Management of Maintenance Hemodialysis Patients under the Coronavirus Disease Pandemic

Coronavirus disease (COVID-19) has spread worldwide and has resulted in high mortality, increased pressure on medical systems, and severe global economic losses. Hemodialysis patients may be highly susceptible to infections due to old age, immunocompromised status, preexisting comorbidities, and frequent hospital visits. Moreover, the closed and crowded environment of dialysis rooms increases the risk of cross-infections. The Wuhan Hemodialysis Quality Control Center has accumulated valuable experience in the prevention and control of the COVID-19 epidemic and has normalized management of the epidemic since early 2020. In this review, we garnered experiences and knowledge from China and worldwide to summarize an approach to COVID-19 prevention, control, and management in hemodialysis patients under normalized epidemic conditions.

An Analysis on the Clinical Features of Maintenance Hemodialysis Patients with Coronavirus Disease 2019: A Single Center Study

Background and Objectives: Patients on maintenance hemodialysis (MHD) are at high risk for coronavirus disease 2019 (COVID-19). However, patients undergoing MHD who are infected with COVID-19 are not fully studied. The objective of this study is to describe the characteristics of patients with COVID-19 undergoing MHD and provide a basis for the recognition and prevention of COVID-19 infection. Materials and Methods: Patients undergoing MHD were assigned into the normal group (537 cases), diagnosed group (66 cases), and suspected group (24 cases). General data, clinical symptoms, hemodialysis indicators, and laboratory indicators were collected and compared. Results: A total of 627 patients undergoing MHD were evaluated. The prevalence of COVID-19 was 10.53% (66/627), mortality was 18.18% (12/66), and death rate was 1.91% (12/627). In addition, 26% of patients were asymptomatic. Cough was the most common symptom (36%), followed by fatigue (16%), dyspnea (16%), and fever (13%). Ultrafiltration volume, ultrafiltration rate, and the duration of weekly dialysis in the diagnosed group were significantly lower than those in the other two groups. Moreover, neutrophil ratio and neutrophil, monocyte, and total carbon dioxide levels in the diagnosed group were significantly higher than those in the normal group, and the lymphocyte ratio was considerably lower than in the normal group. Sixty-five of the suspected and diagnosed patients had positive pulmonary CT findings. Conclusion: Compared with the general population, patients on hemodialysis have a significantly higher risk of contracting COVID-19 and postinfection mortality. Moreover, most patients undergoing hemodialysis have no obvious clinical symptoms after infection with COVID-19 but only have pulmonary changes which make it particularly important to screen and manage patients undergoing hemodialysis on outpatient basis.

Patients with Chronic Kidney Disease Have Higher Acute Kidney Injury Morbidity than those without after SARS-CoV-2 Infection

Background and Objectives: Chronic kidney disease (CKD) and acute kidney injury (AKI) increase the risk of serious disease and mortality in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-infected patients. This study evaluated the occurrence and outcome of AKI in CKD and non-CKD patients infected with SARS-CoV-2. Subjects and Methods: We retrospectively analyzed the medical records of 845 patients with SARS-CoV-2 infection regarding the occurrence and outcome of AKI in a coronavirus disease-2019 (COVID-19)-designated hospital in Wuhan, China, from December 31, 2019, to March 20, 2020. Results: Of the 845 COVID-19 patients, 91 had CKD and 754 had no CKD (non-CKD), of whom 22 and 14 developed AKI, respectively. Finally, 36 patients were included in the analysis. Older patients and those with cardiovascular or cerebrovascular diseases were more likely to develop AKI. More CKD patients progressed to critical illness (72.73%) than non-CKD patients (57.14%), but the degree of AKI in CKD patients was lesser than that in non-CKD patients. Higher urea nitrogen, creatinine, and proteinuria levels were observed in CKD patients. More non-CKD patients were treated with human albumin than CKD patients. The survival probability of CKD patients was lower than that of non-CKD patients, but it was not statistically significant. Conclusion: There were significant differences in the incidence rate of AKI after SARS-CoV-2 infection between CKD and non-CKD patients, and the clinical manifestations and treatments of AKI also differed. These results highlight the necessity of variable treatment methods for optimal clinical management.

Risk factors for the mortality of hemodialysis patients with COVID-19: A multicenter study from the overall hemodialysis population in Wuhan.

INTRODUCTION: Maintenance hemodialysis (MHD) patients are highly threatened in the novel coronavirus disease 2019 (COVID-19) pandemic, but evidence of risk factors for mortality in this population is still lacking. METHODS: We followed outcomes of the overall MHD population of Wuhan, including 7154 MHD patients from 65 hemodialysis centers, from January 1 to May 4, 2020. Among them, 130 were diagnosed with COVID-19. The demographic and clinical data of them were collected and compared between survivors and nonsurvivors. RESULTS: Compared to the corresponding period of last year, the all-cause mortality rate of the Wuhan MHD population significantly rose in February, and dropped down in March 2020. Of the 130 COVID-19 cases, 51 (39.2%) were deceased. Advanced age, decreased oxygen saturation, low diastolic blood pressure (DBP) on admission, and complications including acute cardiac injury (HR 5.03 [95% CI 2.21-11.14], p < 0.001), cerebrovascular event (HR 2.80 [95% CI 1.14-6.86], p = 0.025) and acute respiratory distress syndrome (HR 3.50 [95% CI 1.63-7.51], p = 0.001) were identified as independent risk factors for the death of COVID-19. The median virus shedding period of survivors was 25 days, longer than the general population. CONCLUSIONS: Maintenance hemodialysis patients are a highly vulnerable population at increased risk of mortality and prolonged virus shedding period in the ongoing COVID-19 pandemic. Advanced age, decreased oxygen saturation, low DBP on admission, and complications like acute cardiac injury are parameters independently associated with poor prognosis.

Clinical characteristics of deceased hemodialysis patients affected by COVID-19.

BACKGROUND: The recent outbreak of Coronavirus Disease 2019 (COVID-19) is a public health emergency of international concern. In China, Wuhan, Hubei Province was the epicenter. The disease is more severe in patients with high comorbidities and dialysis patients fall into this category. METHODS: In this report, we reviewed the whole course of the epidemic emerged in the HD center of Wuhan NO.1 Hospital by 28 February 2020. We compared the differences on the epidemiological characteristics and clinical features between patients surviving from COVID-19 and patients who died. RESULT: In this hospital, at time of the present report, 627 patients were on chronic hemodialysis and the prevalence of affected cases was 11.8% (74/627).The median age of the COVID-19-positive patients was 63 years (range 31-88), with an almost even gender distribution (females accounted for 54.4%).The most frequent presenting symptom was cough (41.9%), followed by fatigue (24.2%), fever (17.2%) and dyspnea (14.8%); 22.4% of the cases were and asymptomatic. Fourteen of the 74 patients died (19%), as for presenting symptoms, cough was more frequent in patients who died (P < 0.05). Surviving patients had higher levels of phosphate and albumin, and lower levels of C-reactive protein (CRP). Chest CT scan was positive in all cases, including in asymptomatic ones, and revealed in about three fourths of the cases bilateral (76.2%) lesions; in each lung lesions were multiple in about half of the cases of the cases (52.3%). After diagnosis, median time to death was 7 days in the 14 patients who died, with a range between 4 and 18 days. CONCLUSION: This preliminary, single Center study identifies hemodialysis patients as a population at high risk of severe, and deadly COVID-19 infection. While classic baseline clinical conditions, including age, kidney disease and gender, are not significantly associated with survival in COVID-19 infected hemodialysis, our study also suggests a significant association between risk of and death, poor nutritional status and less than optimal metabolic balance.

Bed-sided short-duration renal replacement therapy provide a possible option to treat non-critical coronavirus disease 2019 in maintenance hemodialysis patients in public health crisis.

HD care may experience great stress with the coronavirus disease 2019 (COVID-19) pandemic. A modified HD modality named bed-sided short-duration renal replacement therapy (BSRRT) was used in noncritical maintenance HD (MHD) patients diagnosed with COVID-19 in Wuhan due to extreme situation. To determine the safety and efficacy as a substitution for intermittent HD (IHD), we conducted this study. We used the data of 88 noncritical COVID-19 MHD patients collected from 65 medical units at the hospitals in Wuhan, China, from January 1 to March 10, 2020. t-test, Wilcoxon rank sum test, and Fisher exact probability method were used to compare the baseline characteristics, treatment, and death. Log-rank test and Cox regression multivariate analysis was used to compare the survival of noncritical patients who were transferred to BSRRT modality versus those who were continued on the IHD. Univariate analysis showed the level of reported fatigue symptom at present, bilateral lung computed tomography infiltration and steroid treatment differed between the two groups. The outcome of death of the two groups did not show significant differences in univariate analysis (P = .0563). Multivariate Cox regression analysis dialysis showed modality of treatment after COVID-19 diagnosis was not a significant predictor of death (P = .1000). These data suggest that for noncritical COVID-19 MHD patients, the transfer from IHD to BSRRT does not have significant difference in the risk of death compared with IHD group. This finding suggests this modified modality could be an option for the substitution for IHD during the COVID-19 pandemic period.

Kidney damage in COVID-19 patients with or without chronic kidney disease: Analysis of clinical characteristics and related risk factors

COVID-19 poses more risk to patients who already suffer from other diseases, particularly respiratory disorder. In this study, we analyzed the clinical characteristics and related risk factors during hospitalization of COVID-19 patients admitted with kidney damage. A total of 102 COVID-19 patients with kidney damage [irrespective of their chronic kidney disease (CKD) history] during hospitalization were included in this study. The patients were divided into a core group and a group who developed critical illness or death. Clinical data included age, gender, length of hospitalization, clinical manifestations, medical history, hypersensitive C-reactive protein (hs -CRP), high serum creatinine, low cardiac troponin I (cTnI), and hemoglobin. Univariate and multivariate logistic regression models were used to analyze the risk factors of patients' outcome. Among the outcomes, 75 patients (73.53%) were cured, 27 (26.47%) developed to critical illness or death, 20 (19.61%) of them died. A total of 36 (4.26%) out of 845 COVID-19 patients, developed acute kidney injury (AKI). Decreased oxygen saturation, elevated hs-CRP, elevated serum creatinine, elevated cTnI, and anemia were related factors for COVID-19 patients who developed to critical illness or death (P <0.05). Decreased oxygen saturation, elevated hs-CRP and anemia were not independent factors, but elevated serum creatinine and elevated cTnI were independent factors for COVID-19 patients who developed to critical illness or death (P <0.05). Among COVID-19 patients with or without CKD but with kidney damage during hospitalization, patients with elevated serum creatinine and elevated Tnl, more likely to developed critical illness or death.

Serologic Detection of SARS-CoV-2 Infections in Hemodialysis Centers: A Multicenter Retrospective Study in Wuhan, China.

RATIONALE & OBJECTIVE: Patients receiving maintenance hemodialysis (MHD) are highly vulnerable to infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The current study was designed to evaluate the prevalence of SARS-CoV-2 infection based on both nucleic acid testing (NAT) and antibody testing in Chinese patients receiving MHD. STUDY DESIGN: Cross-sectional study. SETTING & PARTICIPANTS: From December 1, 2019, to March 31, 2020, a total of 1,027 MHD patients in 5 large hemodialysis centers in Wuhan, China, were enrolled. Patients were screened for SARS-CoV-2 infection by symptoms and initial computed tomography (CT) of the chest. If patients developed symptoms after the initial screening was negative, repeat CT was performed. Patients suspected of being infected with SARS-CoV-2 were tested with 2 consecutive throat swabs for viral RNA. In mid-March 2020, antibody testing for SARS-CoV-2 was obtained for all MHD patients. EXPOSURE: NAT and antibody testing results for SARS-CoV-2. OUTCOMES: Morbidity, clinical features, and laboratory and radiologic findings. ANALYTICAL APPROACH: Differences between groups were examined using t test or Mann-Whitney U test, comparing those not infected with those infected and comparing those with infection detected using NAT with those with infection detected by positive serology test results. RESULTS: Among 1,027 patients receiving MHD, 99 were identified as having SARS-CoV-2 infection, for a prevalence of 9.6%. Among the 99 cases, 52 (53%) were initially diagnosed with SARS-CoV-2 infection by positive NAT; 47 (47%) were identified later by positive immunoglobulin G (IgG) or IgM antibodies against SARS-CoV-2. There was a spectrum of antibody profiles in these 47 patients: IgM antibodies in 5 (11%), IgG antibodies in 35 (74%), and both IgM and IgG antibodies in 7 (15%). Of the 99 cases, 51% were asymptomatic during the epidemic; 61% had ground-glass or patchy opacities on CT of the chest compared with 11.6% among uninfected patients (P<0.001). Patients with hypertensive kidney disease were more often found to have SARS-CoV-2 infection and were more likely to be symptomatic than patients with another primary cause of kidney failure. LIMITATIONS: Possible false-positive and false-negative results for both NAT and antibody testing; possible lack of generalizability to other dialysis populations. CONCLUSIONS: Half the SARS-CoV-2 infections in patients receiving MHD were subclinical and were not identified by universal CT of the chest and selective NAT. Serologic testing may help evaluate the overall prevalence and understand the diversity of clinical courses among patients receiving MHD who are infected with SARS-CoV-2.

Clinical Characteristics of and Medical Interventions for COVID-19 in Hemodialysis Patients in Wuhan, China.

BACKGROUND: Reports indicate that those most vulnerable to developing severe coronavirus disease 2019 (COVID-19) are older adults and those with underlying illnesses, such as diabetes mellitus, hypertension, or cardiovascular disease, which are common comorbidities among patients undergoing maintenance hemodialysis. However, there is limited information about the clinical characteristics of hemodialysis patients with COVID-19 or about interventions to control COVID-19 in hemodialysis centers. METHODS: We collected data retrospectively through an online registration system that includes all patients receiving maintenance hemodialysis at 65 centers in Wuhan, China. We reviewed epidemiologic and clinical data of patients with laboratory-confirmed COVID-19 between January 1, 2020 and March 10, 2020. RESULTS: Of 7154 patients undergoing hemodialysis, 154 had laboratory-confirmed COVID-19. The mean age of the 131 patients in our analysis was 63.2 years; 57.3% were men. Many had underlying comorbidities, with cardiovascular disease (including hypertension) being the most common (68.7%). Only 51.9% of patients manifested fever; 21.4% of infected patients were asymptomatic. The most common finding on chest computed tomography (CT) was ground-grass or patchy opacity (82.1%). After initiating comprehensive interventions-including entrance screening of body temperature and symptoms, universal chest CT and blood tests, and other measures-new patients presenting with COVID-19 peaked at 10 per day on January 30, decreasing to 4 per day on February 11. No new cases occurred between February 26 and March 10, 2020. CONCLUSIONS: We found that patients receiving maintenance hemodialysis were susceptible to COVID-19 and that hemodialysis centers were high-risk settings during the epidemic. Increasing prevention efforts, instituting universal screening, and isolating patients with COVID-19 and directing them to designated hemodialysis centers were effective in preventing the spread of COVID-19 in hemodialysis centers.

An Analysis on the Clinical Features of MHD Patients with Coronavirus Disease 2019: A Single Center Study (preprint)

Background: In this study, we aimed to find out the features of the maintenance hemodialysis (MHD) patients infected with Coronavirus Disease 2019 (COVID-19) in the Blood Purification Center of Wuhan No.1 Hospital, Hubei Province, China, and provide evidences for clinical treatment.Methods: We collected the data of all the MHD patients in this hemodialysis center by February 20, 2020, including those infected with COVID-19. These patients were divided into three groups: the control group (537 cases), confirmed group (66 cases) and suspected group (24 cases). We compared the relevant data of the three groups and analyzed the factors that may affect the possibility of catching COVID-19.Results: 1. By February 20, 2020, there were 627 MHD patients in the Hemodialysis Center of Wuhan No.1 Hospital. The prevalence rate of the COVID-19 was 14.35% (90/627, including 66 confirmed cases and 24 suspected cases); the fatality rate 13.33% (12/90, including 12 death cases); the mortality rate 1.91% (12/627).2. The comparison between the three groups revealed the following results: weekly hemodialysis duration (WHD), ultrafiltration volume (UFV) and ultrafiltration rate (UFR) of the confirmed group were obviously lower than those of the control and suspected groups (P＜0.05); the neutrophil ratio (N%), neutrophil (N#), monocyte (M#) and total carbon dioxide (TCO2) were significantly higher than those of the control group while the lymphocyte ratio (L%) was much lower (P＜0.05).3. The lung CT scans found three common features: bilateral abnormalities (81.54%), multiple abnormalities (84.62%) and patchy opacity (61.54%).4. The binary logstic regression analysis showed that diabetes (OR=5.404,95% CI 1.950～14.976, P=0.001) and hypertension (OR=3.099,95% CI 1.380～6.963, P=0.006) are independent risk factors for MHD patients to be infected with COVID-19; WHD (OR=0.846,95% CI 0.737～0.970, P=0.017), UFR (OR=0.012,95% CI 0.002～0.058, P＜0.001) and serum ferritin (SF, OR=0.823,95% CI 0.748～0.906, P＜0.001) are independent protective factors.Conclusion: MHD patients with diabetes or hypertension are more likely to be infected with COVID-19. In clinical treatment, hemodialysis duration, UFR and SF levels should be controlled appropriately to reduce the risk of infection.