End-Stage Renal Disease Patients on Chronic Hemodialysis Fare Better With COVID-19: A Retrospective Cohort Study From the New York Metropolitan Region

Immune responses of patients on maintenance hemodialysis after infection by SARS-CoV-2: a prospective observational cohort study

BACKGROUND

Immune dysregulation in patients with acute COVID-19 under chronic hemodialysis (CHD) is fully not elucidated. The changes of mononuclear counts and mediators before and after HD and associations with final outcome were studied.

METHOD

In this prospective study, hospitalized patients with moderate-to-severe COVID-19 under CHD and matched comparators under HD were analyzed for their absolute counts of lymphoid cells and circulating inflammatory mediators. Blood samples were collected before start and at the end of the first HD session; dialysate samples were also collected.

RESULT

Fifty-nine patients with acute COVID-19 under CHD and 20 uninfected comparators under CHD were enrolled. Circulating concentrations of tumor necrosis factor-alpha (TNFα), interleukin (IL)-10, interferon-γ and platelet-derived growth factor-A were increased in patients. Concentrations of mediators did not differ before and after HD. Significant decreases of CD4-lymphocytes and CD19-lymphocytes were found in patients. The decrease of the expression of HLA-DR on CD14-monocytes was associated with unfavorable outcome (defined as WHO-CPS 6 or more by day 28); increased counts of CD19-lymphocytes were associated with better outcomes.

CONCLUSION

Patients under CHD develop an inflammatory reaction to SARS-CoV-2 characterized by increase of inflammatory mediators, decrease of circulating T-lymphocytes and decrease of the expression of HLA-DR on CD14-monocytes.

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.

Clinical presentation and outcomes of chronic dialysis patients with COVID-19: A single center experience from Greece

BACKGROUND

Coronavirus disease 2019 (COVID-19) is still a menacing pandemic, especially in vulnerable patients. Morbidity and mortality from COVID-19 in maintenance hemodialysis (MHD) patients are considered worse than those in the general population, but vary across continents and countries in Europe.

AIM

To describe the clinical course and outcomes of hospitalized MHD patients with COVID-19 in a retrospective observational single center study in Greece.

METHODS

We correlated clinical, laboratory, and radiological data with the clinical outcomes of MHD patients hospitalized with COVID-19 during the pandemic. The diagnosis was confirmed by real-time polymerase chain reaction. Outcome was determined as survivors vs non-survivors and “progressors” (those requiring oxygen supplementation because of COVID-19 pneumonia worsening) vs “non-progressors”.

RESULTS

We studied 32 patients (17 males), with a median age of 75.5 (IQR: 58.5-82) years old. Of those, 12 were diagnosed upon screening and 20 with related symptoms. According to the World Health Organization (WHO) score, the severity on admission was mild disease in 16, moderate in 13, and severe in 3 cases. Chest computed tomography (CT) showed 1-10% infiltrates in 24 patients. Thirteen “progressors” were recorded among included patients. The case fatality rate was 5/32 (15.6%). Three deaths occurred among “progressors” and two in “non-progressors”, irrespective of co-morbidities and gender. Predictors of mortality on admission included frailty index, chest CT findings, WHO severity score, and thereafter the increasing values of serum LDH and D-dimers and decreasing serum albumin. Predictors of becoming a “progressor” included increasing number of neutrophils and neutrophils/lymphocytes ratio.

CONCLUSION

Patients on MHD seem to be at higher risk of COVID-19 mortality, distinct from the general population. Certain laboratory parameters on admission and during follow-up may be helpful in risk stratification and management of patients.

A comparative cross-sectional analysis on outcomes of Covid-19 patients requiring dialysis

CONTEXT

Coronavirus Disease 2019 (COVID-19) was declared as a pandemic by the World Health Organization (WHO) on March 11, 2020. COVID-19 disproportionately affects patients with pre-existing comorbidities including those undergoing dialysis at intermittent intervals. These patients requiring renal replacement therapy like intermittent hemodialysis have a preponderance to go into severe clinical states. Hence, this study was planned to analyze the outcomes of such patients requiring dialysis and suffering from the COVID-19 disease.

OBJECTIVES

This study was carried out to compare the outcomes of the COVID-19 patients requiring hemodialysis with those not requiring hemodialysis.

MATERIALS AND METHODS

This cross-sectional observational study was carried out between April 2020 and August 2020 at a dedicated COVID-19 hospital and included COVID-19 patients requiring hemodialysis at the time of admission and an equal number of controls matched for age and sex.

RESULTS

The study included 271 COVID-19-positive patients requiring dialysis and 271 COVID-19-positive controls without the requirement of a dialysis matched for age and sex; 10.3% cases needed intensive care. There were 18.8% deaths in cases as opposed to 8.9% among controls. Multivariate analysis showed that advancing age (OR 2.6 in cases and 1.06 in controls) need for intensive care (OR 27.9 in cases and 331 in controls), and diabetes alone and with other comorbidities were significant predictors of mortality.

CONCLUSIONS

This study showed that the mortality proportions were more in cases as compared to controls; and advancing age, diabetes, and need for intensive care unit (ICU) were significant predictors. The study also highlighted the crisis faced by patients who require dialysis at regular intervals due to this COVID-19 pandemic.

A meta-analysis on the risk factors adjusted association between cardiovascular disease and COVID-19 severity

BACKGROUND

Cardiovascular disease (CVD), one of the most common comorbidities of coronavirus disease 2019 (COVID-19), has been suspected to be associated with adverse outcomes in COVID-19 patients, but their correlation remains controversial.

METHOD

This is a quantitative meta-analysis on the basis of adjusted effect estimates. PubMed, Web of Science, MedRxiv, Scopus, Elsevier ScienceDirect, Cochrane Library and EMBASE were searched comprehensively to obtain a complete data source up to January 7, 2021. Pooled effects (hazard ratio (HR), odds ratio (OR)) and the 95% confidence intervals (CIs) were estimated to evaluate the risk of the adverse outcomes in COVID-19 patients with CVD. Heterogeneity was assessed by Cochran's Q-statistic, I2test, and meta-regression. In addition, we also provided the prediction interval, which was helpful for assessing whether the variation across studies was clinically significant. The robustness of the results was evaluated by sensitivity analysis. Publication bias was assessed by Begg's test, Egger's test, and trim-and-fill method.

RESULT

Our results revealed that COVID-19 patients with pre-existing CVD tended more to adverse outcomes on the basis of 203 eligible studies with 24,032,712 cases (pooled ORs = 1.41, 95% CIs: 1.32-1.51, prediction interval: 0.84-2.39; pooled HRs = 1.34, 95% CIs: 1.23-1.46, prediction interval: 0.82-2.21). Further subgroup analyses stratified by age, the proportion of males, study design, disease types, sample size, region and disease outcomes also showed that pre-existing CVD was significantly associated with adverse outcomes among COVID-19 patients.

CONCLUSION

Our findings demonstrated that pre-existing CVD was an independent risk factor associated with adverse outcomes among COVID-19 patients.

Siblings with coronavirus disease 2019 infection and opposite outcome—the hemodialysis’s better outcome paradox: Two case reports

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a highly contagious infection caused by the severe acute respiratory syndrome coronavirus 2 virus and has a unique underlying pathogenesis. Hemodialysis (HD) patients experience high risk of contamination with COVID-19 and are considered to have higher mortality rates than the general population by most but not all clinical series. We aim to highlight the peculiarities in the immune state of HD patients, who seem to have both immune-activation and immune-depression affecting their outcome in COVID-19 infection.

CASE SUMMARY

We report the opposite clinical outcomes (nearly asymptomatic course vs death) of two diabetic elderly patients infected simultaneously by COVID-19, one being on chronic HD and the other with normal renal function. They were both admitted in our hospital with COVID-19 symptoms and received the same treatment by protocol. The non-HD sibling deteriorated rapidly and was intubated and transferred to the Intensive Care Unit, where he died despite all supportive care. The HD sibling, although considered more “high-risk” for adverse outcome, followed a benign course and left the hospital alive and well.

CONCLUSION

These cases may shed light on aspects of the immune responses to COVID-19 between HD and non-HD patients and stimulate further research in pathophysiology and treatment of this dreadful disease.