Severe acute respiratory syndrome coronavirus 2 and risk of inhospital mortality among end-stage renal disease patients with rheumatoid arthritis: A scientific perspective.

According to the elevated infection mortality risks, the incidence of coronavirus disease 2019 (COVID-19) could be raised in rheumatoid arthritis patients with end-stage renal disease (ESRD). Our objectives are to describe the impact of COVID-19 infection on rheumatoid arthritis patients with end-stage renal disease and to identify the risk of in-hospital mortality, comorbid conditions. and the proper way to deal with this category. It was a retrospective analysis of COVID-19 patients in Saudi Arabia from March 1, 2020 to April 27, 2020 and from May 27, 2020 to August 20, 2020. Of 10,482 patients with COVID-19, 419 had ESRD. We assessed main (in-hospital death) outcomes and secondary (mechanical breathing and residence) outcomes. Patients with ESRD were aged and more comorbid disorders. Rheumatoid arthritis patients with ESRD were aged. ESRD rheumatoid arthritis patients have a higher hospital mortality risk relative to rheumatoid arthritis patients not getting complicated with ESRD (31.7% vs. 25.4%, chances 1.38, and 95% trust range 1.12-1.70). After population and comorbid conditions had changed, the rate of rise stayed the same (changed chances: 1.37, 1.09-1.73). In both the crude and modified study (1.62, 1.26-2.07; vs. 1.57, 1.22-2.02), chances for the period of stay of seven or more days have been higher inside a group than in the non-ESRD group. Old age, respiratory support, lymphopenia, and elevated blood urea nitrogen and low serum ferritin were the independent contributing factors for the in-hospital mortality of ESRD rheumatoid arthritis patients infected with severe acute respiratory syndrome coronavirus 2.

Risk factors for mortality in hemodialysis patients with COVID-19: a systematic review and meta-analysis.

BACKGROUND: New evidence from studies on risk factors for mortality in hemodialysis (HD) patients with COVID-19 became available. We aimed to review the clinical risk factors for fatal outcomes in these patients. METHODS: We performed meta-analysis using the PubMed, EMBASE, and Cochrane databases. A fixed- or random-effects model was used for calculating heterogeneity. We used contour-enhanced funnel plot and Egger's tests to assess potential publication bias. RESULTS: Twenty-one studies were included. The proportion of males was lower in the survivor group than in the non-survivor group (OR = 0.75, 95% CI [0.61, 0.94]). The proportion of respiratory diseases was significantly lower in the survivor group than in the non-survivor group (OR = 0.42, 95% CI [0.29, 0.60]). The proportion of patients with fever, cough, and dyspnea was significantly lower in the survivor group (fever: OR = 0.53, 95% CI [0.31, 0.92]; cough: OR = 0.50, 95% CI [0.38, 0.65]; dyspnea: OR = 0.25, 95% CI [0.14, 0.47]) than in the non-survivor group. Compared with the non-survivor group, the survivor group had higher albumin and platelet levels and lower leucocyte counts. CONCLUSIONS: Male patients might have a higher risk of developing severe COVID-19. Comorbidities, such as respiratory diseases could also greatly influence the clinical prognosis of COVID-19. Clinical features, such as fever, dyspnea, cough, and abnormal platelet, leucocyte, and albumin levels, could imply eventual death. Our findings will help clinicians identify markers for the detection of high mortality risk in HD patients at an early stage of COVID-19.

Volume Balance in Chronic Kidney Disease: Evaluation Methodologies and Innovation Opportunities.

BACKGROUND: Patients affected by chronic kidney disease are at a risk of cardiovascular morbidity and mortality. Body fluids unbalance is one of the main characteristics of this condition, as fluid overload is highly prevalent in patients affected by the cardiorenal syndrome. SUMMARY: We describe the state of the art and new insights into body volume evaluation. The mechanisms behind fluid balance are often complex, mainly because of the interplay of multiple regulatory systems. Consequently, its management may be challenging in clinical practice and even more so out-of-hospital. Availability of novel technologies offer new opportunities to improve the quality of care and patients' outcome. Development and validation of new technologies could provide new tools to reduce costs for the healthcare system, promote personalized medicine, and boost home care. Due to the current COVID-19 pandemic, a proper monitoring of chronic patients suffering from fluid unbalances is extremely relevant. Key Message: We discuss the main mechanisms responsible for fluid overload in different clinical contexts, including hemodialysis, peritoneal dialysis, and heart failure, emphasizing the potential impact provided by the implementation of the new technologies.

End-stage kidney disease and COVID-19 in an urban safety-net hospital in Boston, Massachusetts.

INTRODUCTION: End-stage kidney disease (ESKD) patients are at a high risk for Coronavirus Disease 2019 (COVID-19). In this study, we compared characteristics and outcomes of ESKD and non-ESKD patients admitted with COVID-19 to a large safety-net hospital. METHODS: We evaluated 759 adults (45 with ESKD) hospitalized with COVID-19 in Spring of 2020. We examined clinical characteristics, laboratory measures and clinical outcomes. Logistic regression analyses were performed to investigate the associations between ESKD status and outcomes. RESULTS: 73% of ESKD and 47% of non-ESKD patients identified as Black (p = 0.002). ESKD patients were older and had higher rates of comorbidities. Admission ferritin was approximately 6-fold higher in ESKD patients. During hospitalization, the rise in white blood cell count, lactate dehydrogenase, ferritin and C-reactive protein, and the decrease in platelet count and serum albumin were all significantly greater in ESKD patients. The in-hospital mortality was higher for ESKD [18% vs. 10%; multivariable adjusted odds ratio 1.5 (95% CI, 0.48-4.70)], but this did not reach statistical significance. CONCLUSIONS: Among hospitalized COVID-19 patients, ESKD patients had more co-morbidities and more robust inflammatory response than non-ESKD patients. The odds ratio point estimate for death was higher in ESKD patients, but the difference did not reach statistical significance.

Excess Death Estimates in Patients with End-Stage Renal Disease - United States, February-August 2020.

End-stage renal disease (ESRD) is a condition in which kidney function has permanently declined such that renal replacement therapy* is required to sustain life (1). The mortality rate for patients with ESRD in the United States has been declining since 2001 (2). However, during the COVID-19 pandemic, ESRD patients are at high risk for COVID-19-associated morbidity and mortality, which is due, in part, to weakened immune systems and presence of multiple comorbidities (3-5). The ESRD National Coordinating Center (ESRD NCC) supports the Centers for Medicare & Medicaid Services (CMS) and the ESRD Networks†,§ through analysis of data, dissemination of best practices, and creation of educational materials. ESRD NCC analyzed deaths reported to the Consolidated Renal Operations in a Web-Enabled Network (CROWNWeb), a system that facilitates the collection of data and maintenance of information about ESRD patients on chronic dialysis or receiving a kidney transplant who are treated in Medicare-certified dialysis facilities and kidney transplant centers in the United States. Excess death estimates were obtained by comparing observed and predicted monthly numbers of deaths during February 1-August 31, 2020; predicted deaths were modeled based on data from January 1, 2016, through December 31, 2019. The analysis estimated 8.7-12.9 excess deaths per 1,000 ESRD patients, or a total of 6,953-10,316 excess deaths in a population of 798,611 ESRD patients during February 1-August 31, 2020. These findings suggest that deaths among ESRD patients during the early phase of the pandemic exceeded those that would have been expected based on previous years' data. Geographic and temporal patterns of excess mortality, including those among persons with ESRD, should be considered during planning and implementation of interventions, such as COVID-19 vaccination, infection control guidance, and patient education. These findings underscore the importance of data-driven technical assistance and further analyses of the causes and patterns of excess deaths in ESRD patients.

Clinical features, management, and outcome of hemodialysis patients with SARS-CoV-2.

The aim of the study was to evaluate the clinical features of the patients on HD with COVID-19 and determine the prognostic factors. In this single-center prospective study, a total of 58 chronic renal failure patients on HD and diagnosed COVID-19 infection were enrolled in the study. The patients were divided into two groups according to their need for intensive care unit referral. Demographic features of the patients, clinical manifestations, laboratory data, treatments, and clinical outcome were evaluated. The mean age of 58 HD patients was 63.2 ± 13.8 (30-93) years and female-male ratio was 0.34. SARS-CoV2-PCR positivity rate was 32.8%. 85.2% of patients (n = 46) had bilateral lesions and 14.8% (n = 8) had unilateral one lesion in chest CT. The most common symptoms were fatigue (in 44 patients, 80%) and dyspnea (in 31 patients, 56.4%). The most common comorbidity was HT (in 37 patients, 67.3%). The patients who need intensive care and died were older (p = 0.015). We observed lower platelet and eosinophil counts, potassium levels, higher AST, troponin and CRP levels in the group of patients who need intensive care and died than the group who survived (p = 0.043, 0.005, 0.033, 0.007, 0.001, <0.001, respectively). 15.5% of the patients (n = 9) were transferred to intensive care unit. Among them, two were discharged with cure and seven patients died. Mortality rate was 12.1%. Older age, lower platelet and eosinophil counts and higher AST, troponin and CRP levels were prognostic risk factors in our HD patients who needed intensive care.

Initial Effects of COVID-19 on Patients with ESKD.

BACKGROUND: Reports from around the world have indicated a fatality rate of patients with coronavirus disease 2019 (COVID-19) in the range of 20%-30% among patients with ESKD. Population-level effects of COVID-19 on patients with ESKD in the United States are uncertain. METHODS: We identified patients with ESKD from Centers for Medicare and Medicaid Services data during epidemiologic weeks 3-27 of 2017-2020 and corresponding weeks of 2017-2019, stratifying them by kidney replacement therapy. Outcomes comprised hospitalization for COVID-19, all-cause death, and hospitalization for reasons other than COVID-19. We estimated adjusted relative rates (ARRs) of death and non-COVID-19 hospitalization during epidemiologic weeks 13-27 of 2020 (March 22 to July 4) versus corresponding weeks in 2017-2019. RESULTS: Among patients on dialysis, the rate of COVID-19 hospitalization peaked between March 22 and April 25 2020. Non-Hispanic Black race and Hispanic ethnicity associated with higher rates of COVID-19 hospitalization, whereas peritoneal dialysis was associated with lower rates. During weeks 13-27, ARRs of death in 2020 versus 2017-2019 were 1.17 (95% confidence interval [95% CI], 1.16 to 1.19) and 1.30 (95% CI, 1.24 to 1.36) among patients undergoing dialysis or with a functioning transplant, respectively. Excess mortality was higher among non-Hispanic Black, Hispanic, and Asian patients. Among patients on dialysis, the rate of non-COVID-19 hospitalization during weeks 13-27 in 2020 was 17% lower versus hospitalization rates for corresponding weeks in 2017-2019. CONCLUSIONS: During the first half of 2020, the clinical outcomes of patients with ESKD were greatly affected by COVID-19, and racial and ethnic disparities were apparent. These findings should be considered in prioritizing administration of COVID-19 vaccination.

The COVID-19 Epidemic: Management and Outcomes of Hemodialysis and Peritoneal Dialysis Patients in Stockholm, Sweden.

BACKGROUND: The COVID-19 outbreak has been associated with a high morbidity, mortality, and a risk of long-term sequelae, and patients with severe COVID-19 are at increased risk of acute kidney injury. CKD patients are at high risk of being exposed to COVID-19 and suffer complications and poor outcome. In Sweden, mitigation strategies did not include lockdown. During March-April of 2020, wide-spread infection occurred in Stockholm. METHODS: Management and outcomes in forty hemodialysis (HD) patients and 4 peritoneal dialysis (PD) patients, with symptomatic COVID-19 in greater Stockholm during March and April of 2020 are reported. RESULTS: Twenty-four HD patients (60%) required medical care and hospitalization, whereas 16 patients (40%) were treated at home. Nine patients died (mortality rate of 22.5%), of whom 8 were men. The median age in non-survivors (78 years) was significantly higher than in survivors (p = 0.003). The median time in dialysis (11.5 years) was also significantly longer in non-survivors (p = 0.01). C-reactive protein (CRP) at diagnosis in 7 of non-survivors (median 213 mg/L, range 86-329 mg/L) was significantly higher than the CRP in 25 survivors (median 87 mg/L, range 1-328 mg/L) (p = 0.0003). Maximum CRP also indicated poorer outcome among hospitalized patients (p = 0.0004). The gender imbalance was striking with only men dying apart from 1 elderly woman. Only 4 PD patients were hospitalized with symptomatic COVID-19. One patient died, 2 were discharged, and 1 was treated at the intensive care unit and survived. CONCLUSION: HD patients >70 years were reported with longer dialysis vintage, higher CRP, and males were at an increased risk of dying from COVID-19, whereas those <70 years seemed to have a milder disease. Mitigation strategies to reduce rates of infection in high-risk populations remain essential. Follow-up focusing on long-term prognosis for extrapulmonary manifestations is likely to be important also in dialysis patients.

Longitudinal proteomic profiling of dialysis patients with COVID-19 reveals markers of severity and predictors of death.

End-stage kidney disease (ESKD) patients are at high risk of severe COVID-19. We measured 436 circulating proteins in serial blood samples from hospitalised and non-hospitalised ESKD patients with COVID-19 (n = 256 samples from 55 patients). Comparison to 51 non-infected patients revealed 221 differentially expressed proteins, with consistent results in a separate subcohort of 46 COVID-19 patients. Two hundred and three proteins were associated with clinical severity, including IL6, markers of monocyte recruitment (e.g. CCL2, CCL7), neutrophil activation (e.g. proteinase-3), and epithelial injury (e.g. KRT19). Machine-learning identified predictors of severity including IL18BP, CTSD, GDF15, and KRT19. Survival analysis with joint models revealed 69 predictors of death. Longitudinal modelling with linear mixed models uncovered 32 proteins displaying different temporal profiles in severe versus non-severe disease, including integrins and adhesion molecules. These data implicate epithelial damage, innate immune activation, and leucocyte-endothelial interactions in the pathology of severe COVID-19 and provide a resource for identifying drug targets.

COVID-19 varies from a mild illness in some people to fatal disease in others. Patients with severe disease tend to be older and have underlying medical problems. People with kidney failure have a particularly high risk of developing severe or fatal COVID-19. Patients with severe COVID-19 have high levels of inflammation, causing damage to tissues around the body. Many drugs that target inflammation have already been developed for other diseases. Therefore, to repurpose existing drugs or design new treatments, it is important to determine which proteins drive inflammation in COVID-19. Here, Gisby, Clarke, Medjeral-Thomas et al. measured 436 proteins in the blood of patients with kidney failure and compared the levels between patients who had COVID-19 to those who did not. This revealed that patients with COVID-19 had increased levels of hundreds of proteins involved in inflammation and tissue injury. Using a combination of statistical and machine learning analyses, Gisby et al. probed the data for proteins that might predict a more severe disease progression. In total, over 200 proteins were linked to disease severity, and 69 with increased risk of death. Tracking how levels of blood proteins changed over time revealed further differences between mild and severe disease. Comparing this data with a similar study of COVID-19 in people without kidney failure showed many similarities. This suggests that the findings may apply to COVID-19 patients more generally. Identifying the proteins that are a cause of severe COVID-19 ­ rather than just correlated with it ­ is an important next step that could help to select new drugs for severe COVID-19.

COVID-19 in hemodialysis patients: a single-center experience in Istanbul.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) causes a wide spectrum of symptoms, from asymptomatic conditions to severe inflammatory response. Hemodialysis (HD) patients have a higher risk for developing severe COVID-19 because of older age, multiple co-morbid conditions, and impaired immune system compared to the general population. As little is known about these special groups, we evaluated the clinical characteristics and outcomes of HD patients with COVID-19. METHODS: All hospitalized HD patients with COVID 19 between March 11, 2020 and May 31, 2020 were included in the study. The composite end-points consisted of admission to the intensive care unit (ICU), discharging or death were analysed. Demographic, clinical, laboratory, and treatment data were retrieved and compared between survivors and nonsurvivors. RESULTS: A total of 45 patients (median age 65.33 ± 12.22, 24 female, 53.96 ± 40.68) were enrolled and of whom 14 were admitted to ICU and overall 14 (31.1%) have died. Hypertension was the most common comorbidity and fever (60%), dyspnea (55.6%) and cough (53.3%) were predominant symptoms at admission. 8.8% of patients developed severe complications (acute respiratory distress syndrome, macrophage activation syndrome) and secondary infection was observed in 51.1% of the patients. Elevation in the level of inflammatory markers, lactate dehydrogenase, liver enzymes, troponin, creatine kinase, and decrease in lymphocyte count and serum albumin level were observed in non-survivors compared with survivors throughout the clinical course. No significant difference was observed in the score of chest CT performed on the day of hospitalization for the survivors and non-survivors. CONCLUSION: Mortality of COVID-19 in HD patients is high and follow up of certain laboratory parameters can help to predict the prognosis of the patients.

[Epidemiologic and clinical profile, 90 days survival of incident end stage renal patient in haemodialysis during SARS-CoV2 pandemic: Experience of the General Hospital of Douala]. / Profil épidémiologique et clinique, et survie à 90 jours des patients incidents en hémodialyse chronique au cours de la pandémie à SARS-CoV2 au Cameroun : expérience de l'hôpital général de Douala.

BACKGROUND: The effect of COVID-19 pandemic on end stage renal disease patient who should initiated dialysis are limited in Sub-Saharan Africa is unknown. We sought to describe the epidemiologic and clinical profile of newly admitted patient in chronic haemodialysis during the COVID-19 pandemic in Cameroon and evaluate their survival between 90days of dialysis initiation. MATERIAL AND METHOD: We conducted a cohort study of 6months from April to October 2020. End stage renal disease patients newly admitted in the haemodialysis facility of the General Hospital of Douala were included. Patients with confirmed or suspected COVID-19 were identified. Socio-demographic, clinical and biological data at dialysis initiation as well as mortality between the 90days of dialysis initiation were registered. RESULTS: A total of 57 incident patients were recorded from April to October 2020 with a monthly mean of 9.5 patients. The mean age was 46.95±13.12years. Twenty-four COVID-19 were identified with a frequency of 49% among emergency admission. Pulmonary œdema (79.2% vs. 42.4%; P=0.006) and uremic encephalopathy (83.4% vs. 53.6%; P=0.022) were more common in COVID-19. The overall survival at 90days was 48% with a tendency to poor survival among COVID-19 and patients with low socioeconomic level. In Cox regression, low socioeconomic level increase the risk of instant death by 3.08. CONCLUSION: SARS-CoV2 seem to increase nephrology emergency and poor survival in haemodialysis at 90days.

Dynamic assessment of interleukin-6 during hemodialysis and mortality in coronavirus disease-19.

The impact of the newly discovered severe acute respiratory syndrome coronavirus 2 causing coronavirus disease-19 (COVID-19) in hemodialysis patients remains poorly characterized. Some hemodialysis techniques reduce systemic inflammation but their impact on COVID-19 has not been addressed. The aim of this prospective study was to evaluate factors associated with mortality in COVID-19 hemodialysis patients, including the impact of reducing interleukin-6 using a cytokine adsorbent filter. This is a prospective single-center study including 16 hemodialysis patients with COVID-19. All were dialyzed using a polymethyl methacrylate (PMMA) filter. Interleukin-6 levels were obtained before and after the first admission hemodialysis session and at 1 week. Baseline comorbidities, laboratory values, chest X-ray, and treatments were recorded and compared between survivors and non-survivors. Out of 16 patients (13 males, mean age 72 ± 15 years), 4 (25%) died. Factors associated with mortality were dialysis vintage (P = 0.01), chest X-ray infiltrates (P = 0.032), serum C-reactive protein (P = 0.05), and lactate dehydrogenase (P = 0.02) at 1 week, oxygen therapy requirement (P = 0.02) and anticoagulation (P < 0.01). At admission, non-survivors had higher predialysis and postdialysis interleukin-6 levels (P = 0.02 for both) and did not present the reduction of interleukin-6 levels during the dialysis session with PMMA filter that was observed in survivors (survivors vs. non-survivors: 25.0 [17.5-53.2]% vs. -2.8 [-109.4-12.8]% reduction, P = 0.04). A positive balance of interleukin-6 during the admission dialysis was associated with mortality (P = 0.008). In conclusion, in hemodialysis COVID-19 patients, a positive interleukin-6 balance during the admission hemodialysis session was associated with higher mortality.

The impact of COVID-19 on kidney transplantation and the kidney transplant recipient - One year into the pandemic.

The COVID-19 pandemic has significantly changed the landscape of kidney transplantation in the United States and worldwide. In addition to adversely impacting allograft and patient survival in postkidney transplant recipients, the current pandemic has affected all aspects of transplant care, including transplant referrals and listing, organ donation rates, organ procurement and shipping, and waitlist mortality. Critical decisions were made during this period by transplant centers and individual transplant physicians taking into consideration patient safety and resource utilization. As countries have begun administering the COVID vaccines, new and important considerations pertinent to our transplant population have arisen. This comprehensive review focuses on the impact of COVID-19 on kidney transplantation rates, mortality, policy decisions, and the clinical management of transplanted patients infected with COVID-19.

The risk factors associated with COVID-19-Related death among patients with end-stage renal disease.

BACKGROUND: The extent to which patients with End-stage renal disease (ESRD) are at a higher risk of COVID-19-related death is still unclear. Therefore, the aim of this study was to identify the ESRD patients at increased risk of COVID-19 -related death and its associated factors. METHODS: This retrospective cohort study was conducted on 74 patients with ESRD and 446 patients without ESRD hospitalized for COVID-19 in Alborz province, Iran, from Feb 20 2020 to Apr 26 2020. Data on demographic factors, medical history, Covid-19- related symptoms, and blood tests were obtained from the medical records of patients with confirmed COVID-19. We fitted univariable and multivariable Cox regression models to assess the association of underlying condition ESRD with the COVID-19 in-hospital mortality. Results were presented as crude and adjusted Hazard Ratios (HRs) and 95% confidence intervals (CIs). In the ESRD subgroup, demographic factors, medical history, symptoms, and blood parameters on the admission of survivors were compared with non-survivors to identify factors that might predict a high risk of mortality. RESULTS: COVID-19 patients with ESRD had in-hospital mortality of 37.8% compared to 11.9% for those without ESRD (P value < 0.001). After adjusting for confounding factors, age, sex, and comorbidities, ESRD patients were more likely to experience in-hospital mortality compared to non-ESRD patients (Adjusted HR (95% CI): 2.59 (1.55-4.32)). The Log-rank test revealed that there was a significant difference between the ESRD and non-ESRD groups in terms of the survival distribution (χ2 (1) = 21.18, P-value < 0.001). In the ESRD subgroup, compared to survivors, non-survivors were older, and more likely to present with lack of consciousness or O2 saturation less than 93%; they also had lower lymphocyte but higher neutrophil counts and AST concentration at the presentation (all p -values < 0.05). CONCLUSIONS: Our findings suggested that the presence of ESRD would be regarded as an important risk factor for mortality in COVID-19 patients, especially in those who are older than age 65 years and presented with a lack of consciousness or O2 saturation less than 93%.

Clinical outcomes of COVID-19 in hemodialysis patients in the city of Zonguldak, Turkey.

PURPOSE: Patients on maintenance hemodialysis are vulnerable to viral infections like COVID-19 because of the low chance of obedience and complying with rules besides the need for transfer to distant dialysis facilities. We investigated the impact and clinical effect of treatment of COVID-19 in dialysis patients. METHODS: We included patients on maintenance hemodialysis at different healthcare facilities in Zonguldak city. With the diagnosis of the first infected HD case, all other patients who shared the same session were screened. Hospitalized and clinically confirmed cases were included. COVID-19 diagnosis was made based on clinical, biochemical along radiologic findings. RESULTS: 34 (F/M:19/15, mean age 62 ± 13.2 years, dialysis duration 66.9 ± 57.7 months, length of hospital stay 16.2 ± 7.9 days) were diagnosed with COVID-19 infection. The prevalence of COVID-19 was found to be 18.4% of our exposed population. 38.2% of our patients were initially diagnosed by CT screening while asymptomatic. 35.3% had a fever as the first presenting symptom. Lymphopenia was the most common laboratory finding. Except for one, all had at least one comorbidity. Out of 12 (35.3%) patients admitted to ICU 6(17.6%) died. The deceased patients were older, presented with lower serum albumin and lymphocyte count, and had higher CRP and fibrinogen levels. High CRP level on admission was the only significant predictor of mortality. CONCLUSION: Early detection will lower mortality. In this study, with a low prevalence of COVID-19, the importance of early screening of both symptomatic and asymptomatic patients was shown to be highly important. Further studies are still needed to find out the most appropriate medical management.