COVID-19 in kidney transplant recipients.

There is minimal information on coronavirus disease 2019 (COVID-19) in immunocompromised individuals. We have studied 10 patients treated at 12 adult care hospitals. Ten kidney transplant recipients tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by polymerase chain reaction, and 9 were admitted. The median age was 57 (interquartile range [IQR] 47-67), 60% were male, 40% Caucasian, and 30% Black/African American. Median time from transplant to COVID-19 testing was 2822 days (IQR 1272-4592). The most common symptom was fever, followed by cough, myalgia, chills, and fatigue. The most common chest X-ray and computed tomography abnormality was multifocal patchy opacities. Three patients had no abnormal findings. Leukopenia was seen in 20% of patients, and allograft function was stable in 50% of patients. Nine patients were on tacrolimus and a mycophenolic antimetabolite, and 70% were on prednisone. Hospitalized patients had their antimetabolite agent stopped. All hospitalized patients received hydroxychloroquine and azithromycin. Three patients died (30%), and 5 (50%) developed acute kidney injury. Kidney transplant recipients infected with COVID-19 should be monitored closely in the setting of lowered immunosuppression. Most individuals required hospitalization and presenting symptoms were similar to those of nontransplant individuals.

Novel Aspects of the Immune Response Involved in the Peritoneal Damage in Chronic Kidney Disease Patients under Dialysis.

Chronic kidney disease (CKD) incidence is growing worldwide, with a significant percentage of CKD patients reaching end-stage renal disease (ESRD) and requiring kidney replacement therapies (KRT). Peritoneal dialysis (PD) is a convenient KRT presenting benefices as home therapy. In PD patients, the peritoneum is chronically exposed to PD fluids containing supraphysiologic concentrations of glucose or other osmotic agents, leading to the activation of cellular and molecular processes of damage, including inflammation and fibrosis. Importantly, peritonitis episodes enhance peritoneum inflammation status and accelerate peritoneal injury. Here, we review the role of immune cells in the damage of the peritoneal membrane (PM) by repeated exposure to PD fluids during KRT as well as by bacterial or viral infections. We also discuss the anti-inflammatory properties of current clinical treatments of CKD patients in KRT and their potential effect on preserving PM integrity. Finally, given the current importance of coronavirus disease 2019 (COVID-19) disease, we also analyze here the implications of this disease in CKD and KRT.

One-year all-cause mortality in hospitalized patients with COVID-19 and end-stage renal disease undergoing hemodialysis.

INTRODUCTION: Patients with end-stage renal disease (ESRD) on dialysis and COVID-19 infection have an increased risk of in-hospital mortality, but whether these patients have a higher long-term mortality risk is unknown. MATERIALS AND METHODS: Retrospective chart review of 958 patients admitted with COVID-19 infection or those with ESRD admitted for any other reason between February 2020 and August 2020. We collected data on demographics, comorbidities, laboratory tests, and mortality. The primary outcome was all-cause 1-year mortality. The secondary outcome was in-hospital mortality. We used primarily logistic regression models to assess the mortality risk. RESULTS: In total, 651 patients without ESRD with COVID-19 (COVID+ESRD-), 259 with ESRD without COVID-19 (ESRD+COVID-), and 48 with ESRD with COVID-19 (COVID+ESRD+) were hospitalized between February 2020 and August 2020. Patients were followed after discharge until September 2021. The all-cause 1-year mortality rates were 24% in patients with COVID+ESRD-, 22% in ESRD+COVID- patients, and 40% in those with COVID+ESRD+ (p < 0.05). Compared to the COVID+ESRD- group, the unadjusted and adjusted odds ratio (OR) for all-cause 1-year mortality in the COVID+ESRD+ group was 2.13 (95% confidence interval (CI), 1.16 - 3.91) and 2.15 (95% CI,1.12 - 4.14), respectively. The unadjusted and adjusted OR for all-cause in-hospital mortality in the COVID+ESRD+ group was 1.79 (95% CI, 0.92 - 3.49); and 1.79 (95% CI, 0.88 - 3.65), respectively. We found no statistically significant difference between the COVID+ESRD- and ESRD+COVID- groups for both in-hospital and 1-year mortality (p > 0.05). CONCLUSION: Patients with COVID+ESRD+ have significantly higher odds for all-cause 1-year mortality compared to COVID+ESRD- patients. Future studies should investigate the mechanisms of long-term mortality risk in ESRD patients with COVID-19 infection.

Prevalence and predictors of outcomes among ESRD patients with COVID-19.

BACKGROUND: End-stage renal disease patients on hemodialysis (ESRD) patients are at high risk for contracting COVID-19. In this propensity matched cohort study, we examined the prevalence of COVID-19 in emergency room (ER) patients and examined whether clinical outcomes varied by ESRD status. METHODS: Patients who visited George Washington University Hospital ER from April 2020 to April 2021 were reviewed for COVID-19 and ESRD status. Among COVID-positive ER patients, the propensity for ESRD was calculated using a logistic regression model to create a propensity-matched sample of ESRD vs non-ESRD COVID-19 patients. A multivariable model examined whether ESRD was an independent predictor of death and other outcomes in COVID-19 patients. RESULTS: Among the 27,106 ER patients, 2689 of whom were COVID-positive (9.9%). The odds of testing positive for COVID-19 were 0.97 ([95% CI: 0.78-1.20], p = 0.76) in ESRD vs non-ESRD patients after adjusting for age, sex, and race. There were 2414 COVID-positive individuals with non-missing data, of which 98 were ESRD patients. In this COVID-positive sample, ESRD patients experienced a higher incidence of stroke, sepsis, and pneumonia than non-ESRD individuals. Significant independent predictors of death included age, race, sex, insurance status, and diabetes mellitus. Those with no insurance had odds of death that was 212% higher than those with private insurance (3.124 [1.695-5.759], p < 0.001). ESRD status was not an independent predictor of death (1.215 [0.623-2.370], p = 0.57). After propensity-matching in the COVID-positive patients, there were 95 ESRD patients matched with 283 non-ESRD individuals. In this sample, insurance status continued to be an independent predictor of mortality, while ESRD status was not. ESRD patients were more likely to have lactic acidosis (36% vs 15%) and length of hospital stay ≥ 7 days (48% vs 31%), but no increase in odds for any studied adverse outcomes. CONCLUSIONS: In ER patients, ESRD status was not associated with higher odds for testing positive for COVID-19. Among ER patients who were COVID positive, ESRD was not associated with mortality. However, insurance status had a strong and independent association with death among ER patients with COVID-19.

A case of hemophagocytic lymphohistiocytosis after BNT162b2 COVID-19 (Comirnaty®) vaccination.

RATIONALE: Coronavirus disease (COVID-19), an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 virus, was reported in Wuhan of China in December 2019. The world is still in a state of pandemic owing to COVID-19. COVID-19 vaccines help our bodies develop immunity against the virus that causes COVID-19 without having to get the illness. Herein, we describe a rare case of a critical disorder, hemophagocytic lymphohistiocytosis (HLH), in a patient with nephritic sclerosis associated with hypertension, following mRNA COVID-19 vaccination. HLH is a life-threatening hyperinflammatory syndrome caused by aberrantly activated macrophages and cytotoxic T cells that may rapidly progress to terminal multiple organ failure. PATIENT CONCERNS: An 85-year-old Japanese woman with chronic renal failure and hypertension was included in this study. Routine laboratory investigations provided the following results: white blood cell (WBC) count, 4.6 × 109/L; hemoglobin (Hb), 8.1 g/dL; platelet count, 27 × 109/L; blood urea nitrogen 48.9 mg/dL, and serum creatinine 3.95 mg/dL. The patient developed malaise, vomiting, and persistent high fever (up to 39.7°C) on the 12th day after receiving the second dose of the vaccine. Initial evaluation revealed neutropenia. The total WBC count was 0.40 × 109/L (Neutrophils 0, Lymphocytes 240/µ, blast 0%); Hb 9.0 g/dL, platelet count 27 × 109/L; and, C Reactive Protein 9.64 mg/dL. DIAGNOSIS: Further tests showed hyperferritinemia (serum ferritin 2284.4 µg/L). Bone marrow examination revealed haemophagocytosis. A provisional diagnosis of HLH associated with the Comirnaty® vaccination was made based on the HLH-2004 diagnostic criteria. INTERVENTIONS: The patient was treated with granulocyte colony-stimulating factor and 500 mg methylprednisolone. OUTCOMES: A significant improvement was observed in the patient's condition; the abnormal laboratory results resolved gradually, and the patient was discharged. LESSONS: This case serves to create awareness among clinicians that HLH is a rare complication of COVID-19 vaccination and should be considered, especially in patients with a history of chronic renal failure and hypertension.

Interleukin-6 and Outcome of Chronic Hemodialysis Patients with SARS-CoV-2 Pneumonia.

Background and Objectives: Chronic hemodialysis (CHD) patients are at increased risk of SARS-CoV-2 infection and the related complications and mortality of COVID-19 due to the high rate of comorbidities combined with advanced age. This observational study investigated the clinical manifestations of SARS-CoV-2 infection in CHD and the risk factors for patients' death. Materials and Methods: The study included 26 CHD patients with SARS-CoV-2 pneumonia detected by positive RT-PCR on nasopharyngeal swabs and high-resolution computed tomography at hospital admission, aged 71 + 5.9 years, 14 of which (53.8%) were male, 20 (77%) under hemodiafiltration, and 6 (23%) on standard hemodialysis, with a median follow-up of 30 days. Results: Simple logistic regression analysis revealed that the factors associated with a higher risk of death were older age (OR: 1.133; 95%CI: 1.028-1.326, p = 0.0057), IL-6 levels at admission (OR: 1.014; 95%CI: 1.004-1.028, p = 0.0053), and C-reactive protein (OR: 1.424; 95%CI: 1.158-2.044, p < 0.0001). In the multiple logistic regression model, circulating IL-6 values at admission remained the only significant prognosticator of death. The ROC curve indicated the discriminatory cut-off value of 38.20 pg/mL of blood IL-6 for predicting death in chronic hemodialysis patients with SARS-CoV-2 pneumonia (sensitivity: 100%; specificity: 78%; AUC: 0.8750; p = 0.0027). Conclusions: This study identified a threshold of IL-6 levels at hospital admission for death risk in CHD patients with SARS-CoV-2 pneumonia. This might represent a valuable outcome predictor, feasibly better than other clinical, radiological, or laboratory parameters and preceding the IL-6 peak, which is unpredictable.

Assessment of quality of life determinants in hemodialysis patients of a developing country: A cross-sectional study during ongoing COVID-19 pandemic.

BACKGROUND AND OBJECTIVES: Patients of end-stage renal disease are prone to have a very low quality of life (QoL). Variety of factors influence the QoL among sufferers of chronic kidney disease comprising of type of dialysis, sufficiency/adequacy of dialysis, and associated burden of disease. We conducted this study amidst the pandemic to determine the associated factors for poor QoL in hemodialysis patients during the ongoing pandemic. PATIENTS AND METHODS: This cross-sectional study was conducted in a hemodialysis unit of a tertiary care hospital. A total of 118 participants responded to the validated questionnaire of Quality of Life Index-dialysis version-III (QLI). Higher scores signify good QoL, total scores are further categorized into subgroups desirable, relatively desirable and undesirable. RESULTS: The mean age of the participants was 57.36 ± 10.03 years and mean body mass index of 26.73 ± 5.54 kg/m2. The mean total QoL of the study population was found quite low (12.99 ± 5.89). Majority of respondents fell in undesirable category of QoL (49.2%). Total QoL (P = 0.004) and subscale health/functioning (P = 0.003) were significantly lower in females. All the subscales along with total QoL scores were found lower in twice-weekly dialyzed patients (P < 0.001). Marital status (P = 0.049) and twice-weekly dialysis (P < 0.001) were found significant with undesirable QoL. On multivariate analysis, significant determinants of undesirable QoL were twice-weekly dialysis (P = 0.001), catheter access (P = 0.034), phosphate (P = 0.005) and uric acid (P = 0.006). CONCLUSION: Inadequate dialysis due to lesser frequency per week leading to poorly cleared toxic substances were most significant contributors of poor QoL in our study.

Optimized infection control practices augment the robust protective effect of vaccination for ESRD patients during a hemodialysis facility SARS-CoV-2 outbreak.

BACKGROUND: While dialysis patients are at greater risk of serious SARS-CoV-2 complications, stringent infection prevention measures can help mitigate infection and transmission risks within dialysis facilities. We describe an outbreak of 14 cases diagnosed in a hospital-based outpatient ESRD facility over 13 days in the second quarter of 2021, and our coordinated use of epidemiology, viral genome sequencing, and infection control practices to quickly end the transmission cycle. METHODS: Symptomatic patients and staff members were diagnosed by RT-PCR. Facility-wide screening utilized SARS-CoV-2 antigen tests. SARS-CoV-2 genome sequences were obtained from residual diagnostic specimens. RESULTS: Of the 106 patients receiving dialysis in the facility, 10 were diagnosed with SARS-CoV-2 infection, as was 1 patient support person. Of 3 positive staff members, 2 were unvaccinated and had provided care for 6 and 4 of the affected patients, respectively. Sequencing demonstrated that all cases in the cluster shared an identical B.1.1.7./Alpha substrain. Attack rates were greatest among unvaccinated patients and staff. Vaccine effectiveness was 88% among patients. CONCLUSIONS: Prompt recognition of an infection cluster and rapid intervention efforts successfully ended the outbreak. Alongside consistent adherence to core infection prevention measures, vaccination was highly effective in reducing disease incidence and morbidity in this vulnerable population.

Food insecurity during COVID-19 in children with end-stage kidney disease: a pilot study.

BACKGROUND: Food insecurity, an important social determinant of health among children, has become more common during the COVID-19 pandemic. Children with chronic diseases including end-stage kidney disease (ESKD) are at higher risk of food insecurity due to their complex care needs, medication burden, and dietary restrictions. No data exists describing food insecurity prevalence in pediatric ESKD patients during the COVID-19 pandemic. METHODS: Food insecurity was assessed among families of children (age 0-18 years) with ESKD on chronic dialysis at two pediatric academic medical centers. Families were screened in April 2020 using the Hunger Vital Sign, a validated 2-question screening tool. We assessed impact of COVID-19 on food insecurity. We compared serum phosphorus "pre-COVID" (January/February 2020) to "during COVID" (April/May 2020). RESULTS: A total of 29 families enrolled in this study. 62% (18/29) of children with ESKD lived in food insecure households, and of those, 72% (13/18) reported that COVID-19 had worsened their food insecurity status. During the COVID-19 pandemic, food insecure patients experienced greater rise in their serum phosphorus levels (1.1 mg/dL vs. 0 mg/dL, p = 0.03) and decreased likelihood of having adequate phosphorus control (50% vs. 11%, p = 0.03). CONCLUSION: Food insecurity was common among children with ESKD on chronic dialysis during the COVID-19 pandemic. Children with food insecurity had a greater increase in their phosphorus levels during the pandemic than did food secure children. Further exploration into how food resources such as an onsite food pantry impacts food insecurity and phosphorus control in children with ESKD is essential.

COVID-19 in patients with end stage kidney disease at a large community hospital in Eastern Saudi Arabia. A prospective study.

OBJECTIVES: To report the outcome of patients with end stage kidney disease (ESKD) who were diagnosed with COVID-19 at a large community hospital in Eastern Saudi Arabia. METHODS: A single center, prospective observational study at Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia. Patients with ESKD who were maintained on dialysis and developed COVID-19 between June 15, 2020 and October 31, 2021 were enrolled. RESULTS: In total, 30 patients with ESKD were diagnosed with severe acute respiratory syndrome coronavirus 2 infection. Twenty two (73%) patients developed the disease prior to COVID-19 vaccine rollout. The median age of the cohort was 63 (55-75) years. Most patients were diabetic (73%), hypertensive (97%) and had a median body mass index of 28 kg/m2. Twenty seven (90%) patients required admission, 16 (52%) patients developed pneumonia, and 5 (17%) patients required mechanical ventilation. Patients who developed pneumonia were older, and the majority had diabetes mellitus and coronary artery disease. Five patients died with a total mortality of 17%. CONCLUSION: Patients with ESKD who developed COVID-19 had a poor outcome with high mortality compared to the general population. Presence of diabetes mellitus, coronary artery disease and older age were associated with a higher risk of severe disease. There was a sharp decline in the number of positive cases following implementation of the vaccination program.

Case Report: Severe SARS-CoV-2 Infection Treated with Remdesivir in a Patient with ESRD.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) has led to a global pandemic since its emergence from Wuhan, China, in December of 2019. As research continues to evolve, there is a paucity of reports describing the management and treatment of COVID-19 in patients with acute kidney failure and End-Stage Renal Disease (ESRD). These patients have increased susceptibility to developing severe clinical symptoms from SARS-CoV-2 infection due to their underlying comorbidities. Remdesivir has emerged as a promising antiviral drug against SARS-CoV-2. However, data regarding the clinical benefits of remdesivir in patients with severe renal impairment is unavailable as they have been excluded from clinical trials due to the risk of sulfobutylether-ß-cyclodextrin (SBECD) accumulation in patients with eGFR<30 ml/min per 1.73m2. CASE PRESENTATION: We present the first case of a 47-year-old male with end-stage renal disease who was successfully treated with remdesivir during hospitalization for acute respiratory distress syndrome and respiratory failure arising from COVID-19. The worsening clinical progress of the patient despite intensive care and treatment with intravenous azithromycin therapy led to the decision to utilize remdesivir after a risk-benefit analysis, despite his eGFR being <15 ml/min per 1.73m2. Although the patient developed reversible hepatotoxicity, marked improvement of symptoms was observed after the five-day course of remdesivir was completed. CONCLUSION: Our findings describe the first instance of compassionate use of remdesivir for the treatment of COVID-19 in the setting of end-stage renal disease, acute respiratory distress syndrome, and hypoxemic respiratory failure.

A case of Bacillus subtilis var. natto bacteremia caused by ingestion of natto during COVID-19 treatment in a maintenance hemodialysis patient with multiple myeloma.

A 70-year-old woman, who started on hemodialysis 7 months before for end-stage renal disease due to diabetic nephropathy and was diagnosed with symptomatic multiple myeloma 1 month before, was admitted to our hospital with critical coronavirus disease 2019 and treated with long-term immunosuppressive therapy such as steroids and tocilizumab. During treatment, Bacillus subtilis was detected in the blood cultures. We could not exclude the association of natto (fermented soybeans) with B. subtilis var. natto, which the patient had been eating every day from 8 days after admission. She was prohibited from eating natto and treated with vancomycin. Later, B. subtilis detected in the blood culture was identified as B. subtilis var. natto, which was identical with those contained in the natto that the patient consumed daily using a next-generation sequencer. Gut dysbiosis due to old age, malignant tumor, diabetes mellitus, end-stage renal disease, and intestinal inflammation caused by severe acute respiratory syndrome coronavirus 2 increased intestinal permeability and the risk of bacterial translocation, causing B. subtilis var. natto bacteremia. Therefore, careful consideration might be given to the intake of fermented foods containing live bacteria in patients with severe immunocompromised conditions.

Chronic inflammation and calciphylaxis.

Calciphylaxis also known as calcific uraemic arteriolopathy is a rare condition mostly seen in patients with end-stage kidney disease. We report a case of a simultaneous-kidney-pancreas transplant patient with functioning grafts developing biopsy-proven calciphylaxis in the setting of chronic inflammation. Despite several modalities of management, the patient developed progression of her disease leading to multiple amputations. This case illustrates chronic inflammation driven by persistent infection as a probable contributing factor to the development and progression of calciphylaxis in a simultaneous kidney-pancreas recipient. Calciphylaxis should be considered in the differential for a painful, non-healing ulcer even in the absence of common risk factors.

Renin-angiotensin system blocker and the COVID-19 aggravation in patients with hypertension, diabetes, renal failure, Cerebro-cardiovascular disease, or pulmonary disease: Report by the COVID-19 Registry Japan.

BACKGROUND: The role of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB) in the pandemic context of coronavirus disease 2019 (COVID-19) continues to be debated. Patients with hypertension, diabetes mellitus, chronic renal failure, cerebro-cardiovascular disease, or chronic obstructive pulmonary disease (COPD), who often use ACEi/ARB, may be at risk of severe COVID-19. However, there are no data available on the association of ACEi/ARB use with COVID-19 severity in this population. METHODS: This study is an observational study of patients with a positive severe acute respiratory syndrome coronavirus 2 test and inpatient treatment at a healthcare facility, using the registry information of COVIREGI-JP. Our primary outcomes were in-hospital death, ventilator support, extracorporeal membrane oxygenation support, and intensive care unit admission. Out of the 6055 patients, 1921 patients with preexisting hypertension, diabetes mellitus, chronic renal failure, cerebro-cardiovascular disease, or COPD were enrolled. RESULTS: Factors associated with an increased risk of the primary outcomes were aging, male sex, COPD, severe renal impairment, and diabetes mellitus. No correlations were observed with ACEi/ARB, cerebro-cardiovascular diseases, or hypertension. Associated factors in male patients were aging, renal impairment, hypertension, and diabetes. In female patients, factors associated with an increased risk were aging, ACEi/ARB, renal impairment, and diabetes, whereas hypertension was associated with a lower risk of the primary outcomes. CONCLUSIONS: Independent factors for the primary outcomes were aging, male sex, COPD, severe renal impairment, and diabetes, but not ACEi/ARB. Based on this registry data analysis, more detailed data collection and analysis is needed with the cooperation of multiple healthcare facilities.