Strategies to prevent SARS-CoV-2 transmission in hemodialysis centres across Europe - Lessons for the future

Background

Early reports on the pandemic nature of COVID-19 directed the nephrology community to develop infection prevention and control guidance. We aimed to make an inventory of strategies that dialysis centres followed to prevent infection with COVID-19 in the first pandemic wave.

Methods

We analyzed IPC measures taken by hemodialysis centres treating patients presenting with COVID-19 between March 1, 2020 and July 31, 2020 and that completed the European Renal Association COVID-19 Database centre questionnaire. Additionally, we made an inventory of guidelines published in European countries to prevent spread of SARS-CoV-2 in dialysis centres.

Results

Data from 73 dialysis units located in and bordering Europe were analyzed. All participating centres implemented IPC measures to mitigate the impact of SARS-CoV-2 during the first pandemic wave. Measures mentioned most often included triage with questions before entering the dialysis ward, measuring body temperature, hand disinfection, masking for all patients and staff, and personal protective equipment for staff members. These measures were also recommended in most of the 14 guidelines that were identified in the inventory of national guidelines and were also scored as being among the most important measures by the authors of this paper. Heterogeneity existed between centres and national guidelines regarding the minimal distance between dialysis chairs and recommendations regarding isolation and cohorting.

Conclusions

Although variation existed, measures to prevent transmission of SARS-CoV-2 were relatively similar across centres and national guidelines. Further research is needed to assess causal relationships between measures taken and spread of SARS-CoV-2.

Occurrence of the polyomavirus among kidney transplant recipients: a single-center study

Polyoma virus-associated nephropathy is an increasingly recognized cause of graft dysfunction among kidney transplant recipients and could be the result of use of potent immunosuppression following transplantation. Because there is no safe and effective anti-viral therapy available presently, screening-based prevention and pre-emptive strategy are recommended. This study, which was conducted at the Nephrology Unit, Internal Medicine Department, Alexandria University, consisted of two phases: Phase 1 was a cross-sectional study and phase 2 was a 6-month follow-up study only for polyoma virus-positive cases. Phase 1 included 75 renal allograft recipients from living donors. Urine cytology for decoy cells and quantitative real-time blood polymerase chain reaction (PCR) for the BK virus (BKV) were performed on all the study patients. Renal biopsy was performed only in patients with deteriorating renal function associated with positive urine cytology. Patients who showed positive urine cytology for decoy cells and/or positive quantitative BKV PCR assay were followed-up for six months. During follow-up, the serum creatinine level, with or without urine cytology for decoy cells, and BKV PCR viral load assay were performed. Among the 75 kidney transplant recipients studied, eight were positive for decoy cells (11%), three showed viremia by quantitative PCR for BKV (4.1%), while two others showed nephropathy (2.7%) in the form of tubulointerstitial nephritis with intra-nuclear inclusions in the tubular cells. Cases with stable renal function and positive decoy cells or viremia cleared the virus spontaneously during follow-up without any intervention. Only one case with biopsyproven nephropathy and deteriorating graft function, with undetectable BKV in blood, lost the graft while another case with viremia died during follow-up due to septicemia. Our study suggests that polyoma virus should be considered as a cause of nephropathy in renal transplant recipients. Further research is required to understand this entity better.

Fasting the month of Ramadan by Muslims: could it be injurious to their kidneys?

Ramadan is the ninth lunar month of the Islamic calendar. During Ramadan, Muslims abstain from food and drink from dawn to sunset (fasting) to express their gratitude to God; eating and drinking is permitted only at night. Muslims typically consume two meals each day, one after sunset, and the other just before dawn. The effect of fasting during the month of Ramadan on patients with renal impairment is still a matter of controversy. This is a prospective study performed on 15 predialysis chronic kidney disease (CKD) patients and six healthy volunteers as control. They were studied during two phases: when the subjects were drinking and eating freely before the start of Ramadan, and a second phase toward the end of Ramadan. We estimated glomerular filtration rate (GFR) using DTPA dynamic renal scan, and tubular cell damage by measuring the level of N-acetyl-B-D- glucosaminidase (NAG). The change in glomerular filtration rate was -6.56 +/- 31.10 in the CKD group compared to 9.58 +/- 30.10 in the control group with no significant difference between them (p= 0.43). However, the urinary NAG percentage change was found to be significantly higher in the CKD patients compared to the control group (236 +/- 332, -49.1 +/- 60.1 respectively p= 0.03). There was a significantly positive correlation between the NAG values and the change in the blood glucose level (p=0.001), hence diabetic CKD patients should be meticulously followed during Ramadan fasting. In conclusion, fasting Ramadan may have injurious effect on the renal tubules in CKD patients. Larger studies are recommended to determine the extent of tubular injury and renal function in CKD patients during Ramadan fasting.

Molecular characterization of Egyptian Giardia lamblia isolates

Six Giardia lamblia strains (4 from Egypt, one from the USA and one from Sudan) were used to study the phenotypic and genotypic variation in some Egyptian G. lamblia strains compared to other G. lamblia strains, which may be responsible for the difference in their behavioral characteristics. By using SDS-PAGE for antigenic study, E1 strain appeared different from the rest of the strains with two bands; one at 121 Kda and the other at 34 Kda which were not present in other strains, while bands at 130 and 43 Kda were present in all strains but absent in E1 strain. Another difference between E1 strain and the rest of the strains was obtained by CAE, using PGM enzyme where E1 strain gave a different zymodeme than the other strains. Based on the computerized RAPD- PCR analysis, 4 rapdemes were identified; rapdeme 1 contained E1 strain, rapdeme 2 contained E2, E3 and E4 isolates, rapdeme 3 contained Sudan strain and rapdeme 4 contained USA strain. In conclusion this study revealed diversity between G. lamblia strains especially E1 strain which showed unique characters.

Effect of schistosoma mansoni egg deposition on multiple low doses streptozotocin induced insulin dependent diabetes

To explore the role of Schistosoma mansoni infection in the prevention of autoimmune mediated insulin dependant diabetes mellitus, we examined the effects of multiple low doses of the pancreatic islets beta cell toxin, streptozotocin (STZ) 40mg/kg body weight i.p., given 8 weeks post infection, period of S. mansoni egg deposition, on S. mansoni infected C57BL/6J mice, in comparison to non-infected STZ given group. Mice treated with STZ (G III) became gradually hyperglycemic reaching highest level on days 17 post STZ with mean blood glucose level of 334.9 +/- 14.9 vs 130.3 +/- 9.2 mg/dl in control group (G IV). S. mansoni infection (G II) significantly reduced the elevation in blood glucose levels from days 7 post STZ onwards reaching 224mg/dl +/- 12.7 on days 17 (P < .0.001). Morphologic examination of pancreas on day 21 post STZ, revealed that the non-infected STZ (G III) given mice had significantly smaller mean islets area (5,060.51 mu2 +/- 1,567.28) and significantly fewer mean number of beta cells/islets (76.23 +/- 19.18) than the infected STZ given group (G II) which had mean islets area (9,305. 3l mu2 +/- 3,277.59) and 116.75 +/- 27.27 beta-cells/islets. Pancreatic tissue revealed also focal degeneration in the cells of islets of Langrhans in the non-infected STZ given mice (G III), in comparison, to the infected STZ given group (G II). which had much less evident cells degeneration. These findings revealed that S. mansoni egg deposition which leads to a shift from Th1 (IFN-gamma mainly) to Th2 (IL4, IL5, IL10 and TGF-beta cytokine profiles causes down-regulation of the Th1 cell mediated autoimmune insulin dependant diabetes mellitus (IDDM). On the other hand, S. mansoni eggs excretions were significantly lower in the infected STZ given group (G II) than the infected group (G I). This finding may be the result of impaired maturation of egg in diabetic mice. It is concluded that the modulation of immune response in S. mansoni infected mice with S. mansoni egg deposition, can suppress the autoimmune type 1 insulin dependant diabetes mellitus induced by multiple low doses streptozotocin.