Monoclonal gammopathy of undetermined significance causing large vessel vasculitis.

A man in his late 50s presented with unilateral pain and discolouration of his fourth and fifth toes suggestive of digital ischaemia. He had a medical history of two unprovoked venous thromboembolisms in the preceding 18 months and a history of monoclonal gammopathy of undetermined significance (MGUS). A CT scan showed evidence of large vessels vasculitis in the absence of circulating antineutrophil cytoplasmic antibodies. Biopsy of the toes showed evidence of light chain and immunoglobulin deposition on immunofluorescence suggesting vasculitis secondary to his haematological diagnosis of MGUS. The patient was treated with high dose glucocorticoids and immunosuppressive treatment with a significant improvement in his symptoms and features of digital ischaemia.

Teledermatology: How It Is Impacting the Underserved.

The rapid mobilization of telemedicine during the COVID-19 pandemic has brought about renewed concern about the digital divide. Understanding the benefits and limitations of remote medical care is an ongoing process. Access to telemedicine appointments, as well as the experience of the virtual appointment itself, varies across demographic groups. Telemedicine has promise in dermatology. However, if it continues to expand beyond the pandemic, federal changes may be necessary to improve access to remote care for all patients moving forward. This involves creating mandates for increased broadband access, deploying digital health tools and portals usable by underserved populations, and increasing access to interpreters. Information technology personnel may also become necessary members of the clinical care team. Parity between video and phone visit reimbursement for providers is also necessary.

Using CPAP in COVID-19 patients outside of the intensive care setting: a comparison of survival and outcomes between dialysis and non-dialysis dependent patients.

BACKGROUND: SARS-CoV-2 (COVID-19) is a novel coronavirus associated with high mortality rates. The use of Continuous Positive Airway Pressure (CPAP) has been recognised as a management option for severe COVID-19 (NHS, Specialty guides for patient management during the coronavirus pandemic Guidance for the role and use of non-invasive respiratory support in adult patients with coronavirus (confirmed or suspected), https://www.nice.org.uk/guidance/ng159 ). We offered ward-based CPAP to COVID-19, dialysis patients not suitable for escalation to ICU. The aim of the study was to evaluate the use of CPAP for COVID-19 dialysis patients compared to non-dialysis COVID-19 patients outside of the intensive care setting. We further aimed to investigate factors associated with improved outcomes. METHODS: Data was collected from a single centre (Royal Preston Hospital, UK), from March to June 2020. Treatment outcomes were compared for dialysis and non-dialysis dependent patients who received CPAP with limitations on their escalation and resuscitation status. Kaplan-Meier survival curves and Cox regression models were used to compare outcomes. The primary study outcome was 30 day mortality. Confounders including length of admission, systemic anticoagulation and ultrafiltration volumes on dialysis were also analysed. RESULTS: Over the study period, 40 dialysis patients tested positive for COVID-19, with 30 requiring hospital admission. 93% (n = 28) required supplementary oxygen and 12% (n = 9) required CPAP on the ward. These patients were compared to a serial selection of 14 non-dialysis patients treated with CPAP during the same period. Results showed a significant difference in 30 day survival rates between the two groups: 88.9% in the dialysis group vs. 21.4% in the non-dialysis group. Statistical modelling showed that anticoagulation was also an important factor and correlated with better outcomes. CONCLUSION: This is to the best of our knowledge, the largest series of COVID-19 dialysis patients treated with CPAP in a ward-based setting. In general, dialysis dependent patients have multiple co-morbidities including cardiovascular disease and diabetes mellitus making them vulnerable to COVID-19 and not always suitable for treatment in ICU. We showed a significantly lower 30 day mortality rate with the use of CPAP in the dialysis group (11.1%) compared to the non-dialysis group (78.6%). Despite a small sample size, we believe this study provides impetus for further work clarifying the role of CPAP in treating COVID-19 dialysis dependent patients.

The impact of COVID-19 pandemic on patients with ANCA associated vasculitis.

INTRODUCTION: The coronavirus 2019 (COVID-19) pandemic has brought on challenges not only to acute care, but also chronic care of patients. Individuals maintained on immunosuppression appear to be especially susceptible to COVID-19 infection. Patients with ANCA-associated vasculitis (AAV) frequently require immunosuppression and may be at increased risk for developing COVID-19. The incidence and impact of COVID-19 on patients with AAV is currently not known. We aimed to investigate this impact via a telephone questionnaire-based patient survey and chart review. METHODS: A cross-sectional study of AAV patients followed at two centers was conducted. Data regarding demographics, disease characteristics and therapy were confirmed by chart review. A telephone survey was conducted to ascertain symptoms and contact exposure related to COVID-19, as well as changes in health care delivery during the pandemic period between January and July, 2020. RESULTS: Of the 206 patients surveyed, the median age was 64 years, 51% were female and mean (SD) disease duration was 7 (5) years. The majority had kidney (n = 160) and lung (n = 108) involvement. Seventy-five percent (n = 155) were receiving immunosuppression, with 77 patients (50%) receiving rituximab during the pandemic period. Of the 10 patients tested for severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) by PCR, three were positive. Patients had a significant disruption in care; none had an in-person visit and 69% had a telemedicine consultation. Rituximab maintenance was postponed in 21 patients. Twelve patients experienced disease relapse. CONCLUSION: The incidence of COVID-19 in patients with AAV appears to be similar to that of the general population. For a patient population that requires active clinical surveillance, there is significant disruption in care as a result of the pandemic. Reduction of immunosuppression may not be indicated, and the risk of relapse likely far outweighs the risk of COVID-19.

Opportunities in the cloud or pie in the sky? Current status and future perspectives of telemedicine in nephrology.

The use of telehealth to support, enhance or substitute traditional methods of delivering healthcare is becoming increasingly common in many specialties, such as stroke care, radiology and oncology. There is reason to believe that this approach remains underutilized within nephrology, which is somewhat surprising given the fact that nephrologists have always driven technological change in developing dialysis technology. Despite the obvious benefits that telehealth may provide, robust evidence remains lacking and many of the studies are anecdotal, limited to small numbers or without conclusive proof of benefit. More worryingly, quite a few studies report unexpected obstacles, pitfalls or patient dissatisfaction. However, with increasing global threats such as climate change and infectious disease, a change in approach to delivery of healthcare is needed. The current pandemic with coronavirus disease 2019 (COVID-19) has prompted the renal community to embrace telehealth to an unprecedented extent and at speed. In that sense the pandemic has already served as a disruptor, changed clinical practice and shown immense transformative potential. Here, we provide an update on current evidence and use of telehealth within various areas of nephrology globally, including the fields of dialysis, inpatient care, virtual consultation and patient empowerment. We also provide a brief primer on the use of artificial intelligence in this context and speculate about future implications. We also highlight legal aspects and pitfalls and discuss the 'digital divide' as a key concept that healthcare providers need to be mindful of when providing telemedicine-based approaches. Finally, we briefly discuss the immediate use of telenephrology at the onset of the COVID-19 pandemic. We hope to provide clinical nephrologists with an overview of what is currently available, as well as a glimpse into what may be expected in the future.