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Background: Access to nephrology care including dialysis in rural Alabama (AL) hospitals is lacking. The University of Alabama at Birmingham (UAB) with Sanderling Inc. started inpatient tele-nephrology (TN) services in 2019 and currently serves 3 rural AL hospitals. Since the COVID-19 pandemic, transfer to TN-equipped hospitals in AL played a pivotal role for patients needing nephrology services when primary referral centers were at capacity. Method(s): TN services were 100% virtual and video-based. Consults were completed by UAB nephrology faculty. Home hemodialysis machine (HHD) was used to provide kidney replacement therapy (KRT) in the hospital, with aid of inpatient dialysis technicians supervised remotely by TN dialysis nurses. TN consults were evaluated from Jun 2019 to Dec 2021. Retrospective chart review for pre-defined outcomes was performed and analyzed. Result(s): There were 694 inpatient TN encounters. Mean age was 64 (18-96) yr. 74% of consultations involved black patients. Mean stay was 6 d. 44% were ICU patients;18% were COVID-19 positive. AKI and known ESKD patients contributed to 48% and 44% consults, respectively. 11% had AKI necessitating KRT. 20% and 13% of consults involved hyperkalemia and dysnatremias, respectively. 792 dialysis treatments were performed with 11% complicated by intradialytic hypotension (IDH). Patients were discharged 64% and transferred to higher level of care 18% of the time. 90 patients expired. 66% of deaths were attributable to COVID-19. Preliminary economics analysis at the hospital with the most consults showed increase in case-mix index and higher census since implementation of TN services. Conclusion(s): Inpatient TN in community hospitals in rural AL provided essential nephrology care to underserved populations amidst a pandemic limiting transfer to nephrology-staffed medical centers at capacity. Most patient encounters resulted in discharge without need for transfer to bigger centers thus saving vital time and resources. Dialysis safety was favorable with low IDH prevalence likely given HHD use. TN services can be beneficial for nephrology care in remote community hospitals with further studies warranted.
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New onset high anion gap metabolic acidosis in patients on continuous kidney replacement therapy (CKRT) frequently raises suspicion of elevated lactate or inadequate CKRT dose. Often it is managed by escalating CKRT dose rather than evaluating for the underlying etiology. We describe a unique case of refractory metabolic acidosis on CKRT. A 31-year-old female presented with severe hypoxic respiratory failure secondary to Coronavirus Disease 2019 infection necessitating mechanical ventilation. Hospitalization was complicated by refractory septic shock requiring multiple broadspectrum antimicrobials and vasopressors. She had a baseline serum creatinine of 0.8 mg/dl and developed worsening oligoanuric acute kidney injury (peak serum creatinine of 3.4 mg/dl) likely due to multifactorial acute tubular injury. Continuous Venovenous Hemodiafiltration modality of CKRT was started with initial improvement of her metabolic parameters. She was receiving tube feeds via a nasogastric tube. 45 days after initiation of CKRT, she developed refractory metabolic acidosis that had worsened over 3 days. Serum lactic acid and blood glucose levels were 3.3 mmol/L and 80 mg/dl, respectively. ABG was consistent with an acute uncompensated primary metabolic acidosis (pH 6.9 and serum bicarbonate level of 7 mEq/L). The prefilter, dialysate, and postfilter replacement fluids in CKRT were increased to 2200 cc/hr., 2200 cc/hr. and 200 cc/hr. respectively. Each of these solutions contained 35 mEq/L of bicarbonate given worsening metabolic acidosis. Effluent dose was 35 ml/kg/hr. Analysis of the effluent revealed 1(+) ketone. Serum acetoacetate was >400 mcg/L and betahydroxybutyrate was 8 mmol/L. She was diagnosed with starvation ketoacidosis (SK). She did not receive tube feeds over the last 3 days given high gastric residual volumes. Tube feeds was reinstated along with prokinetic agents along with intravenous dextrose infusions with rapid improvement of metabolic acidosis. Her overall clinical condition worsened subsequently, and she died thereafter. SK is a potentially missed etiology of unexplained high anion gap metabolic acidosis in patients on CKRT. SK is rapidly correctable with reinstating nutrition and dextrose infusion. Unrecognized and untreated SK could have catastrophic clinical consequences.
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INTRODUCTION: Point-of-care lung ultrasound (POCUS) has been advocated as a tool to assess the severity of COVID19 and thereby aid risk stratification. METHODS: We conducted a retrospective service evaluation between the 3rd March and the 5th May 2020 to describe and characterise the use of POCUS within an acute care pathway designed specifically for the assessment of suspected or confirmed COVID-19. A novel POCUS severity scale was formulated by assessing pleural and interstitial abnormalities within six anatomical zones (three for each lung). An aggregated score was calculated for each patient and evaluated as a marker of disease severity using standard metrics of discriminatory performance. RESULTS: POCUS was performed in the assessment of 100 patients presenting with suspected COVID-19. POCUS was consistent with COVID-19 infection in 92% (n = 92) of the patients assessed. Severity, as assessed by POCUS, showed good discriminatory performance to predict all-cause inpatient mortality, death or critical care admission, and escalated oxygen requirements (AUC .80, .80, 82). The risk of all-cause mortality in patients with scores in lowest quartile was 2.5% (95%CI 0.12- 12.95) compared with 42.9% (95CI 15.8 - 75.0%) in the highest quartile. POCUS assessed severity correlated with length of stay and duration of supplemental oxygen therapy. CONCLUSION: A simple aggregated score formed by the summating the degree of pleural and interstitial change within six anatomical lung zones showed good discriminatory performance in predicting a range of adverse outcomes in patients with suspected COVID-19.