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Quílez Trasobares N, González-Fernández M, Barea-Mendoza JA, Arias-Verdú MD, Barrueco-Francioni JE, Seller-Pérez G, Molina-Collado Z, Lesmes González-de Aledo A, Herrera-Gutiérrez M, Sánchez-Izquierdo Riera JÁ. The Role of Immunomodulatory Therapy with Oxiris in COVID-19 with Renal Failure and Immune Dysfunction. Blood Purif 2024:1-9. [PMID: 38991521 DOI: 10.1159/000539833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 06/10/2024] [Indexed: 07/13/2024]
Abstract
INTRODUCTION The main objective of this study was to evaluate the impact of hemoadsorption on the elimination of inflammatory mediators. METHODS A prospective, bicenter, observational cohort study was conducted between March 2020 and February 2022 to explore the immunomodulatory response, demographic and clinical characteristics of individuals with COVID-19 admitted to the ICU with severe acute respiratory failure and in need of CRRT with Oxiris® with or without AKI. RESULTS Sixty-four patients were analyzed. Statistically significant differences were observed between exposed and unexposed groups, in relation to the reduction in D-dimer levels -15,614 (24,848.9) versus -4,136.5 (9,913.47) (p 0.031, d: 1.59, 95% CI: -21,830, -1,126). An increase in PCT was observed 0.47 (2.08) versus -0.75 (2.3) (p 0.044 95% CI: 0.03, 2.44). No differences were found in a decrease in CRP -4.21 (7.29) versus -1.6 (9.02) (p 0.22) nor in the rest of inflammatory parameters fibrinogen, IL-6, ferritin, lymphocytes, and neutrophils. Subgroup analysis in patients exposed to therapy also showed a significant decrease in D-dimer of 55% from baseline: 6,000 (1,984.5-27,750) pre-therapy versus 2,700 (2,119.5-6,145) (95% CI: -23,000, -2,489) post-therapy with a strong effect size (p 0.001, d: 0.65). CONCLUSION The hemoadsorptive therapy in COVID-19 was associated with a significant decrease in D-dimer parameters without showing decreases in the rest of the clinical, inflammatory parameters and severity scales analyzed.
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Nishikawa A, Ito I, Yonezawa A, Itohara K, Matsubara T, Sato Y, Matsumura K, Hamada S, Tanabe N, Kai S, Imoto E, Yoshikawa K, Ohtsuru S, Yanagita M, Hirai T, Terada T. Pharmacokinetics of GS-441524, the active metabolite of remdesivir, in patients receiving continuous renal replacement therapy: A case series. J Infect Chemother 2024; 30:348-351. [PMID: 37866621 DOI: 10.1016/j.jiac.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/22/2023] [Accepted: 10/19/2023] [Indexed: 10/24/2023]
Abstract
Remdesivir plays a key role in the treatment of coronavirus disease in 2019 (COVID-19). Haemodialysis is sometimes required for hospitalised patients with COVID-19, and patients undergoing haemodialysis are at an increased risk of severe COVID-19. In the present study, we report the serum concentrations of GS-441524, the active metabolite of remdesivir, in four patients undergoing continuous renal replacement therapy (CRRT). Patient 1, a male aged 70s, received a loading dose of 200 mg remdesivir on day 1, followed by 100 mg remdesivir from day 2, according to the package insert as in non-haemodialysis patients. The mean trough serum concentration of GS-441524 was 783.5 ng/mL, which was approximately 7-fold higher than the mean for patients with an estimated glomerular filtration rate (eGFR) ≥ 60 mL/min. Patients 2-4 received a loading dose of 200 mg remdesivir on day 1, followed by 100 mg once every 2 days from day 2. The mean trough serum concentrations of GS-441524 were 302.2 ng/mL, 585.8 ng/mL and 677.3 ng/mL, respectively. These were 3 to 6-fold higher than the mean for patients with eGFR ≥60 mL/min. The target doses for patients 1, 2, 3, and 4 receiving CRRT were 13.6 mL/kg/h, 6.0-12.5 mL/kg/h, 20.1 mL/kg/h, and 15.1 mL/kg/h, respectively, using a polysulphone membrane. The package insert dose of remdesivir is an overdose for CRRT patients with a target dose of 10-20 mL/kg/h. In low-intensity CRRT, as in Japan, it may be necessary to extend the interval between the doses of remdesivir.
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Affiliation(s)
- Asami Nishikawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Isao Ito
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan; Division of Integrative Clinical Pharmacology, Faculty of Pharmacy, Keio University, Tokyo, Japan.
| | - Kotaro Itohara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Takeshi Matsubara
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuki Sato
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Katsuyuki Matsumura
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Satoshi Hamada
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Naoya Tanabe
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichi Kai
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | | | | | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Institute for the Advanced Study of Human Biology (WPI-ASHBi), Kyoto University, Kyoto, Japan
| | - Toyohiro Hirai
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
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Adwan L, Al-Sadi T, Shawakha S, Al-Shami NA. Clinical outcomes of COVID-19 in hemodialysis patients. Front Med (Lausanne) 2023; 10:1281594. [PMID: 38020138 PMCID: PMC10679386 DOI: 10.3389/fmed.2023.1281594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) is known for its effects on the respiratory system. Three years after the pandemic morbid and mortal consequences, growing evidence is showing that the disease also has adverse outcomes and complications on additional organs including the kidneys. This study aims at investigating the effects of COVID-19 on hemodialysis patients receiving services at Palestine Medical Complex (PMC) kidney dialysis department, and to identify mortality related risk factors. Methods In April 2022, data was collected using the electronic medical records system for the dialysis department at PMC. The study included all PMC hemodialysis patients that were infected with COVID-19 between January 2020-April 2022. The collected data included patient demographics, clinical features, laboratory tests, dialysis frequency and the disease outcome. Results The results showed that the patients' outcomes and dialysis frequency were impacted by their blood urea nitrogen (BUN), serum creatinine (SCr) and calcium levels. About one third of the study population died after being infected with COVID-19. The frequency of dialysis was also affected by the presence of comorbidities like hypertension, diabetes mellitus (DM) and myocardial infarction (MI). Conclusion This study found that there was a high mortality rate within the hemodialysis patients infected with COVID-19. Having comorbidities affected the frequency of dialysis following COVID-19 infection. Dialysis patients should be protected from infections such as COVID-19 and their comorbidities should be monitored and kept under control as much as possible.
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Affiliation(s)
- Lina Adwan
- Department of Pharmacy, College of Pharmacy Nursing and Health Professions, Birzeit University, Birzeit, Palestine
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Pethő ÁG, Kevei P, Juha M, Kóczy Á, Ledó N, Tislér A, Takács I, Tabák ÁG. The impact of COVID-19 infection before the vaccination era on the hospitalized patients requiring hemodialysis: a single-center retrospective cohort. Ren Fail 2023; 45:2251593. [PMID: 37732362 PMCID: PMC10515667 DOI: 10.1080/0886022x.2023.2251593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/19/2023] [Indexed: 09/22/2023] Open
Abstract
Due to effective vaccinations, the COVID-19 (coronavirus disease 2019) infection that caused the pandemic has a milder clinical course. We aimed to assess the mortality of hospitalized COVID-19 patients before the vaccination era. We investigated the mortality in those patients between 1 October 2020 and 31 May 2021 who received hemodialysis treatment [patients with previously normal renal function (nCKD), patients with chronic kidney disease previously not requiring hemodialysis (CKDnonHD), chronic kidney disease (CKD), and patients on regular hemodialysis (pHD)]. In addition, participants were followed up for all-cause mortality in the National Health Service database until 1 December 2021. In our center, 83 of 108 (76.9%) were included in the analysis due to missing covariates. Over a median of 26 (interquartile range 11-266) days of follow-up, 20 of 22 (90.9%) of nCKD, 23 of 24 (95.8%) of CKDnonHD, and 17 of 37 (45.9%) pHD patients died (p < 0.001). In general, patients with nCKD had fewer comorbidities but more severe presentations. In contrast, the patients with pHD had the least severe symptoms (p < 0.001). In a model adjusted for independent predictors of all-cause mortality (C-reactive protein and serum albumin), CKDnonHD patients had increased mortality [hazard ratio (HR) 1.91, 95% confidence interval (CI), 1.02-3.60], while pHD patients had decreased mortality (HR 0.41, 95% CI 0.20-0.81) compared to nCKD patients. After further adjustment for the need for intensive care, the difference in mortality between the nCKD and pHD groups became non-significant. Despite the limitations of our study, it seems that the survival of previously hemodialysis patients was significantly better.
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Affiliation(s)
- Ákos Géza Pethő
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Kevei
- Hemodialysis Unit, Fresenius Medical Care Hungary, Budapest, Hungary
| | - Márk Juha
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Ágnes Kóczy
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Nóra Ledó
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - András Tislér
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - István Takács
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Ádám G. Tabák
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Department of Epidemiology and Public Health, Semmelweis University Faculty of Medicine, Budapest, Hungary
- Department of Epidemiology and Public Health, University College London, London, UK
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Sethi J, Kumar V, Yadav AK, Bharti J, Divyaveer SS, Ramachandran R, Rathi M, Kohli HS. Poor Outcome after Hospital Discharge in Patients with ESKD and COVID-19. Indian J Nephrol 2023; 33:150-151. [PMID: 37234430 PMCID: PMC10208531 DOI: 10.4103/ijn.ijn_286_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/14/2021] [Indexed: 05/28/2023] Open
Affiliation(s)
- Jasmine Sethi
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivek Kumar
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok K. Yadav
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Joyita Bharti
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Smita S. Divyaveer
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harbir S. Kohli
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Kaswa R. Acute kidney injury among hospitalised patients who died due to COVID-19 in the Eastern Cape, South Africa. S Afr Fam Pract (2004) 2023; 65:e1-e5. [PMID: 36744486 PMCID: PMC9900244 DOI: 10.4102/safp.v65i1.5616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/29/2022] [Accepted: 10/31/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) commonly occurs in coronavirus disease 2019 (COVID-19) patients who have been hospitalised and is associated with a poor prognosis. This study aimed to determine the incidence of AKI among COVID-19 patients who died in a regional hospital in South Africa. METHODS This retrospective record review was conducted at the Mthatha Regional Hospital in South Africa's Eastern Cape province. Data were collected between 10 July 2020 and 31 January 2021. RESULTS The incidence of AKI was 38% among the hospitalised patients who died due to COVID-19. Most study participants were female, with a mean age of 63.3 ± 16 years. The most common symptom of COVID-19 at the time of hospitalisation was shortness of breath, followed by fever and cough. Half of the patients had hypertension, while diabetes, human immunodeficiency viruses (HIV) and tuberculosis (TB) were other comorbidities. At admission, the average oxygen saturation was 75.5% ± 17. CONCLUSION The study revealed a high incidence of AKI among hospitalised patients who died due to COVID-19. It also found that those received adequate crystalloid fluids at the time of admission had a lower incidence of AKI.Contribution: Acute kidney injury can be prevented by adequate fluid management during early stage of COVID-19. Majority of COVID-19 patients were referred from lower level of care and primary care providers have their first encounter with these patients. Adequate fluid resuscitation in primary care settings can improve the outcome of hospitalised COVID-19 patients.
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Affiliation(s)
- Ramprakash Kaswa
- Department of Family Medicine and Rural Health, Faculty of Health Sciences, Walter Sisulu University, Mthatha.
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Gilmore NT, Alsbrooks K, Hoerauf K. The Association Between Catheter Type and Dialysis Treatment: A Retrospective Data Analysis at Two U.S.-Based ICUs. Crit Care Explor 2023; 5:e0795. [PMID: 36699249 PMCID: PMC9829250 DOI: 10.1097/cce.0000000000000795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Dialysis catheter type may be associated with differences in continuous renal replacement therapy (CRRT) treatment in the critically ill, with potential implications for patient outcomes and healthcare costs. OBJECTIVES To evaluate the association between the catheter type and multiple dialysis treatment outcomes among the critically ill. DESIGN Retrospective, observational study. SETTING Two U.S.-based ICUs. PARTICIPANTS Critically ill patients receiving CRRT between April 1, 2018, and July 1, 2020. A total of 1,037 CRRT sessions were analyzed. MAIN OUTCOMES AND MEASURES Circuit life, alarm interruption frequency (including a subset of vascular access [VA]-related alarms), termination type (elective vs nonelective), and blood flow rates. Pre- (n = 530) and post-catheter change (n = 507) periods were assessed, and the post-change period was further divided into intervals of pre-COVID (n = 167) and COVID contemporaneous (n = 340) to account for the pandemic's impact. RESULTS Compared with pre-change sessions, post-change sessions had 31% longer circuit life (95% CI, 1.14-1.49; p < 0.001), 3% higher blood flow rate (1.01-1.05; p < 0.01), and lower proportion of nonelective terminations (adjusted odds ratio [OR], 0.42 [0.28-0.62]; p < 0.001). There were fewer interruptions for all alarms (adjusted count ratio, 0.95 [0.87-1.05]; p = 0.31) and VA-related alarms (0.80 [0.66-0.96]; p = 0.014). The sessions during COVID period were statistically similar to pre-COVID sessions for all outcomes except a lower proportion of nonelective terminations (adjusted OR, 0.39 [0.22-0.70]; p < 0.01). CONCLUSIONS A change in catheter type was associated with longer CRRT sessions with fewer interruptions and unexpected terminations in a population of critical patients.
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Affiliation(s)
- Nathan T. Gilmore
- Department of Critical Care, Hoag Health Center Newport Beach, Newport Beach, CA
| | | | - Klaus Hoerauf
- Medical Affairs, Becton, Dickinson, and Company, Franklin Lakes, NJ., Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
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Impact of Dialysis Clinical Operating Conditions on Human Serum Protein-Mediated Inflammatory Biomarkers Released in Patients Using Polyarylethersulfone Membranes. JOURNAL OF COMPOSITES SCIENCE 2022. [DOI: 10.3390/jcs6080226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Hemodialysis (HD) is a life-sustaining treatment of crucial importance in managing end-stage renal disease (ESRD). However, this membrane-based therapy is associated with acute side-effects due to bioincompatibility issues and limitations on the removal of uremic toxins. The present study assessed the influence of hydrodynamic conditions applied during HD treatment on protein-mediated inflammatory and thrombotic responses. The membrane modules considered are commonly used in Canadian hospitals and are comprised of a polymer blend of polyarylether sulfone-polyvinylpyrrolidone (PAES). The membranes morphology and hydrophilicity were assessed using SEM, AFM, BET, and zeta potential. An in vitro study evaluated the adsorptive behavior of fibrinogen (FB) to the membrane under different flow conditions. Lower rates of 200 mL/min promoted slower and significant FB adsorption, leading to more severe inflammatory and thrombotic responses. Hydrodynamic conditions also affected the concentration of all inflammatory biomarkers. Lower flow rates triggered more complement activation as well as coagulation, clotting, and inflammatory responses compared to higher flow rates. At the end of the dialysis session, patients treated with a Qb of 200 mL/min presented a significant increase in the concentration of C5a (232%), properdin (114%), serpin (545%), IL-1α (50%), IL-6 (450%), and vWF (212%). IL-1β and TNF-α concentrations declined by 12.5 and 35.5%, respectively. Male patients experienced more severe inflammatory responses than female patients at the operating conditions considered. Comparing the pre- and post-dialysis levels of female and male patients, female patients experienced significantly higher levels of IL-6 and properdin, while male patients presented higher levels of C5a, IL-1α, and IL-6. The results of this study will help clinical doctors evaluate the impact of HD operating conditions on blood activations before prescribing treatment and inform expectations for outcomes in female and male patients.
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Kooman JP, Carioni P, Kovarova V, Arkossy O, Winter A, Zhang Y, Bellocchio F, Kotanko P, Zhang H, Usvyat L, Larkin J, Stuard S, Neri L. Modifiable Risk Factors Are Important Predictors of COVID-19-Related Mortality in Patients on Hemodialysis. FRONTIERS IN NEPHROLOGY 2022; 2:907959. [PMID: 37674993 PMCID: PMC10479683 DOI: 10.3389/fneph.2022.907959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/01/2022] [Indexed: 09/08/2023]
Abstract
Introduction Patients with end-stage kidney disease face a higher risk of severe outcomes from SARS-CoV-2 infection. Moreover, it is not well known to what extent potentially modifiable risk factors contribute to mortality risk. In this historical cohort study, we investigated the incidence and risk factors for 30-day mortality among hemodialysis patients with SARS-CoV-2 infection treated in the European Fresenius Medical Care NephroCare network using conventional and machine learning techniques. Methods We included adult hemodialysis patients with the first documented SARS-CoV-2 infection between February 1, 2020, and March 31, 2021, registered in the clinical database. The index date for the analysis was the first SARS-CoV-2 suspicion date. Patients were followed for up to 30 days until April 30, 2021. Demographics, comorbidities, and various modifiable risk factors, expressed as continuous parameters and as key performance indicators (KPIs), were considered to tap multiple dimensions including hemodynamic control, nutritional state, and mineral metabolism in the 6 months before the index date. We used logistic regression (LR) and XGBoost models to assess risk factors for 30-day mortality. Results We included 9,211 patients (age 65.4 ± 13.7 years, dialysis vintage 4.2 ± 3.7 years) eligible for the study. The 30-day mortality rate was 20.8%. In LR models, several potentially modifiable factors were associated with higher mortality: body mass index (BMI) 30-40 kg/m2 (OR: 1.28, CI: 1.10-1.50), single-pool Kt/V (OR off-target vs on-target: 1.19, CI: 1.02-1.38), overhydration (OR: 1.15, CI: 1.01-1.32), and both low (<2.5 mg/dl) and high (≥5.5 mg/dl) serum phosphate levels (OR: 1.52, CI: 1.07-2.16 and OR: 1.17, CI: 1.01-1.35). On-line hemodiafiltration was protective in the model using KPIs (OR: 0.86, CI: 0.76-0.97). SHapley Additive exPlanations analysis in XGBoost models shows a high influence on prediction for several modifiable factors as well, including inflammatory parameters, high BMI, and fluid overload. In both LR and XGBoost models, age, gender, and comorbidities were strongly associated with mortality. Conclusion Both conventional and machine learning techniques showed that KPIs and modifiable risk factors in different dimensions ascertained 6 months before the COVID-19 suspicion date were associated with 30-day COVID-19-related mortality. Our results suggest that adequate dialysis and achieving KPI targets remain of major importance during the COVID-19 pandemic as well.
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Affiliation(s)
- Jeroen Peter Kooman
- Department of Internal Medicine, University Hospital Maastricht, Maastricht, Netherlands
| | - Paola Carioni
- Fresenius Medical Care Italia SpA, Palazzo Pignano, Italy
| | | | - Otto Arkossy
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Anke Winter
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Yan Zhang
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | - Peter Kotanko
- Renal Research Institute, New York, NY, United States
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Hanjie Zhang
- Renal Research Institute, New York, NY, United States
| | - Len Usvyat
- Fresenius Medical Care, Waltham, MA, United States
| | - John Larkin
- Fresenius Medical Care, Waltham, MA, United States
| | - Stefano Stuard
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Luca Neri
- Fresenius Medical Care Italia SpA, Palazzo Pignano, Italy
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Jamale TE, Thakare SB. COVID-19: A nephrologists' perspective. J Postgrad Med 2022; 68:187-193. [PMID: 36348604 PMCID: PMC9841537 DOI: 10.4103/jpgm.jpgm_470_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- TE Jamale
- Department of Nephrology, Seth GSMC and KEMH, Mumbai, Maharashtra, India,Address for correspondence: Dr. Jamale TE, E-mail:
| | - SB Thakare
- Department of Nephrology, Seth GSMC and KEMH, Mumbai, Maharashtra, India
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SARS-CoV-2 Infection in Patients on Dialysis: Incidence and Outcomes in the Lazio Region, Italy. J Clin Med 2021; 10:jcm10245818. [PMID: 34945114 PMCID: PMC8708577 DOI: 10.3390/jcm10245818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 11/25/2021] [Accepted: 12/09/2021] [Indexed: 01/08/2023] Open
Abstract
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.
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Abdelrasoul A, Westphalen H, Saadati S, Shoker A. Hemodialysis biocompatibility mathematical models to predict the inflammatory biomarkers released in dialysis patients based on hemodialysis membrane characteristics and clinical practices. Sci Rep 2021; 11:23080. [PMID: 34845257 PMCID: PMC8630185 DOI: 10.1038/s41598-021-01660-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 10/20/2021] [Indexed: 02/07/2023] Open
Abstract
Chronic kidney disease affects millions of people around the globe and many patients rely on hemodialysis (HD) to survive. HD is associated with undesired life-threatening side effects that are linked to membrane biocompatibility and clinical operating conditions. The present study develops a mathematical model to predict the inflammatory biomarkers released in HD patients based on membrane morphology, chemistry, and interaction affinity. Based on the morphological characteristics of two clinical-grade HD membrane modules (CTA and PAES-PVP) commonly used in Canadian hospitals, a molecular docking study, and the release of inflammatory cytokines during HD and in vitro incubation experiments, we develop five sets of equations that describe the concentration of eight biomarkers (serpin/antithrombin-III, properdin, C5a, 1L-1α, 1L-1β, C5b-9, IL6, vWF). The equations developed are functions of membrane properties (pore size, roughness, chemical composition, affinity to fibrinogen, and surface charge) and HD operating conditions (blood flow rate, Qb, and treatment time, t). We expand our model based on available clinical data and increase its range of applicability in terms of flow rate and treatment time. We also modify the original equations to expand their range of applicability in terms of membrane materials, allowing the prediction and validation of the inflammatory response of several clinical and synthesized membrane materials. Our affinity-based model solely relies on theoretical values of molecular docking, which can significantly reduce the experimental load related to the development of more biocompatible materials. Our model predictions agree with experimental clinical data and can guide the development of novel materials and support evidence-based membrane synthesis of HD membranes, reducing the need for trial-and-error approaches.
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Affiliation(s)
- Amira Abdelrasoul
- Department of Chemical and Biological Engineering, University of Saskatchewan, 57 Campus Drive, Saskatoon, SK, S7N 5A9, Canada.
- Division of Biomedical Engineering, University of Saskatchewan, 57 Campus Drive, Saskatoon, SK, S7N 5A9, Canada.
| | - Heloisa Westphalen
- Department of Chemical and Biological Engineering, University of Saskatchewan, 57 Campus Drive, Saskatoon, SK, S7N 5A9, Canada
| | - Shaghayegh Saadati
- Department of Chemical and Biological Engineering, University of Saskatchewan, 57 Campus Drive, Saskatoon, SK, S7N 5A9, Canada
- Division of Biomedical Engineering, University of Saskatchewan, 57 Campus Drive, Saskatoon, SK, S7N 5A9, Canada
| | - Ahmed Shoker
- Nephrology Division, College of Medicine, University of Saskatchewan, 107 Wiggins Rd, Saskatoon, SK, S7N 5E5, Canada
- Saskatchewan Transplant Program, St. Paul's Hospital, 1702 20th Street West, Saskatoon, SK, S7M 0Z9, Canada
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13
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Faour WH, Choaib A, Issa E, Choueiry FE, Shbaklo K, Alhajj M, Sawaya RT, Harhous Z, Alefishat E, Nader M. Mechanisms of COVID-19-induced kidney injury and current pharmacotherapies. Inflamm Res 2021; 71:39-56. [PMID: 34802072 PMCID: PMC8606168 DOI: 10.1007/s00011-021-01520-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/31/2021] [Accepted: 11/01/2021] [Indexed: 01/08/2023] Open
Abstract
The COVID-19 pandemic created a worldwide debilitating health crisis with the entire humanity suffering from the deleterious effects associated with the high infectivity and mortality rates. While significant evidence is currently available online and targets various aspects of the disease, both inflammatory and noninflammatory kidney manifestations secondary to COVID-19 infection are still largely underrepresented. In this review, we summarized current knowledge about COVID-19-related kidney manifestations, their pathologic mechanisms as well as various pharmacotherapies used to treat patients with COVID-19. We also shed light on the effect of these medications on kidney functions that can further enhance renal damage secondary to the illness.
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Affiliation(s)
- Wissam H Faour
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, P.O. Box 36, Byblos, Lebanon.
| | - Ali Choaib
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, P.O. Box 36, Byblos, Lebanon
| | - Elio Issa
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, P.O. Box 36, Byblos, Lebanon
| | - Francesca El Choueiry
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, P.O. Box 36, Byblos, Lebanon
| | - Khodor Shbaklo
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, P.O. Box 36, Byblos, Lebanon
| | - Maryline Alhajj
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, P.O. Box 36, Byblos, Lebanon
| | - Ramy Touma Sawaya
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, P.O. Box 36, Byblos, Lebanon
| | - Zeina Harhous
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, P.O. Box 36, Byblos, Lebanon
| | - Eman Alefishat
- Department of Pharmacology, College of Medicine and Health Sciences, Khalifa University of Science and Technology, P.O. Box 127788, Abu Dhabi, United Arab Emirates
- Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman, Jordan
| | - Moni Nader
- Department of Physiology and Immunology, College of Medicine and Health Sciences, Khalifa University of Science and Technology, P.O. Box 127788, Abu Dhabi, United Arab Emirates.
- Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates.
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14
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Seck SM, Mbow M, Kane Y, Cisse MM, Faye G, Kama A, Sarr M, Nitcheu P, Dahaba M, Diallo IM, Diawara MS, Latou LNM, Dia Y, Mboup S. Prevalence of SARS-CoV-2 antibodies in hemodialysis patients in Senegal: a multicenter cross-sectional study. BMC Nephrol 2021; 22:384. [PMID: 34789170 PMCID: PMC8595275 DOI: 10.1186/s12882-021-02582-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 10/08/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Hemodialysis patients are among high-risk groups for COVID-19. Africa is the continent with the lowest number of cases in the general population but we have little information about the disease burden in dialysis patients. OBJECTIVES This study aimed to describe the seroprevalence of SARS-CoV-2 antibodies in the hemodialysis population of Senegal. PATIENTS AND METHODS We conducted a multicenter cross-sectional survey, between June and September 2020 involving 10 public dialysis units randomly selected in eight regions of Senegal. After seeking their consent, we included 303 patients aged ≥ 18 years and hemodialysis for ≥ 3 months. Clinical symptoms and biological parameters were collected from medical records. Patients' blood samples were tested with Abbott SARS-CoV-2 Ig G assay using an Architect system. Statistical tests were performed with STATA 12.0. RESULTS Seroprevalence of SARS-CoV-2 antibodies was 21.1% (95% CI = 16.7-26.1%). We noticed a wide variability in SARS-CoV-2 seroprevalence between regions ranging from 5.6 to 51.7%. Among the 38 patients who underwent nasal swab testing, only six had a PCR-confirmed infection and all of them did seroconvert. Suggestive clinical symptoms were reported by 28.1% of seropositive patients and the majority of them presented asymptomatic disease. After multivariate analysis, a previous contact with a confirmed case and living in a high population density region were associated with the presence of SARS-CoV-2 antibodies. CONCLUSION This study presents to our knowledge the first seroprevalence data in African hemodialysis patients. Compared to data from other continents, we found a higher proportion of patients with SARS-CoV-2 antibodies but a lower lethality rate.
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Affiliation(s)
- Sidy Mohamed Seck
- Department of Nephrology/Internal Medicine, Faculty of Health Sciences, University Gaston Berger of Saint-Louis, Route de Ngallele, BP 234, Sanar, Saint-Louis, Senegal. .,Dialysis Center, Military Hospital of Ouakam, Dakar, Senegal. .,IRL-ESS-3189, Faculty of Medicine, University Cheikh Anta Diop, Dakar, Senegal.
| | - Moustapha Mbow
- Dialysis Center, Military Hospital of Ouakam, Dakar, Senegal.,University Cheikh Anta Diop, Dakar, Senegal
| | - Yaya Kane
- University Assane Seck, Ziguinchor, Senegal
| | | | | | | | | | | | | | - Ibrahima Mbemba Diallo
- Department of Nephrology/Internal Medicine, Faculty of Health Sciences, University Gaston Berger of Saint-Louis, Route de Ngallele, BP 234, Sanar, Saint-Louis, Senegal
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15
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Choe PG, Jeong SI, Kang CK, Yang L, Lee S, Cho JY, Han SS, Kim DK, Lee SM, Park WB, Oh MD, Kim NJ. Exploration for the effect of renal function and renal replacement therapy on pharmacokinetics of remdesivir and GS-441524 in patients with COVID-19: A limited case series. Clin Transl Sci 2021; 15:732-740. [PMID: 34761554 PMCID: PMC8652615 DOI: 10.1111/cts.13194] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 10/26/2021] [Accepted: 10/31/2021] [Indexed: 11/28/2022] Open
Abstract
Remdesivir, an antiviral agent for the treatment of coronavirus disease 2019 (COVID‐19), is metabolized intracellularly, with these metabolites eliminated predominantly in urine. Because of a lack of safety and pharmacokinetic (PK) data, remdesivir is not currently recommended for patients with estimated glomerular filtration rate less than 30 ml/min/1.73 m2 and those on hemodialysis. This study evaluated the PKs of remdesivir and its metabolite, GS‐441524, in patients with COVID‐19 who were and were not receiving renal replacement therapy (RRT). This study enrolled two patients with normal renal function, two with impaired renal function not receiving RRT, two receiving continuous RRT (CRRT), and three undergoing intermittent hemodialysis (IHD). Patients were administered 200 mg remdesivir on the first day, followed by 100 mg/day for 5–10 days. Serial blood samples were collected for PK analysis, and PK parameters were assessed by a noncompartmental method. Systemic exposure to remdesivir was higher in patients with impaired renal function and those receiving CRRT than in patients with normal renal function, but was similar in patients undergoing IHD and those with normal renal function. By contrast, systemic exposure to GS‐441524 was highest in patients undergoing IHD, followed by patients with impaired renal function and those receiving CRRT, and lowest in patients with normal renal function. The PK profiles of remdesivir and GS‐441524 varied according to renal function and RRT. The impact of PK changes of remdesivir and its metabolite on safety and efficacy should be considered when administering remdesivir to patients with COVID‐19 with renal impairment.
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Affiliation(s)
- Pyoeng Gyun Choe
- Department of Internal Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Sae Im Jeong
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Chang Kyung Kang
- Department of Internal Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Liju Yang
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - SeungHwan Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Joo-Youn Cho
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Sang Min Lee
- Department of Internal Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Myoung-Don Oh
- Department of Internal Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Nam Joong Kim
- Department of Internal Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
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16
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COVID-19 in Solid Organ Transplantation: Results of the National COVID Cohort Collaborative. Transplant Direct 2021; 7:e775. [PMID: 34646938 PMCID: PMC8500600 DOI: 10.1097/txd.0000000000001234] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 01/03/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has resulted in significant morbidity and mortality in solid organ transplant (SOT) recipients. The National COVID Cohort Collaborative was developed to facilitate analysis of patient-level data for those tested for COVID-19 across the United States. METHODS In this study, we identified a cohort of SOT recipients testing positive or negative for COVID-19 (COVID+ and COVID-, respectively) between January 1, 2020, and November 20, 2020. Univariable and multivariable logistic regression were used to determine predictors of a positive result among those tested. Outcomes following COVID-19 diagnosis were also explored. RESULTS Of 18 121 SOT patients tested, 1925 were positive (10.6%). COVID+ SOT patients were more likely to have a kidney transplant and be non-White race. Comorbidities were common in all SOT patients but significantly more common in those who were COVID+. Of COVID+ SOT, 42.9% required hospital admission. COVID+ status was the strongest predictor of acute kidney injury (AKI), rejection, and graft failure in the 90 d after testing. A total of 40.9% of COVID+ SOT experienced a major adverse renal or cardiac event, 16.3% experienced a major adverse cardiac event, 35.3% experienced AKI, and 1.5% experienced graft loss. CONCLUSIONS In the largest US cohort of COVID+ SOT recipients to date, we identified patient factors associated with the diagnosis of COVID-19 and outcomes following infection, including a high incidence of major adverse renal or cardiac event and AKI.
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17
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Abstract
Abstract The infection by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and resultant coronavirus diseases-19 (COVID-19) disproportionally affects minorities, especially African Americans (AA) compared to the Caucasian population. The AA population is disproportionally affected by COVID-19, in part, because they have high prevalence of underlying conditions such as obesity, diabetes, and hypertension, which are known to exacerbate not only kidney diseases, but also COVID-19. Further, a decreased adherence to COVID-19 guidelines among tobacco smokers could result in increased infection, inflammation, reduced immune response, and lungs damage, leading to more severe form of COVID-19. As a result of high prevalence of underlying conditions that cause kidney diseases in the AA population coupled with tobacco smoking make the AA population vulnerable to severe form of both COVID-19 and kidney diseases. In this review, we describe how tobacco smoking interact with SARS-CoV-2 and exacerbates SARS-CoV-2-induced kidney diseases including renal failure, especially in the AA population. We also explore the role of extracellular vesicles (EVs) in COVID-19 patients who smoke tobacco. EVs, which play important role in tobacco-mediated pathogenesis in infectious diseases, have also shown to be important in COVID-19 pathogenesis and organ injuries including kidney. Further, we explore the potential role of EVs in biomarker discovery and therapeutics, which may help to develop early diagnosis and treatment of tobacco-induced renal injury in COVID-19 patients, respectively. Graphical Abstract ![]()
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18
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Kotanko P, Rosales L, Ronco C. 23rd International Conference on Dialysis: Advances in Chronic Kidney Disease 2021 (April 20-23, 2021, USA). Blood Purif 2021; 50:591-594. [PMID: 34198286 DOI: 10.1159/000517786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Peter Kotanko
- Renal Research Institute, New York, New York, USA.,Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy.,International Renal Research Institute of Vicenza, Vicenza, Italy.,Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
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19
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Conca W, Alabdely M, Albaiz F, Foster MW, Alamri M, Alkaff M, Al-Mohanna F, Nagelkerke N, Almaghrabi RS. Serum β2-microglobulin levels in Coronavirus disease 2019 (Covid-19): Another prognosticator of disease severity? PLoS One 2021; 16:e0247758. [PMID: 33647017 PMCID: PMC7920360 DOI: 10.1371/journal.pone.0247758] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 02/14/2021] [Indexed: 12/15/2022] Open
Abstract
β2-microglobulin (β2-m), a 11.8 kDa protein, pairs non-covalently with the α3 domain of the major histocompatibility class (MHC) I α-chain and is essential for the conformation of the MHC class I protein complex. Shed β2-m is measurable in circulation, and various disorders are accompanied by increases in β2-m levels, including several viral infections. Therefore, we explored whether β2-m levels could also be elevated in Coronavirus disease 2019 (Covid-19) and whether they predict disease severity. Serum β2-m levels were measured in a cohort of 34 patients infected with SARS-CoV-2 on admission to a tertiary care hospital in Riyadh, Saudi Arabia, as well as in an approximately age-sex matched group of 34 uninfected controls. Mean β2-m level was 3.25±1.68 mg/l (reference range 0.8-2.2 mg/l) in patients (mean age 48.2±21.6) and 1.98±0.61 mg/l in controls (mean age 48.2±21.6). 17 patients (mean age 36.9± 18.0) with mean β2-m levels of 2.27±0.64 mg/l had mild disease by WHO severity categorization, 12 patients (mean age 53.3±18.1) with mean β2-m levels of 3.57±1.39 mg/l had moderate disease, and five patients (of whom 2 died; mean age 74.4±13.8) with mean β2-m levels of 5.85±1.85 mg/l had severe disease (P < = 0.001, by ANOVA test for linear trend). In multivariate ordinal regression β2-m levels were the only significant predictor of disease severity. Our findings suggest that higher β2-m levels could be an early indicator of severity of disease and predict outcome of Covid-19. As the main limitations of the study are a single-center study, sample size and ethnicity, these results need confirmation in larger cohorts outside the Arabian Peninsula in order to delineate the value of β2-m measurements. The role of β2-m in the etiology and pathogenesis of severe Covid-19 remains to be elucidated.
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Affiliation(s)
- Walter Conca
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.,Department of Executive Health Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.,Department of Cell Biology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Mayyadah Alabdely
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Faisal Albaiz
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Michael Warren Foster
- Department of Executive Health Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Maha Alamri
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Morad Alkaff
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Futwan Al-Mohanna
- Department of Cell Biology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Nicolaas Nagelkerke
- Department of Community Medicine, United Arab University, Al Ain, United Arab Emirates
| | - Reem Saad Almaghrabi
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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