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      COVID-19 in Hemodialysis Patients: A Report of 5 Cases

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          In December 2019, an outbreak of coronavirus disease (COVID-19) due to the novel SARS-CoV-2 virus began in China and spread rapidly worldwide. It is unknown whether hemodialysis patients represent a distinct group of patients with certain characteristics that may make them susceptible to infection or severe disease. In this Case Report, we describe the clinical and epidemiological features of COVID-19 in 201 maintenance hemodialysis patients in Zhongnan Hospital of Wuhan university, including 5 maintenance hemodialysis patients who contracted COVID-19 disease. Of the 5 patients with COVID-19, one had a definite history of contact with an infected person. The age range of the patients was 47–67 years. Diarrhea (80%), fever (60%), and fatigue (60%) were the most common symptoms. Lymphopenia occurred in all patients.Chest computerized tomography (CT) scans showed ground glass opacity in the lungs of all patients. Up to February 13, 2020, none of the patients had developed severe complications (acute respiratory distress syndrome, shock, multiple organ dysfunction) or died.

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          The first 2019 novel coronavirus case in Nepal

          In January, 2020, the outbreak of the 2019 novel coronavirus (2019-nCoV) in China spread progressively to other countries,1, 2 with WHO declaring it a Public Health Emergency of International Concern. 3 Among the affected countries beyond China (where 12 307 cases and 259 deaths were reported as of Feb 1, 2020) are others in Asia, including Nepal. 4 On Jan 13, 2020, a 32-year-old man, a Nepalese student at Wuhan University of Technology, Wuhan, China, with no history of comorbidities, returned to Nepal. He presented at the outpatient department of Sukraraj Tropical and Infectious Disease Hospital, Kathmandu, with a cough. He had become ill on Jan 3, 6 days before he flew to Nepal. He indicated no exposure to the so-called wet market in Wuhan. Throat swabs obtained from the patient tested positive for 2019-nCoV on real-time RT-PCR assays at the WHO laboratory in Hong Kong. On admission to hospital in Kathmandu, his temperature was 37·2°C (99°F), with throat congestion, but with no other relevant signs or symptoms. He was isolated and treated with broad-spectrum antibiotics and supportive therapies. After 6 h, he complained of mild breathing difficulty and had decreased oxygen saturation (SpO2 87% on room air). Chest radiographs obtained on admission showed an infiltrate in the upper lobe of the left lung (figure ). On Jan 14, his temperature rose to 38·9°C (102°F) and the next day he had breathing difficulties while in the supine position, with crepitations in the right lower lung field. His fever was no longer present on Jan 16, and his clinical condition improved. He was discharged the next day and instructed to self-quarantine at home. Laboratory tests showed no abnormalities. Real-time RT-PCR assays for influenza A and B viruses, and NS1 antigen rapid tests for dengue viruses, scrub typhus, and Brucella spp were negative. Follow-up assessments on Jan 29 and Jan 31 gave an RT-PCR negative throat swab for 2019-nCoV. Informed consent was obtained from the patient to be included in this Correspondence. Figure Initial radiograph of the patient Compared with other recently reported cases, which included rapid worsening and even progression to death,1, 2, 5, 6 our patient had only mild disease and survived and recovered after 13 days. A previous importation of 2019-nCoV in a family cluster in Vietnam included a father returning from Wuhan who transmitted the virus to his wife and son. They all recovered in less than 2 weeks. 5 In two cohorts in China (n=41, n=99), the case fatality rates were 15% 1 and 11%. 7 Some reports have indicated that few patients with 2019-nCoV infection have prominent upper respiratory tract signs and symptoms (eg, sore throat),1, 7 as occurred with the Nepalese student. As expected, fever and cough are the main clinical findings in patients with confirmed 2019-nCoV infection, with up to a quarter requiring admission to the intensive care unit. Further studies in outpatient, primary care, and community settings are needed to get a full spectrum of clinical severity in imported, secondary, or autochthonous cases in all countries. These studies will be increasingly relevant as more cases of 2019-nCoV are diagnosed among people returning from Wuhan and other affected cities in China, but also among those who have acquired the infection from imported cases, even asymptomatic ones, as occurred in Germany. 8
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            Immunologic defects and vaccination in patients with chronic renal failure.

             E L Pesanti (2001)
            Patients with chronic renal failure suffer from defective host defenses which are directly the result of the renal impairment, in addition to those dependent on the primary illness leading to the renal failure. The mechanisms underlying the defective responses in phagocytic cells, lymphocytes and antigen processing are likely due to either failure to adequately eliminate suppressive compounds by the defective kidneys or to improper metabolic processing of the factors by the damaged renal parynchema. That some of the defects are reversed by transplantation and not dialysis suggests that renal parenchymal metabolic activities may be involved, although it is also possible that functioning glomerular cells are capable of filtering substances that membranes are not currently capable of eliminating. The current strategy for dealing with the immunodeficiency appears to be totally based on developing means to circumvent the defective function. The other approach, correction of the impaired function, cannot be even considered until the mechanisms underlying the defective function of the cells involved in defenses are better delineated. It seems possible that one or a few compounds are pivotal in altering the function of all the affected cell lines, since, with only a small amount of effort, it is possible to relate the dysfunction to abnormal cell membrane functions in phagocytic cells, dendritic cells and lymphocytes. Until the biochemical basis of the dysfunction of all the cell types affected are better defined, such exercises cannot be translated into better management of patients with chronic renal failure. Proper function of host defenses requires that appropriate cells can properly respond to threats to host viability. For the cells of the immune system (phagocytes and lymphocytes) this means that their response to regulatory molecules be appropriate, that their mobility be normal, that their adherence to substrates be preserved, and that they can generate the appropriate response to the challenge. For neutrophils, for example, it is necessary that they recognize and mobilize appropriately to chemotactic stimuli, that they be able to adhere to and migrate through endothelial lining, that their phagocytic activity be sufficient, and that they can kill and degrade endocytosed particles and generate appropriate secretions. Similar lists of requirements for good function can be generated for any cell type in the immune defense system. Uremia, as well as currently available treatments for uremia, directly or indirectly alters the function of all phases of appropriate immune cell function. Defective host responses in uremia have been recognized for decades and there has been considerable effort in the past decade to better define the extent and mechanisms of impaired defenses. Despite the multitude of major defects in humoral, cellular, and inflammatory processes, uremic patients who are cared for today, although they remain at higher risk of serious infectious complications, can and do maintain a good quality of life, with most remaining free of major infections for years and decades.
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              Clinical presentation and outcome of severe acute respiratory syndrome in dialysis patients

              There was a major outbreak of severe acute respiratory syndrome (SARS) affecting more than 300 patients occurring in a private housing estate in Hong Kong, in which an infected renal patient was suspected to be the primary source. It is unknown whether renal patients would represent a distinct group of patients who share some characteristics that could predispose them to have higher infectivity. In this context, we have encountered 4 dialysis patients contracting SARS in a minor outbreak, which involved 11 patients and 4 health care workers, in a medical ward of a regional hospital. Of these 4 dialysis patients, 1 patient was receiving hemodialysis while the other 3 patients were on continuous ambulatory peritoneal dialysis. Fever and radiological changes were their dominant presenting features. All were having positive results for SARS-associated coronavirus ribonucleic acid by reverse transcriptase-polymerase chain reaction performed on their nasopharyngeal aspirates or stool samples. It appeared that treatment with high-dose intravenous ribavirin and corticosteroids could only resolve the fever, but it could not stop the disease progression. All 4 patients developed respiratory failure requiring mechanical ventilation on days 9 through 12. At the end, all of the patients died from sudden cardiac arrest, which was associated with acute myocardial infarction in 2 cases. From this small case series, it appeared that dialysis patients might have an aggressive clinical course and poor outcome after contracting SARS. However, a large-scale study is required to further examine this issue, and further investigation into the immunologic abnormalities associated with the uremic state in this group of patients is also warranted.

                Author and article information

                Am J Kidney Dis
                Am. J. Kidney Dis
                American Journal of Kidney Diseases
                Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.
                31 March 2020
                31 March 2020
                [1 ]Department of Nephrology, Zhongnan Hospital, Wuhan University, Wuhan, 430071,China
                [2 ]Laboratory Medicine, Zhongnan Hospital, Wuhan University, Wuhan, 430071, China
                [3 ]Department of Immunology, School of Basic Medical Sciences, Wuhan University, Wuhan, 430071, China
                [4 ]Imaging Department, Zhongnan Hospital, Wuhan University, Wuhan, 430071 China
                Author notes
                [∗∗ ]Corresponding author: Hua Shui, PhD Department of Nephrology, Zhongnan Hospital, Wuhan University, No.169, Road East lake, Wuhan, Hubei, P.R. China. Postal code: 430071; shuihua@

                R.W. and C.L. contributed equally to this work.

                © 2020 Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.



                coronavirus, covid-19, hemodialysis


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