Chronic dysglycemia and risk of SARS-CoV-2 associated respiratory failure in hospitalized patients.

BACKGROUND: Diabetes is common among patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced respiratory failure. We aimed to investigate the relationship between different stages of chronic dysglycemia and development of respiratory failure in hospitalized SARS-CoV-2 positive patients. METHODS: In this retrospective observational study, we included 385 hospitalized SARS-CoV-2 positive patients at Karolinska University Hospital, Sweden with an HbA1c test obtained within 3 months before admission. Based on HbA1c level and previous diabetes history, we classified patients into the following dysglycemia categories: prediabetes, unknown diabetes, controlled diabetes, or uncontrolled diabetes. We used multivariable logistic regression analysis adjusted for age, sex, and body mass index, to assess the association between dysglycemia categories and development of SARS-CoV-2-induced respiratory failure. RESULTS: Of the 385 study patients, 88 (22.9%) had prediabetes, 68 (17.7%) had unknown diabetes, 36 (9.4%) had controlled diabetes, and 83 (21.6%) had uncontrolled diabetes. Overall, 299 (77.7%) patients were admitted with or developed SARS-CoV-2-induced respiratory failure during hospitalization. In multivariable logistic regression analysis compared with no chronic dysglycemia, prediabetes (OR 14.41, 95% CI 5.27-39.43), unknown diabetes (OR 15.86, 95% CI 4.55-55.36), and uncontrolled diabetes (OR 17.61, 95% CI 5.77-53.74) was independently associated with increased risk of SARS-CoV-2-induced respiratory failure. CONCLUSION: In our cohort of hospitalized SARS-CoV-2 positive patients with available HbA1c data, prediabetes, undiagnosed diabetes, and poorly controlled diabetes were associated with a markedly increased risk of SARS-CoV-2-associated respiratory failure.

Experiences of Renal Replacement Therapy Delivery in Swedish Intensive Care Units during the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic led to a rapidly increased demand for intensive care unit (ICU) and renal replacement therapy (RRT) worldwide. RRT delivery was threatened by a lack of specially trained staff and equipment. We investigated how the first wave of COVID-19 affected RRT delivery in Swedish ICUs. METHODS: An Internet-based questionnaire was sent to ICU lead physicians which included quantitative and qualitative questions regarding RRT demand, equipment availability, and use of continuous renal replacement therapy (CRRT), intermittent haemodialysis (IHD), and peritoneal dialysis (PD) during spring 2020. RESULTS: Twenty-five ICUs responded and these treated 64% of COVID-19 ICU patients in Sweden. ICU capacity increased by 292% (IQR 171-347%). Median peak capacity was reached during the 18th week of the year. RRT use increased overall by 133% and in Stockholm by 188%. 36% of units sequestered CRRT machines. IHD was used in 68% and PD in 12% of ICUs. RRT fluid and filter shortages were experienced by 45% and 33% of wards, respectively; consequently, prescription alterations were made by 24% of ICUs. Calcium solution shortages were reported in 12% of units that led to citrate protocol changes. Staffing shortages resulted in RRT sometimes being delivered by non-RRT-trained staff, safety incidents relating to this occurred, although no patient harm was reported. CONCLUSION: During the first wave of the COVID-19 pandemic, RRT demand increased extensively causing staff and equipment shortages, altered CRRT protocols, and increased use of IHD and PD. The impact on patient outcomes should be assessed to effectively plan for further surge capacity RRT demand.

Continuous renal replacement therapy in intensive care patients with COVID-19; survival and renal recovery.

BACKGROUND: Outcome for critically ill patients with COVID-19 treated with continuous renal replacement therapy (CRRT) is largely unknown. We describe mortality and renal outcome in this group. METHODS: This observational study was conducted at a university hospital in Sweden. We studied critically ill adult COVID-19 patients with Acute Kidney injury (AKI) who received CRRT. RESULTS: In 451 patients, AKI incidence was 43.7%. 18.2% received CRRT. Median age of CRRT patients was 60 years (IQR 54-65), 90% were male, median BMI was 29 (IQR 25-32), 23.2% had Diabetes, 37.8% hypertension and 6.1% chronic kidney disease prior to admission. 100% required mechanical ventilation. 8.5% received Extra Corporeal Membrane Oxygenation. Median length of stay was 23 days (IQR 15-26). ICU mortality was 39% and 90-day mortality was 45.1%. Age, baseline creatinine values and body weight change were associated with 60 days mortality. Of the survivors, no patients required dialysis at hospital discharge, 73.8% recovered renal function and a median 10.5% of body weight was lost during admission. CONCLUSIONS: Critically ill COVID-19 patients with AKI who received CRRT had a 90-day mortality of 45.1%. At follow-up, three quarters of survivors had recovered renal function. This information is important in the clinical management of COVID-19.

Renal resistive index is associated with acute kidney injury in COVID-19 patients treated in the intensive care unit.

BACKGROUND: Renal resistive index (RRI) is a promising tool for the assessment of acute kidney injury (AKI) in critically ill patients in general, but its role and association to AKI among patients with Coronavirus disease 2019 (COVID-19) is not known. OBJECTIVE: The aim of this study was to describe the pattern of RRI in relation to AKI in patients with COVID-19 treated in the intensive care unit. METHODS: In this observational cohort study, RRI was measured in COVID-19 patients in six intensive care units at two sites of a Swedish University Hospital. AKI was defined by the creatinine criteria in the Kidney Disease Improving Global Outcomes classification. We investigated the association between RRI and AKI diagnosis, different AKI stages and urine output. RESULTS: RRI was measured in 51 patients, of which 23 patients (45%) had AKI at the time of measurement. Median RRI in patients with AKI was 0.80 (IQR 0.71-0.85) compared to 0.72 (IQR 0.67-0.78) in patients without AKI (p = 0.004). Compared to patients without AKI, RRI was higher in patients with AKI stage 3 (median 0.83, IQR 0.71-0.85, p = 0.006) but not in patients with AKI stage 1 (median 0.76, IQR 0.71-0.83, p = 0.347) or AKI stage 2 (median 0.79, min/max 0.79/0.80, n = 2, p = 0.134). RRI was higher in patients with an ongoing AKI episode compared to patients who never developed AKI (median 0.72, IQR 0.69-0.78, p = 0.015) or patients who developed AKI but had recovered at the time of measurement (median 0.68, IQR 0.67-0.81, p = 0.021). Oliguric patients had higher RRI (median 0.84, IQR 0.83-0.85) compared to non-oliguric patients (median 0.74, IQR 0.69-0.81) (p = 0.009). After multivariable adjustment, RRI was independently associated with AKI (OR for 0.01 increments of RRI 1.22, 95% CI 1.07-1.41). CONCLUSIONS: Critically ill COVID-19 patients with AKI have higher RRI compared to those without AKI, and elevated RRI may have a role in identifying severe and oliguric AKI at the bedside in these patients.