatinine (sCr), urine protein-to-creatinine ratio (UPCR), and serological workup were recorded. KBx were routinely evaluated by light microscopy (LM), immunofluorescence microscopy (IF), and electron microscopy (EM), followed by confocal examination of relative IgG and nephrin localization in all patients;serological studies for anti-nephrin antibodies using human glomerular extract and recombinant nephrin extracellular domain were performed using plasma available on 2 patients. Results: In all patients, sCr was 0.5-1.2 mg/dl and UPCR 4.5-7.6 g/g. 1 patient had MCD in remission diagnosed 6 months prior;others had no relevant PMH. All workup was negative, except low positive ANA in 2 patients. On KBx, diagnosis of MCD was made in 4 and stage I membranous nephropathy (MN) in 1 patient(s) (serum albumin 2.0-2.4g/dl in MCD and 3.6g/dl in MN patient(s));all had mild chronic changes. All 4 MCD patients had fine granular punctate podocyte staining for polyclonal IgG colocalizing with nephrin by IF and diffuse FPE by EM;in 1 patient plasma was saved during NS and was serologically positive for anti-nephrin. The MN patient had 3+ fine granular IF staining for polyclonal IgG and PLA2r along GBMs with sparse superficial subepithelial electron-dense deposits on EM, and was serologically negative for antinephrin. All MCD patients were successfully treated with oral glucocorticoids, while the MN patient was monitored closely under RAAS blockage. Conclusions: COVID-19 mRNA vaccines can trigger de-novo or relapsing anti-nephrin-and PLA2r-mediated NS, thus adding both autoimmune-mediated podocytopathies to vaccine-induced complications. Temporal association is essential for diagnosis;prompt accurate diagnosis benefits treatment and response.
ABSTRACT
A viable alternative to in person assessments, telemedicine offered providers cost effective and safe alternative to patient care delivery during COVID19. Resource limitations, state and organizational safety precautions accelerated our system adoption of video visits for stroke post hospitalization assessments. Utilizing mixed methods we aimed to investigate an association between patients characteristics (age, gender, race, Modified Rankin Score-mRS, residence) and their choice for post-acute care during a five-month period. The subset selecting in-person visits was further interviewed regarding perceptions of barriers to telehealth. We analyzed data from 85 patients' records (45 in the urban telehealth and 40 in the suburban clinic visit groups) according to ICD10 codes. While total volume of televisits increased during COVID 19, stroke accounted for <1% of them. There was no significant difference in the mean age between the two groups-68.5 years in the clinic and 64.4 in the tele. The clinic subset had 42% of patients age greater than 75 years. Significant difference was detected in disabilities (t=3.5, p<.001) with one-point higher mean mRS (1.7 vs .7) and stronger positive correlation of age to disabilities in the suburban group (r2=.26 vs r2=.16). Patients selecting in-person care outlined as barriers to telehealth a lack of technology, poor connectivity, no caregiver availability for tele exam, inability to communicate or other major comorbidities, family's perception of complexity of patient's condition, fragmentation of care during the period. Patients selecting video assessment were more connected with a health care system and from the urban center. Strengths of the study are the application of mix methods and investigation of suburban patients' perceptions of barriers to telehealth. Limitations consist of small sample size and 90% Caucasian population. Current technology advancements, software applications, and the goal of Healthy People 2030 of removing disparities in heart and stroke disease will require a new multipronged approach to improving stroke telehealth at population level. Further studies at national level including social determinates of health need to examine barriers to telemedicine in post-acute stroke care.
ABSTRACT
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.
ABSTRACT
Introduction: We describe a patient with COVID-19 and clinically significant kidney biopsy proven TMA Case Description: 69-year-old Caucasian female with medical history of asthma came to the ED with productive cough, fever and dyspnea for 2 weeks. She was afebrile, tachypneic and hypoxic. Initial laboratories showed a normal WBC, hemoglobin level and platelet count. Inflammatory markers were elevated. SARS-CoV-2 infection was confirmed by PCR assay. CXR showed bilateral diffuse patchy opacities. Treated with hydroxychloroquine, enoxaparin and oxygen was started. Patient received anakinra and tocilizumab. On day 12, the patient developed thrombocytopenia, anemia and worsening kidney function concerning for microangiopathic hemolytic anemia. Due to worsening hypoxemia, patient received convalescent plasma. On day 17, she was intubated due to worsening respiratory failure. Findings suggestive of hemolysis were present. Urinalysis showed hematuria and proteinuria. Patient's kidney function worsened requiring initiation of CRRT. On day 20, the patient underwent a kidney biopsy that revealed severe acute TMA with cortical necrosis. Beta 2 glycoprotein-1 IgM levels were elevated, antiphospholipid antibodies were absent. A disintegrin and ADAMTS13 level were not low. C3,C4 were in normal range. Heparin induced antibody testing was negative. Coagulation parameters were normal. Kidney doppler was unremarkable. No other systemic findings of macro thrombi were found. Low factor H complement antigen, elevated plasma CBb complement and plasma SC5b-9 complement levels suggesting an activation of the alternative complement pathway were found. Genetic testing was not done. Plasma exchange was not performed, but received a single dose of eculizumab on day 21. Unfortunately, she died on day 23. Discussion: Coagulopathy associated with SARS-CoV-2 has been widely reported. Profound hypoxia, inflammation, disseminated intravascular coagulation(DIC) have all been implicated as potential causes, but were not present in our patient. To the best of our knowledge, we report the first case of TMA associated with SARS-CoV-2 with presence of diffuse cortical necrosis and widespread microthrombi in kidney biopsy. It is not clear if the virus played a direct pathogenic role or unmasked a latent complement defect leading to widespread endothelial damage and micro thrombi.