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      COVID-19 in Grade 4–5 Chronic Kidney Disease Patients

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          Chronic kidney disease (CKD) increases the risk of mortality during coronavirus disease 2019 (COVID-19) episodes, and some reports have underlined the high incidence and severity of this infection in dialysis patients. Information on COVID-19 in nondialysis CKD patients is not available yet.

          Case Reports

          Here we present 7 patients with grade 4–5 CKD who developed symptomatic COVID-19; they comprise 2.6% of our 267 advanced CKD patients. The estimated GFR was between 12 and 20 mL/min during the month prior to COVID-19. The 3 major symptoms were fever, cough, and dyspnea, and 5 patients showed bilateral pneumonia. Hydroxychloroquine, azithromycin, ceftriaxone, and steroids were the most frequently prescribed drugs. Two patients needed noninvasive mechanical ventilation. All patients showed minimal to moderate kidney function deterioration during admission, with an eGFR decline below 5 mL/min in 6 cases. No patient required acute dialysis. Six patients were discharged alive and remained dialysis free athe t the time of reporting, and one 76-year-old patient died.


          COVID-19 affects grade 4–5 CKD patients, but prognosis may be acceptable if prompt supportive measures are applied. These findings should be confirmed in larger cohorts, and further observations will be needed to understand the full spectrum of clinical features and the optimal approach to COVID-19 in patients with advanced CKD.

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          Most cited references 13

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          Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study

          Summary Background An ongoing outbreak of pneumonia associated with the severe acute respiratory coronavirus 2 (SARS-CoV-2) started in December, 2019, in Wuhan, China. Information about critically ill patients with SARS-CoV-2 infection is scarce. We aimed to describe the clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia. Methods In this single-centered, retrospective, observational study, we enrolled 52 critically ill adult patients with SARS-CoV-2 pneumonia who were admitted to the intensive care unit (ICU) of Wuhan Jin Yin-tan hospital (Wuhan, China) between late December, 2019, and Jan 26, 2020. Demographic data, symptoms, laboratory values, comorbidities, treatments, and clinical outcomes were all collected. Data were compared between survivors and non-survivors. The primary outcome was 28-day mortality, as of Feb 9, 2020. Secondary outcomes included incidence of SARS-CoV-2-related acute respiratory distress syndrome (ARDS) and the proportion of patients requiring mechanical ventilation. Findings Of 710 patients with SARS-CoV-2 pneumonia, 52 critically ill adult patients were included. The mean age of the 52 patients was 59·7 (SD 13·3) years, 35 (67%) were men, 21 (40%) had chronic illness, 51 (98%) had fever. 32 (61·5%) patients had died at 28 days, and the median duration from admission to the intensive care unit (ICU) to death was 7 (IQR 3–11) days for non-survivors. Compared with survivors, non-survivors were older (64·6 years [11·2] vs 51·9 years [12·9]), more likely to develop ARDS (26 [81%] patients vs 9 [45%] patients), and more likely to receive mechanical ventilation (30 [94%] patients vs 7 [35%] patients), either invasively or non-invasively. Most patients had organ function damage, including 35 (67%) with ARDS, 15 (29%) with acute kidney injury, 12 (23%) with cardiac injury, 15 (29%) with liver dysfunction, and one (2%) with pneumothorax. 37 (71%) patients required mechanical ventilation. Hospital-acquired infection occurred in seven (13·5%) patients. Interpretation The mortality of critically ill patients with SARS-CoV-2 pneumonia is considerable. The survival time of the non-survivors is likely to be within 1–2 weeks after ICU admission. Older patients (>65 years) with comorbidities and ARDS are at increased risk of death. The severity of SARS-CoV-2 pneumonia poses great strain on critical care resources in hospitals, especially if they are not adequately staffed or resourced. Funding None.
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            Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study

            Abstract Objective To characterise the clinical features of patients admitted to hospital with coronavirus disease 2019 (covid-19) in the United Kingdom during the growth phase of the first wave of this outbreak who were enrolled in the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) World Health Organization (WHO) Clinical Characterisation Protocol UK (CCP-UK) study, and to explore risk factors associated with mortality in hospital. Design Prospective observational cohort study with rapid data gathering and near real time analysis. Setting 208 acute care hospitals in England, Wales, and Scotland between 6 February and 19 April 2020. A case report form developed by ISARIC and WHO was used to collect clinical data. A minimal follow-up time of two weeks (to 3 May 2020) allowed most patients to complete their hospital admission. Participants 20 133 hospital inpatients with covid-19. Main outcome measures Admission to critical care (high dependency unit or intensive care unit) and mortality in hospital. Results The median age of patients admitted to hospital with covid-19, or with a diagnosis of covid-19 made in hospital, was 73 years (interquartile range 58-82, range 0-104). More men were admitted than women (men 60%, n=12 068; women 40%, n=8065). The median duration of symptoms before admission was 4 days (interquartile range 1-8). The commonest comorbidities were chronic cardiac disease (31%, 5469/17 702), uncomplicated diabetes (21%, 3650/17 599), non-asthmatic chronic pulmonary disease (18%, 3128/17 634), and chronic kidney disease (16%, 2830/17 506); 23% (4161/18 525) had no reported major comorbidity. Overall, 41% (8199/20 133) of patients were discharged alive, 26% (5165/20 133) died, and 34% (6769/20 133) continued to receive care at the reporting date. 17% (3001/18 183) required admission to high dependency or intensive care units; of these, 28% (826/3001) were discharged alive, 32% (958/3001) died, and 41% (1217/3001) continued to receive care at the reporting date. Of those receiving mechanical ventilation, 17% (276/1658) were discharged alive, 37% (618/1658) died, and 46% (764/1658) remained in hospital. Increasing age, male sex, and comorbidities including chronic cardiac disease, non-asthmatic chronic pulmonary disease, chronic kidney disease, liver disease and obesity were associated with higher mortality in hospital. Conclusions ISARIC WHO CCP-UK is a large prospective cohort study of patients in hospital with covid-19. The study continues to enrol at the time of this report. In study participants, mortality was high, independent risk factors were increasing age, male sex, and chronic comorbidity, including obesity. This study has shown the importance of pandemic preparedness and the need to maintain readiness to launch research studies in response to outbreaks. Study registration ISRCTN66726260.
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              Chronic kidney disease is associated with severe coronavirus disease 2019 (COVID-19) infection

              Editor, As the novel Coronavirus Disease 2019 (COVID-19) outbreak expands, identification of predictive factors for severe infection is essential to enable risk stratification, optimize reallocation of hospital resource, and guide public health recommendations and interventions. Chronic Kidney disease (CKD) is associated with an increased risk of both inpatient and outpatient pneumonia [1]. Moreover, the pneumonia-related mortality rate in CKD patients seems to be 14–16 times higher than in the general population [2]. In this article, we aim to explore the potential association between CKD and severity of COVID-19 infection. A search of electronic databases, based on Medline (PubMed interface), Scopus and Web of Science, was carried out with the keywords “chronic renal disease” OR “chronic kidney disease” OR “clinical characteristics” AND “coronavirus 2019” OR “COVID-19” OR “2019-nCoV” OR “SARS-CoV-2”, between 2019 and present time (i.e., March 9, 2020) with no language restrictions applied. The title, abstract and full text of all articles identified that matched the search criteria were assessed, and those reporting the rate of CKD in COVID-19 patients with clinically validated definition of “severe disease” were included in this meta-analysis. The references of all identified studies were also analyzed (forward and backward citation tracking) to identify other potentially eligible articles. A meta-analysis was performed on retrievable data, including the estimation of the odds ratio (OR) and its 95% confidence interval (95% CI) in patients with or without severe forms of COVID-19. The statistical analysis was performed with MetaXL, software Version 5.3 (EpiGear International Pty Ltd., Sunrise Beach, Australia). The study was carried out in accordance with the Declaration of Helsinki and with the term of local legislation. Overall, 84 articles could be originally detected based on our electronic and reference search which, after screening by title, abstract and full text, 80 were excluded as not specifically related to COVID-19 (n = 25), were review articles (n = 7), did not provide relevant data (n = 28), were editorials (n = 10), did not include information on severity and/or comorbidities (n = 8), compared patients by mortality but not by severity (n = 1), or compared mild to critical cases (n = 1). Therefore, a final number of four studies could be included in our meta-analysis, including 1389 COVID-19 patients, among which 273 (19.7%) were classified as having severe disease [3–6]. The essential characteristics of included studies are summarized in Table 1, whilst the individual and pooled ORs for CKD predicting severe COVID-19 is shown in Fig. 1. No study individually found CKD as significant clinical predictor of severe COVID-19. However, when data of individual studies were pooled, a significant association of CKD with severe COVID-19 was observed, with no relevant heterogeneity [OR 3.03 (95% CI 1.09–8.47), I 2 = 0.0%, Cochran’s Q, p = 0.84]. Table 1 Characteristics of included studies Study Setting Sample size Outcomes Severe patients Non-severe patients n (%) Age (years)a Women (%) n (%) Age (years)a Women (%) Guan W et al. 2020 China 1099 Admission to ICU, MV, death 173 (15.7%) 52 (40–65) 42 926 (84.3%) 45 (34–57) 42 Liu Y et al. 2020 China 12 Respiratory failure, MV 6 (50%) 64 (63–65) 50 6 (50.0%) 44 (35–55) 17 Wang D et al. 2020 China 138 Clinical variables, MV, death 36 (26.1%) 66 (57–78) 39 102 (73.9%) 51 (37–62) 48 Zhang JJ et al. 2020 China 140 Respiratory distress/insufficiency 58 (41.4%) 64 (25–87) 43 82 (58.6%) 52 (26–78) 54 MV mechanical ventilation, ICU intensive care unit aAge data presented as median (IQR) Fig. 1 Forest plot of demonstrating association of chronic kidney disease with severe COVID-19 disease Based on a contrite meta-analysis of early and preliminarily available data, CKD seems to be associated with enhanced risk of severe COVID-19 infection. Patients with CKD should hence be advised to take extra precaution to minimize risk exposure to the virus. Physicians should also be engaged in close monitoring of CKD patients with suspected COVID-19, for timely detecting signs of disease progression. Finally, the presence of CKD shall be regarded as an important factor in future risk stratification models for COVID-19.

                Author and article information

                Kidney Blood Press Res
                Kidney Blood Press Res
                Kidney & Blood Pressure Research
                S. Karger AG (Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34, )
                8 September 2020
                : 1-7
                aDepartment of Nephrology, Hospital del Mar, Barcelona, Spain
                bDepartment of Infectious Diseases, Hospital del Mar, Barcelona, Spain
                cDepartment of Nephrology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
                dDepartment of Radiology, Hospital del Mar, Barcelona, Spain
                Author notes
                *Julio Pascual, Department of Nephrology, Hospital del Mar, Passeig Maritim 25–29, ES–08003 Barcelona (Spain), jpascual@
                Copyright © 2020 by S. Karger AG, Basel

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

                Page count
                Figures: 1, Tables: 1, References: 12, Pages: 7
                Case Report

                sars-cov-2, covid-19, chronic kidney disease, pneumonia


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