Evaluation of central venous catheter and other risk factors for mortality in chronic hemodialysis patients with COVID-19 in Brazil

Relationship between clinical-epidemiological parameters and outcomes of patients with COVID-19 admitted to the intensive care unit: a report from a Brazilian hospital

Background

People in low-income countries, especially those with low socio-economic conditions, are likelier to test positive for SARS-CoV-2. The unequal conditions of public health systems also increase the infection rate and make early identification and treatment of at-risk patients difficult. Here, we aimed to characterize the epidemiological profile of COVID-19 patients in intensive care and identify laboratory and clinical markers associated with death.

Materials and methods

We conducted an observational, descriptive, and cross-sectional study in a reference hospital for COVID-19 treatment in the Southern Region of Bahia State, in Brazil, to evaluate the epidemiological, clinical, and laboratory characteristics of COVID-19 patients admitted to the intensive care unit (ICU). Additionally, we used the area under the curve (AUC) to classify survivors and non-survivors and a multivariate logistic regression analysis to assess factors associated with death. Data was collected from the hospital databases between April 2020 and July 2021.

Results

The use of bladder catheters (OR 79.30; p < 0.0001) and central venous catheters (OR, 45.12; p < 0.0001) were the main factors associated with death in ICU COVID-19 patients. Additionally, the number of non-survivors increased with age (p < 0.0001) and prolonged ICU stay (p < 0.0001). Besides, SAPS3 presents a higher sensibility (77.9%) and specificity (63.1%) to discriminate between survivors and non-survivor with an AUC of 0.79 (p < 0.0001).

Conclusion

We suggest that multi-laboratory parameters can predict patient prognosis and guide healthcare teams toward more assertive clinical management, better resource allocation, and improved survival of COVID-19 patients admitted to the ICU.

Brazilian Dialysis Survey 2021

INTRODUCTION

The Brazilian Dialysis Survey (BDS) is an important source of national data about people on chronic dialysis that contributes to the formulation of health policies regarding kidney failure.

OBJECTIVE

To report the 2021 epidemiological data from the BDS of the Brazilian Society of Nephrology (BSN).

METHODS

A survey was carried out in Brazilian chronic dialysis centers using an online questionnaire covering clinical and epidemiological aspects of patients in chronic dialysis, data on dialysis therapy, characteristics of dialysis centers, and the impact of the COVID-19 pandemic of 2021.

RESULTS

Thirty percent (n = 252) of the centers answered the questionnaire. In July 2021, the estimated total number of patients on dialysis was 148,363. The estimated prevalence and incidence rates of patients per million population (pmp) were 696 and 224, respectively. Of the prevalent patients, 94.2% were on hemodialysis (HD) (1.8% of these on hemodiafiltration), and 5.8% on peritoneal dialysis (PD); 21% were on the transplant waiting list. The incidence rate of confirmed COVID-19 between January and July 2021 was 1,236/10,000 dialysis patients, and the case-fatality rate reached 25.5%. Up to July 2021, 88.6% of patients had received at least one dose of the anti-SARS-CoV-2 vaccine. The estimated overall and COVID-19 crude annual mortality rates were 22.3% and 5.3%, respectively.

CONCLUSION

The absolute number and the prevalence rate of patients on chronic dialysis continue to increase. Most dialysis patients were vaccinated against COVID-19 during the year. The COVID-19 pandemic was associated to the overall mortality rate.

Chronic hemodialysis patients with COVID-19 cared for by the public health system have higher mortality than those treated in private facilities: analysis of the Brazilian dialysis registry

PURPOSE

Brazil is the third country globally in dialysis patients. Little is known about the impact of the type of health insurance on the outcome of these patients after COVID-19.

METHODS

We analyzed comorbidities, sociodemographic factors, and dialysis-related parameters from a retrospective cohort study of 1866 Brazilian chronic hemodialysis patients with COVID-19 from Feb 2020-July 2021. We evaluated the influence of health insurance (private vs. public) on the intensive care unit admission and 90 day fatality risk.

RESULTS

From 1866 hemodialysis patients, 455 (24%) were admitted to the intensive care unit, and 350 (19%) died. The mean age was 57.5 years, 88% had public health insurance. Crude case-fatality rate was not different between groups (private vs. public risk ratio 1.11; 95% CI 0.82-1.52, p = 0.498). In fully adjusted multivariate models, patients with private health insurance did not have a higher chance to be admitted to an intensive care unit (odds ratio 0.97; 95% CI 0.63-1.50, p = 0.888), but they presented a lower death risk (hazard ratio 0.56; 95% CI 0.37-0.85, p = 0.006).

CONCLUSION

The type of health insurance did not influence the access of hemodialysis patients with COVID-19 to an intensive care unit, but patients with private health insurance had a lower mortality risk.

The vulnerability of maintenance dialysis patients with COVID-19: mortality and risk factors from a developing country

Patients on maintenance dialysis therapy are especially vulnerable to COVID-19 and its complications. This study aimed to assess the incidence, epidemiological characteristics, and mortality rate of COVID-19 among maintenance dialysis patients. This retrospective observational chart review study included 548 patients from all dialysis units in the West Bank of Palestine who acquired COVID-19 between 5 March 2020, and 11 August 2021. We collected data on patients' demographics, clinical features, and outcomes. A multivariable logistic regression model was used to assess independent risk factors for COVID-19-related mortality. The incidence of COVID-19 among maintenance dialysis patients was 35.3%, as 548 out of 1554 patients have tested positive during the study period. Patients on haemodialysis were three times riskier to get infected than those on peritoneal dialysis (37% vs 11.3%). Half (50.2%) of infected patients required hospitalisation, and 24.5% were admitted to an intensive care unit, while the mortality rate stood at 26.8%. Old age, male sex, central venous catheter use, comorbid diabetes, smoking, and having an RH negative blood group type were determined to be significantly associated with increased risk of mortality. In conclusion, the incidence of COVID-19 among Palestinian maintenance dialysis patients was notably high, especially among haemodialysis patients. High rates of hospitalisation, ICU admission, intubation and death were observed, and predictive factors for COVID-19-related mortality were identified. Therefore, the implementation of strict infection control measures and promotion of home dialysis are warranted to reduce the infection rate.KEY MESSAGESThe incidence of COVID-19 among Palestinian maintenance dialysis patients was notably high; more than one-third of the total dialysis population acquired COVID-19, with haemodialysis patients being three times more likely to get infected compared to their peritoneal dialysis counterparts.The mortality rate among maintenance dialysis patients was 26.8%, more than 25 times higher than that of the general population. The risk of mortality was significantly increased with age, male sex, smoking, diabetes, and having central venous catheter as vascular access for haemodialysis.Strict infection control measures, as well as the promotion of home dialysis, are necessary to reduce the risk of infection.

Censo Brasileiro de Diálise 2021

RESUMO Introdução: O Censo Brasileiro de Diálise (CBD) constitui importante fonte de dados nacionais sobre pessoas em diálise crônica que contribui para a formulação de políticas de saúde. Objetivo: Relatar dados epidemiológicos de 2021 do CBD da Sociedade Brasileira de Nefrologia (SBN). Métodos: Realizou-se pesquisa em centros brasileiros de diálise crônica utilizando questionário online abrangendo aspectos clínicos e epidemiológicos de pacientes em diálise crônica, dados sobre terapia dialítica, características dos centros de diálise e o impacto da pandemia COVID-19 em 2021. Resultados: Trinta por cento (n = 252) dos centros responderam ao questionário. Em Julho de 2021, o número total estimado de pacientes em diálise foi 148.363. As taxas estimadas de prevalência e incidência de pacientes por milhão da população (pmp) foram 696 e 224, respectivamente. Dos pacientes prevalentes, 94,2% estavam em hemodiálise (HD) (1,8% destes em hemodiafiltração), e 5,8% em diálise peritoneal (DP); 21% estavam na lista de espera para transplante. A taxa de incidência de COVID-19 confirmada entre Janeiro e Julho de 2021 foi 1.236/10.000 pacientes em diálise, e a taxa de letalidade atingiu 25,5%. Até Julho de 2021, 88,6% dos pacientes haviam recebido pelo menos uma dose da vacina anti-SARS-CoV-2. As taxas estimadas de mortalidade bruta anual geral e por COVID-19 foram de 22,3% e 5,3%, respectivamente. Conclusão: O número absoluto e a taxa de prevalência de pacientes em diálise crônica continuam aumentando. A maioria dos pacientes em diálise foram vacinados contra COVID-19 durante o ano. A pandemia COVID-19 contribuiu com a taxa de mortalidade geral.

Predictors of shorter- and longer-term mortality after COVID-19 presentation among dialysis patients: parallel use of machine learning models in Latin and North American countries

Background

We developed machine learning models to understand the predictors of shorter-, intermediate-, and longer-term mortality among hemodialysis (HD) patients affected by COVID-19 in four countries in the Americas.

Methods

We used data from adult HD patients treated at regional institutions of a global provider in Latin America (LatAm) and North America who contracted COVID-19 in 2020 before SARS-CoV-2 vaccines were available. Using 93 commonly captured variables, we developed machine learning models that predicted the likelihood of death overall, as well as during 0–14, 15–30, > 30 days after COVID-19 presentation and identified the importance of predictors. XGBoost models were built in parallel using the same programming with a 60%:20%:20% random split for training, validation, & testing data for the datasets from LatAm (Argentina, Columbia, Ecuador) and North America (United States) countries.

Results

Among HD patients with COVID-19, 28.8% (1,001/3,473) died in LatAm and 20.5% (4,426/21,624) died in North America. Mortality occurred earlier in LatAm versus North America; 15.0% and 7.3% of patients died within 0–14 days, 7.9% and 4.6% of patients died within 15–30 days, and 5.9% and 8.6% of patients died > 30 days after COVID-19 presentation, respectively. Area under curve ranged from 0.73 to 0.83 across prediction models in both regions. Top predictors of death after COVID-19 consistently included older age, longer vintage, markers of poor nutrition and more inflammation in both regions at all timepoints. Unique patient attributes (higher BMI, male sex) were top predictors of mortality during 0–14 and 15–30 days after COVID-19, yet not mortality > 30 days after presentation.

Conclusions

Findings showed distinct profiles of mortality in COVID-19 in LatAm and North America throughout 2020. Mortality rate was higher within 0–14 and 15–30 days after COVID-19 in LatAm, while mortality rate was higher in North America > 30 days after presentation. Nonetheless, a remarkable proportion of HD patients died > 30 days after COVID-19 presentation in both regions. We were able to develop a series of suitable prognostic prediction models and establish the top predictors of death in COVID-19 during shorter-, intermediate-, and longer-term follow up periods.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02961-x.

Mortality rate of COVID-19 infection in end stage kidney disease patients on maintenance hemodialysis: A systematic review and meta-analysis

BACKGROUND

Coronavirus disease 2019 (COVID-19) has been the most talked-about disease of the past few years. Patients with significant comorbidities have been at particular risk of adverse outcomes. This study looked at the outcomes and risk factors for adverse outcomes among patients on chronic hemodialysis for end-stage renal disease, a group of patients known to be particularly susceptible to infectious complications.

AIM

To assess outcomes and risk factors for adverse outcomes of COVID-19 infection among patients on chronic hemodialysis.

METHODS

We searched PubMed/MEDLINE, EMBASE, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and Web of Science databases for relevant terms and imported the results into the Covidence platform. From there, studies were assessed in two stages for relevance and quality, and data from studies that satisfied all the requirements were extracted into a spreadsheet. The data was then analyzed descriptively and statistically.

RESULTS

Of the 920 studies identified through the initial database search, only 17 were included in the final analysis. The studies included in the analysis were mostly carried out during the first wave. We found that COVID-19 incidence among patients on hemodialysis was significant, over 10% in some studies. Those who developed COVID-19 infection were most likely going to be hospitalized, and over 1 in 5 died from the infection. Intensive care unit admission rate was lower than the infection lethality rate. Biochemical abnormalities and dyspnea were generally reported to be associated with adverse outcomes.

CONCLUSION

This systematic review confirms that patients on chronic hemodialysis are very high-risk individuals for COVID-19 infections, and a significant proportion was infected during the first wave. Their prognosis is overall much worse than in the general population, and every effort needs to be made to decrease their exposure.

The association between stroke and COVID-19-related mortality: a systematic review and meta-analysis based on adjusted effect estimates

Objective

To investigate the association between stroke and the risk for mortality among coronavirus disease 2019 (COVID-19) patients.

Methods

We performed systematic searches through electronic databases including PubMed, Embase, Scopus, and Web of Science to identify potential articles reporting adjusted effect estimates on the association of stroke with COVID-19-related mortality. To estimate pooled effects, the random-effects model was applied. Subgroup analyses and meta-regression were performed to explore the possible sources of heterogeneity. The stability of the results was assessed by sensitivity analysis. Publication bias was evaluated by Begg’s test and Egger’s test.

Results

This meta-analysis included 47 studies involving 7,267,055 patients. The stroke was associated with higher COVID-19 mortality (pooled effect = 1.30, 95% confidence interval (CI): 1.16–1.44; I² = 89%, P < 0.01; random-effects model). Subgroup analyses yielded consistent results among area, age, proportion of males, setting, cases, effect type, and proportion of severe COVID-19 cases. Statistical heterogeneity might result from the different effect type according to the meta-regression (P = 0.0105). Sensitivity analysis suggested that our results were stable and robust. Both Begg’s test and Egger’s test indicated that potential publication bias did not exist.

Conclusion

Stroke was independently associated with a significantly increased risk for mortality in COVID-19 patients.

Comparison of 30-day case-fatality rate between dialysis and transplant Covid-19 patients: a propensity score matched cohort study

BACKGROUND AND OBJECTIVES

Patients undergoing kidney replacement therapies (KRTs) have a poor prognosis after Covid-19 infection. Few studies have compared the outcomes of such patients in the different KRT modalities. This study aimed to analyze the 30-day Covid-19-associated case-fatality rate of dialysis and kidney transplant patients.

METHODS

Retrospective cohort study analyzing data from patients with confirmed Covid-19 between Mar/20 and Jan/21 included in two multicenter studies, the Brazilian Covid-19 Dialysis Study (Dialysis group, n = 703) and the Covid-19-KT Brazilian Study (Transplant group, n = 1907). To assess the risk factors for death, adjusted Cox hazards models were used. A sensitivity analysis was performed using a propensity score analysis to match the groups (n = 587 patients in each group).

RESULTS

A higher percentage of transplant patients required hospitalization (68 vs. 51%, p < 0.001), intensive care (37 vs. 30%, p = 0.023), and invasive mechanical ventilation (28 vs. 22%, p = 0.035). Multivariate analysis of the before-matching sample showed that subjects in the transplant group were at a lower death risk at baseline (HR 0.380.560.85). However, they showed higher risk over time (HR 1.031.061.09). Kaplan-Meier analysis after propensity score matching confirmed the inferior 30-day cumulative survival in the transplant recipients (83 vs. 78%, p = 0.0014).

CONCLUSION

Both transplant and dialysis patients have high 30-day case-fatality rates after a Covid-19 diagnosis. Despite lower death risk at baseline, transplant patients have an increased death risk of 6% per day than dialysis patients.

Risk factors for mortality in hemodialysis patients with COVID-19: a systematic review and meta-analysis

Background

New evidence from studies on risk factors for mortality in hemodialysis (HD) patients with COVID-19 became available. We aimed to review the clinical risk factors for fatal outcomes in these patients.

Methods

We performed meta-analysis using the PubMed, EMBASE, and Cochrane databases. A fixed- or random-effects model was used for calculating heterogeneity. We used contour-enhanced funnel plot and Egger’s tests to assess potential publication bias.

Results

Twenty-one studies were included. The proportion of males was lower in the survivor group than in the non-survivor group (OR = 0.75, 95% CI [0.61, 0.94]). The proportion of respiratory diseases was significantly lower in the survivor group than in the non-survivor group (OR = 0.42, 95% CI [0.29, 0.60]). The proportion of patients with fever, cough, and dyspnea was significantly lower in the survivor group (fever: OR = 0.53, 95% CI [0.31, 0.92]; cough: OR = 0.50, 95% CI [0.38, 0.65]; dyspnea: OR = 0.25, 95% CI [0.14, 0.47]) than in the non-survivor group. Compared with the non-survivor group, the survivor group had higher albumin and platelet levels and lower leucocyte counts.

Conclusions

Male patients might have a higher risk of developing severe COVID-19. Comorbidities, such as respiratory diseases could also greatly influence the clinical prognosis of COVID-19. Clinical features, such as fever, dyspnea, cough, and abnormal platelet, leucocyte, and albumin levels, could imply eventual death. Our findings will help clinicians identify markers for the detection of high mortality risk in HD patients at an early stage of COVID-19.