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Patients on hemodialysis have a mild clinical course of COVID 19 infection. It could be due to multiple reasons. | Patients on hemodialysis have a mild clinical course of COVID 19 infection. It could be due to multiple reasons. | ||
*Patients with chronic kidney disease or end-stage renal disease have low immunity. The low immunity results in low-intensity cytokine storm in response to viral antigens. The patients on maintenance hemodialysis rarely present with a full-blown clinical picture of pneumonia.<ref name="pmid32434211">{{cite journal| author=Zhang X, Tan Y, Ling Y, Lu G, Liu F, Yi Z | display-authors=etal| title=Viral and host factors related to the clinical outcome of COVID-19. | journal=Nature | year= 2020 | volume= | issue= | pages= | pmid=32434211 | doi=10.1038/s41586-020-2355-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32434211 }} </ref> | *Patients with chronic kidney disease or end-stage renal disease have low immunity. The low immunity results in low-intensity cytokine storm in response to viral antigens. The patients on maintenance hemodialysis rarely present with a full-blown clinical picture of pneumonia.<ref name="pmid32434211">{{cite journal| author=Zhang X, Tan Y, Ling Y, Lu G, Liu F, Yi Z | display-authors=etal| title=Viral and host factors related to the clinical outcome of COVID-19. | journal=Nature | year= 2020 | volume= | issue= | pages= | pmid=32434211 | doi=10.1038/s41586-020-2355-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32434211 }} </ref> | ||
Hypercoagulation plays an important role in aggravating the disease. Hypercoagulation initiates the coagulation cascade resulting in disseminated intravascular coagulation (DIC). DIC results in organ dysfunction and high mortality in COVID 19 infection. Anticoagulants administered during hemodialysis inhibit coagulation cascade preventing hypercoagulation and DIC.<ref name="pmid32073213">{{cite journal| author=Tang N, Li D, Wang X, Sun Z| title=Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. | journal=J Thromb Haemost | year= 2020 | volume= 18 | issue= 4 | pages= 844-847 | pmid=32073213 | doi=10.1111/jth.14768 | pmc=7166509 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32073213 }} </ref> | *Hypercoagulation plays an important role in aggravating the disease. Hypercoagulation initiates the coagulation cascade resulting in disseminated intravascular coagulation (DIC). DIC results in organ dysfunction and high mortality in COVID 19 infection. Anticoagulants administered during hemodialysis inhibit coagulation cascade preventing hypercoagulation and DIC.<ref name="pmid32073213">{{cite journal| author=Tang N, Li D, Wang X, Sun Z| title=Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. | journal=J Thromb Haemost | year= 2020 | volume= 18 | issue= 4 | pages= 844-847 | pmid=32073213 | doi=10.1111/jth.14768 | pmc=7166509 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32073213 }} </ref> | ||
In a study done at a hemodialysis center at Renmin Hospital in Wuhan, 37 out of a total of 230 patients were infected with covid 19 infections in one month. Four members of the health care staff were also infected. The peripheral blood examination of the covid 19 infected hemodialysis patients had reduced levels of killer T cells, helper T cells, Natural killer cells, and lower level of inflammatory cytokines as compared to non-dialysis infected patients.<ref name="pmid02.24.20027201">{{cite journal| author=Bose KS, Sarma RH| title=Delineation of the intimate details of the backbone conformation of pyridine nucleotide coenzymes in aqueous solution. | journal=Biochem Biophys Res Commun | year= 1975 | volume= 66 | issue= 4 | pages= 1173-9 | pmid=02.24.20027201 | doi=10.1016/0006-291x(75)90482-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2 }} </ref> | *In a study done at a hemodialysis center at Renmin Hospital in Wuhan, 37 out of a total of 230 patients were infected with covid 19 infections in one month. Four members of the health care staff were also infected. The peripheral blood examination of the covid 19 infected hemodialysis patients had reduced levels of killer T cells, helper T cells, Natural killer cells, and lower level of inflammatory cytokines as compared to non-dialysis infected patients.<ref name="pmid02.24.20027201">{{cite journal| author=Bose KS, Sarma RH| title=Delineation of the intimate details of the backbone conformation of pyridine nucleotide coenzymes in aqueous solution. | journal=Biochem Biophys Res Commun | year= 1975 | volume= 66 | issue= 4 | pages= 1173-9 | pmid=02.24.20027201 | doi=10.1016/0006-291x(75)90482-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2 }} </ref> | ||
===Epidemiology and Demographics=== | ===Epidemiology and Demographics=== | ||
*Patients on maintenance hemodialysis and end-stage kidney disease have low immunity and multiple co-morbidities. They are at an increased risk of contracting the covid-19 infection. A case series of 5,700 patients with covid-19 infection was done in 12 hospitals under the Northwell Health system in New York. It showed a prevalence of 5% chronic kidney disease and 3.5% end-stage renal disease in hospitalized covid-19 patients.<ref name="pmid32320003">{{cite journal| author=Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW | display-authors=etal| title=Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. | journal=JAMA | year= 2020 | volume= | issue= | pages= | pmid=32320003 | doi=10.1001/jama.2020.6775 | pmc=7177629 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32320003 }} </ref> | *Patients on maintenance hemodialysis and end-stage kidney disease have low immunity and multiple co-morbidities. They are at an increased risk of contracting the covid-19 infection. A case series of 5,700 patients with covid-19 infection was done in 12 hospitals under the Northwell Health system in New York. It showed a prevalence of 5% chronic kidney disease and 3.5% end-stage renal disease in hospitalized covid-19 patients.<ref name="pmid32320003">{{cite journal| author=Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW | display-authors=etal| title=Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. | journal=JAMA | year= 2020 | volume= | issue= | pages= | pmid=32320003 | doi=10.1001/jama.2020.6775 | pmc=7177629 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32320003 }} </ref> | ||
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*A study was done in 208 acute care hospitals in the UK. The total patients studied were 20,133. It showed chronic kidney disease was one of the most common co-morbidity in hospitalized covid-19 patients present in 16% of patients.<ref name="pmid32444460">{{cite journal| author=Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L | display-authors=etal| title=Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. | journal=BMJ | year= 2020 | volume= 369 | issue= | pages= m1985 | pmid=32444460 | doi=10.1136/bmj.m1985 | pmc=7243036 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32444460 }} </ref> | *A study was done in 208 acute care hospitals in the UK. The total patients studied were 20,133. It showed chronic kidney disease was one of the most common co-morbidity in hospitalized covid-19 patients present in 16% of patients.<ref name="pmid32444460">{{cite journal| author=Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L | display-authors=etal| title=Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. | journal=BMJ | year= 2020 | volume= 369 | issue= | pages= m1985 | pmid=32444460 | doi=10.1136/bmj.m1985 | pmc=7243036 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32444460 }} </ref> | ||
*Clinical research was done by Alberici et al. at four outpatient dialysis facilities in Italy showed high overall mortality of 29% in dialysis patients.<ref name="pmid32437768">{{cite journal| author=Alberici F, Delbarba E, Manenti C, Econimo L, Valerio F, Pola A | display-authors=etal| title=A report from the Brescia Renal COVID Task Force on the clinical characteristics and short-term outcome of hemodialysis patients with SARS-CoV-2 infection. | journal=Kidney Int | year= 2020 | volume= 98 | issue= 1 | pages= 20-26 | pmid=32437768 | doi=10.1016/j.kint.2020.04.030 | pmc=7206428 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32437768 }} </ref> | *Clinical research was done by Alberici et al. at four outpatient dialysis facilities in Italy showed high overall mortality of 29% in dialysis patients.<ref name="pmid32437768">{{cite journal| author=Alberici F, Delbarba E, Manenti C, Econimo L, Valerio F, Pola A | display-authors=etal| title=A report from the Brescia Renal COVID Task Force on the clinical characteristics and short-term outcome of hemodialysis patients with SARS-CoV-2 infection. | journal=Kidney Int | year= 2020 | volume= 98 | issue= 1 | pages= 20-26 | pmid=32437768 | doi=10.1016/j.kint.2020.04.030 | pmc=7206428 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32437768 }} </ref> | ||
===Treatment=== | |||
====Measures to prevent COVID 19 infection in hemodialysis patients==== | |||
Strict measures should be taken to prevent covid 19 infections in hemodialysis patients and health care workers. The measures include: | |||
=====Screening of the patients===== | |||
*Appropriate screening of patients should be done before dialysis. The best approach is to call patients and inquire about covid 19 symptoms. | |||
*Patients reporting illness or covid 19 symptoms should be placed in screening area. Hand sanitizers and face masks should be provided to patients. | |||
*A triage protocol should be instituted in dialysis facilities to take patients to testing clinics, particular dialysis facilities, and hospitals. | |||
==References== | ==References== | ||
{{Reflist}} | {{Reflist}} | ||
Revision as of 13:06, 25 June 2020
Associate Editor(s)-in-Chief: Mydah Sajid, MD[1]
Patients on Hemodialysis before the pandemic
Overview
The Covid-19 infection has high mortality among dialysis patients as compared to normal individuals. One of the factors for increased mortality for dialysis patients as compared to the general population due to COVID-19 infection is the increased age of the patients. Adequate measures should be taken to prevent the spread of COVID 19 infection in dialysis patients.
Pathophysiology
Patients on hemodialysis have a mild clinical course of COVID 19 infection. It could be due to multiple reasons.
- Patients with chronic kidney disease or end-stage renal disease have low immunity. The low immunity results in low-intensity cytokine storm in response to viral antigens. The patients on maintenance hemodialysis rarely present with a full-blown clinical picture of pneumonia.[1]
- Hypercoagulation plays an important role in aggravating the disease. Hypercoagulation initiates the coagulation cascade resulting in disseminated intravascular coagulation (DIC). DIC results in organ dysfunction and high mortality in COVID 19 infection. Anticoagulants administered during hemodialysis inhibit coagulation cascade preventing hypercoagulation and DIC.[2]
- In a study done at a hemodialysis center at Renmin Hospital in Wuhan, 37 out of a total of 230 patients were infected with covid 19 infections in one month. Four members of the health care staff were also infected. The peripheral blood examination of the covid 19 infected hemodialysis patients had reduced levels of killer T cells, helper T cells, Natural killer cells, and lower level of inflammatory cytokines as compared to non-dialysis infected patients.[3]
Epidemiology and Demographics
- Patients on maintenance hemodialysis and end-stage kidney disease have low immunity and multiple co-morbidities. They are at an increased risk of contracting the covid-19 infection. A case series of 5,700 patients with covid-19 infection was done in 12 hospitals under the Northwell Health system in New York. It showed a prevalence of 5% chronic kidney disease and 3.5% end-stage renal disease in hospitalized covid-19 patients.[4]
- A research study done in Japan showed a higher mortality 16.2% (16/99) in dialysis patients as compared to the general population 5.3% (874/16,532). The average age of patients on dialysis was 70 to 90 years while of the general population was 20 to 60 years.[5]
- A study was done in 208 acute care hospitals in the UK. The total patients studied were 20,133. It showed chronic kidney disease was one of the most common co-morbidity in hospitalized covid-19 patients present in 16% of patients.[6]
- Clinical research was done by Alberici et al. at four outpatient dialysis facilities in Italy showed high overall mortality of 29% in dialysis patients.[7]
Treatment
Measures to prevent COVID 19 infection in hemodialysis patients
Strict measures should be taken to prevent covid 19 infections in hemodialysis patients and health care workers. The measures include:
Screening of the patients
- Appropriate screening of patients should be done before dialysis. The best approach is to call patients and inquire about covid 19 symptoms.
- Patients reporting illness or covid 19 symptoms should be placed in screening area. Hand sanitizers and face masks should be provided to patients.
- A triage protocol should be instituted in dialysis facilities to take patients to testing clinics, particular dialysis facilities, and hospitals.
References
- ↑ Zhang X, Tan Y, Ling Y, Lu G, Liu F, Yi Z; et al. (2020). "Viral and host factors related to the clinical outcome of COVID-19". Nature. doi:10.1038/s41586-020-2355-0. PMID 32434211 Check
|pmid=value (help). - ↑ Tang N, Li D, Wang X, Sun Z (2020). "Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia". J Thromb Haemost. 18 (4): 844–847. doi:10.1111/jth.14768. PMC 7166509 Check
|pmc=value (help). PMID 32073213 Check|pmid=value (help). - ↑ Bose KS, Sarma RH (1975). "Delineation of the intimate details of the backbone conformation of pyridine nucleotide coenzymes in aqueous solution". Biochem Biophys Res Commun. 66 (4): 1173–9. doi:10.1016/0006-291x(75)90482-9. PMID 02.24.20027201 Check
|pmid=value (help). - ↑ Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW; et al. (2020). "Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area". JAMA. doi:10.1001/jama.2020.6775. PMC 7177629 Check
|pmc=value (help). PMID 32320003 Check|pmid=value (help). - ↑ Kikuchi K, Nangaku M, Ryuzaki M, Yamakawa T, Hanafusa N, Sakai K; et al. (2020). "COVID-19 in dialysis patients in Japan: Current status and guidance on preventive measures". Ther Apher Dial. doi:10.1111/1744-9987.13531. PMC 7301044 Check
|pmc=value (help). PMID 32506762 Check|pmid=value (help). - ↑ Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L; et al. (2020). "Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study". BMJ. 369: m1985. doi:10.1136/bmj.m1985. PMC 7243036 Check
|pmc=value (help). PMID 32444460 Check|pmid=value (help). - ↑ Alberici F, Delbarba E, Manenti C, Econimo L, Valerio F, Pola A; et al. (2020). "A report from the Brescia Renal COVID Task Force on the clinical characteristics and short-term outcome of hemodialysis patients with SARS-CoV-2 infection". Kidney Int. 98 (1): 20–26. doi:10.1016/j.kint.2020.04.030. PMC 7206428 Check
|pmc=value (help). PMID 32437768 Check|pmid=value (help).