Coronavirus disease 2019 in chronic kidney disease

Unhealthy Food Consumption Is Associated with Post-Acute Sequelae of COVID-19 in Brazilian Elderly People

Background/Objectives: The factors associated with post-acute sequelae of COVID-19 (PASC) are not yet fully understood in developing countries. Our objective was to investigate the relationship between food consumption and the occurrence of PASC in Brazilian elderly people. Methods: This cross-sectional study included 1322 elderly people aged 60 or over, infected with SARS-CoV-2 in 2020, living in the state of Roraima in Brazil. Using the Brazilian National Food and Nutrition Surveillance System (SISVAN, in Portuguese) tool, food consumption markers were evaluated. The persistence of post-acute sequelae of COVID-19 was assessed three months after SARS-CoV-2 infection. Poisson regression with robust variance was performed to estimate the prevalence ratio (PR) with a 95% confidence interval (95% CI). Results: Fruit consumption [PR 0.92; 95% CI: 0.85-0.99] was associated with a lower occurrence of PASC, with a significant interaction in individuals aged 60 to 69 years old, not hospitalized, and those without chronic kidney disease. In addition, the consumption of sugar-sweetened beverages [PR 1.23; 95% CI: 1.12-1.35], sandwich cookies, sweets, and treats [PR 1.12; 95% CI 1.03-1.22] was positively associated with the occurrence of PASC in the elderly people, with a significant interaction in individuals living in the capital and without hypercholesterolemia. Conclusions: Unhealthy food consumption was associated with PASC in Brazilian elderly people. An improvement in the diet quality of elderly people is necessary to minimize health complications in PASC.

Chronic kidney disease amplifies severe kidney injury and mortality in a mouse model of skin arsenical exposure

In previously published work, we elucidated the role of cutaneous arsenical exposure in promoting acute kidney injury (AKI) in adult healthy mice. Here, we determine whether preexisting chronic kidney disease (CKD) increases the severity of AKI. Following exposure to aristolochic acid (AA) (a nephrotoxic phytochemical in humans), mice manifested classical markers of CKD, including robust interstitial fibrosis and loss in kidney function. Skin challenge with phenylarsine oxide (PAO), a surrogate for warfare arsenicals, led to significantly worse kidney injury, as evidenced by tubulointerstitial fibrosis, glomerulosclerosis, a persistent loss of estimated glomerular filtration rate, and mortality in AA-induced CKD mice compared with mice without CKD. These PAO-challenged CKD mice exhibited enhanced production of serum/urine neutrophil gelatinase-associated lipocalin and a significant rise in serum creatinine along with histological markers of kidney injury, including brush border loss, tubular atrophy, cast formation, glomerular injury, and interstitial inflammatory cell infiltration. Serum cytokines IL-4, IL-6, IFN-γ, IL-12p70, TNF-α, and IL-18 significantly elevated in CKD mice following PAO exposure when compared with animals exposed to PAO alone. Furthermore, we found increased TUNEL-positive tubular cells in the kidneys of CKD mice following PAO exposure, suggesting enhanced PAO-mediated cell death in CKD mice. Mechanistically, we determined that DNA damage-regulated p53 signaling was a major mediator of cellular responses to PAO in CKD mice. In summary, our data demonstrate that CKD significantly increased the severity of AKI following exposure to arsenicals and suggest that human populations with preexisting CKD could be highly susceptible to arsenical-mediated kidney injury and associated morbidity and mortality.NEW & NOTEWORTHY Preexisting chronic kidney disease (CKD) predisposes experimental animals to augmented morbidity and mortality following cutaneous vesicant exposure. The mechanism underlying increased susceptibility to renal injury and associated morbidity involves the DNA damage-regulated p53 signaling pathway.

Impact of COVID-19 on preexisting comorbidities

COVID-19 is a highly contagious viral disease caused by SARS-CoV-2, leading to a tragic global pandemic, where it was ranked in 2020 as the third leading cause of death in the USA, causing approximately 375,000 deaths, following heart disease and cancer. The CDC reports that the risk of death increases with age and preexisting comorbidities such as such as hypertension, diabetes, respiratory system disease, and cardiovascular disease. this report will delineate and analyze the paramount comorbidities and their repercussions on individuals infected with SARS-CoV-2.

Fungal infection-related conditions and outcomes in severe COVID-19: a nationwide case-control study

BACKGROUND

Fungal infections are significant complications of severe coronavirus disease 2019 (COVID-19). Although various risk factors for poor outcomes in patients with COVID-19 have been identified, clinical and treatment factors associated with fungal infections in patients with severe COVID-19 remain unclear. This study aimed to elucidate clinical factors associated with fungal infections during severe COVID-19 treatment.

METHODS

This was a post hoc analysis of the J-RECOVER study, a multicenter retrospective observational study involving patients with COVID-19 who required admission at 66 hospitals between January and September 2020. Inclusion criteria were ages ≥ 18 years, COVID-19 diagnosis with reverse-transcription polymerase chain reaction, and treatment with mechanical ventilation (MV). Patients who received antifungal drugs before MV were excluded. Potential predictors were identified through univariate analysis of patient and treatment characteristics between patients with- and those without fungal infection, which was defined as antifungal agent use for ≥ 5 days. To account for facility-specific data clustering, generalized estimating equations (GEE) were employed as adjusted analyses to calculate the relative risks of potentially associated factors. Two sensitivity analyses were performed with modified definitions for the two groups: patients who received antifungal drugs for ≤ 4 days were excluded, and fungal infection was re-defined as antifungal drug use for ≥ 14 days.

RESULTS

Among 4,915 patients in the J-RECOVER study, 559 adults with COVID-19 who required MV were included. Fungal infections occurred in 57 (10.2%) patients. Univariate analyses identified age, age ≥ 65 years, D-dimer level, remdesivir use, steroid use, and duration of steroid therapy as potential predictors of fungal infections. Multivariate analysis using GEE on these six factors revealed that only the duration of steroid use was significantly associated with an increased risk of fungal infection (odds ratio [OR] for a day increase: 1.01; 95% confidence interval [CI]: 1.00-1.01; p < 0.001). The two sensitivity analyses similarly showed that the duration of steroid use was associated with fungal infection (odds ratio for a day increase: 1.01; 95% CI: 1.00-1.01; p < 0.001 for both).

CONCLUSIONS

In patients with severe COVID-19 requiring MV, each additional day of steroid use was associated with prolonged use of antifungal medications for ≥ 5 days.

High inflammatory indices are significant predictors of disease severity in maintenance hemodialysis patients with COVID-19: A cross-sectional study

Background

The patients with kidney failure who undergo maintenance hemodialysis (MHD) at high risk of morbidity and mortality from COVID-19. Previous studies showed that inflammation plays an important role in the progression of COVID-19. This study aimed to evaluate the prognostic value of the inflammatory indices in MHD patients with COVID-19.

Methods

We included 141 patients receive MHD in this single-center. SARS-CoV-2 infection was confirmed by a positive result in RT-PCR analysis of nasal and pharyngeal swab samples, and the demographic, clinical, and laboratory data from December 1, 2022, to January 31, 2023 were reviewed. Inflammatory indices including PLR, NLR and SII were calculated. Binary logistics regression was used to examine the association between inflammatory indices and SARS-CoV-2 infection in MHD patients. The ROC curves were used to detect the sensitivity and specificity of these inflammatory indices in prediction of SARS-CoV-2 infection status in MHD patients.

Results

SARS-CoV-2 infection was detected in 76.43 % of the 141 MHD patients. Lymphocyte (LY), aspartate transaminase (AST), blood urea nitrogen (BUN), uric acid (UA), PLR, NLR and SII were significant predictors of no SARS-CoV-2 infection and symptomatic SARS-CoV-2 infection. In addition, LY, serum ferritin (SF), AST, BUN, UA, PLR and NLR were significant predictors of asymptomatic SARS-CoV-2 infection and symptomatic SARS-CoV-2 infection. The ROC curves showed the best sensitivity and specificity of PLR (66.7 % sensitivity; 68.8 % specificity) and NLR (51.9 % sensitivity; 86.3 % specificity) in predicting symptomatic SARS-CoV-2 infection.

Conclusion

PLR and NLR can be used as simple and inexpensive biomarkers in predicting the prognosis of COVID-19 in MHD patients.

Prognostic significance of chronic kidney disease and impaired renal function in Japanese patients with COVID-19

BACKGROUND

Renal impairment is a predictor of coronavirus disease (COVID-19) severity. No studies have compared COVID-19 outcomes in patients with chronic kidney disease (CKD) and patients with impaired renal function without a prior diagnosis of CKD. This study aimed to identify the impact of pre-existing impaired renal function without CKD on COVID-19 outcomes.

METHODS

This retrospective study included 3,637 patients with COVID-19 classified into three groups by CKD history and estimated glomerular filtration rate (eGFR) on referral: Group 1 (n = 2,460), normal renal function without a CKD history; Group 2 (n = 905), impaired renal function without a CKD history; and Group 3 (n = 272), history of CKD. We compared the clinical characteristics of these groups and assessed the effect of CKD and impaired renal function on critical outcomes (requirement for respiratory support with high-flow oxygen devices, invasive mechanical ventilation, or extracorporeal membrane oxygen, and death during hospitalization) using multivariable logistic regression.

RESULTS

The prevalence of comorbidities (hypertension, diabetes, and cardiovascular disease) and incidence of inflammatory responses (white blood counts, and C-reactive protein, procalcitonin, and D-dimer levels) and complications (bacterial infection and heart failure) were higher in Groups 2 and 3 than that in Group 1. The incidence of critical outcomes was 10.8%, 17.7%, and 26.8% in Groups 1, 2, and 3, respectively. The mortality rate and the rate of requiring IMV support was lowest in Group 1 and highest in Group 3. Compared with Group 1, the risk of critical outcomes was higher in Group 2 (adjusted odds ratio [aOR]: 1.32, 95% confidence interval [CI]: 1.03-1.70, P = 0.030) and Group 3 (aOR: 1.94, 95% CI: 1.36-2.78, P < 0.001). Additionally, the eGFR was significantly associated with critical outcomes in Groups 2 (odds ratio [OR]: 2.89, 95% CI: 1.64-4.98, P < 0.001) and 3 (OR: 1.87, 95% CI: 1.08-3.23, P = 0.025) only.

CONCLUSIONS

Clinicians should consider pre-existing CKD and impaired renal function at the time of COVID-19 diagnosis for the management of COVID-19.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Immunosenescence, gut dysbiosis, and chronic kidney disease: Interplay and implications for clinical management

Immunosenescence refers to the immune system changes observed in individuals over 50 years old, characterized by diminished immune response and chronic inflammation. Recent investigations have highlighted similar immune alterations in patients with reduced kidney function. The immune system and kidney function have been found to be closely interconnected. Studies have shown that as kidney function declines, both innate and adaptive immunity are affected. Chronic kidney disease (CKD) patients exhibit decreased levels of naive and regular T cells, as well as naive and memory B cells, while memory T cell counts increase. Furthermore, research suggests that CKD and end-stage kidney disease (ESKD) patients experience early thymic dysfunction and heightened homeostatic proliferation of naive T cells. In addition to reduced thymic T cell production, CKD patients display shorter telomeres in both CD4+ and CD8+ T cells. Declining kidney function induces uremic conditions, which alter the intestinal metabolic environment and promote pathogen overgrowth while reducing diversity. This dysbiosis-driven imbalance in the gut microbiota can result in elevated production of uremic toxins, which, in turn, enter the systemic circulation due to compromised gut barrier function under uremic conditions. The accumulation of gut-derived uremic toxins exacerbates local and systemic kidney inflammation. Immune-mediated kidney damage occurs due to the activation of immune cells in the intestine as a consequence of dysbiosis, leading to the production of cytokines and soluble urokinase-type plasminogen activator receptor (suPAR), thereby contributing to kidney inflammation. In this review, we delve into the fundamental mechanisms of immunosenescence in CKD, encompassing alterations in adaptive immunity, gut dysbiosis, and an overview of the clinical findings pertaining to immunosenescence.

A narrative review on adverse drug reactions of COVID-19 treatments on the kidney

Studies showed that the respiratory is not the only system affected by coronavirus 2, while cardiovascular, digestive, and nervous systems, as well as essential organs such as the kidneys, can be affected by this virus. In this review, we have studied the epidemiology, clinical, and laboratory findings on COVID-19 infection renal involvement, mortality, physiopathology, remaining renal sequels after recovery, underlying renal disease, and renal injury due to its treatment. Also, protective measures for kidney injury are explained in three levels. Evidence of viral particles and genome in the urine and renal tubular cells and signs of damage such as microangiopathy, hypercoagulopathy, and fibrosis are found in COVID-19 patients. The result of this study showed, in hospitalized COVID-19 patients, that the rate of acute kidney injury (AKI) was up to 46%, with a mortality ranging from 11 to 96%. A considerable proportion of patients with AKI would remain on renal replacement therapy. Proteinuria and hematuria are observed in 87 and 75% patients, and increased Cr and glomerular filtration rate (GFR) <60 ml/min per 1.73 m2 are observed in 29.6 and 35.3% of the patients, respectively. Remedsivir is considered to have adverse effects on GFR. COVID-19 patients need special attention to prevent AKI. Those with underlying chronic kidney disease or AKI need proper and explicit evaluation and treatment to improve their prognosis and decrease mortality, which should not be limited to the hospitalization period.

Chronic kidney disease in the shadow of COVID-19: insights from the bibliometric analysis

OBJECTIVE

This study aims to present the current status and frontiers of research on COVID-19 in relation to chronic kidney disease through bibliometric analysis and visualization.

METHODS

Access to information through the Web of Science Core Collection, retrieved from December 2019 to May 2023. The bibliometric visualization of countries, institutions, and keywords was analyzed using VOSviewer.

RESULTS

A total of 1038 publications are included. The global scientific community showed a high level of collaborative consensus. The three countries with the most publications are the USA, China, and the UK. The institution with the most publications is Harvard Medical School. The research frontier for 2020 is thrombosis, for 2021 is telemedicine, for 2022 is depression, and for 2019-2023 is the COVID-19 vaccines.

CONCLUSIONS

This is the first bibliometric report to establish a link between COVID-19 and CKD. The USA, China, and some European countries and their institutions are major contributors to these publications. Thrombosis, telemedicine, depression, and COVID-19 vaccines are current hot topics in the field and have the potential to shape future research trends.

SCARF Genes in COVID-19 and Kidney Disease: A Path to Comorbidity-Specific Therapies

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), which has killed ~7 million persons worldwide. Chronic kidney disease (CKD) is the most common risk factor for severe COVID-19 and one that most increases the risk of COVID-19-related death. Moreover, CKD increases the risk of acute kidney injury (AKI), and COVID-19 patients with AKI are at an increased risk of death. However, the molecular basis underlying this risk has not been well characterized. CKD patients are at increased risk of death from multiple infections, to which immune deficiency in non-specific host defenses may contribute. However, COVID-19-associated AKI has specific molecular features and CKD modulates the local (kidney) and systemic (lung, aorta) expression of host genes encoding coronavirus-associated receptors and factors (SCARFs), which SARS-CoV-2 hijacks to enter cells and replicate. We review the interaction between kidney disease and COVID-19, including the over 200 host genes that may influence the severity of COVID-19, and provide evidence suggesting that kidney disease may modulate the expression of SCARF genes and other key host genes involved in an effective adaptive defense against coronaviruses. Given the poor response of certain CKD populations (e.g., kidney transplant recipients) to SARS-CoV-2 vaccines and their suboptimal outcomes when infected, we propose a research agenda focusing on CKD to develop the concept of comorbidity-specific targeted therapeutic approaches to SARS-CoV-2 infection or to future coronavirus infections.

The Impact of the COVID-19 Pandemic on Patients With CKD: Systematic Review of Qualitative Studies

RATIONALE & OBJECTIVE

COVID-19 disproportionately affects people with comorbidities, including chronic kidney disease (CKD). We describe the impact of COVID-19 on people with CKD and their caregivers.

STUDY DESIGN

A systematic review of qualitative studies.

SETTING & STUDY POPULATIONS

Primary studies that reported the experiences and perspectives of adults with CKD and/or caregivers were eligible.

SEARCH STRATEGY & SOURCES

MEDLINE, Embase, PsycINFO, CINAHL searched from database inception to October 2022.

DATA EXTRACTION

Two authors independently screened the search results. Full texts of potentially relevant studies were assessed for eligibility. Any discrepancies were resolved by discussion with another author.

ANALYTICAL APPROACH

A thematic synthesis was used to analyze the data.

RESULTS

Thirty-four studies involving 1,962 participants were included. Four themes were identified: exacerbating vulnerability and distress (looming threat of COVID-19 infection, intensifying isolation, aggravating pressure on families); uncertainty in accessing health care (overwhelmed by disruption of care, confused by lack of reliable information, challenged by adapting to telehealth, skeptical about vaccine efficacy and safety); coping with self-management (waning fitness due to decreasing physical activity, diminishing ability to manage diet, difficulty managing fluid restrictions, minimized burden with telehealth, motivating confidence and autonomy); and strengthening sense of safety and support (protection from lockdown restrictions, increasing trust in care, strengthened family connection).

LIMITATIONS

Non-English studies were excluded, and inability to delineate themes based on stage of kidney and treatment modality.

CONCLUSIONS

Uncertainty in accessing health care during the COVID-19 pandemic exacerbated vulnerability, emotional distress, and burden, and led to reduced capacity to self-manage among patients with CKD and their caregivers. Optimizing telehealth and access to educational and psychosocial support may improve self-management and the quality and effectiveness of care during a pandemic, mitigating potentially catastrophic consequences for people with CKD.

PLAIN-LANGUAGE SUMMARY

During the COVID-19 pandemic, patients with chronic kidney disease (CKD) faced barriers and challenges to accessing care and were at an increased risk of worsened health outcomes. To understand the perspectives about the impact of COVID-19 among patients with CKD and their caregivers, we conducted a systematic review of 34 studies involving 1,962 participants. Our findings demonstrated that uncertainty in accessing care during the COVID-19 pandemic exacerbated the vulnerability, distress, and burden of patients and impaired their abilities for self-management. Optimizing the use of telehealth and providing education and psychosocial services may mitigate the potential consequences for people with CKD during a pandemic.

From past to present: Exploring COVID-19 in Qatar's hemodialysis population across Omicron dominant and pre-Omicron periods

COVID-19 carries a high risk of morbidity and mortality in dialysis patients. Multiple SARS-CoV-2 variants have been identified since the start of the COVID-19 pandemic. The current study aimed to compare the incidence and outcomes of the COVID-19 Omicron dominant period versus other pre-Omicron period in hemodialysis patients. In this observational, analytical, retrospective, nationwide study, we reviewed adult chronic hemodialysis patients between March 1, 2020, and January 31, 2022. Four hundred twenty-one patients had COVID-19 during the study period. The incidence of COVID-19 due to the Omicron dominant period was significantly higher than other pre-Omicron period (30.3% vs. 18.7%, P<0.001). In contrast, the admission rate to ICU was significantly lower in the Omicron dominant period than in the pre-Omicron period (2.8% vs. 25%, P<0001) but with no significant difference in ICU length of stay. The mortality rate was lower in the Omicron dominant period compared to the pre-Omicron period (2.4% vs. 15.5%, P<0.001). Using multivariate analysis, older age [OR 1.093 (95% CI 1.044-1.145); P<0.0001] and need for mechanical ventilation [OR 70.4 (95% CI 20.39-243.1); P<0.0001] were identified as two independent risk factors for death in hemodialysis patients with COVID-19. In Conclusion, the COVID-19 Omicron variant had a higher incidence and lower morbidity and mortality than pre-Omicron period in our hemodialysis population.

The relationship between CT value and clinical outcomes in renal patients with COVID-19

PURPOSE

Concomitant kidney diseases raise the mortality rate due to the SARS-CoV-2 virus as an independent factor. Although a qualitative PCR test's result is sufficient for diagnosis, Cycle threshold value may present relevant information to the physicians in providing faster treatment in patients with chronic conditions, including kidney diseases, to prevent morbidity and subsequent mortality. Thus, the present study was conducted to determine the relationship between the Cycle threshold value and clinical outcomes in renal patients with the coronavirus 2019.

METHODS

This retrospective study was conducted on renal patients with the coronavirus 2019 infection admitted to Labbafinejad Hospital in Tehran, the capital of Iran, within a period of one year, from late February 2020 to February 2021. Data were collected per the prepared checklist. Cycle threshold values were measured by performing PCR on nasopharynx and oropharynx swab samples of patients.

RESULTS

According to the adjusted analysis, having high viral load increased the odds of in-hospital mortality (aOR = 11.65, 95% CI 3.93-34.54), ICU admission (aOR = 5.49, 95% CI 2.16-13.97), and invasive ventilation (aOR = 7.18, 95% CI 2.61-19.74). Having high viral load also increased the odds of O2 therapy (aOR = 3.08, 95% CI 0.79-12.01), although the difference was not statistically significant (P = 0.105).

CONCLUSION

Cycle threshold value was a significant predictor of mortality in renal patients. Nevertheless, further studies are required on how to render optimal use of the Cycle threshold value, given that the quality of the test sample and the different groups of patients under study affect the effectiveness of this marker in predicting disease severity.

Real-World Effectiveness of SARS-CoV-2 Vaccine Booster in Hemodialysis Patients with COVID-19 Receiving Molnupiravir

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine booster is one of the most essential strategies against coronavirus disease 2019 (COVID-19) in the era of emerging variants. However, the effectiveness of SARS-CoV-2 vaccine boosters has not much been investigated in hemodialysis (HD) patients receiving oral antiviral agents. In this retrospective study involving 258 HD patients with COVID-19 receiving molnupiravir, we stratified the study cohort according to vaccination status and compared the baseline characteristics and risks of 30-day composite events (COVID-19-related acute care visits, hospitalization, or mortality) among groups. Our analysis demonstrated that the SARS-CoV-2 vaccine boosters markedly decreased the risk of composite events in HD patients (hazard ratio (95% confidence interval), 0.163 (0.063-0.423) for three vs. ≤ two doses of vaccination, p < 0.001; 0.309 (0.115-0.830) for four vs. ≤ two doses of vaccination, p = 0.020). The benefits of vaccine boosters were similar between patients receiving mRNA-based and protein-based boosters and between those with post-booster intervals of ≤ 120 and > 120 days. In conclusion, for HD patients with initially mild or asymptomatic COVID-19 receiving molnupiravir, the benefits of SARS-CoV-2 vaccine boosters are prominent, irrespective of booster vaccine types.

Sex differences in determinants of COVID-19 severe outcomes - findings from the National COVID Cohort Collaborative (N3C)

OBJECTIVE

The impact of comorbidities and biomarkers on COVID-19 severity vary by sex but have not yet been verified in population-based studies. We examined the association of comorbidities, inflammatory biomarkers, and severe outcomes in men and women hospitalized for COVID-19.

DESIGN

This is a retrospective cohort analysis based on the National COVID Cohort Collaborative (N3C). We included 574,391 adult patients admitted for COVID-19 at hospitals or emergency rooms between 01/01/2020 and 12/31/2021.

METHODS

We defined comorbidities at or before the first admission for COVID-19 by Charlson Comorbidity Index (CCI) and CCI components. We used the averaged lab values taken within 15 days before or after the admission date to measure biomarkers including c-reactive protein (CRP), ferritin, procalcitonin, N-terminal pro b-type natriuretic peptide (NT proBNP), d-dimer, absolute lymphocyte counts, absolute neutrophil counts, and platelets. Our primary outcome was all-cause mortality; secondary outcomes were invasive mechanical ventilation (IMV) and hospital length of stay (LOS). We used logistic regression adjusted for age, race, ethnicity, visit type, and medications to assess the association of comorbidities, biomarkers, and mortality disaggregating by sex.

RESULTS

Moderate to severe liver disease, renal disease, metastatic solid tumor, and myocardial infarction were the top four fatal comorbidities among patients who were hospitalized for COVID-19 (adjusted odds ratio [aOR] > 2). These four comorbid conditions remained the most lethal in both sexes, with a higher magnitude of risk in women than in men (p-interaction < 0.05). Abnormal elevations of CRP, ferritin, procalcitonin, NT proBNP, neutrophil, and platelet counts, and lymphocytopenia were significantly associated with the risk of death, with procalcitonin and NT proBNP as the strongest predictors (aOR > 2). The association between the abnormal biomarkers and death was stronger in women than in men (p-interaction < 0.05).

CONCLUSION

There are sex differences in inpatient mortality associated with comorbidities and biomarkers. The significant impact of these clinical determinants in women with COVID-19 may be underappreciated as previous studies stressed the increased death rate in male patients that is related to comorbidities or inflammation. Our study highlights the importance and the need for sex-disaggregated research to understand the risk factors of poor outcomes and health disparities in COVID-19.

Impaired kidney function biomarkers and risk of severe COVID-19: Analysis of population-based cohort data

BACKGROUND

Patients with impaired kidney function were found at a high risk of COVID-19 hospitalization and mortality in many observational, cross-sectional, and hospital-based studies, but evidence from large-scale prospective cohorts has been lacking. We aimed to examine the association of kidney function-related biomarkers and their genetic predisposition with the risk of developing severe COVID-19 in population-based data.

METHODS

We analyzed data from UK Biobank to examine the prospective association of abnormal kidney function biomarkers with severe COVID-19, defined by laboratory-confirmed COVID-19 hospitalizations. Using genotype data, we constructed polygenic risk scores (PRS) to represent an individual's overall genetic risk for these biomarkers. We also identified tipping points where the risk of severe COVID-19 began to increase significantly for each biomarker.

RESULTS

Of the 502,506 adults, 1650 (0.32%) were identified as severe COVID-19, before August 12, 2020. High levels of cystatin C (OR: 1.3; 95% CI: 1.2-1.5; FDR = 1.5 × 10^-5 ), serum creatinine (OR: 1.7; 95% CI: 1.3-2.1; p = 3.5 × 10^-4 ; FDR = 3.5 × 10^-4 ), microalbuminuria (OR: 1.4; 95% CI: 1.2-1.6; FDR = 4 × 10^-4 ), and UACR (urinary albumin creatinine ratio; OR: 1.4; 95% CI: 1.2-1.6; p = 3.5 × 10^-4 ; FDR = 3.5 × 10^-4 ) were found significantly associated with severe COVID-19. Individuals with top 10% of PRS for elevated cystatin C, urate, and microalbuminuria had 28% to 43% higher risks of severe COVID-19 than individuals with bottom 30% PRS (p < 0.05). Tipping-point analyses further supported that severe COVID-19 could occur even when the values of cystatin C, urate (male), and microalbuminuria were within their normal value ranges (OR >1.1, p < 0.05).

CONCLUSIONS

Findings from this study might point to new directions for clinicians and policymakers in optimizing risk-stratification among patients based on polygenic risk estimation and tipping points of kidney function markers. Our results call for further investigation to develop a better strategy to prevent severe COVID-19 outcomes among patients with genetic predisposition to impaired kidney function. These findings could provide a new tool for clinicians and policymakers in the future especially if we need to live with COVID-19 for a long time.

COVID-19 and Kidney Disease: Progress in Health Inequity From Low-Income Settings

The acute coronavirus disease-2019 (COVID-19) pandemic has had a significant impact on the incidence and prevalence of acute kidney injury and chronic kidney disease globally and in low-income settings. Chronic kidney disease increases the risk of developing COVID-19 and COVID-19 causes acute kidney injury directly or indirectly and is associated with high mortality in severe cases. Outcomes of COVID-19-associated kidney disease were not equitable globally owing to a lack of health infrastructure, challenges in diagnostic testing, and management of COVID-19 in low-income settings. COVID-19 also significantly impacted kidney transplant rates and mortality among kidney transplant recipients. Vaccine availability and uptake remains a significant challenge in low- and lower-middle-income countries compared with high-income countries. In this review, we explore the inequities in low- and lower-middle-income countries and highlight the progress made in the prevention, diagnosis, and management of patients with COVID-19 and kidney disease. We recommend further studies into the challenges, lessons learned, and progress made in the diagnosis, management, and treatment of patients with COVID-19-related kidney diseases and suggest ways to improve the care and management of patients with COVID-19 and kidney disease.

Identifying factors contributing to increased susceptibility to COVID-19 risk: a systematic review of Mendelian randomization studies

BACKGROUND

To summarize modifiable factors for coronavirus disease 2019 (COVID-19) suggested by Mendelian randomization studies.

METHODS

In this systematic review, we searched PubMed, EMBASE and MEDLINE, from inception to 15 November 2021, for Mendelian randomization studies in English. We selected studies that assessed associations of genetically predicted exposures with COVID-19-related outcomes (severity, hospitalization and susceptibility). Risk of bias of the included studies was evaluated based on the consideration of the three main assumptions for instrumental variable analyses.

RESULTS

We identified 700 studies through systematic search, of which 50 Mendelian randomization studies were included. Included studies have explored a wide range of socio-demographic factors, lifestyle attributes, anthropometrics and biomarkers, predisposition to diseases and druggable targets in COVID-19 risk. Mendelian randomization studies suggested that increases in smoking, obesity and inflammatory factors were associated with higher risk of COVID-19. Predisposition to ischaemic stroke, combined bipolar disorder and schizophrenia, attention-deficit and hyperactivity disorder, chronic kidney disease and idiopathic pulmonary fibrosis was potentially associated with higher COVID-19 risk. Druggable targets, such as higher protein expression of histo-blood group ABO system transferase (ABO), interleukin (IL)-6 and lower protein expression of 2'-5' oligoadenylate synthetase 1 (OAS1) were associated with higher risk of COVID-19. There was no strong genetic evidence supporting the role of vitamin D, glycaemic traits and predisposition to cardiometabolic diseases in COVID-19 risk.

CONCLUSION

This review summarizes modifiable factors for intervention (e.g. smoking, obesity and inflammatory factors) and proteomic signatures (e.g. OAS1 and IL-6) that could help identify drugs for treating COVID-19.

Liver Function Tests in COVID-19: Assessment of the Actual Prognostic Value

Deviations in laboratory tests assessing liver function in patients with COVID-19 are frequently observed. Their importance and pathogenesis are still debated. In our retrospective study, we analyzed liver-related parameters: aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyltransferase (GGT), total bilirubin (TBIL), albumin, comorbidities and other selected potential risk factors in patients admitted with SARS-CoV-2 infection to assess their prognostic value for intensive care unit admission, mechanical ventilation necessity and mortality. We compared the prognostic effectiveness of these parameters separately and in pairs to the neutrophil-to-lymphocyte ratio (NLR) as an independent risk factor of in-hospital mortality, using the Akaike Information Criterion (AIC). Data were collected from 2109 included patients. We created models using a sample with complete laboratory tests n = 401 and then applied them to the whole studied group excluding patients with missing singular variables. We estimated that albumin may be a better predictor of the COVID-19-severity course compared to NLR, irrespective of comorbidities (p < 0.001). Additionally, we determined that hypoalbuminemia in combination with AST (OR 1.003, p = 0.008) or TBIL (OR 1.657, p = 0.001) creates excellent prediction models for in-hospital mortality. In conclusion, the early evaluation of albumin levels and liver-related parameters may be indispensable tools for the early assessment of the clinical course of patients with COVID-19.

Mortality and risk factors for COVID-19 in hemodialysis patients: A systematic review and meta-analysis

Introduction: The present study systematically reviewed the clinical features and risk factors in patients undergoing maintenance hemodialysis (MHD) who also acquired coronavirus disease 2019 (COVID-19). More specifically, clinical manifestations, prognosis, and risk factors for death among this population were explored. Method: A literature search using the PubMed, Web of Science, and Embase databases, for articles involving patients with laboratory-confirmed COVID-19 and undergoing MHD published between January 1, 2020, and March 13, 2022, was performed. Random-effects meta-analyses were performed to calculate the weighted mean prevalence and corresponding 95% confidence interval (CI) or weighted means and 95% CI. Heterogeneity among studies was assessed using I2 statistics. Results: Twenty-two studies including 13,191 patients with COVID-19 undergoing MHD were selected. The most common symptoms included fever (53% [95% CI 41%-65%]) and cough (54% [95% CI 48%-60%]); however, 17% (95% CI 11%-22%) of the cases were asymptomatic. In subgroup analysis, the proportion of male patients (65% [95% CI 58%-71%]), and patients with coronary artery disease (30% [95% CI 17%-44%) and chronic obstructive pulmonary disease (9% [95% CI 4%-15%]) was greater in the non-survivor group compared with the survivor group. Furthermore, patients undergoing MHD, who were also positive for COVID-19, exhibited a high mortality rate (24% [95% CI 19%-28%]). Conclusions: MHD patients with COVID-19 may initially present as asymptomatic or with mild symptoms; nevertheless, in this study, these patients exhibited a higher risk for death compared with COVID-19 patients not undergoing MHD. Moreover, male sex and underlying cardiovascular and respiratory diseases increased the mortality risk.

Neural Network Training with Highly Incomplete Medical Datasets

Neural network training and validation rely on the availability of large high-quality datasets. However, in many cases only incomplete datasets are available, particularly in health care applications, where each patient typically undergoes different clinical procedures or can drop out of a study. Since the data to train the neural networks need to be complete, most studies discard the incomplete datapoints, which reduces the size of the training data, or impute the missing features, which can lead to artefacts. Alas, both approaches are inadequate when a large portion of the data is missing. Here, we introduce GapNet, an alternative deep-learning training approach that can use highly incomplete datasets without overfitting or introducing artefacts. First, the dataset is split into subsets of samples containing all values for a certain cluster of features. Then, these subsets are used to train individual neural networks. Finally, this ensemble of neural networks is combined into a single neural network whose training is fine-tuned using all complete datapoints. Using two highly incomplete real-world medical datasets, we show that GapNet improves the identification of patients with underlying Alzheimer’s disease pathology and of patients at risk of hospitalization due to Covid-19. Compared to commonly used imputation methods, this improvement suggests that GapNet can become a general tool to handle incomplete medical datasets.

Association between chronic kidney disease and mortality in patients with a confirmed COVID-19 diagnosis

Objective

To determine the association between chronic kidney disease (CKD) and mortality in persons with a confirmed coronavirus disease 2019 (COVID-19) diagnosis.

Methods

Cross-sectional secondary baseline study. The study population consisted of 243,065 patients confirmed to have COVID-19 during May-December 2020. Stata 16.0 was used for statistical analysis, Chi-square test was used for bivariate analysis, and Poisson regression with robust variances was used for multiple analysis.

Results

The prevalence of patients with a confirmed COVID-19 diagnosis who had CKD and died was 1.42 times the prevalence of mortality in those without CKD. The comorbidities combined with CKD that presented the highest probability of mortality were diabetes mellitus and hypertension.

Conclusions

CKD is associated with a high mortality rate in patients with a confirmed COVID-19 diagnosis. Patients with CKD, diabetes mellitus, and arterial hypertension have a higher prevalence of mortality than those without comorbidities.

Chronic Kidney Disease and COVID-19: Outcomes of hospitalised adults from a tertiary care centre in North India

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a novel disease caused by the SARS-CoV-2 virus and has emerged as a deadly pandemic affecting countries all over the world. Here we share our experience of managing adults with chronic kidney disease (CKD) and concomitant COVID-19 infection jointly managed by pediatric and adult nephrology teams.

METHODS

This retrospective study was done on patient admissions (>18 years) between 20th June- 30th October 2020 with previously diagnosed CKD and hospitalised with COVID-19 infection. The demographic details, underlying comorbidities, clinical presentation, medications, laboratory, radiological profile and outcomes were studied.

RESULTS

A total of 213 adults (62% males) with CKD were admitted during this period with a median (IQR) age of 52 (42, 60) years; 75 (35.2%) had associated diabetes mellitus, 83.1% hypertension, 5.2% hypothyroidism and 7% coronary artery disease. 165 (77.5%) were on maintenance haemodialysis (MHD), and 72.8% had arteriovenous fistula as vascular access at presentation. Most (84.5%) patients were symptomatic for COVID-19, and about 2/3 diarrhoea had moderate to severe disease. Oxygen therapy was needed in 62.9%, and medications used were hydroxychloroquine in 84.5%, azithromycin in 21.6%, ivermectin in 82.6%, steroids in 63.8% and Low molecular weight heparin in 59.2%. A further comparison of patients with CKD5D and CKDND revealed similar parameters except for a higher incidence of diarrhoea, acute kidney injury (AKI) and a shorter period to RTPCR negativity (12.5 vs 15 days; P = 0.038) in CKDND. The overall mortality was 24.4%, with similar mortality rates in both groups (P = 0.709) and 20.7% needed ICU transfer.

CONCLUSIONS

Adults with CKD especially on haemodialysis, are prone to more severe COVID-19 infection and take a longer time for viral clearance (>2 weeks); the mortality too is higher in these patients.

Risk factors for COVID-19 severity and mortality among inpatients in Southern Iran

Introduction

COVID-19 is a highly contagious respiratory disease and many factors can affect its severity and mortality. This study aimed to investigate the risk factors associated with the severity and mortality of COVID-19.

Methods

In this cross-sectional study, 311 cases with COVID-19 approved by the CORONALAB database in the Center for Disease Control and Prevention (CDC) in southern Iran were selected using systematic random sampling from 15 May to 13 June 2020. The data were collected through interviews and phone calls using a researcher-made questionnaire.

Results

The mean age of the participants was 45.82 ± 17.92 years, and the male to female ratio was 1.57:1. In addition, the Case Fatality Rate (CFR) was 4.50%, and the disease was severe in 47.5% of the cases. The most common clinical symptoms were cough (39.22%), fever (31.83%), and dyspnea (24.76%). The severity of COVID-19 was significantly associated with age and history of Cardiovascular Disease (CVD). Besides, the mortality of COVID-19 was significantly related to age, gender, hypertension, CVD, and Chronic Kidney Disease (CKD). The mean interval between the onset of the first symptom and referral to a health center was 3.02 ± 2.82 days. Additionally, the mean interval between the referral to health centers and testing was 0.88 ± 2.20 days.

Conclusion

Older patients, males, and those who had CVD, CKD, and hypertension required accurate healthcare and early intervention to prevent the exacerbation of COVID-19. Furthermore, the interval between the onset of the first symptom and testing was relatively long. Overall, early diagnosis, isolation, and treatment of patients were found to be essential to control COVID-19.

Abrupt worsening of occult IgA nephropathy after the first dose of SARS-CoV-2 vaccination

Here, we report a case of abrupt onset of gross hematuria and nephrotic range proteinuria after the first dose of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination, which led to a diagnosis of immunoglobulin A nephropathy (IgAN). A Japanese woman in their forties with a significant medical history of occult blood by urine dipstick test (over the past 3 years) presented with fever, chills, shivering, marked thrombocytopenia, and gross hematuria 9 days after the first dose of the BNT162b2 mRNA vaccine (Pfizer) against SARS-CoV-2 infection. Although thrombotic microangiopathy (TMA) was first suspected as the cause of the severe thrombocytopenia, TMA was clinically excluded after two sessions of plasma exchange were performed. Renal biopsy was performed as the patient's platelet count improved. We made a diagnosis of acute worsening IgAN, triggered by the first dose of SARS-CoV-2 vaccination. In this case, we speculated that vaccine-induced immune activation may be involved in the exacerbation of occult IgAN, leading to the definite diagnosis. We should pay more attention to the development/worsening of clinically significant kidney disease after SARS-CoV-2 vaccination not only in those with known glomerular disease but also in those with only mild urinary abnormality.

OUP accepted manuscript

The year 2021 was the last full year of Alberto Ortiz’s editorship at Clinical Kidney Journal (CKJ). On May 2022, Maria José Soler will start her term as the Editor-in-Chief. Over these years, CKJ obtained its first journal impact factor and has consolidated its position among the top journals in the field, consistently ranking among the top 25% (first quartile) journals in Urology and Nephrology. The 2020 journal impact factor rose to 4.45, becoming the top open access journal in Nephrology and the ninth ranked Nephrology journal overall. We now review the recent history of the journal and the most highly cited topics which include the epidemiology of kidney disease, chronic kidney disease topics, such as the assessment and treatment of chronic kidney disease, onconephrology, cardionephrology, glomerular disease, transplantation and coronavirus disease 2019 (COVID-19).

Characteristics of COVID-19 patients with preexisting CKD history

PURPOSE

This paper was intended to describe the characteristics of coronavirus disease 2019 (COVID-19) patients with known chronic kidney disease (CKD) history.

METHODS

Clinical information of 20 COVID-19 pneumonia patients with CKD history diagnosed between January 20th and March 1st, 2020 were collected in Tongji Hospital, Wuhan. We listed the clinical baseline data, laboratory findings, chest computed tomography (CT) changes and processed a short period of follow-up of these 20 patients.

RESULTS

Based on the estimated glomerular filtration rate (eGFR) on admission, 6 patients were classified as stage 2 of CKD, 5 were as 3a, 2 were as 3b, 3 were as 4 and 4 were as 5, respectively. COVID-19 patients with CKD history were elder and hypertension was the most common comorbidity. Cough and fever accounted for more than 80% of the infectious cases. Lymphopenia, increased D-dimer and elevated infectious indications such as hypersensitive C response protein (hsCRP), interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α) were also common among these patients. Ground-glass opacity (GGO) and consolidation were the major manifestations in CT scans. 4 patients died and 7 patients underwent acute kidney injury (AKI) during observation. Among 16 discharged patients, 12 were with stable renal function and 4 had deteriorating renal function compared with that of admission.

CONCLUSION

Compared to general population infected with SARS-CoV-2, COVID-19 patients with CKD history had a preference to develop to severity with higher fatality rate.

Cardiovascular complications after COVID-19 in chronic kidney disease, dialysis and kidney transplant patients

The coronavirus disease 2019 (COVID-19) is associated with increased mortality in patients with chronic kidney disease (CKD), dialysis patients and kidney transplant recipients (KTR). Cardiovascular complications, such as sudden arrhythmias, thromboembolic events, coronary events, cardiomyopathies and heart failure, may present in about 10–20% of patients with COVID-19. Patients with CKD, dialysis patients and KTR are all at increased cardiovascular risk and present with more cardiovascular complications after COVID-19 compared to the general population. During the pandemic, health care giving has rapidly changed by reducing elective outpatient reviews, which may refrain these high-risk patients from the appropriate management of their medical conditions, further increasing cardiovascular risk. Importantly, acute kidney injury (AKI) is another common complication of severe COVID-19 and associates with increased mortality. A large proportion of the AKI patients need renal replacement treatment, while 30% of them may not present renal function recovery and remain dialysis-dependent after discharge, thereby having potentially increased future cardiovascular risk. This review summarizes current knowledge regarding the cardiovascular events and mortality in patients with CKD or undergoing hemodialysis and in KTR.

Association Between Cardiovascular Risk Factors and the Severity of Coronavirus Disease 2019: Nationwide Epidemiological Study in Korea

Background: Acute respiratory viral infections can result in cardiovascular involvement, with such patients having a significantly higher mortality rate than those without cardiovascular involvement. Due to the ongoing coronavirus disease 2019 (COVID-19) pandemic, it is important to determine whether cardiovascular risk factors are associated with the severity of COVID-19.

Methods: These nationwide data were provided by the Korea Disease Control and Prevention Agency. We defined a patient as having a “critical illness” if they required more than invasive mechanical ventilation and “fatal illness” if they died.

Results: Among the total 5,307 patients, 2,136 (40.8%) were male. The critical illness rate was 5.1% (males: 6.7, females: 4.0%) and the fatality rate was 4.54%. The multivariable analysis showed that age ≥60 years, male sex, diabetes mellitus, hypertension, heart failure, chronic kidney disease, cancer, and dementia were independent risk factors for critical illness. The risk scoring model showed the significance of multiple risk factors. Patients with four risk factors; old age (≥60 years), male sex, hypertension, and diabetes mellitus had a more than a 100 times higher risk for severe COVID-19 than those without these risk factors (OR; 95% confidence interval, 104; 45.6–240.6 for critical, 136.2; 52.3–3547.9 for fatal illness).

Conclusions: This study demonstrated that cardiovascular risk factors are also significant risk factors for severe COVID-19. In particular, patients who have multiple cardiovascular risk factors are more likely to progress to severe COVID-19. Therefore, early and appropriate treatment of these patients is crucial.

Clinical Characteristics and Outcomes of COVID-19 Patients Hospitalized in Intensive Care Unit

BACKGROUND

Meta-analysis and clinical studies suggest coronavirus disease-2019 (COVID-19) patients in ICU have a high mortality rate of 30-45%, which has evolved as a function of criteria of admission and the management modalities.

MATERIALS AND METHODS

We conducted a retrospective evaluation for characteristics and outcomes in critical care set up across six months.

RESULTS

514 patients (74.3% males and 25.6% females) were evaluated. 9.72% (n = 50) patients expired, 78% (n = 39) were males. Mean age (years) was 57 (±14, range 64, 95% CI 55-58). 65.7% (n = 338) were of age more than 50 years, of which 71.5% (n = 242) were males. Males at 20% higher risk for death than women. (RR = 1.2, 95% CI 0.66-2.31, p = 0.61 NS). There was 18% less risk of mortality in female vs male with comorbidities (RR 0.82, 95% CI 0.67-1.12, p = 0.32 NS). Risk for mortality in diabetics was significantly increased by 116% vs nondiabetics. (RR 2.16, p = 0.0055, 95% CI 1.28-3.67). Highly significant risk of mortality in age group >50 years (3.13 times higher) vs age ≤50 years. (RR 3.18, 95% CI 1.71-8.64, p = 0.0003). 50.2% had moderate ARDS at admission. High flow nasal cannula was used in 47.2%. There is 5.79 times more likelihood to be on the ventilator with moderate to severe ARDS vs mild ARDS (RR = 5.79, 95% CI 3.10-11.05, p <0.0001). Risk for death was six times higher for patients on ventilator vs not on ventilator (RR = 6.08, 95% CI 3.49-10.59, p <0.0001). The mean number of days on ventilator for patients who underwent tracheostomy (n = 49) was 14 days as compared to 6.6 days in patients who were extubated (n = 57) (p <0.0001). P/F ratio had negative correlation with number of days of hospitalisation (Pearson r -0.391, 95% CI -0.46- -0.31, p <0.0001). 67% less chances of mortality in patients on steroids (RR = 0.33, 95% CI 0.19-60, p = 0.0012). Mean duration of ICU stay (days) was 8 (± 5, range 29, 95% CI 7.5-8.4).

CONCLUSIONS

We observed that a strict adherence to the basic principles of ARDS management resulted in a lower mortality in ICU setting.

HOW TO CITE THIS ARTICLE

Pandit RA, Gagana BN, Vaity C, Mulakavalupil B, Choudhary JS, Jain V, et al. Clinical Characteristics and Outcomes of COVID-19 Patients Hospitalized in Intensive Care Unit. Indian J Crit Care Med 2021;25(9):992-1000.

Incidence and Outcomes of COVID-19 in People With CKD: A Systematic Review and Meta-analysis

Rationale & Objective

Coronavirus disease 2019 (COVID-19) disproportionately affects people with chronic diseases such as chronic kidney disease (CKD). We assessed the incidence and outcomes of COVID-19 in people with CKD.

Study Design

Systematic review and meta-analysis by searching MEDLINE, EMBASE, and PubMed through February 2021.

Setting & Study Populations

People with CKD with or without COVID-19.

Selection Criteria for Studies

Cohort and case-control studies.

Data Extraction

Incidences of COVID-19, death, respiratory failure, dyspnea, recovery, intensive care admission, hospital admission, need for supplemental oxygen, hospital discharge, sepsis, short-term dialysis, acute kidney injury, and fatigue.

Analytical Approach

Random-effects meta-analysis and evidence certainty adjudicated using an adapted version of GRADE (Grading of Recommendations Assessment, Development and Evaluation).

Results

348 studies (382,407 participants with COVID-19 and CKD; 1,139,979 total participants with CKD) were included. Based on low-certainty evidence, the incidence of COVID-19 was higher in people with CKD treated with dialysis (105 per 10,000 person-weeks; 95% CI, 91-120; 95% prediction interval [PrI], 25-235; 59 studies; 468,233 participants) than in those with CKD not requiring kidney replacement therapy (16 per 10,000 person-weeks; 95% CI, 4-33; 95% PrI, 0-92; 5 studies; 70,683 participants) or in kidney or pancreas/kidney transplant recipients (23 per 10,000 person-weeks; 95% CI, 18-30; 95% PrI, 2-67; 29 studies; 120,281 participants). Based on low-certainty evidence, the incidence of death in people with CKD and COVID-19 was 32 per 1,000 person-weeks (95% CI, 30-35; 95% PrI, 4-81; 229 studies; 70,922 participants), which may be higher than in people with CKD without COVID-19 (incidence rate ratio, 10.26; 95% CI, 6.78-15.53; 95% PrI, 2.62-40.15; 4 studies; 18,347 participants).

Limitations

Analyses were generally based on low-certainty evidence. Few studies reported outcomes in people with CKD without COVID-19 to calculate the excess risk attributable to COVID-19, and potential confounders were not adjusted for in most studies.

Conclusions

The incidence of COVID-19 may be higher in people receiving maintenance dialysis than in those with CKD not requiring kidney replacement therapy or those who are kidney or pancreas/kidney transplant recipients. People with CKD and COVID-19 may have a higher incidence of death than people with CKD without COVID-19.

Efficacy and safety of convalescent plasma therapy in SARS-CoV2 patients on hemodialysis

Background

The passive immunization of patients with SARS‐CoV2 with convalescent plasma (CP) is theoretically beneficial in patients with end‐stage renal disease who are immunosuppressed and unable to mount an adequate immune response. Hence, this study was conducted to evaluate the safety and efficacy of CP in patients with chronic kidney disease on hemodialysis with moderate‐to‐severe SARS‐CoV2 infection.

Methods

A prospective observational cohort study was conducted in consecutive 68 moderate‐to‐severe SARS‐CoV2 infected patients who were on maintenance hemodialysis or with acute worsening of chronic kidney disease which required initiation of hemodialysis. Patients who received CP were compared with those who did not. The primary outcome was death during hospitalization. Clinical characteristics, duration of hospitalization and inflammatory parameters were compared between the two groups. A subgroup analysis was done to find whether early initiation of plasma was associated with better outcome.

Results

Sixteen patients (44%) in the plasma group and 14 (45%) patients in the control group died during hospitalization (p = 0.95). The median duration of hospitalization was 9 (6–14) days in the plasma group and 9 (6–16) in the control group (p = 0.60). There was no difference in mortality or duration of hospitalization with respect to early initiation of CP (p = 0.29). Fistula thrombosis occurred in two patients (11.1%) in the plasma group.

Conclusion

Therapy with CP does not appear to confer any clinical benefit in moderate‐to‐severe SARS‐CoV‐2 infected patients with chronic kidney disease on hemodialysis.

Proportion and mortality of Iranian diabetes mellitus, chronic kidney disease, hypertension and cardiovascular disease patients with COVID-19: a meta-analysis

BACKGROUND

Currently, the number of patients with SARS-COV-2 infection has increased rapidly in Iran, but the risk and mortality of SARS-COV-2 infection in Iranian patients with diabetes mellitus (DM), chronic kidney disease (CKD), hypertension and cardiovascular diseases (CVDs) still not clear. The aim of this meta-analysis was to estimate the proportion and mortality of SARS-COV-2 in these patients.

METHODS

A comprehensive literature search was carried out in PubMed, Web of Sciences, Cochrane Library, EMBASE, CNKI, SciELO, and other databases to identify all relevant studies published up to 10 January, 2020. The proportion and mortality in the patients were assessed by odd ratio (OR) and the corresponding 95 % confidence interval (95 % CI).

RESULTS

A total of ten case-series including 11,755 cases with SARS-COV-2 infection and 942 deaths were selected. Among them, there were total of 791 DM patients with 186 deaths, 225 CKD patients with 45 deaths, 790 hypertension cases with 86 deaths, and 471 CVDs cases with 60 deaths. Pooled data revealed that the proportion of SARS-COV-2 infection in the patients with hypertension, DM, CVDs and CKD were 21.1 %, 16.3 %, 14.0 % and 5.0 %, respectively. Moreover, the SARS-COV-2 infection were associated with an increased risk of mortality in DM (OR = 0.549, CI 95 % 0.448-0.671, p ≤ 0.001) and CKD (OR = 0.552, 95 % CI 0.367-0.829, p = 0.004) patients, but not hypertension and CVDs. There was no publication bias.

CONCLUSIONS

Our pooled data showed that the proportion of SARS-COV-2 infection was the highest in the Iranian patients with hypertension (21.1 %) followed by DM (16.3 %), CVDs (14.0 %) and CKD (5.0 %). Moreover, DM and CKD in patients with SARS-COV-2 infection were associated with a 0.549 and 0.552-fold increase in mortality, respectively. Clinicians in Iran should be aware of these findings, to identifying patients at higher risk and inform interventions to reduce the risk of death. Moreover, well-designed, large-scale and multicenter studies are needed to improve and validate our findings.

Insights into SARS-CoV-2 Persistence and Its Relevance

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), continues to wreak havoc, threatening the public health services and imposing economic collapse worldwide. Tailoring public health responses to the SARS-CoV-2 pandemic depends on understanding the mechanism of viral replication, disease pathogenesis, accurately identifying acute infections, and mapping the spreading risk of hotspots across the globe. However, effective identification and isolation of persons with asymptomatic and mild SARS-CoV-2 infections remain the major obstacles to efforts in controlling the SARS-CoV-2 spread and hence the pandemic. Understanding the mechanism of persistent viral shedding, reinfection, and the post-acute sequalae of SARS-CoV-2 infection (PASC) is crucial in our efforts to combat the pandemic and provide better care and rehabilitation to survivors. Here, we present a living literature review (January 2020 through 15 March 2021) on SARS-CoV-2 viral persistence, reinfection, and PASC. We also highlight potential areas of research to uncover putative links between viral persistence, intra-host evolution, host immune status, and protective immunity to guide and direct future basic science and clinical research priorities.

A clinical study on the changing dynamics of disease severity, management strategies and outcomes of COVID-19 in patients requiring haemodialysis

INTRODUCTION

In this observational study, we describe the change in the clinical profile and outcome of Corona Virus Disease 2019 (COVID-19) over the course of the outbreak, among patients requiring dialysis, including chronic haemodialysis therapy.

METHODS

This is a single-centre prospective observational study of patients with COVID-19 (as confirmed by RT-PCR) and renal failure requiring haemodialysis. Their clinical profiles and outcomes were analysed, vis-à-vis the changing disease severity.

FINDINGS

A total of 483 patients were included, of whom 416 had end-stage renal disease and were on maintenance haemodialysis. Patients who were symptomatic at presentation had significantly higher levels of Neutrophil-lymphocyte ratio (NLR) (p < 0.001), C-reactive protein (CRP) (p < 0.001), lactate dehydrogenase (LDH) (p < 0.001), higher degrees of lung involvement (p < 0.001) and required more respiratory support (p < 0.001). The overall mortality observed was 18.8%. In the late phases of the outbreak, there was a significant increase in disease severity without a statistically significant increase in mortality. Predictors of mortality on univariate analysis were age, diabetes mellitus, acute on chronic kidney disease, presence of symptoms on admission, NLR, CRP, LDH, computed tomography (CT) chest grades 3 and 4, and need for respiratory support; however, only age and the renal syndrome of acute on chronic kidney disease retained significance on multivariate analysis (p0.003 and p0.019, respectively).

CONCLUSION

Among patients on haemodialysis, higher mortality was observed in patients who were older, and among those with acute on chronic kidney disease. In the late phase of the outbreak, there was a statistically significant increase in disease severity without a corresponding increase in mortality.

SARS-CoV-2 vs. Hepatitis Virus Infection Risk in the Hemodialysis Population: What Should We Expect?

Since the dramatic rise of the coronavirus infection disease 2019 (COVID-19) pandemic, patients receiving dialysis have emerged as especially susceptible to this infection because of their impaired immunologic state, chronic inflammation and the high incidence of comorbidities. Although several strategies have thus been implemented to minimize the risk of transmission and acquisition in this population worldwide, the reported severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence varies across studies but is higher than in the general population. On the contrary, the screening for hepatitis viruses (HBV and HCV) has seen significant improvements in recent years, with vaccination in the case of HBV and effective viral infection treatment for HCV. In this sense, a universal SARS-CoV-2 screening and contact precaution appear to be effective in preventing further transmission. Finally, regarding the progress, an international consensus with updated protocols that prioritize between old and new indicators would seem a reasonable tool to address these unexpended changes for the nephrology community.

Evaluation of SARS-CoV-2 Spike S1 Protein Response on PI3K-Mediated IL-8 Release

A novel coronavirus related to a condition known as a severe acute respiratory syndrome (SARS) was termed as SARS Coronavirus-19 (SARS-CoV-2 or COVID-19), which has caused an unprecedented global pandemic. Extensive efforts have been dedicated worldwide towards determining the mechanisms of COVID-19 associated pathogenesis with the goals of devising potential therapeutic approaches to mitigate or overcome comorbidities and mortalities. While the mode of SARS-CoV-2 infection, its structural configuration, and mechanisms of action, including the critical roles of the Spike protein have been substantially explored, elucidation of signaling pathways regulating its cellular responses is yet to be fully determined. Notably, phosphoinositide 3-kinases (PI3K) and its downstream pathway have been exploited among potential therapeutic targets for SARS-CoV-2, and its activation modulates the release of cytokines such as IL-8. To that end, the current studies were sought to determine the response of the SARS-CoV-2 Spike S1 protein on PI3K-mediated IL-8 release using relevant and widely used cellular models. Overall, these studies indicate that PI3K signaling does not directly mediate Spike S1 protein-induced IL-8 release in these cellular models.

IgA-Dominant Infection-Associated Glomerulonephritis Following SARS-CoV-2 Infection

The renal involvement of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been reported. The etiology of kidney injury appears to be tubular, mainly due to the expression of angiotensin-converting enzyme 2, the key joint receptor for SARS-CoV-2; however, cases with glomerular implication have also been documented. The multifactorial origin of this renal involvement could include virus-mediated injury, cytokine storm, angiotensin II pathway activation, complement dysregulation, hyper-coagulation, and microangiopathy. We present the renal histological findings from a patient who developed acute kidney injury and de novo nephrotic syndrome, highly suggestive of acute IgA-dominant infection-associated glomerulonephritis (IgA-DIAGN) after SARS-CoV-2 infection, as evidenced by the presence of this virus detected in the renal tissue of the patient via immunohistochemistry assay. In summary, we document the first case of IgA-DIAGN associated to SARS-CoV-2. Thus, SARS-CoV-2 S may act as a super antigen driving the development of multisystem inflammatory syndrome as well as cytokine storm in patients affected by COVID-19, reaching the glomerulus and leading to the development of this novel IgA-DIAGN.

Outcomes of coronavirus 2019 infection in patients with chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

Information on coronavirus disease 2019 (COVID-19) infection in patients with chronic kidney disease (CKD) remains limited. To understand the influence of COVID-19 infection in patients with pre-existing CKD, we conducted a systematic review and meta-analysis to evaluate and compare the risks of all-cause mortality, hospitalization, and critical progression between patients with and without CKD.

METHODS

We selected randomized controlled trials (RCTs), prospective or retrospective observational, case-control, cross-sectional, and case-series studies analyzing outcomes of COVID-19 infection in patients with pre-existing CKD from the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases published on the Internet before 16 July 2020.

RESULTS

A total of 27 studies comprising 77,856 patients with COVID-19 infection was identified; 3922 patients with pre-existing CKD were assigned CKD group, and 73,934 patients were assigned to the non-CKD group. The pooled analysis showed that patients with CKD had a significantly higher risk of all-cause mortality and hospitalization than those without CKD [odds ratio (OR) 2.25, 95% confidence interval (CI) 1.91-2.66, p < 0.001; OR 4.29, 95% CI 2.93-6.28, p < 0.001; respectively]. Patients with CKD had a higher risk of critically ill conditions than those without CKD in the pooled analysis of studies with multivariable adjustment (adjusted OR 2.12, 95% CI 0.95-4.77, p = 0.07) and in the analysis of all included studies (OR 1.27, 95% CI 0.71-2.26, p = 0.41), but both analyses did not attain statistical significance.

CONCLUSION

COVID-19 infected patients with CKD had significantly increased risks of all-cause mortality and hospitalization compared with those without CKD.

Treatment for severe COVID-19 with a biomimetic sorbent haemoperfusion device in patients on haemodialysis

Haemodialysis (HD) patients present more morbidity and mortality risk in coronavirus disease 2019 (COVID-19). In patients who may develop severe symptoms, the process called 'viral sepsis' seems to be a crucial mechanism. In those cases, the HD procedure provides an excellent tool to explore the benefit of some extracorporeal therapies. We reported the outcome of four HD patients with severe COVID-19 treated with Seraph^®100 haemoperfusion (HP) device. Three of the four cases presented a good clinical response after HP. In conclusion, the treatment with Seraph^®100 device may be a simultaneous treatment to improve HD patients with severe acute respiratory syndrome coronavirus 2.

Higher Mortality and Intensive Care Unit Admissions in COVID-19 Patients with Liver Enzyme Elevations

The aim of the present study is to evaluate if an independent association exists between liver enzyme elevations (LEE) and the risk of mortality or intensive care unit (ICU) admissions in patients with COVID-19. This was a single-center observational study, recruiting all consecutive adults with COVID-19. The elevation of aspartate aminotransferase (AST) or alanine aminotransferase (ALT) to the highest level between COVID-19 diagnosis and hospital discharge was categorized according to a standardized toxicity grade scale. In total, 799 patients were included in this study, 39% of which were female, with a mean age of 69.9 (±16.0) years. Of these patients, 225 (28.1%) developed LEE of grade ≥2 after a median of three days (interquartile range (IQR): 0–8 days) from the diagnosis of COVID-19, and they were estimated to have a higher hazard of death or ICU admission (adjusted hazard ratio (aHR): 1.46, 95% confidence interval (CI): 1.14–1.88). The clinical and laboratory variables associated with the development of LEE were male sex, higher respiratory rate, higher gamma glutamyl transpeptidase (GGT) and lower albumin levels at baseline. Among the analyzed treatments, steroids, tocilizumab and darunavir/ritonavir correlated with LEE. In conclusion, LEE were associated with mortality and ICU admission among COVID-19 patients. While the origin of LEE is probably multifactorial, LEE evaluation could add information to the clinical and laboratory variables that are commonly evaluated during the course of COVID-19.

Clinical Characteristics and Risk Factors for Fatality and Severity in Patients with Coronavirus Disease in Korea: A Nationwide Population-Based Retrospective Study Using the Korean Health Insurance Review and Assessment Service (HIRA) Database

BACKGROUND

We aimed to investigate the clinical characteristics and risk factors for fatality and severity in these patients.

METHODS

In this nationwide population-based retrospective study, we investigated the data of 7339 laboratory-confirmed COVID-19 patients, aged ≥ 18 years, using the Korean Health Insurance Review and Assessment Service (HIRA) database. Comorbidities and medications used were identified using HIRA codes, and severe COVID-19 was defined as that requiring oxygen therapy, mechanical ventilator, cardiopulmonary resuscitation, or extracorporeal membrane oxygenation. The outcomes were death due to COVID-19 and COVID-19 severity.

RESULTS

Mean patient age was 47.1 years; 2970 (40.1%) patients were male. Lopinavir/ritonavir, hydroxychloroquine, antibiotics, ribavirin, oseltamivir, and interferon were administered to 35.8%, 28.4%, 38.1%, 0.1%, 0.3%, and 0.9% of patients, respectively. After adjusting for confounding factors, diabetes mellitus, chronic kidney disease, previous history of pneumonia, aging, and male were significantly associated with increased risk of death and severe disease. No medication was associated with a reduced risk of fatality and disease severity.

CONCLUSIONS

We found several risk factors for fatality and severity in COVID-19 patients. As the drugs currently used for COVID-19 treatment have not shown significant efficacy, all efforts should be made to develop effective therapeutic modalities for COVID-19.

Sustainable Development Goals relevant to kidney health: an update on progress

Globally, more than 5 million people die annually from lack of access to critical treatments for kidney disease — by 2040, chronic kidney disease is projected to be the fifth leading cause of death worldwide. Kidney diseases are particularly challenging to tackle because they are pathologically diverse and are often asymptomatic. As such, kidney disease is often diagnosed late, and the global burden of kidney disease continues to be underappreciated. When kidney disease is not detected and treated early, patient care requires specialized resources that drive up cost, place many people at risk of catastrophic health expenditure and pose high opportunity costs for health systems. Prevention of kidney disease is highly cost-effective but requires a multisectoral holistic approach. Each Sustainable Development Goal (SDG) has the potential to impact kidney disease risk or improve early diagnosis and treatment, and thus reduce the need for high-cost care. All countries have agreed to strive to achieve the SDGs, but progress is disjointed and uneven among and within countries. The six SDG Transformations framework can be used to examine SDGs with relevance to kidney health that require attention and reveal inter-linkages among the SDGs that should accelerate progress.

Working towards sustainable development is essential to tackle the rise in the global burden of non-communicable diseases, including kidney disease. Five years after the Sustainable Development Goal agenda was set, this Review examines the progress thus far, highlighting future challenges and opportunities, and explores the implications for kidney disease.

Each Sustainable Development Goal (SDG) has the potential to improve kidney health and prevent kidney disease by improving the general health and well-being of individuals and societies, and by protecting the environment.

Achievement of each SDG is interrelated to the achievement of multiple other SDGs; therefore, a multisectoral approach is required.

The global burden of kidney disease has been relatively underestimated because of a lack of data.

Structural violence and the social determinants of health have an important impact on kidney disease risk.

Kidney disease is the leading global cause of catastrophic health expenditure, in part because of the high costs of kidney replacement therapy.

Achievement of universal health coverage is the minimum requirement to ensure sustainable and affordable access to early detection and quality treatment of kidney disease and/or its risk factors, which should translate to a reduction in the burden of kidney failure in the future.

Risk factors for severity of COVID-19 in chronic dialysis patients from a multicentre French cohort

BACKGROUND

Coronavirus disease 2019 (COVID-19) is an emerging infectious disease, related to severe acute respiratory syndrome coronavirus 2 infection. Few data are available in patients with end-stage renal disease (ESRD).

METHODS

We conducted an observational cohort study of COVID-19 patients at 11 dialysis centres in two distinct districts of France to examine the epidemiological and clinical characteristics of COVID-19 in this population, and to determine risk factors of disease severity (defined as a composite outcome including intensive care unit admission or death) and mortality.

RESULTS

Among the 2336 patients enrolled, 5.5% had confirmed COVID-19 diagnosis. Of the 122 patients with a follow-up superior to 28 days, 37% reached the composite outcome and 28% died. Multivariate analysis showed that oxygen therapy on diagnosis and a decrease in lymphocyte count were independent risk factors associated with disease severity and with mortality. Chronic use of angiotensin II receptor blockers (ARBs) (18% of patients) was associated with a protective effect on mortality. Treatment with azithromycin and hydroxychloroquine (AZT/HCQ) (46% of patients) were not associated with the composite outcome and with death in univariate and multivariate analyses.

CONCLUSIONS

COVID-19 is a severe disease with poor prognosis in patients with ESRD. Usual treatment with ARBs seems to be protective of critical evolution and mortality. There is no evidence of clinical benefit with the combination of AZT/HCQ.

Often forgotten, transport modality to dialysis may be life-saving

Haemodialysis patients commute to the dialysis facility thrice weekly, for a total of six trips per week. While nephrologists may think that how patients do this is up to them and their insurance companies, there is growing evidence that providing advice on how to commute to dialysis is part of an integrated care plan for dialysis patients. In this issue of Clinical Kidney Journal, two reports emphasize the importance of transport modality on dialysis patient well-being and even survival. Rincon et al. report on the epidemiology and clinical spectrum of coronavirus disease 2019 (COVID-19) in a Spanish haemodialysis unit. A key source of infection was related to access to healthcare or elderly care facilities. Indeed, healthcare transportation with future symptomatic [odds ratio (OR) = 3.33] or asymptomatic (OR = 4.73) COVID-19 patients increased the risk of infection. Working with transport providers to minimize cross-infection between patients during transport was one of the measures taken to stop disease transmission. Lessons learned from COVID-19 may also apply to influenza and other infections. In the second report, Yazawa et al. describe an association between transport modality to the dialysis facility and health-related quality of life (QOL) among haemodialysis patients in the Japanese Dialysis Outcomes and Practice Patterns study. These reports emphasize the need for nephrologists to understand how patients are transported to dialysis and how transport modality may be optimized to promote QOL and decrease potentially life-threatening complications.