| Abstract|| |
With the declaration of severe acute respiratory syndrome novel coronavirus-2019 as pandemic by the World Health Organization on March 11, 2020, there has been a steady rise in number of cases. Chronic kidney disease and dialysis population are risk factors for increased severity of illness. Literature about the coronavirus disease 2019 (COVID-19) in dialysis population is scarce. Management of COVID-19 patients in resource poor setting in a developing country does vary compared to developed nations. Nonavailability of the advanced laboratory facility and the newer medicines forces the treating team to manage the patients with available investigations and drugs. We aimed at analysis of clinical characteristics and outcomes of 84 patients on maintenance hemodialysis (HD). Data of all COVID-positive patients on maintenance HD, who were referred to our center were collected. All patients were given HD on NIKISSO machines. Outcomes of all the admitted patients were analyzed. Maintenance HD group formed majority of the kidney referrals (54%). Age group that was commonly affected was >50 years. Factors associated with mortality were age, diabetes, thrombocytopenia, prolonged baseline activated partial thromboplastin time, admission hypoxemia, high qSOFA score. Institutional Ethics Committee approval has been obtained for the study. Methodology of the study was in accordance with the Declaration of Helsinki. Verbal consent was obtained from patients/ attendants. In the ongoing COVID pandemic, in a developing nation where resources are constrained, it is difficult to salvage the critically ill patients. With the drugs available and the changing strategies, treatment was given to all the patients admitted with bedside renal replacement therapies. Our mortality rate was high compared to other studies due to delay in referral, admission hypoxemia, and late initiation of steroids.
|How to cite this article:|
Yadla M, Vadakkeveetil AK, Cherian A, Rahul. Clinical features and outcomes of 84 COVID-Positive hemodialysis patients in a resource poor setting from India. Saudi J Kidney Dis Transpl 2021;32:504-9
|How to cite this URL:|
Yadla M, Vadakkeveetil AK, Cherian A, Rahul. Clinical features and outcomes of 84 COVID-Positive hemodialysis patients in a resource poor setting from India. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Jan 28];32:504-9. Available from: https://www.sjkdt.org/text.asp?2021/32/2/504/335463
| Introduction|| |
Since the emergence of first case of severe acute respiratory syndrome coronavirus-2019 (SARS CoV-19) in Wuhan in December 2019, there has been rapid rise in number of cases globally. The World Health Organization has declared coronavirus disease 2019 (COVID-19) as pandemic on March 11, 2020. Centers for Disease Control has recently updated the list of risk factors which are associated with increased risk of severity, of which presence of chronic kidney disease is one factor.
Hemodialysis (HD) population is unique with altered immunological status making them vulnerable to all infections. In the COVID pandemic, their inability to maintain social distancing in dialysis units, the burden of travel very alternate day instead of staying at home, the air conditioning of dialysis units make them indirectly susceptible to (COVID-19. Clinical features and outcomes of COVID-19 in general population have been established in many studies. However, literature in patients on maintenance dialysis is sparse. Till date, only three studies have reported the clinical features and outcomes in maintenance HD population.,,
It is understood that dialysis patients are vulnerable to all infections including pneumonia due to altered state of immunity. It is reported that in patients on dialysis, clinical features are less but mortality rate is high., The clinical features may vary from asymptomatic carriers (85%), mild-moderate pneumonia (<15%) to severe pneumonia (<5%). Wu et al reported clinical features in 49 HD patients and Goicoechea et al has reported mortality rate to be high in a study of 36 maintenance HD patients compared to general population.
We aimed to analyze the clinical features and outcomes in COVID-positive maintenance HD patients admitted in our center.
| Methodology|| |
Our hospital is a major teaching hospital and a tertiary care referral government funded center. During the COVID pandemic, our hospital was designated as state government COVID center.
All patients with either the suspected infection or confirmed infection are admitted in our center. Baseline investigations, drugs like hydroxychloroquine, azithromycin are given to all the patients. With the evolution of treatment protocols, steroids and heparin are given in those with breathlessness/hypoxemia. Drugs such as remdesivir, favipiravir, tocilizumab could not be given.
All patients had SARS CoV-19 positive in nasal swab on reverse transcription-polymerase chain reaction (PCR). There were patients undergoing dialysis in the same shift in dialysis centers suggesting transmission in dialysis units. Patients who were hemodynamically stable were given HD and those with compromised hemodynamics were supported with sustained low-efficiency dialysis/peritoneal dialysis.
All the patients were treated with hydroxychloroquine, azithromycin, and Vitamins B, C, and zinc. Steroids and heparin were given in those with hypoxia. Organ saving supports were given depending on the severity of organ failure.
Data were collected from March 11, 2020, to July 31, 2020. There was slow evolution of treatment policies in the hospital, especially to those who were admitted to intensive care unit. Earlier, treatment was only azithromycin and hydroxychloroquine which later included steroids and low-molecular-weight heparin.
Ethical consent was obtained from Institution Ethics Committee. Verbal informed consent was obtained from patients (or attendants over telephone depending on the patient’s condition and as attendants were not allowed inside the hospital due to Government regulations).
| Results|| |
In our teaching tertiary care referral center, since March 11, 2020, 160 COVID-positive patients were admitted with renal insufficiency, of whom 84 patients are on maintenance dialysis (52.5%). Of the total 9304 admissions till July 31, 2020, maintenance HD population was 0.9% (84/9304).
Median age of the cohort was 51 years. Male- to-female ratio was 57–27. Majority had hypertension, had diabetes, coronary artery disease was present in four patients and cerebrovascular accident in three patients. Presenting complaints in our cohort were fever in 67 (79.76%), cough in 25 (29.76%), and breathlessness in 54 (64.28%). Dialysis vintage ranged from one month to 10 years. Mean duration of dialysis vintage was 2.3 ±2.1 years. Dialysis access was arteriovenous fistula in 74/84 patients and remaining 10 patients underwent temporary catheter placement either femoral or jugular cannulation. All patients were given dialysis on NIKKISSO machines either bedside or in the positive unit. Baseline characteristics are represented in [Table 1]. Radiologically, bilateral ground-glass opacities were present in and unilateral changes in two patients. At the time of write-up, 47 patients were discharged with follow-up policy of swab check for viral clearance.
|Table 1: Demographic, clinical and laboratory characteristics of population.|
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We also analyzed the factors influencing mortality [Table 2]. Established risk factors such as age and diabetes were more common among nonsurvivors. Certain basic investigations also showed statistically significant association with mortality. Advanced investigations and other investigations could not be done in all patients and hence not analyzed.
| Discussion|| |
With the literature being scarce about COVID in maintenance HD population, we aimed to assess the outcomes in our cohort. Ma et al studied 37 HD patients and reported mortality of 6/37 patients. Goicoechea et al reported clinical features and outcomes in 36 dialysis patients.
Our center is a tertiary care teaching hospital funded by government. Advanced treatment strategies could not be given. Symptomatic patients were given steroids and heparin, hydroxychloroquine, azithromycin, and broad spectrum antibiotics, based on the limited literature about treatment strategies in dialysis population
In our cohort, mean age of the group is 49.6 ± 12.9 years and the median age is 51 years. Age distribution varied between 27 years and 76 years, with 20 patients being more than 50 years of age.
In our cohort, most common presenting symptom was fever 67/84 (79.76%). This is in contrast to study done by Ma et al in 37 patients and by Wu et al in 101 patients in whom fatigue and anorexia were common., Previous studies reported that patients on dialysis have less symptoms or may present with atypical symptoms thus confusing the clinical presentation with uremic symptoms or causing delay in diagnosis. Our findings were similar to the study done by Goicoechea et al. Apart from fever, breathlessness was another presenting complaint.
In our cohort, thrombocytopenia and prolonged baseline activated partial thromboplastin time (aPTT) were observed among nonsurvivors. Other parameters did not show statistically significant difference between the two groups.
Consistent with the existing literature, 82/84 (97.6%) showed bilateral pneumonitis on imaging. CT reports were suggestive of bilateral ground-glass opacities in majority of the patients with unilateral consolidation in two patients.
In the early part of the pandemic, steroids and heparin were not used as there was no defined guideline. With the changing understanding of the disease over time, our center has used steroids and heparin in those with hypoxemia/ breathlessness. Whether initiation of early steroids had added, benefit on survival was difficult to assess in our study
Steroids with or without heparin were given in those with admission hypoxemia. As this treatment protocol was adopted in the institute in mid June, comparison of survival benefit with steroids was assessed using Fishers exact test (P <0.05). In our cohort, the beneficial effect of steroids and heparin did not have statistical significance, though majority of patients improved with this therapy. Transplant patients were not included in this cohort, but initiation of early steroids (injection dexamethasone 12 mg/day with or without steroids) was associated with favorable outcome.
Patients were checked for viral clearance through periodical nasal swabs of twice weekly. This measure was taken as ours was the only center doing regular maintenance HD for all COVID-19-positive patients in the state. Mean time taken for clearance of virus was 26.30 days and the median was 25 days. Literature about viral clearance in dialysis population is scarce. Although stool PCR could not be checked in all patients, it is understood that there is delayed clearance of virus ranging between 20 days and 43 days.
Mortality in our cohort was higher than other series (41.6% vs. 16.2%–30.5%) despite being younger in age compared to other cohorts. Higher mortality rates were reported by Scarpioni et al (41%) from Italy. In our cohort, age, breathlessness, thrombocytopenia, deranged baseline aPTT at baseline, admission hypoxemia, high qSOFA were predictors of mortality. Laboratory parameters such as LDH, CRP, serum ferritin could not be done in all the patients. D-dimer levels are not good predictor of mortality unlike in general population as these patients are reported to have higher levels and clearance in dialysis.
In our cohort, number of deaths was 36 (41.6%). Among the factors which influenced survival, age, presence of diabetes, breathlessness, admission hypoxemia, leukopenia, thrombocytopenia, need for oxygen supports, higher qSOFA was associated with statistical significance (P <0.05). Number of patients needing mechanical ventilation was significantly more among survivors compared to nonsurvivors.
Compared to the earlier studies [Table 3], our cohort was younger in age. Most common symptom was fever in our study which is consistent with Spanish study. The prevalence of bilateral pneumonitis on imaging was 88% in our study, in concordance with Ma et al and Wu et al study.
Mortality was higher in our study compared to studies done by Ma et al, Wu et al and Goicoechea et al.,, The possible reasons could be delayed referral to our hospital of patients after initial management elsewhere, relatively higher prevalence of diabetes, hypoxemia at admission, higher prevalence of radiological abnormalities.
Apart from the known risk factors such as age and diabetes which are found to be associated with higher mortality in our cohort, the presence of admission hypoxemia, thrombocytopenia, deranged baseline aPTT was also significantly associated with mortality.
Our hospital, being a government funded, catered to the whole state with high inflow of COVID-positive patients. All the patients admitted were below poverty line and the patients who were initially treated elsewhere and referred to our hospital for further management. Due to lack of affordability and nonavailability of all investigations in our set up, we could do the basic investigations and tried to assess the outcomes.
In a resource poor setting, where feasibility of laboratory investigations is less as in our cohort, it was observed that the regular clinical predictors and the basic investigation would still help the treating clinicians in identifying at risk patients thus helping in prognostication and early change of treatment strategies.
| Observations|| |
- Dialysis cohort formed more than half of the total renal referrals (54%)
- Most common symptoms in our dialysis cohort were fever and breathlessness
- In a resource poor setting, basic parameters such as thrombocytopenia, prolonged baseline aPTT, admission hypoxemia may serve as prognostic factors
- Established risk factors such as age and diabetes were associated with mortality
- Viral clearance in hemodialysis patients may range between 20 and 45 days
- Steroids with heparin did not show statistically significant benefit toward survival.
| Limitations|| |
- All the laboratory parameters and the serial parameters in all patients are not available
- Survival benefit of steroids to be assessed in large sample size cohort.
| Strengths|| |
- Size of the study cohort was more compared to earlier studies
- Gives a guidance and prediction of at risk patients in resource poor setting
- Management strategies including renal replacement therapy were homogenous in study cohort.
Conflict of interest: None declared.
| References|| |
Ma Y, Diao B, Lv X, et al. Epidemiological, clinical and immunological features of cluster of COVID-19 contracted hemodialysis patients. Clin Res 2020;5:1331-41.
Wang R, Liao C, He H, et al. COVID-19 in hemodialysis patients: A report of 5 cases. Am J Kidney Dis 2020;76:141-3.
Wu J, Li J, Zhu G, et al. Clinical features of maintenance hemodialysis patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. Clin J Am Soc Nephrol 2020; 15:1139-45.
Goicoechea M, Sánchez Cámara LA, Macías N, et al. COVID-19: Clinical course and outcomes of 36 hemodialysis patients in Spain. Kidney Int 2020;98:27-34.
Scarpioni R, Manini A, Valsania T, et al. Covid- 19 and its impact on nephropathic patients: The experience at Ospedale “Guglielmo da Saliceto” in Piacenza. G Ital Nefrol 2020;37:2020-vol2.
Department of Nephrology, Gandhi Medical College, Hyderabad, Telangana
[Table 1], [Table 2], [Table 3]