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      Critical Coronavirus Disease 2019 in a Hemodialysis Patient: A Proposed Clinical Management Strategy

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          Abstract

          The coronavirus disease 2019 (COVID-19) pandemic has caused a catastrophic global health crisis. There is a lack of mitigation and clinical management strategies for COVID-19 in specific patient cohorts such as hemodialysis (HD) patients. We report our experience in treating the first case of COVID-19 in a HD patient in Singapore who had a severe clinical course including acute respiratory distress syndrome and propose a clinical management strategy. We propose a clinical workflow in managing such patients based on available evidence from literature review. We also highlight the importance of early recognition and intervention for disease control, dialysis support in an acute hospital isolation facility, deisolation protocol, and discharge planning due to prolonged viral shedding. The case highlights important points specific to a HD patient with a COVID-19 diagnosis, tailored interventions for each stage of the disease, and deisolation considerations in the recovery phase.

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          Most cited references 5

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          Management Of Patients On Dialysis And With Kidney Transplant During SARS-COV-2 (COVID-19) Pandemic In Brescia, Italy

          The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as coronavirus disease (COVID-19) is a major pandemic challenging health care systems around the world. The optimal management of COVID-19 infected patients is still unclear, although the consensus is moving towards the need of a biphasic approach. During the first phase of the disease (from onset of the symptoms up to 7-10 days) viral-induced effects are prominent with the opportunity to institute antiviral therapy. In the second inflammatory phase of the disease, immunosuppressive strategies (for example with glucocorticoids or anti-cytokines drugs)may be considered. This latter stage is characterized by the development of progressive lung involvement with increasing oxygen requirements and occasionally signs of the haemophagocitic syndrome. The management of the disease in patients with kidney disease is even more challenging, especially in those who are immunosuppressed or with severe comorbidities. Here we present the therapeutic approach employed in Brescia (Italy) for managing kidney transplant and hemodialysis patients with COVID-19. Furthermore, we provide some clinical and physiopathological background, as well as preliminary outcome data of our cohort, in order to better clarify the pathogenesis of the disease and clinical management.
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            Severe acute respiratory syndrome in dialysis patients.

            Reviewed are the clinical features and outcome of 12 chronic dialysis patients (six men) who contracted severe acute respiratory syndrome (SARS) compared with 23 sex- and age-matched nonuremic SARS patients as controls. Eight were on peritoneal dialysis (PD) and four on hemodialysis. Mean age was 58 +/- 12 yr for the dialysis patients, and 57 +/- 12 yr for the controls. The presenting symptoms of dialysis patients were similar to the controls. With appropriate protection measures, hemodialysis was performed in a dedicated area of the SARS isolation ward, while PD was continued as intermittent PD. In all seven patients with PD effluent tested, SARS-related coronavirus (CoV) could not be identified by polymerase chain reaction (PCR) or viral culture. Three dialysis patients had persistent positive stool PCR after 5 wk, whereas all nondialysis patients had negative stool PCR after 1 wk. Despite dosage adjustment, ribavirin-induced hemolytic anemia was more severe in the dialysis patients. Dialysis patients required longer hospitalization than the controls, but the mortality was similar. With appropriate protective measures, dialysis could be safely performed. Dialysis patients with SARS often require prolonged hospitalization. Furthermore, these patients may have an extended period of viral shedding, which should be carefully monitored for the purpose of infection control.
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              Radiological Diagnosis of New Coronavirus Infected Pneumonitis: Expert Recommendation from the Chinese Society of Radiology (First edition)

               Radiology CSo (2020)
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                Author and article information

                Journal
                CND
                CND
                10.1159/issn.2296-9705
                Case Reports in Nephrology and Dialysis
                S. Karger AG
                2296-9705
                2020
                May – August 2020
                30 July 2020
                : 10
                : 2
                : 86-94
                Affiliations
                aDivision of Nephrology, Department of Medicine, National University Hospital, Singapore, Singapore
                bDepartment of Medicine, National University Hospital, Singapore, Singapore
                cDepartment of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
                Author notes
                *Weng Kin Wong, Department of Medicine, National University Health System, 1E Kent Ridge Road, Level 10 NUHS Tower Block, Singapore 119228 (Singapore), weng_kin_wong@nuhs.edu.sg
                Article
                509792 PMC7443685 Case Rep Nephrol Dial 2020;10:86–94
                10.1159/000509792
                PMC7443685
                32884935
                © 2020 The Author(s). Published by S. Karger AG, Basel

                This article is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC). Usage and distribution for commercial purposes requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 3, Pages: 9
                Categories
                Case Report

                Cardiovascular Medicine, Nephrology

                Infection control, Hemodialysis, Coronavirus disease 2019

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