A Case of Novel Coronavirus Disease 19 in a Chronic Hemodialysis Patient Presenting with Gastroenteritis and Developing Severe Pulmonary Disease

Efficacy of treatments tested in COVID-19 patients with cardiovascular disease. A meta-analysis

BACKGROUND

The COVID-19 pandemic has spread globally infecting and killing millions. Those with cardiovascular disease (CVD) are at higher risk of increased disease severity and mortality. We performed a systematic review and meta-analysis to estimate the rate of in-hospital mortality following different treatments on COVID-19 in patients with CVD.

METHODS

Pertinent articles were identified from the PubMed, Google Scholar, Ovid MEDLINE, and Ovid EMBASE databases. This study protocol was registered under PROSPERO with the identifier CRD42020183057.

RESULTS

Of the 1673 papers scrutinized, 46 were included in the review. Of the 2553 patients (mean age 63.9 ± 2.7 years/o; 57.2% male), the most frequent CVDs were coronary artery disease (9.09%) and peripheral arterial disease (5.4%) and the most frequent cardiovascular risk factors were hypertension (86.7%) and diabetes (23.7%). Most patients were on multiple treatments. 14 COVID-19 treatments were compared with controls. The pooled event rate for in-hospital mortality was 20% (95% confidence interval (CI): 11-33%); certain heterogeneity was observed across studies.

CONCLUSIONS

COVID-19 is associated with a high in-hospital mortality rate in patients with CVD. This study shows that previous CVD determines mortality, regardless of the type of COVID-19 administered therapy. Treatments for at-risk patients should be administered carefully and monitored closely until further data are available.

The Impact of Clostridioides Difficile Infection in Hospitalized Patients: What Changed during the Pandemic?

(1) Background: Clostridioides difficile (C. difficile) and SARS-CoV-2 coronavirus represent significant health threats. Our study focused on the impact of concurrent infections on patient outcomes against the backdrop of changes imposed by the pandemic. (2) Materials and methods. We performed a retrospective analysis and included patients diagnosed with CDI who were admitted in our hospital before and during the pandemic. We compared patient exposure to risk factors for CDI in both groups and patient negative outcomes: need for ICU care, prolonged hospitalization, organ failure, toxic megacolon, and death. (3) Results. Overall, 188 patients were included, of which 100 had CDI (the pre-pandemic group), and 88 patients presented both CDI and COVID-19 (the pandemic group). Patients in the pandemic group were significantly older, with a higher Charlson Comorbidity Index (CCI) and a greater exposure to antibiotics and corticosteroids, and were more likely to develop organ dysfunction, to require ICU care and have prolonged hospitalization. The severity of COVID-19, leukocytosis and increased D-dimer levels were indicators of poor prognosis in the pandemic group. Higher CCI scores and leukocytosis increased the risk for negative outcomes in CDI alone patients. (4) Conclusions. The study highlights the negative impact of associated infections on patient outcome. The severity of COVID-19 directly influences the prognosis of patients with concurrent infections.

COVID-19: mortality rates of patients on hemodialysis and peritoneal dialysis

Objective

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection might have a higher mortality rate in patients with end-stage renal disease due to immunosuppression. This study investigates the mortality rates of SARS-CoV-2 infection and the factors affecting mortality among patients who were on maintenance hemodialysis and continuous ambulatory peritoneal dialysis.

Materials and methods

A total of 200 patients, including 157 maintenance hemodialysis and 43 continuous ambulatory peritoneal dialysis patients followed in our hospital, were included in the study. The patients' sociodemographic characteristics, comorbidities, history of SARS-CoV-2 infection in the previous year, death event, source of death (SARS-CoV-2 or not), presence of hospitalization due to SARS-CoV-2 infection, need for intensive care unit, need for ventilatory support in intensive care unit were obtained from the clinical file records.

Results

85 of the 200 patients had a history of SARS-Cov-2 infection during the last 12 months. Forty-two (49.5%) patients with SARS-CoV-2 infection were hospitalized. Patients with SARS-CoV-2 had longer dialysis time, increased mortality, and significantly higher comorbidities such as coronary artery disease, congestive heart failure. Besides, heart failure and hypertension were the determining factors in the risk factor analysis for SARS-CoV-2 infection. In dialysis patients, the mortality rate in the last year, due to all causes, including SARS-CoV-2 infection, was 23% while the mortality rate due to "SARS-CoV-2 infection only" was 13%) (p > 0.05). Our findings are important in guiding clinical decision-making and informing the public and health authorities about the risk of death associated with COVID-19 in this patient group.

Presentation and Outcomes of Patients With End-Stage Kidney Disease Hospitalized With COVID-19 at a Tertiary Center in Riyadh, Kingdom of Saudi Arabia

Background

Patients with end-stage kidney disease (ESKD) are disproportionately vulnerable to COVID-19 and its complications due to the older age and significant burden of comorbid conditions. Data about the impact of COVID-19 on the ESKD population in the Kingdom of Saudi Arabia is scarce, and this study aims to bridge this gap.

Method

This is a retrospective cohort study that included ESKD patients who were receiving either in-center hemodialysis (HD) or peritoneal dialysis (PD) for at least three months and were hospitalized due to COVID-19 at King Abdulaziz Medical City in Riyadh (KAMC) between March 2020 and March 2021. Of note, the in-center hemodialysis means that the patients come to the dialysis center three times per week to receive their dialysis sessions, as home hemodialysis is not available at our center. Multivariate logistic regression was performed to explore the association of clinical characteristics and laboratory parameters with ICU admission and mortality.

Results

A total of 104 patients were included in the analysis. The mean age was 62.6 (SD=17.4) years, 101 (97%) were on HD, predominantly through a central venous catheter (72%), and 53 patients (51%) were male. Patients with COVID-19 were either asymptomatic (42%) or had mild symptoms (37%), mainly cough and fever. At the time of admission, 37 patients (36%) had extrapulmonary symptoms, and 13 patients (12%) had altered mental status. Normal chest X-ray (48%), followed by bilateral lung infiltrates (24%), and unilateral lung infiltrate (11%) were the most common radiological findings. We did not observe any thromboembolic events. Twenty patients (19%) required ICU admission and 19 patients (18%) died during hospitalization. Predictors for in-hospital mortality were: 1) the need for inotropes (adjusted OR: 53.01, p=0.006), 2) age (adjusted OR: 1.07, p=0.019), and 3) C-reactive protein (CRP) level on admission (adjusted OR: 1.02, p=0.04). We did not find any strong predictor for ICU admission.

Conclusion

Our study demonstrated that COVID-19 carries significant mortality and morbidity in the ESKD population. Age, inotropic support requirement and elevated CRP on admission predicted mortality in our population. The high rate of adverse outcomes of COVID-19 among ESRD patients calls for strict implementation of preventive measures, including vaccination, social distancing, and universal masking at the level of both the healthcare providers and patients. Further studies are needed to assess the association of COVID-19 and hypercoagulability ESKD population.

Long-term effect of COVID-19 infection on hemodialysis patients: Should we follow hemodialysis patients more closely?

During the coronavirus disease 2019 (COVID-19) pandemic, hemodialysis patients constitute one of the most vulnerable patient populations as they have more significant comorbidities and need to visit healthcare settings frequently even under pandemic conditions. It was also largely demonstrated that hemodialysis patients have high mortality rates with severe to fatal disease due to COVID-19 during their initial hospitalization. Even though the functional decline and fatigue after severe infections are not a novel entity, some long-term effects of COVID-19 have drawn attention with their prolonged effects even after discharge. A recent prospective, observational study by Carriazo et al. provided the first evidence to compare long-term mortality rates of hemodialysis patients with and without COVID-19. Carriazo et al. stated a hazard ratio of 3.00 for the mortality rates of hemodialysis patients over a 1-year follow-up period after their COVID-19 diagnosis. They emphasized that the high mortality rates of hemodialysis patients with COVID-19 are not limited to the initial hospitalization period but also continue after discharge, especially in the first 3 months. In light of this study, it can be recommended that hemodialysis patients with COVID-19 should be monitored closely and continuously, and hemodialysis patients should be prioritized for vaccination against COVID-19 with close follow-up for their antibody levels.

Thrombotic Microangiopathy Syndromes-Common Ground and Distinct Frontiers

Thrombotic microangiopathies (TMAs) have in common a terminal phenotype of microangiopathic hemolytic anemia with end-organ dysfunction. Thrombotic thrombocytopenic purpura results from von Willebrand factor multimerization, Shiga toxin-mediated hemolytic uremic syndrome causes toxin-induced endothelial dysfunction, while atypical hemolytic uremic syndrome results from complement system dysregulation. Drug-induced TMA, rheumatological disease-induced TMA, and renal-limited TMA exist in an intermediate space that represents secondary complement activation and may overlap with atypical hemolytic uremic syndrome clinically. The existence of TMA without microangiopathic hemolytic features, renal-limited TMA, represents an undiscovered syndrome that responds incompletely and inconsistently to complement blockade. Hematopoietic stem cell transplant-TMA represents another more resistant form of TMA with different therapeutic needs and clinical course. It has become apparent that TMA syndromes are an emerging field in nephrology, rheumatology, and hematology. Much work remains in genetics, molecular biology, and therapeutics to unravel the puzzle of the relationships and distinctions apparent between the different subclasses of TMA syndromes.

SARS-CoV-2 Infection in Patients on Dialysis: Incidence and Outcomes in the Lazio Region, Italy

Patients with end-stage kidney disease represent a frail population and might be at higher risk of SARS-CoV-2 infection. The Lazio Regional Dialysis and Transplant Registry collected information on dialysis patients with a positive swab. The study investigated incidence of SARS-CoV-2 infection, mortality and their potential associated factors in patients undergoing maintenance hemodialysis (MHD) in the Lazio region. Method: The occurrence of infection was assessed among MHD patients included in the RRDTL from 1 March to 30 November 2020. The adjusted cumulative incidence of infection and mortality risk within 30 days of infection onset were estimated. Logistic and Cox regression models were applied to identify factors associated with infection and mortality, respectively. Results: The MHD cohort counted 4942 patients; 256 (5.2%) had COVID-19. The adjusted cumulative incidence was 5.1%. Factors associated with infection included: being born abroad, educational level, cystic renal disease/familial nephropathy, vascular disease and being treated in a dialysis center located in Local Health Authority (LHA) Rome 2. Among infected patients, 59 (23.0%) died within 30 days; the adjusted mortality risk was 21.0%. Factors associated with 30-day mortality included: age, malnutrition and fever at the time of swab. Conclusions: Factors associated with infection seem to reflect socioeconomic conditions. Factors associated with mortality, in addition to age, are related to clinical characteristics and symptoms at the time of swab.

Characteristics of patients undergoing hemodialysis during Covid-19 pandemic

Objective

This study aimed to explore the characteristics of hemodialysis patients during the COVID-19 pandemic.

Method

This descriptive study employed a cross-sectional approach using 30 participants purposively selected from two hemodialysis centers in Riau Province, Indonesia. A personal information form and observation sheets were used for data collection. This study was conducted in May and June 2020. Distribution frequency and Pearson Correlation tests were applied during analysis.

Results

A total of 16 (53.3%) patients were female, and most respondents (90%) were married. In addition, the predominant occupation was employees (40%), and the majority has graduated from Senior High School (43.3%). The Mean, Median, and Standard Deviation (SD) of age were 49.9, 50.5, and 11.24. These parameters were respectively 37.88, 29.5, and 34.06 months for the duration from the first dialysis, while 2.04, 2, and 0.24 were correspondingly reported in terms of dialysis adequacy. The Mean, Median, and SD of Inter-dialytic weight gain were 2.25, 2.61, and 0.65, respectively. A correlation was established between age and IDWG (p value = 0.047) with r score = −0.50, and also between IDWD and dialysis adequacy (p value = 0.014) at r score = −0.60.

Conclusion

The study identified the need for nurses to carefully consider IDWG and dialysis adequacy while caring for hemodialysis patients. This approach is expected to facilitating survival during the COVID-19 pandemic.

COVID-19 Risk Factors and Mortality Outcomes Among Medicare Patients Receiving Long-term Dialysis

Importance

There is a need for studies to evaluate the risk factors for COVID-19 and mortality among the entire Medicare long-term dialysis population using Medicare claims data.

Objective

To identify risk factors associated with COVID-19 and mortality in Medicare patients undergoing long-term dialysis.

Design, Setting, and Participants

This retrospective, claims-based cohort study compared mortality trends of patients receiving long-term dialysis in 2020 with previous years (2013-2019) and fit Cox regression models to identify risk factors for contracting COVID-19 and postdiagnosis mortality. The cohort included the national population of Medicare patients receiving long-term dialysis in 2020, derived from clinical and administrative databases. COVID-19 was identified through Medicare claims sources. Data were analyzed on May 17, 2021.

Main Outcomes and Measures

The 2 main outcomes were COVID-19 and all-cause mortality. Associations of claims-based risk factors with COVID-19 and mortality were investigated prediagnosis and postdiagnosis.

Results

Among a total of 498 169 Medicare patients undergoing dialysis (median [IQR] age, 66 [56-74] years; 215 935 [43.1%] women and 283 227 [56.9%] men), 60 090 (12.1%) had COVID-19, among whom 15 612 patients (26.0%) died. COVID-19 rates were significantly higher among Black (21 787 of 165 830 patients [13.1%]) and Hispanic (13 530 of 86 871 patients [15.6%]) patients compared with non-Black patients (38 303 of 332 339 [11.5%]), as well as patients with short (ie, 1-89 days; 7738 of 55 184 patients [14.0%]) and extended (ie, ≥90 days; 10 737 of 30 196 patients [35.6%]) nursing home stays in the prior year. Adjusting for all other risk factors, residing in a nursing home 1 to 89 days in the prior year was associated with a higher hazard for COVID-19 (hazard ratio [HR] vs 0 days, 1.60; 95% CI 1.56-1.65) and for postdiagnosis mortality (HR, 1.31; 95% CI, 1.25-1.37), as was residing in a nursing home for an extended stay (COVID-19: HR, 4.48; 95% CI, 4.37-4.59; mortality: HR, 1.12; 95% CI, 1.07-1.16). Black race (HR vs non-Black: HR, 1.25; 95% CI, 1.23-1.28) and Hispanic ethnicity (HR vs non-Hispanic: HR, 1.68; 95% CI, 1.64-1.72) were associated with significantly higher hazards of COVID-19. Although home dialysis was associated with lower COVID-19 rates (HR, 0.77; 95% CI, 0.75-0.80), it was associated with higher mortality (HR, 1.18; 95% CI, 1.11-1.25).

Conclusions and Relevance

These results shed light on COVID-19 risk factors and outcomes among Medicare patients receiving long-term chronic dialysis and could inform policy decisions to mitigate the significant extra burden of COVID-19 and death in this population.

Evaluation of Dialysis Adequacy, Interdialytic Weight Gain and Quality of Life of Hemodialysis Patients within Coronavirus Disease 2019 Pandemic

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic harmed the world community including hemodialysis patients. It has affected the physical and psychological status of hemodialysis patients. AIM: This study aimed to evaluate the dialysis adequacy, interdialytic weight gain, and quality of life in patients undergoing hemodialysis during the COVID-19 pandemic. METHODS: A quantitative study with a cross-sectional approach was conducted on 105 regular hemodialysis patients from three hemodialysis centers in Riau Province, Indonesia. The patients were purposively recruited. Data on hemodialysis adequacy and interdialytic weight gain were collected in April–May 2020 using an observation sheet, while the quality of life was measured using SF 36. To analyze the data, Pearson’s correlation test and linear regression were performed. RESULTS: Within the sample of 53 male patients was 50.5% and 52 female patients was 49.5%. The mean score of dialysis adequacy during April–May was 1.75, while the mean IDWG was 2.2 kg, and the mean quality of life was 91.51. There was a relationship between adequacy and IDWG (p = 0.002), and between IDWG and quality of life (p =0.015). There was no relationship between adequacy and quality of life (p = 0.360). CONCLUSION: IDWG influenced the quality of life of hemodialysis patients. Health-care professionals need to help patients to keep their IDWG in the normal range to survive within COVID-19 pandemic.

Rapid analysis of local data to inform off-label tocilizumab use early in the COVID-19 pandemic

The interleukin-6 receptor antagonist tocilizumab became widely used early in the coronavirus disease 2019 (COVID-19) pandemic based on small observational studies that suggested clinical benefit in COVID-19 patients with a hyperinflammatory state. To inform our local treatment algorithms in the absence of randomized clinical trial results, we performed a rapid analysis of the first 11 hospitalized COVID-19 patients treated with tocilizumab at our academic medical center. We report their early clinical outcomes and describe the process by which we assembled a team of diverse trainees and stakeholders to extract, analyze, and disseminate data during a time of clinical uncertainty.

Excessive eating and weight gain:A rare post-acute COVID-19 syndrome

The coronavirus disease - 2019 (COVID-19) is a multisystem illness associated with several metabolic derangements. Studies report that post-acute COVID-19 syndromes (PACs) continue to evolve, however, polyphagia is not uncommon. Herein, we report a rare occurrence of polyphagia in a patient following acute COVID-19 illness. A-41-year-old Ugandan female with a negative past medical history presented with complains of excessive appetite, eating large amounts of food, inability to feel satisfied, failure to control desire to eat, and weight gain 6 months following recovery from a mild episode of acute COVID-19 pneumonia. Her body mass index rose to 30 Kg/m² from 22 Kg/m² prior to suffering from COVID-19. There was no history of polyuria, polydipsia, pruritus, or prior eating disorder or related history. Investigation found that brain computed tomography scan was normal, fasting blood sugar to be 5.6 mmol/L (normal range, 3.9-7.0 mmol/L), adrenocorticotropin hormone level to be 8.763 pg/mL (normal range, 6-40 pg/mL), erythrocyte sedimentation rate to be 12 mm/hour (0-30 mm/hour), but there was an elevation in glycosylated hemoglobin level (HbA_1c, 7.7%). She was commenced on psychotherapy and behavioral changes with good outcomes. Polyphagia may be one of the rare PACs, requiring further research.

Dairy-Derived and Egg White Proteins in Enhancing Immune System Against COVID-19

Coronavirus disease (COVID-19) is a global health challenge, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) triggers a plethora of respiratory disturbances and even multiple organs failure that can be fatal. Nutritional intervention is one of the key components toward to a proper management of COVID-19 patients, especially in those requiring medication, and should thus be considered the first-line treatment. Immuno-modulation and -stimulation are currently being explored in COVID-19 management and are gaining interest by food and pharmaceutical industries. Various dietary combinations, bioactive components, nutrients and fortified foods have been reported to modulate inflammation during disease progression. Dietary combinations of dairy-derived products and eggs are gaining an increasing attention given the huge immunomodulatory and anti-inflammatory properties attributed to some of their chemical constituents. Eggs are complex dietary components containing many essential nutrients and bioactive compounds as well as a high-quality proteins. Similarly, yogurts can replenish beneficial bacteria and contains macronutrients capable of stimulating immunity by enhancing cell immunity, reducing oxidative stress, neutralizing inflammation and regulating the intestinal barriers and gut microbiome. Thus, this review highlights the impact of nutritional intervention on COVID-19 management, focusing on the immunomodulatory and inflammatory effects of immune-enhancing nutrients.

COVID-19 and chronic kidney disease: a comprehensive review

Kidney impairment in hospitalized patients with SARS-CoV-2 infection is associated with increased in-hospital mortality and worse clinical evolution, raising concerns towards patients with chronic kidney disease (CKD). From a pathophysiological perspective, COVID-19 is characterized by an overproduction of inflammatory cytokines (IL-6, TNF-alpha), causing systemic inflammation and hypercoagulability, and multiple organ dysfunction syndrome. Emerging data postulate that CKD under conservative treatment or renal replacement therapy (RRT) is an important risk factor for disease severity and higher in-hospital mortality amongst patients with COVID-19. Regarding RAAS blockers therapy during the pandemic, the initial assumption of a potential increase and deleterious impact in infectivity, disease severity, and mortality was not evidenced in medical literature. Moreover, the challenge of implementing social distancing in patients requiring dialysis during the pandemic prompted national and international societies to publish recommendations regarding the adoption of safety measures to reduce transmission risk and optimize dialysis treatment during the COVID-19 pandemic. Current data convey that kidney transplant recipients are more vulnerable to more severe infection. Thus, we provide a comprehensive review of the clinical outcomes and prognosis of patients with CKD under conservative treatment and dialysis, and kidney transplant recipients and COVID-19 infection.

Analysis of inflammatory factor levels in serum and risk factors in patients with chronic renal failure undergoing maintenance hemodialysis

PURPOSE

To investigate the therapeutic effect of maintenance hemodialysis in patients with chronic renal failure and summarize the analysis of inflammatory factors in serum, and the risk factors in patients with chronic renal failure undergoing maintenance hemodialysis.

METHODS

A total of 50 patients with chronic renal failure undergoing maintenance hemodialysis who were admitted to our hospital from January 2017 to January 2019 were selected as the research subjects to analyze the therapeutic effects and complications of maintenance hemodialysis of these patients, compare the changes of inflammatory factor levels in serum such as interleukin-2 (IL-2), interleukin-6 (IL-6), and high-sensitivity C-reactive protein (hs-CRP) and renal function indicators such as creatinine, urea nitrogen, and urinary albumin clearance, and analyze the risk factors of maintenance hemodialysis in patients with chronic renal failure by multivariate logistic factor analysis.

RESULTS

The effective rate of maintenance hemodialysis in patients with chronic renal failure was 64% (32 cases). After dialysis, urea nitrogen, urinary albumin and creatinine clearance were significantly decreased (P < 0.05). As for the complications, 10 patients died, and 8 patients had infection. The levels of inflammatory factors in serum, such as IL-2, hs CRP were significantly decreased after maintenance hemodialysis (P < 0.05), and the difference was statistically significant. The results of multivariate logistic factor analysis showed that high capacity load and anemia were independent risk factors for death in patients with chronic renal failure undergoing maintenance hemodialysis. Simultaneously, diabetes mellitus, central venous catheterization, and hypoalbuminemia were independent risk factors for infection in patients with chronic renal failure undergoing maintenance hemodialysis.

CONCLUSION

The level of inflammatory factors in the serum of patients with chronic renal failure after maintenance hemodialysis was significantly reduced. The risk factors of death and infection include hypertension, anemia, diabetes, etc. In contrast, the independent risk factors of death were anemia and high capacity load, and the independent risk factors of infection were diabetes, hypoalbuminemia, and central venous catheterization.

Role of Invasive Mechanical Ventilation and ECMO in the Management of COVID-19: A Systematic Review

OBJECTIVES

This systematic review aims to provide insight into the outcome of extracorporeal membrane oxygenation (ECMO) and invasive mechanical ventilation use in critically ill COVID-19 patients.

DATA SOURCES

Electronic databases PubMed Central and PubMed were searched from January 2020 to June 2020 for published studies about ECMO and/or invasive mechanical ventilation use in COVID-19 patients. Data Extraction and Study Selection: The search strategy retrieved 766 articles, of which 19 studies consisting of 204 patients fulfilled the inclusion criteria and were included in the analysis.

DATA SYNTHESIS

Primary outcomes evaluated were discharge and/or clinical improvement and mortality rate. Secondary outcomes evaluated included reported complications and the mean number of days of hospitalization for survivors. Weighted averages of included studies were calculated, and data were pooled in forest plots. Nearly, 68.1% of the patients received invasive mechanical ventilation without ECMO support, and 31.9% were placed on ECMO. Also, 22.5% of the patients were discharged and/or clinically improved and 51.5% died. Twenty-six percent of the study population deteriorated but remained alive or experienced no improvement in clinical condition. And 75.2% of those who died belonged to the non-ECMO group and 24.8% to the ECMO group. The mortality rate in the non-ECMO group was 56.8% compared to 40% in the ECMO group.

CONCLUSION

The utility of ECMO during a pandemic is uncertain as it is a resource-intensive modality, especially when the mortality rate in severely ill patients infected with COVID-19 virus is already known to be high.

HOW TO CITE THIS ARTICLE

Nagraj S, Karia R, Hassanain S, Ghosh P, Shah VR, Thomas A. Role of Invasive Mechanical Ventilation and ECMO in the Management of COVID-19: A Systematic Review. Indian J Crit Care Med 2021;25(6):691-698.

Comparative incidence and outcomes of COVID-19 in kidney or kidney-pancreas transplant recipients versus kidney or kidney-pancreas waitlisted patients: A single-center study

BACKGROUND

COVID-19 epidemiologic studies comparing immunosuppressed and immunocompetent patients may provide insight into the impact of immunosuppressants on outcomes.

METHODS

In this retrospective cohort study, we assembled kidney or kidney-pancreas transplant recipients who underwent transplant from January 1, 2010, to June 30, 2020, and kidney or kidney-pancreas waitlisted patients who were ever on the waitlist from January 1, 2019, to June 30, 2020. We identified laboratory-confirmed COVID-19 until January 31, 2021, and tracked its outcomes by leveraging informatics infrastructure developed for an outcomes research network.

RESULTS

COVID-19 was identified in 62 of 887 kidney or kidney-pancreas transplant recipients and 20 of 434 kidney or kidney-pancreas waitlisted patients (7.0% vs. 4.6%, p = .092). Of these patients with COVID-19, hospitalization occurred in 48 of 62 transplant recipients and 8 of 20 waitlisted patients (77% vs. 40%, p = .002); intensive care unit admission occurred in 18 of 62 transplant recipients and 2 of 20 waitlisted patients (29% vs. 10%, p = .085); and 7 transplant recipients were mechanically ventilated and died, whereas no waitlisted patients were mechanically ventilated or died (11% vs. 0%, p = .116).

CONCLUSIONS

Our study provides single-center data and an informatics approach that can be used to inform the design of multicenter studies.

Hydroxychloroquine: A review of its safety and efficacy in COVID-19

SARS-CoV-2 is a novel virus that has infected millions of people across the world. Given the compelling need to develop a therapeutic strategy, hydroxychloroquine has been advocated as an effective drug for the infection. However, multiple clinical trials conducted using hydroxychloroquine have yielded contrasting results. An electronic search using the primary databases from WHO, PubMed and Google Scholar was performed that yielded 21 studies eligible for inclusion. Among a total of 1,350 patients who received hydroxychloroquine, 689 (51.04%) were females. The most commonly reported comorbidities include hypertension (15.18%), diabetes mellitus (8.44%) and pulmonary disease (8.96%). Of the hydroxychloroquine-treated patients, 70% were virologically cured compared to 12.5% of the control group (p = 0.001). A good clinical outcome with virological cure was reported in 973 patients (91%) within 10 days out of 1,061 hydroxychloroquine-treated patients. A total of 29 (65%) renal transplant recipients achieved complete recovery following hydroxychloroquine administration. A total of 37 (2.7%) patients reported QT prolongation. Hydroxychloroquine was found to reduce mortality in healthy, SARS-Cov-2 positive patients and improve clinical recovery in renal transplant recipients. However, a definitive conclusion regarding its effect on viral clearance can only be reached by conducting more clinical trials involving bigger and diverse samples.

Ultramicronized Palmitoylethanolamide (um-PEA): A New Possible Adjuvant Treatment in COVID-19 patients

The Coronavirus Disease-19 (COVID-19) pandemic has caused more than 100,000,000 cases of coronavirus infection in the world in just a year, of which there were 2 million deaths. Its clinical picture is characterized by pulmonary involvement that culminates, in the most severe cases, in acute respiratory distress syndrome (ARDS). However, COVID-19 affects other organs and systems, including cardiovascular, urinary, gastrointestinal, and nervous systems. Currently, unique-drug therapy is not supported by international guidelines. In this context, it is important to resort to adjuvant therapies in combination with traditional pharmacological treatments. Among natural bioactive compounds, palmitoylethanolamide (PEA) seems to have potentially beneficial effects. In fact, the Food and Drug Administration (FDA) authorized an ongoing clinical trial with ultramicronized (um)-PEA as an add-on therapy in the treatment of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection. In support of this hypothesis, in vitro and in vivo studies have highlighted the immunomodulatory, anti-inflammatory, neuroprotective and pain-relieving effects of PEA, especially in its um form. The purpose of this review is to highlight the potential use of um-PEA as an adjuvant treatment in SARS-CoV-2 infection.

The protective effect of rheumatic disease agents in COVID-19

Several immunosuppressive therapies have been investigated as potential treatments for patients with severe and critical coronavirus disease 2019 (COVID-19). Notable examples include corticosteroids, interleukin 6 (IL-6), interleukin 1 (IL-1), Janus kinase (JAK), and tumor necrosis factor alpha (TNF-α) inhibitors. The aim of this narrative review is to analyze the mechanistic rationale and available evidence for these selected anti-rheumatic drugs for the treatment of COVID-19. Currently, only corticosteroids have consistently proven to be effective in decreasing mortality and are recommended in clinical guidelines for the treatment of severe and critical COVID-19. Multiple randomized controlled trials (RCTs) are ongoing to determine the role of other immunosuppressants.

"Tocilizumab-an option for patients with COVID-19 associated cytokine release syndrome: A single center experience", a retrospective study-original article

BACKGROUND

The first case of Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was diagnosed in Wuhan, China in 2019. In the first half of 2020, this disease has already converted into a global pandemic. This study aimed to find that treatment of patients with COVID-19 pneumonia with Tocilizumab or steroids was associated with better outcomes. Objectives: To analyze the effectiveness of Tocilizumab in moderate to severe Covid-19 patients based on predefined assessment criteria . Study Settings: Single-center, Fatima Memorial Hospital, Lahore.

STUDY DESIGN

Quasi-experimental.

DURATION OF STUDY

From May 12, 2020 to June 12, 2020.

PATIENTS & METHODS SAMPLE SIZE AND TECHNIQUE

Sample size was 93; 33 patients were kept in the experimental group, given Tocilizumab, 8 mg/kg intravenously or 162 mg subcutaneously, and the rest of the 60 patients were given corticosteroids, methylprednisolone 80 mg/day. Consecutive sampling. Failure of therapy was labeled when patients were intubated or died, and the endpoints were failure-free survival which was the primary endpoint, and overall survival secondary at the time of discharge.

RESULTS

A total of 93 patients were enrolled, the Tocilizumab (TCZ) group (case) and Corticosteroid (CS) group (Control). The median age was 58 years (IQR-21), 37 (39.8%) patients with diabetes mellitus, 11 (11.8%) in the TCZ group, and 26 (28%) in the CS group. On the whole, the total median hospital stay in days was 7 with IQR (4), a total of 83 (89.2%) patients recovered successfully and discharged, 27 (29%) in the TCZ group and 56 (60.2%) in the CS group. Total 10 (10.8%) patients died, out of which 6 (6.5%) belonged to the TCZ group and 4 (4.3%) belonged to the CS group The median Oxygen requirement with IQR was 8 (9) in both the groups and in total as well, p-value (0.714).

CONCLUSIONS

Tocilizumab is a quite effective treatment option for critically sick patients of Covid-19 by reducing their oxygen requirement drastically and so the ICU stay, median hospital stay and so the mortality as well.

CLINICALS TRIALS REGISTRATION

UIN # NCT04730323.

Clinical Characteristics and Short-Term Outcomes of Chronic Dialysis Patients Admitted for COVID-19 in Metro Manila, Philippines

AIM

Data published on COVID-19 in the Filipino population, particularly those with end stage kidney disease (ESKD) are still lacking.

METHODS

We performed a retrospective, observational study of 68 ESKD patients admitted with COVID-19 infection at a tertiary hospital in Metro Manila, Philippines from April 1, 2020 to July 31, 2020. We compared the clinical features, baseline laboratory data, treatment strategies and short-term outcomes between those who survived and those who died. We also determined the risk factors associated with mortality from COVID-19.

RESULTS

Mean age was 54.5 years old, 66% were male. All patients admitted were on maintenance hemodialysis (HD). The most common presenting symptoms were dyspnea (57%), fever (47%) and cough (38%). There was an equal number of patients on high flow nasal cannula (17.7%) and invasive mechanical ventilation (17.7%). ICU admission was required in 17.7% of the cohort. In-hospital death occurred in 25% of the patients. Admission PaO2/FiO2 (PF) ratios (162 ± 134 versus 356 ± 181; p=0.0009) were lower, and procalcitonin (6.07 ± 10.5ng/mL versus 0.73 ± 3.61 ng/mL; p=0.02), lactate dehydrogenase (396 ± 274U/L versus 282 ± 148 U/L; p=0.03), and white blood cell counts (10 ± 7.3 x 109/L versus 6.3 ± 4.2 x 109/L; p= 0.0039) were significantly higher among those who died compared to those who survived. After adjusting for confounders, only low PF ratio (HR 1.01 for every unit decrease, 95% CI 1-1.01) and need for ventilation (HR 6.45, 95% CI 1.16-35.97) conferred a significant risk for in-hospital mortality.

CONCLUSION

Short-term, in-hospital mortality is high among patients on chronic hemodialysis admitted for COVID-19 infection. They present similarly with the general population. Low PF ratio on admission and need for ventilation are independent risk factors for in-hospital mortality.

SARS-CoV-2-related ARDS in a maintenance hemodialysis patient: case report on tailored approach by daily hemodialysis, noninvasive ventilation, tocilizumab, anxiolytics, and point-of-care ultrasound

Without rescue drugs approved, holistic approach by daily hemodialysis, noninvasive ventilation, anti-inflammatory medications, fluid assessment by bedside ultrasound, and anxiolytics improved outcomes of a maintenance hemodialysis patient affected by severe COVID-19.

Effective treatment with Tocilizumab in a COVID-19 patient on maintenance hemodialysis: A case report

Coronavirus disease 2019 (COVID-19) is a rapidly spreading infective disease caused by the severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2). The management of this disease remains a challenge particularly in certain subgroups of patients such in hemodialysis patients who have higher exposure rates due to the nature of their in-hospital care, and higher mortality due to their burden of comorbidities. We report a case of a 52-year-old patient with Von Hippel Lindau syndrome and end-stage renal disease on hemodialysis who contracted COVID-19 infection. Despite the patient’s rapidly deteriorating clinical status he was successfully treated with Tocilizumab, after which he showed rapid improvement in his clinical, biological and radiological parameters. Although few studies were available regarding the use of Tocilizumab in the dialysis population, its use proved to be effective and well tolerated in our patient.

The kidney, COVID-19, and the chemokine network: an intriguing trio

On December 30th 2019, some patients with pneumonia of unknown etiology were reported in the Program for Monitoring Emerging Diseases (ProMED), a program run by the International Society for Infectious Diseases (ISID), hypothesized to be related to subjects who had had contact with the seafood market in Wuhan, China. Chinese authorities instituted an emergency agency aimed at identifying the source of infection and potential biological pathogens. It was subsequently named by the World Committee on Virus Classification as 2019-nCoV (2019-novel coronavirus) or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A number of studies have demonstrated that 2019-nCoV and the SARS-CoV shared the same cell entry receptor named angiotensin-converting enzyme 2 (ACE2). This is expressed in human tissues, not only in the respiratory epithelia, but also in the small intestines, heart, liver, and kidneys. Here, we examine the most recent findings on the effects of SARS-CoV-2 infection on kidney diseases, mainly acute kidney injury, and the potential role of the chemokine network.

Novel therapeutic approaches for COVID-19 in chronic kidney disease and transplant

PURPOSE OF REVIEW

Severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) is the novel virus responsible for the current worldwide pandemic. The scientific and healthcare communities have made every effort to discover and implement treatment options at a historic pace. Patients with kidney disease are uniquely vulnerable to an infectious pandemic because of their need to be in frequent contact with the healthcare system for life-sustaining renal replacement therapy whether it be by dialysis or transplant.

RECENT FINDINGS

The use of targeted viral therapies, extracorporeal therapies, immunosuppressive therapy and public health interventions are important in the management of patients with COVID-19 but require special consideration in patients with kidney disease because of the complexity of their condition.

SUMMARY

Here, we discuss some of the major efforts made to prevent spread and emerging treatment options for this virus, as they pertain to patients with kidney disease.

Coronavirus Disease 2019: Quick Diet and Nutrition Guide for Patients With Chronic Kidney Disease

Considering the Covid-19 pandemic and that patients with CKD are included in a high-risk group, a quick nutrition guide for patients with CKD in all stages was developed, and it is available in Portuguese at https://bit.ly/2zfSjl0, in English at https://bit.ly/covid19ckd, in Spanish at https://bit.ly/guia enfermedad renal and in French at https://bit.ly/covid19maladierenale.

Building a hemodiafiltration system from readily available components for continuous renal replacement therapy under disasters and pandemics: preparing for an acute kidney injury surge during COVID-19

PURPOSE OF REVIEW

The novel corona virus (SARS-CoV2) has been demonstrated to cause acute kidney injury due to direct cellular toxicity as well as due to a variety of autoimmune glomerular diseases. The concept of a surge of infected patients resulting in an overwhelming number of critical patients has been a central concern in healthcare planning during the COVID-19 era.

RECENT FINDINGS

One crucial question remains as to how to manage patients with end stage renal disease and acute kidney injury in case of a massive surge of critically ill infected patients. Some publications address practical and ingenious solutions for just such a surge of need for renal replacement therapy. We present a plan for using a blood pump, readily available dialysis filter, and a prefilter and postfilter replacement fluid set up. This is in conjunction with multiple intravenous pumps to develop a simple hemofiltration apparatus.

SUMMARY

The current set up may be a readily available option for use in critical situations where the need for renal replacement therapy outstrips the capacity of traditional hemodialysis services in a hospital or region.

Acute Respiratory Distress Syndrome and COVID-19: A Scoping Review and Meta-analysis

Acute respiratory distress syndrome (ARDS) is a fatal complication of the new severe acute respiratory syndrome coronavirus (SARS-CoV-2), which causes COVID-19 disease. This scoping review was carried out with international, peer-reviewed research studies and gray literature published up to July 2020 in Persian and English languages. Using keywords derived from MESH, databases including Magiran, IranMedex, SID, Web of Sciences, PubMed, Embase via Ovid, Science Direct, and Google Scholar were searched. After screening titles and abstracts, the full texts of selected articles were evaluated, and those which passed the criteria were analyzed and synthesized with inductive thematic analysis. Study quality was also evaluated using a standard tool. The overall prevalence of ARDS was estimated using a random-effects model. This led to identification of 23 primary studies involving 2880 COVID-19 patients. All articles were observational with a cross-sectional, retrospective, case report, and cohort design with moderate to strong quality. The main findings showed that COVID-19-related ARDS has a high prevalence and is different to ARDS due to other etiologies. Elderly and patients with comorbidities and organ failure should be closely surveyed for respiratory organ indications for several weeks after the onset of respiratory symptoms. There is currently no definitive treatment for ARDS in COVID-19 disease, and supportive therapies and their effects are somewhat controversial.

A new scoring system for Covid-19 in patients on hemodialysis: Modified Early Warning score

Introduction. At the very beginning of the Corona virus epidemic there was not enough data on whether hemodialysis patients have a higher risk for Corona virus infection and which factors may affect the severity of clinical picture. Objective. The aim of the study was to determine the significance of the Modified Early Warning Assessment (MEWS) score for the assessment of coronavirus disease exacerbation. Methods. The research was conducted in COVID dialysis, as a retrospective, descriptive-analytical study, at the University Clinical Center Kragujevac, Serbia, which was organized ad-hoc for treatment of SARS-Cov-2 infection positive patients, which are transfered from Center for Hemodialysis "Ćuprija". They were evaluated routine laboratory findings, demographic and gender structure, arterial blood pressure, presence of comorbidities and residual diuresis, duration of dialysis, radiological evaluation of lungs, determination of MEWS score were the parameters that were monitored. The results were monitored on admission and and in the end of treatment. Results. A statistically significant difference was registered in serum lactate dehydrogenase concentration (486 ± 107.62 vs. 423.7 ± 92.4 U/L); p = 0.022 and absolute monocyte count (0.46 ± 0.15 vs. 0.67 ± 0.34 x 103; p = 0.008). The significant increase in MEWS score was also found (b = 0.017; p = 0.030). There was a positive correlation between increase of MEWS score and age (b = 0.027; p = 0.002) and arterial hypertension as a concomitant comorbidity (b = 0.700; p = 0.033). Conclusion. In the observed period, there was a significant increase in the degree of MEWS score of dialysis patients who had SARS-Cov-2 infection.

Road Map to Understanding SARS-CoV-2 Clinico-Immunopathology and COVID-19 Disease Severity

SARS-CoV-2, a novel coronavirus, was first identified in Wuhan, China in December 2019. The rapid spread of the virus worldwide prompted the World Health Organization (WHO) to declare COVID-19 a pandemic in March 2020. COVID-19 discontinuing's a global health crisis. Approximately 80% of the patients infected with SARS-CoV-2 display undetectable to mild inflammation confined in the upper respiratory tract. In remaining patients, the disease turns into a severe form affecting almost all major organs predominantly due to an imbalance of innate and adaptive arms of host immunity. The purpose of the present review is to narrate the virus's invasion through the system and the host's reaction. A thorough discussion on disease severity is also presented regarding the behavior of the host's immune system, which gives rise to the cytokine storm particularly in elderly patients and those with comorbidities. A multifaceted yet concise description of molecular aspects of disease progression and its repercussion on biochemical and immunological features in infected patients is tabulated. The summary of pathological, clinical, immunological, and molecular accounts discussed in this review is of theranostic importance to clinicians for early diagnosis of COVID-19 and its management.

Impact of COVID-19 infections on hemodialysis patients in the province of Blida, Algeria

Patients on hemodialysis are a group at risk for infection with SARS-CoV-2 due to impaired immunity. Our knowledge of the specific characteristics of the disease in this population is limited. Our study aims to improve our understanding of diagnostic, therapeutic, and prognostic aspects of this disease. Seventy hemodialysis patients tested by RT-PCR positive for SARS-CoV-2 were hospitalized in the nephrology department from April 1 to September 30, 2020. The patients' average age was 60.3 ± 15.0 years (18 - 88 years); including 39 patients (55.7%) were male. The comorbidities found were hypertension (67.1%), diabetes (32.9%), and obesity (17.1%). Our patients' laboratory abnormalities were leukopenia (15.7%) and lymphopenia in 60% of patients. The pulmonary involvement on computed tomography was classified as moderate (74.3%) and severe in 24.3% of cases. Fifty-seven patients (78.6%) had received hydroxychloroquine and 14 patients (20%) antivirals therapy. We recorded 82.9% of cured patients and 17.1% of deaths in our series. The death occurred 8 ± 7.5 days (1 - 25 days) of hospitalization. Hemodialysis centres are high-risk places, and hemodialysis patients are considered a vulnerable population during the COVID-19 pandemic. They should be given special attention.

Low incidence of SARS-CoV-2, risk factors of mortality and the course of illness in the French national cohort of dialysis patients

The aim of this study was to estimate the incidence of COVID-19 disease in the French national population of dialysis patients, their course of illness and to identify the risk factors associated with mortality. Our study included all patients on dialysis recorded in the French REIN Registry in April 2020. Clinical characteristics at last follow-up and the evolution of COVID-19 illness severity over time were recorded for diagnosed cases (either suspicious clinical symptoms, characteristic signs on the chest scan or a positive reverse transcription polymerase chain reaction) for SARS-CoV-2. A total of 1,621 infected patients were reported on the REIN registry from March 16th, 2020 to May 4th, 2020. Of these, 344 died. The prevalence of COVID-19 patients varied from less than 1% to 10% between regions. The probability of being a case was higher in males, patients with diabetes, those in need of assistance for transfer or treated at a self-care unit. Dialysis at home was associated with a lower probability of being infected as was being a smoker, a former smoker, having an active malignancy, or peripheral vascular disease. Mortality in diagnosed cases (21%) was associated with the same causes as in the general population. Higher age, hypoalbuminemia and the presence of an ischemic heart disease were statistically independently associated with a higher risk of death. Being treated at a selfcare unit was associated with a lower risk. Thus, our study showed a relatively low frequency of COVID-19 among dialysis patients contrary to what might have been assumed.

Drug repurposing approach to fight COVID-19

Currently, there are no treatment options available for the deadly contagious disease, coronavirus disease 2019 (COVID-19). Drug repurposing is a process of identifying new uses for approved or investigational drugs and it is considered as a very effective strategy for drug discovery as it involves less time and cost to find a therapeutic agent in comparison to the de novo drug discovery process. The present review will focus on the repurposing efficacy of the currently used drugs against COVID-19 and their mechanisms of action, pharmacokinetics, dosing, safety, and their future perspective. Relevant articles with experimental studies conducted in-silico, in-vitro, in-vivo, clinical trials in humans, case reports, and news archives were selected for the review. Number of drugs such as remdesivir, favipiravir, ribavirin, lopinavir, ritonavir, darunavir, arbidol, chloroquine, hydroxychloroquine, tocilizumab and interferons have shown inhibitory effects against the SARS-CoV2 in-vitro as well as in clinical conditions. These drugs either act through virus-related targets such as RNA genome, polypeptide packing and uptake pathways or target host-related pathways involving angiotensin-converting enzyme-2 (ACE2) receptors and inflammatory pathways. Using the basic knowledge of viral pathogenesis and pharmacodynamics of drugs as well as using computational tools, many drugs are currently in pipeline to be repurposed. In the current scenario, repositioning of the drugs could be considered the new avenue for the treatment of COVID-19.

Tocilizumab Use in a Chronic Hemodialysis Patient for the Management of COVID-19-Associated Pneumonia and Acute Respiratory Distress Syndrome

Novel coronavirus disease 2019 (COVID-19) is a highly infectious, rapidly spreading viral disease. As of writing this article, there are over 4.4 million people affected by COVID-19, and unfortunately, 300,000 have succumbed to the infection. In this article, we address a particularly more susceptible group of the population of end-stage renal disease (ESRD) patients on dialysis who may potentially benefit from being treated with tocilizumab. The use of tocilizumab has not been reported widely in ESRD patients on dialysis to treat COVID-19. In this case report, we describe a patient with ESRD on hemodialysis who was admitted to the intensive care unit, with severe pneumonia secondary to COVID-19 infection. This patient was treated with tocilizumab 400 mg intravenous and had a favorable outcome with no apparent adverse events.

COVID-19 and maintenance hemodialysis: a systematic scoping review of practice guidelines

Background

Coronavirus Disease 2019 (COVID-19) has substantially impacted the provision of medical services. During the pandemic, many medical services, including facilities providing care to patients with end stage renal disease faced challenges in safeguarding patients and staff while providing clinical care. This study aims to identify the extent, range, and nature of articles related to COVID-19 and maintenance hemodialysis to understand the research gaps and propose recommendations for future research.

Methods

Using the terms: “Dialysis” OR “RRT” OR “Renal replacement therapy” AND “SARS-COV-2” OR “COVID-19” OR “novel coronavirus” OR “2019-nCov”, we performed a multi-step systematic search of the literature in the English language in Pubmed, Scopus, Embase, and Web of Science published from December 1, 2019, to May 13, 2020. Two authors separately screened the title and abstracts of the documents and ruled out irrelevant articles. We obtained a full report of the papers that met our inclusion criteria and screened the full texts. We conducted a descriptive analysis of the characteristics of the included articles and performed a narrative synthesis of the results. We conducted this scoping review in accordance with the PRISMA-ScR Checklist.

Results

We included 22 articles in this scoping review. Perspectives (n = 9), editorials (n = 4), and case series (n = 5) were the most common types of articles. Most articles were from Italy and the United States. Seventeen (77.3%) of the articles focused on the topic of recommendation for outpatient hemodialysis units. While many of the recommendations overlapped in several articles, there were also many unique recommendations.

Conclusions

most of the articles are based on single-center experience, which spontaneously developed best practices. Many of these practices have formed the basis for policies and guidelines that will guide future prevention of infection and management of patients with End Stage Renal Disease (ESRD) and COVID-19.

COVID-19: a novel menace for the practice of nephrology and how to manage it with minor devastation?

Coronavirus disease 19 (COVID-19) became a nightmare for the world since December 2019. Although the disease affects people at any age; elderly patients and those with comorbidities were more affected. Everyday nephrologists see patients with hypertension, chronic kidney disease, maintenance dialysis treatment or kidney transplant who are also high-risk groups for the COVID-19. Beyond that, COVID-19 or severe acute respiratory syndrome (SARS) due to infection may directly affect kidney functions. This broad spectrum of COVID-19 influence on kidney patients and kidney functions obviously necessitate an up to date management policy for nephrological care. This review overviews and purifies recently published literature in a question to answer format for the practicing nephrologists that will often encounter COVID-19 and kidney related cases during the pandemic times.

The first case of COVID-19 pneumonia in a hemodialysis patient in Japan

On 31 December 2019, cases of pneumonia whose cause was later identified as SARS-CoV-2 were detected in Wuhan City, Hubei Province of China, and now COVID-19 has spread worldwide. On March 1, 2020, a 69-year-old Japanese man who had been on hemodialysis for 3 years was diagnosed as having COVID-19 pneumonia and hospitalized at our Medical Center. Pulmonary CT revealed bilateral multiple consolidation with bilateral pleural effusion. Aggressive weight reduction was needed to improve the patient’s respiratory condition. Hemodialysis therapy was performed in isolation with hydroxychloroquine administration, but the formation of a dialysis membrane clot forced the withdrawal of dialysis therapy. Changing the dialysis membrane material and anticoagulant enabled the resumption of dialysis therapy, allowing the body weight to correct downward. On the 5th hospitalization day, the patient’s fever dropped and he showed improved oxygenation and chest X-ray. He was eventually discharged. The hydroxychloroquine and appropriate fluid management may have contributed to the patient’s recovery. Clinicians should pay close attention to avoid dialysis-related problems when treating a patient with COVID-19.

COVID-19 in Patients Undergoing Hemodialysis: Prevalence and Asymptomatic Screening During a Period of High Community Prevalence in a Large Paris Center

Rationale & Objective

Due to extensive comorbid conditions, coronavirus disease 2019 (COVID-19) has a poor prognosis in people receiving maintenance hemodialysis. In this article, we describe our experience with 200 maintenance hemodialysis patients in a hemodialysis center that used universal reverse transcriptase-polymerase chain reaction testing, including 38 COVID-19–positive patients.

Study Design

Descriptive observational cohort, including the time line of patient diagnoses along with contextual events including precautions, testing, screening algorithms, clinical diagnostics and therapy, and the clinical course of COVID-19–infected patients and their final outcomes.

Setting & Participants

200 patients within a single hemodialysis center with 2 dialysis clinics in Paris.

Results

Among 200 maintenance hemodialysis patients, 38 (19%) had COVID-19 diagnosed; of these, 15 (39.5%) were admitted to the hospital, including 4 who required intensive care unit (ICU) care. There were 8 (21%) deaths. The most common symptom was fever, followed by dry cough, fatigue, and dyspnea. All COVID-19–infected patients had lymphopenia and an increase in C-reactive protein levels. Median time from the onset of respiratory symptoms to ICU admission was 1 to 2 days. Durations of non-ICU hospitalizations and ICU stays were 7 and 13 days, respectively.

Limitations

Retrospective study, single hemodialysis center.

Conclusions

Dialysis patients are a highly susceptible population and hemodialysis centers are a high-risk area in a COVID-19 epidemic. “Unexplained” lymphopenia and/or an increase in C-reactive protein level should lead physicians to the diagnosis of COVID-19 and should, when possible, be followed by diagnostic testing with universal reverse transcriptase-polymerase chain reaction, as well as the reinforcement of contamination barrier measures.

COVID-19 and Gastrointestinal Disease: Implications for the Gastroenterologist

BACKGROUND

COVID-19 was initially considered a respiratory disease but the SARS-CoV-2 virus can lead to serious systemic consequences affecting major organs including the digestive system.

SUMMARY

This review brings new clinically important information for the gastroenterologist. This includes: the mechanisms of tissue damage seen with the SARS-CoV-2 virus; the consequences of immunosuppression in patients with inflammatory bowel disease (IBD) and chronic liver disease with the additional risks of decompensation in patients with cirrhosis; the impact of COVID-19 on gastrointestinal emergencies, on gastrointestinal endoscopy, diagnosis and treatments. These highlight the need to understand the clinical pharmacology, toxicology and therapeutic implications of drugs commonly used by gastroenterologists and their links with COVID-19. Key Messages: Any part of the digestive system may be affected by the SARS-CoV-2 virus, and those with pre-existing disease are at greatest risk of adverse outcomes. The risk for drug-drug interactions is considerable in patients seriously ill with COVID-19 who often require mechanical ventilation and life support. Some repurposed drugs used against SARS-CoV-2 can cause or aggravate some of the COVID-19-related gastrointestinal symptoms and can also induce liver injury. Ongoing clinical studies will hopefully identify effective drugs with a more favourable risk-benefit ratio than many initially tried treatments.

The possibility of SARS-CoV-2 transmission in a haemodialysis unit - report from a large in-hospital centre

Data on the possibility of transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) during the provision of chronic haemodialysis, which often entails many person-to-person contacts, are lacking. We report a follow-up of the in-centre contacts of three positive chronic haemodialysis patients. Under strict preventive measures, only one patient out of 21 patient-contacts and 29 personnel-contacts tested positive within 2 weeks after the last contact. This patient, case #3, most likely became infected during unprotected, organised group transportation to the dialysis centre.

Gastrointestinal Manifestations and Dynamics of Liver Enzymes in Children and Adolescents with COVID-19 Infection: A Systematic Review and Meta-Analysis

Objectives: To improve the knowledge on Coronavirus Disease (COVID-19) infection, we aimed to study the prevalence of gastrointestinal symptoms and the dynamics of liver enzymes in children infected with COVID-19. Methods: We performed a systematic search of all the articles published up to May 2020 in the following databases: PubMed-MEDLINE, Scopus, and Cochrane. We chose the fixed- or random-effect model for analysis based on the I2 statistic. The included data were analyzed to identify the prevalence of gastrointestinal symptoms (diarrhea, vomiting or nausea) and to identify the dynamics of liver enzymes in children and adolescents diagnosed with COVID-19. Results: We detected an overall prevalence of all gastrointestinal symptoms of 26% (95% CI: 0.18 - 0.35). The pooled prevalence of diarrhea and nausea/vomiting was 12% (95% CI: 0.08 - 0.16) with no heterogeneity (P = 0.19; I2 = 23.53%) and 11% (95% CI: 0.05 - 0.17), respectively. The pooled prevalence of elevated ALT and AST and LDH was 12% (95% CI: 0.07 - 0.17), 14% (95% CI: 0.10 - 0.18) and 33% (95% CI: 0.12 - 0.54), respectively among the included studies. Conclusions: According to our systematic review and meta-analysis, 26% of the children and adolescents diagnosed with COVID-19 present gastrointestinal symptoms. This paper has provided a comprehensive overview of the prevalence of digestive symptoms of COVID-19 and of the liver enzymes dynamics in children and adolescents.

Tackling the cytokine storm in COVID-19, challenges and hopes

The outbreak of Coronavirus disease 2019 (COVID-19) is the current world health concern, presenting a public health dilemma with ascending morbidity and mortality rates exceeding any previous viral spread, without a standard effective treatment yet. SARS-CoV-2 infection is distinguished with multiple epidemiological and pathological features, one of them being the elevated levels of cytokine release, which in turn trigger an aberrant uncontrolled response known as "cytokine storm". This phenomenon contributes to severe acute respiratory distress syndrome (ARDS), leading to pneumonia and respiratory failure, which is considered a major contributor to COVID-19-associated fatality rates. Taking into account that the vast majority of the COVID-19 cases are aggravated by the respiratory and multiorgan failure triggered by the sustained release of cytokines, implementing therapeutics that alleviate or diminish the upregulated inflammatory response would provide a therapeutic advantage to COVID-19 patients. Indeed, dexamethasone, a widely available and inexpensive corticosteroid with anti-inflammatory effects, has shown a great promise in reducing mortality rates in COVID-19 patients. In this review, we have critically compared the clinical impact of several potential therapeutic agents that could block or interfere with the cytokine storm, such as IL-1 inhibitors, IL-6 inhibitors, mast cell targeting agents, and corticosteroids. This work focused on highlighting and contrasting the current success and limitations towards the involvement of these agents in future treatment protocols.

Impact of first-wave COronaVIrus disease 2019 infection in patients on haemoDIALysis in Alsace: the observational COVIDIAL study

BACKGROUND

There are only scarce data regarding the presentation, incidence, severity and outcomes of coronavirus disease 2019 (COVID-19) in patients undergoing long-term haemodialysis (HD). A prospective observational study was conducted in eight HD facilities in Alsace, France, to identify clinical characteristics of HD patients with COVID-19 and to assess the determinants of the risk of death.

METHODS

All HD patients tested positive for COVID-19 from 5 March to 28 April 2020 were included. Collected data included patient characteristics, clinical features at diagnosis, laboratory data, treatments and outcomes.

RESULTS

Among 1346 HD patients, 123 tested positive for COVID-19. Patients had a median age of 77 years (interquartile range 66-83), with a high number of comorbidities (3.2 ± 1.6 per patient). Symptoms were compatible in 63% of patients. Asthenia (77%), diarrhoea (34%) and anorexia (32%) were frequent at diagnosis. The delay between the onset of symptoms and diagnosis, death or complete recovery was 2 (0-5), 7 (4-11) and 32 (26.5-35) days, respectively. Treatment, including lopinavir/ritonavir, hydroxychloroquine and corticosteroids, was administered in 23% of patients. The median C-reactive protein (CRP) and lymphocyte count at diagnosis was 55 mg/L (IQR 25-106) and 690 Ly/µL (IQR 450-960), respectively. The case fatality rate was 24% and determinants associated with the risk of death were body temperature {hazard ratio [HR] 1.96 [95% confidence interval (CI) 1.11-3.44]; P = 0.02} and CRP at diagnosis [HR 1.01 (95% CI 1.005-1.017); P < 0.0001].

CONCLUSIONS

HD patients were found to be at high risk of developing COVID-19 and exhibited a high rate of mortality. While patients presented severe forms of the disease, they often displayed atypical symptoms, with the CRP level being highly associated with the risk of death.

Going to war on COVID-19: Mobilizing an academic nephrology group practice

Aim

The COVID‐19 pandemic poses unprecedented operational challenges to nephrology divisions in every country as they cope with COVID‐19‐related kidney disease in addition to regular patient care. Although general approaches have been proposed, there is a lack of practical guidance for nephrology division response in a hospital facing a surge of cases. Here, we describe the specific measures that our division has taken in the hope that our experience in Singapore may be helpful to others.

Methods

Descriptive narrative.

Results

A compilation of operational responses to the COVID‐19 pandemic taken by a nephrology division at a Singapore university hospital.

Conclusion

Nephrology operational readiness for COVID‐19 requires a clinical mindset shift from usual standard of care to a crisis exigency model that targets best outcomes for available resources. Rapid multi‐disciplinary efforts that evolve flexibly with the local dynamics of the outbreak are required.

A valuable experience and operational response to COVID‐19 pandemic threat by a nephrology division at a Singapore university hospital. This article gives good example of shift of clinical mindset from usual standard of care to a crisis exigency model that targets best outcomes for available resources.

Clinical benefits of Tocilizumab in COVID-19-related cytokine release syndrome in a patient with end-stage kidney disease on haemodialysis in Australia

COVID‐19 remains a global pandemic with more than 10 million cases and half a million deaths worldwide. The disease manifestations in patients with chronic kidney disease and especially those on haemodialysis are still being understood, with only a few overseas case series, and small observational trials thus far. It appears that the disease is more severe in this patient cohort. Part of the pathophysiology of severe COVID‐19 is related to accompanying cytokine release syndrome (CRS). Tocilizumab, an interleukin‐6 inhibitor, has been trialled for treatment of CRS in COVID‐19, but not yet approved. We present a case of an Australian patient on long‐term haemodialysis with severe COVID‐19 who was successfully treated with Tocilizumab. The peak of her illness was on day 7, with a C‐reactive protein of 624 mg/L (reference < 5 mg/L), ferritin of 5293 ng/mL (reference 30‐500 ng/mL), and interleukin‐6 level 1959.7 pg/mL, consistent with CRS. She was severely hypoxic on a ventilator, with rising inotropic requirements. With the use of Tocilizumab, there was a significant and immediate response in her inflammatory markers, and she made a steady recovery. The patient was discharged home 6 weeks after presentation.

A report of an elderly long‐term haemodialysis patient who successfully recovered from a cytokine release syndrome due to severe COVID‐19 using an IL‐6 inhibitor, tocilizumab.