Outcomes Among Patients Hospitalized With COVID-19 and Acute Kidney Injury

RATIONALE & OBJECTIVE

Outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19) and acute kidney injury (AKI) are not well understood. The goal of this study was to investigate the survival and kidney outcomes of these patients.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Patients (aged≥18 years) hospitalized with COVID-19 at 13 hospitals in metropolitan New York between March 1, 2020, and April 27, 2020, followed up until hospital discharge.

EXPOSURE

AKI.

OUTCOMES

Primary outcome: in-hospital death.

SECONDARY OUTCOMES

requiring dialysis at discharge, recovery of kidney function.

ANALYTICAL APPROACH

Univariable and multivariable time-to-event analysis and logistic regression.

RESULTS

Among 9,657 patients admitted with COVID-19, the AKI incidence rate was 38.4/1,000 patient-days. Incidence rates of in-hospital death among patients without AKI, with AKI not requiring dialysis (AKI stages 1-3), and with AKI receiving dialysis (AKI 3D) were 10.8, 31.1, and 37.5/1,000 patient-days, respectively. Taking those without AKI as the reference group, we observed greater risks for in-hospital death for patients with AKI 1-3 and AKI 3D (HRs of 5.6 [95% CI, 5.0-6.3] and 11.3 [95% CI, 9.6-13.1], respectively). After adjusting for demographics, comorbid conditions, and illness severity, the risk for death remained higher among those with AKI 1-3 (adjusted HR, 3.4 [95% CI, 3.0-3.9]) and AKI 3D (adjusted HR, 6.4 [95% CI, 5.5-7.6]) compared with those without AKI. Among patients with AKI 1-3 who survived, 74.1% achieved kidney recovery by the time of discharge. Among those with AKI 3D who survived, 30.6% remained on dialysis at discharge, and prehospitalization chronic kidney disease was the only independent risk factor associated with needing dialysis at discharge (adjusted OR, 9.3 [95% CI, 2.3-37.8]).

LIMITATIONS

Observational retrospective study, limited to the NY metropolitan area during the peak of the COVID-19 pandemic.

CONCLUSIONS

AKI in hospitalized patients with COVID-19 was associated with significant risk for death.

Outcomes of patients with end-stage kidney disease hospitalized with COVID-19

Given the high risk of infection-related mortality, patients with end-stage kidney disease (ESKD) may be at increased risk with COVID-19. To assess this, we compared outcomes of patients with and without ESKD, hospitalized with COVID-19. This was a retrospective study of patients admitted with COVID-19 from 13 New York hospitals from March 1, 2020, to April 27, 2020, and followed through May 27, 2020. We measured primary outcome (in-hospital death), and secondary outcomes (mechanical ventilation and length of stay). Of 10,482 patients with COVID-19, 419 had ESKD. Patients with ESKD were older, had a greater percentage self-identified as Black, and more comorbid conditions. Patients with ESKD had a higher rate of in-hospital death than those without (31.7% vs 25.4%, odds ratio 1.38, 95% confidence interval 1.12 - 1.70). This increase rate remained after adjusting for demographic and comorbid conditions (adjusted odds ratio 1.37, 1.09 - 1.73). The odds of length of stay of seven or more days was higher in the group with compared to the group without ESKD in both the crude and adjusted analysis (1.62, 1.27 - 2.06; vs 1.57, 1.22 - 2.02, respectively). There was no difference in the odds of mechanical ventilation between the groups. Independent risk factors for in-hospital death for patients with ESKD were increased age, being on a ventilator, lymphopenia, blood urea nitrogen and serum ferritin. Black race was associated with a lower risk of death. Thus, among patients hospitalized with COVID-19, those with ESKD had a higher rate of in-hospital death compared to those without ESKD.

SAT-128 Evaluating the Accuracy of Glycemic Markers and Risk of Hypoglycemia in Patients with Type 2 Diabetes Mellitus and Chronic Kidney Disease by Continuous Glucose Monitoring

Background: Chronic kidney disease (CKD) is a growing global health problem due to the increasing prevalence of Type 2 Diabetes Mellitus (T2DM). Consequently, the management of T2DM becomes challenging with advancing non-dialysis CKD (n-CKD). Prior studies have not confirmed the accuracy of markers such as serum fructosamine (SF) and glycosylated hemoglobin A1c (HbA1c) in this population. Also, there is a paucity of data on the incidence of hypoglycemia in these patients. The present study is twofold; evaluating the accuracy of HbA1c and exploring the frequency and severity of hypoglycemia in T2DM patients with n-CKD by continuous glucose monitoring (CGM). Methods: We studied 80 patients with T2DM and n-CKD defined as eGFR 0-45 ml/min. Patients wore the CGM (Abbott FreeStyle Libre Pro) for up to 14 days, with glucose recorded every 15 minutes, with a maximum of 1,344 glucose measurements. Blood tests were performed in the fasting state at the end of the 14 day CGM. HbA1C and SF were compared by linear regression to patients’ average glucose concentration (AGC) calculated as all of a patient’s CGM glucose results divided by the total number of measurements. Hypoglycemia was defined as plasma glucose below 70 mg/dL. Results: 80 patients wore the CGM for a mean of 12.6±2.8 days. Mean age was 71.3±10.9 years, 77% of patients were men, 12% were black, and mean eGFR 27.0±11.1 ml/min. The mean glucose concentration was 151.4±55.7 mg/dL, mean HbA1C 7.2±1.5% and SF 304.1±57.2 μmol/L. HbA1C significantly correlated with AGC, r=0.82, p<0.0001. The relationship was characterized by the formula, AGC=31.8 x HbA1C - 73.3. There was no significant correlation between serum fructosamine and AGC, r=0.54, p=0.8. 61/80 (76.2%) patients had at least one hypoglycemic episode. The mean number of episodes was 7.4±8.9, with a range of 0-53 episodes. The mean number of minutes of hypoglycemia was 1501±2165. This represents a mean of 7.4±10.1% of total measurement time being hypoglycemic, compared to studies in T2DM without CKD where the number is closer to 1.5%. Conclusion: HbA1C, but not serum fructosamine, was an excellent measure of glycemic control in patients with T2DM and n-CKD. Confirming this with a larger sample size is imperative for disease management. The high burden of hypoglycemia highlights the need to avoid medications that increase risk of hypoglycemia and consider adjusting glycemic targets in this patient population.

Pregnancy outcomes in women on hemodialysis: a national survey

Background. Pregnancy occurs among 1–7% of women on chronic dialysis. Experience regarding pregnancy and dialysis originates from anecdotal reports, case series and surveys. This survey updates the US nephrologists’ experience with pregnancy on hemodialysis (HD) over the past 5 years. We evaluated maternal and fetal outcomes, certain practice patterns such as dialysis regimens utilized and nephrologist knowledge and comfort level when caring for a pregnant patient on HD.

Methods. An anonymous Internet-based 23-question survey was e-mailed to end-stage renal disease Networks of America program directors for forwarding to practicing nephrologists.

Results. A total of 196 nephrologists responded to the survey, reporting >187 pregnancies. Of the respondents, 45% had cared for pregnant females on HD and 78% of pregnancies resulted in live births. In 44% of the pregnancies a diagnosis of preeclampsia was made. There were no maternal deaths. Nephrologists most commonly prescribe 4–4.5 h of HD 6 days/week for pregnant women on dialysis. Women dialyzed cumulatively for >20 h/week were 2.2 times more likely to develop preeclampsia than those who received ≤20 h of HD per week.

Conclusion. Providing intensive HD is a common treatment approach when dialyzing pregnant women. Maternal and fetal outcomes can be improved. There is a trend toward better live birthrates with more intense HD. Whether more cumulative hours of dialysis per week increases the risk of preeclampsia needs to be further investigated.

Adverse Renal Effects of Novel Molecular Oncologic Targeted Therapies: A Narrative Review

Novel targeted anti-cancer therapies have resulted in improvement in patient survival compared to standard chemotherapy. Renal toxicities of targeted agents are increasingly being recognized. The incidence, severity, and pattern of renal toxicities may vary according to the respective target of the drug. Here we review the adverse renal effects associated with a selection of currently approved targeted cancer therapies, directed to EGFR, HER2, BRAF, MEK, ALK, PD1/PDL1, CTLA-4, and novel agents targeted to VEGF/R and TKIs. In summary, electrolyte disorders, renal impairment and hypertension are the most commonly reported events. Of the novel targeted agents, ipilumumab and cetuximab have the most nephrotoxic events reported. The early diagnosis and prompt recognition of these renal adverse events are essential for the general nephrologist taking care of these patients.

Nephrotoxicity of the BRAF Inhibitors Vemurafenib and Dabrafenib

IMPORTANCE

The selective BRAF inhibitors vemurafenib and dabrafenib have shown significant improvement in patient survival compared with standard therapy in BRAF V600-mutant metastatic melanoma.

OBSERVATIONS

We reviewed Food and Drug Administration Adverse Event Reporting System (FAERS) data for both agents for renal toxic effects. From July 2011 through June 2014, 132 cases of acute kidney injury in patients receiving vemurafenib therapy were reported. Renal injury was more common in men (85 men vs 47 women; P<.001). From April 2013 through June 2014, 13 cases of renal injury in patients receiving dabrafenib therapy were reported (12 men and 1 woman). Hypokalemia (6 cases in patients receiving vemurafenib and 2 cases in patients receiving dabrafenib) and hyponatremia (8 and 6 cases, respectively) were also reported.

CONCLUSIONS AND RELEVANCE

Vemurafenib seems to be more nephrotoxic than dabrafenib. This renal toxicity seems to be more prevalent among male patients with melanoma. On the basis of the few published case reports, the mode of injury seems to be tubular interstitial injury. Our findings suggest a need to monitor renal function and electrolyte levels in all patients who receive these drugs. Dermatologists, oncologists, and nephrologists need to be aware of this potential hazard.