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Background: COVID-19 syndrome is associated with high morbidity and mortality in haemodialyzed patients. Pancreatic Stone Protein (PSP) is an early biomarker of sepsis and a prognostic biomarker of disease severity in critically-ill patients and can be rapidly measured at the patient's bedside with a point-of-care-test from a small drop of whole blood. The aim of our pilot was to investigate PSP in patients requiring haemodialysis with SARS-CoV-2 infection, at different severities of COVID-19 disease. Method(s): Between February and July 2021, 23 patients (6 severe COVID-19 with Acute Kidney Injury, 6 moderate COVID-19 haemodialyzed, 2 haemodialyzed without COVID-19 and 3 healthy controls) were recruited at the University Hospital of Foggia for PSP evaluation. Biomarker's measurements were performed within 48 hours after admission or upon arrival for haemodialysis (pre-treatment). PSP was measured at the patient's bedside with "abioSCOPE", a point-of-care test capable of evaluating PSP levels in five minutes from a small drop (50mul) of whole blood or serum. Result(s): The preliminary results of this pilot study showed a trend for PSP to increase along with the severity of disease. In fact, serum PSP levels were significantly higher in Intensive Care Unit subjects than in COVID-19 negative haemodialysis subjects and controls (ANOVA p=0.032). Furthermore, PSP levels were significantly higher in subjects who died (p<0.017). Whether this increase is due to the kidney injury or COVID-19 disease remains unknown, and more research is needed to understand the relationship. Conclusion(s): Several clinical studies published in literature have shown the predictive value of PSP in the early identification of sepsis and severity of the clinical outcome. In our experience we have seen a trend for PSP to increase with disease severity also in COVID-19 patients. These results are preliminary, but PSP was significantly higher in patients who died, in accordance with the literature. This experience also has demonstrated the feasibility of a point of care system to be easily implemented in the unit and adopted by personnel and its design enables fast results and immediate decisions to be taken, especially in urgent situations.
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Background: Lung-protective ventilation (LPV) with low tidal volumes (TV), aimed to reduce ventilator-induced lung injury, is one of the cornerstones in the treatment of acute respiratory distress syndrome (ARDS), including that secondary to Coronavirus disease 2019 (COVID-19). To allow LPV, and avoid the risk of progressive hypercapnia and respiratory acidosis, a wide range of extracorporeal CO2 removal (ECCO2R) techniques have been developed. These treatments may be performed alone or in combination with other organ support therapies. Here, we report our experience with a pregnant woman with multiorgan failure (MOF), occurring as a sequela of COVID-19, who was successfully treated with ECCO2R coupled with continuous renal replacement therapy (CRRT). Case Presentation: A 34-year-old pregnant patient at the 16th gestational week affected by COVID-19 was admitted for dyspnea, rapidly complicated by MOF. Because of concomitant hypercapnia and acute kidney injury the patient was treated with an ECCO2R membrane inserted in series after a hemofilter in a common CRRT platform. ECCO2R was provided using a polymethyl pentene, hollow fiber, gas-exchanger membrane of 1.35 m2. ECCO2R+CRRT was set in continuous venovenous hemodialysis (CVVHD) mode with blood flow of 300 mL/min and a sweep gas blood flow of 5 l/min. Systemic anticoagulation was obtained by continuous administration of unfractionated heparin (UFH), with a target activated partial thromboplastin time (aPTT) of 70-80 seconds. (In table 1, ventilatory and hemodynamic parameters collected during ECCO2R+CRRT treatment are reassumed). The combined treatment was effective in reducing hypercapnia, allowing the maintenance of LPV. Moreover, it was associated with the hemodynamic stability of both mother and fetus and it was well-tolerated. Anyway, the treatment was complicated by minor bleeding episodes mainly linked to the anticoagulation required to maintain the patency of the extracorporeal circuit. After ECCO2R+CRRT termination, the patient progressively recovered pulmonary and kidney function, so that it was possible to withdraw any support therapy. Moreover, she underwent a preterm spontaneous vaginal delivery of an alive baby. Conclusion(s): Our case supports the use of ECCO2R+CRRT as a suitable approach in complex patients, including those with severe COVID-19, being aware of the potential complications linked to this treatment.
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Background: Occurrence of acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) in patients with Coronavirus disease-19 (COVID-19) is associated with an elevated mortality rate. However, due to the high clinical impact, the COVID-19 has been the object of extensive studies that have potentially changed disease presentation and outcomes. In this regard, the development of vaccination has shown high effectiveness in preventing severe disease, hospitalization, and death related to COVID- 19. Thus, this study aimed at investigating whether any difference exists in clinical presentation, management, and mortality of COVID- 19 critically ill patients requiring CRRT before and after the vaccination campaigns. Method(s): We performed a retrospective study on critically ill adult COVID-19 patients with AKI undergoing CRRT in the Intensive care Unit (ICU) before (from March 2020 to March 2021- 1st Group) and after (from April 2021 to March 2022- 2nd Group) the availability of COVID-19 vaccines. Result(s): Overall, we considered 111 patients, aged 64 (62-65) years, 75.7 % males. The main comorbidities were diabetes (DM), lung diseases, cardiovascular disease, and hypertension. Among them, 88 (79%) were in 1st and 23 (21%) in the 2nd group, respectively. The 2nd group included 5 (22%) patients vaccinated against COVID-19, a percentage significantly lower than that reported for the Italian age-matched general population (i.e. 84.4%) There were no significant differences in general characteristics, such as in comorbidities, except for a higher prevalence of hypertension in the 1st group. Lab examinations at ICU admission were similar between the two groups except for procalcitonin and lactate dehydrogenase, which were higher in the 2nd group. While ventilation strategies were not different between the two groups, ECMO was used in a significantly higher number of patients in the 2nd group (30 vs 4%, p<0.001). Regarding specific drug therapy, while hydroxychloroquine was abandoned in the 2nd group, the use of heparin significantly increased, and monoclonal antibodies were introduced in the clinical practice (and prescribed in 4/23 patients of the 2nd group). CRRT was mostly provided according to CVVHD modality (about 87% in both groups) and sepsis devices were used in 45.4 and 56.5% of the 1st and the 2nd group, respectively. Looking at the outcomes, in terms of length of ICU stay and mortality, we found no significant difference between the two groups. Indeed, 58 (66%) and 15 (68%) patients died in ICU in the 1st and the 2nd group, respectively. Finally, considering the whole population at multivariate Cox regression, the length of ICU hospitalization, days on CRRT, invasive ventilation, and DM were independently related to the 90-day mortality rate. Conclusion(s): Despite the recent acquisitions and progress in COVID-19 pathogenesis and management, when compared with patients undergoing CRRT during the first phases of the pandemic, patients critically ill COVID-19 requiring CRRT after the availability of vaccines presented similar clinical characteristics and poor outcomes. This population was characterized by a low vaccination rate when compared with the general population, suggesting that this factor could be a key determinant of the clinical course of these patients. These data further reinforce the concept that in absence of established effective treatments, the most useful strategy to reduce COVID-19-related mortality is constituted by the prevention of the severe form of the disease, through the wide diffusion and universal implementation of vaccines.
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BACKGROUND AND AIMS: Acute kidney injury (AKI) is a common complication of coronavirus disease-19 (COVID-19), which, particularly in critically ill patients requiring continuous renal replacement therapy (CRRT), is associated with an elevated mortality risk [1, 2]. However, knowledge about COVID-19 pathogenesis and management is evolving, and clinical practice is changing rapidly. Here, we evaluated if this process had an impact on the management and outcome of AKI patients. METHODS: We performed a retrospective observational study on critically ill adult COVID-19 patients who received CRRT in the intensive care unit (ICU) during the first two pandemic waves before the availability of COVID-19 vaccines: the first one from March to August 2020 (first) and the second one (second) from September to December 2020. RESULTS: Overall, we considered 63 patients, aged 65 (60-69) years, 76.2% males. The main comorbidities were diabetes (DM), cardiovascular disease (CVD) and chronic kidney disease (CKD). Among them, 28 (44%) were in the first group and 35 (66%) in the second group. There were no significant differences in general characteristics, such as in comorbidities, except for a higher prevalence of CVD in the first group (Fig. 1). Lab examinations at ICU admission, including serum creatinine level (sCr), were not different between the two groups. While all patients required respiratory support, non-invasive ventilation was more prevalent in the second wave. Notably, during this period, decapneization combined with CRRT was introduced. Regarding drugs, we found that in the second group, hydroxychloroquine was abandoned, tocilizumab use was reduced and heparin administration significantly increased. The AKI time course was similar between the patients of the two waves (Fig. 2). There were no significant differences in CRRT techniques. However, in the second, the use of additional CRRT-devices, in particular adsorption-based filters, significantly increased. In most cases, citrate anticoagulation was used in both groups. Looking at the outcomes, we found no significant difference between the two waves. Indeed, 17 (60.2%) and 22 (62.8%) patients died in the ICU in the first and second groups, respectively. The length of ICU hospitalization, days on CRRT, invasive ventilation and DM were significantly related to overall mortality;time of ICU hospitalization was the only remaining significant at multivariate Cox regression. Overall, 21 (33%) patients survived hospitalization. At the 6 months after the discharge, 3 of them died, 3 were on HD and 15 were dialysis-free, even if 6 of them presented CKD. CONCLUSION: Our data confirm the high complexity and mortality of COVID-19 patients undergoing CRRT. Comparing the first two pandemic waves, we found that the patients also presented similar characteristics in terms of renal function and AKI time course. Regarding treatments, we observed some significant modifications in the management of ventilation, drug administration and dialysis membranes, mainly because of the results of ongoing clinical trials. However, these changes did not impact patients' outcomes. These data support the view that only game-change strategies, such as vaccination or infection-specific drugs, may impact the presentation and outcome of COVID-19 patients undergoing CRRT. Finally, patients surviving this condition deserve special attention in the follow-up. (Table Presented).