key: cord-0764791-3fiqxd0i authors: Prasad, Narayan; Behera, Manas Ranjan; Bhatt, Mansi; Agarwal, Sanjay Kumar; Gopalakrishnan, N.; Fernando, Edwin; Chaudhary, Arpita Roy; Sahay, Manisha; Singh, Shivendra; Jain, Apoorva; Tapiawala, Shruti; Kamble, Aniket; Khanna, Umesh; Bohra, Rubina; Gupta, Anurag; Anandh, Urmila; Jha, Vivekanand title: Outcomes of symptomatic coronavirus disease 19 in maintenance hemodialysis patient in India date: 2021-07-14 journal: Semin Dial DOI: 10.1111/sdi.13000 sha: cf38ec0719afde094fb857846d32a7d7ff42e6a5 doc_id: 764791 cord_uid: 3fiqxd0i BACKGROUND: Maintenance hemodialysis (MHD) patients face disadvantages with higher risk of acquiring SARS‐CoV‐2 infection, atypical manifestations, and associated multiple comorbidities. We describe patients' outcomes with symptomatic COVID‐19 on MHD in a large cohort of patients from India. METHODS: Data were collected prospectively from hemodialysis units in 11 public and private hospitals between March 15, 2020, and July 31, 2020. The survival determinants were analyzed using stepwise backward elimination cox‐regression analysis. RESULTS: Of the 263 total patients (mean age 51.76 ± 13.63 years and males 173) on MHD with symptomatic COVID‐19, 35 (13.3%) died. Those who died were older (p = 0.01), had higher frequency of diabetic kidney disease (p = 0.001), comorbidities (p = 0.04), and severe COVID‐19 (p = 0.001). Mortality was higher among patients on twice‐weekly MHD than thrice‐weekly (p = 0.001) and dialysis through central venous catheter (CVC) as compared to arteriovenous fistula (p = 0.001). On multivariate analysis, CVC use (HR 2.53, 95% CI 1.26–5.07, p = 0.009), disease severity (HR = 3.54, 95% CI 1.52–8.26, p = 0.003), and noninvasive ventilatory support (HR 0.59, 95% CI 0.25–0.99, p = 0.049) had significant effect on mortality. CONCLUSION: The adjusted mortality risk of COVID‐19 in MHD patients is high in patients associated with severe COVID‐19 and patients having CVC as vascular access. Over 69 million people in 220 countries have been identified to have SARS-CoV2 infection around the world in the last 10 months since the first case was reported from Wuhan, China. 1, 2 The high infectivity of the contagion and the public health actions taken to limit its spread and protect the vulnerable populations has adversely affected the care of people with preexisting conditions, including those with kidney disease. [3] [4] [5] COVID manifestations and fatalities vary and have shown enormous differences in different parts of the world and, in some cases, even within countries. [5] [6] [7] [8] In part, they are determined by the surveillance, testing, quarantine, isolation, and hospitalization policies and differences in population characteristics. [9] [10] [11] [12] Patients on in-center maintenance hemodialysis (MHD) present unique management challenges because of their need to report to a healthcare facility several times every week. 6, [13] [14] [15] Further, dialysis patients may be at increased risk of adverse outcomes if they contract the coronavirus disease (COVID-19) by virtue of having associated comorbidities like diabetes mellitus, hypertension, and cardiovascular disease that independently increase the risk of severe COVID-19 and mortality. 13, 16, 17 Further, inherent immunocompromised state of these patients also affects the outcome. [17] [18] [19] The cytokine storm manifestation in patients on dialysis may be different from the general population. 20 A few studies have been published from developed nations about epidemiology and clinical presentation of dialysis patients with COVID-19. 6, 14, 15 These studies revealed that while dialysis centers represented high risk, most affected individuals had clinically mild COVID due to impaired cellular immune function [17] [18] [19] and poor cytokine response. 20 Severe COVID, however, poses a higher mortality risk because of the collateral impact of comorbidities. 6, 7, 14, 15, 21, 22 During the pandemic, dialysis patients' management has presented unique challenges-with high dropout rates and death due to missing treatment. 23 Further, there are several differences between the dialysis population in the developed world and those in emerging countries. For example, India's dialysis population is relatively younger than that of the western dialysis population, 12, 24, 25 and age has been consistently identified as a risk factor for death from COVID-19 in the United States. 3, 12 There are no data, however, that has examined the impact of COVID-19 on the outcome of patients on MHD in developing countries. The present study was conducted to assess the outcomes of MHD patients and predictors of mortality with symptomatic COVID-19 disease. In this prospective cohort study, data were collected from dialysis units in 11 public and private hospitals between March 15, 2020, and June 30, 2020, after obtaining approval by the institutional ethics committee. All centers started screening patients for fever, respiratory symptoms (cough and breathlessness), and new-onset digestive tract symptoms at a designated station before entering the dialysis room. Symptomatic patients were treated as COVID-19 "suspect" and dialyzed in isolation and underwent screening with reverse transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 infection in an approved laboratory. 22 Those with positive RT-PCR were diagnosed as confirmed COVID-19 cases. Cases were categorized as mild, moderate, and severe as per the Revised Guidelines on Clinical Management of COVID-19, Ministry of Health and Family Welfare, the Government of India. 26 The disease was classified as mild when symptoms were present without features of viral pneumonia on imaging (X-ray chest or high-resolution computed tomography [HRCT] scans), moderate if manifestation were present, while severe disease refers to the presence of hypoxia with respiratory rate >30 breaths/min, severe respiratory distress, SpO2 < 90% on room air including acute respiratory distress syndrome (ARDS). All comorbidities like diabetes, hypertension, chronic obstructive airway diseases, cardiovascular diseases, and cancers were noted. All laboratory testings were performed according to the clinical care needs of the patient. Laboratory assessments consisted of a complete blood count, blood chemical analysis, coagulation testing, assessment of liver function, and measurement of electrolytes. The C-reactive protein (CRP), serum ferritin, D-dimer, and the interleukin-6 level was done as per the decision and availability of the test. The chest imaging criteria varied from center to center. An X-ray chest was performed in all cases, and HRCT was done as per the availability and decision of the treating physician. All patients were admitted to a COVID facility and received antiviral, antibiotic therapy, glucocorticoid therapy, and respiratory support as required. MHD was continued as per the ongoing schedule of individual patients. Data were collected in an Excel sheet from all participating centers. Continuous variables were expressed as mean ± standard deviation (SD). Categorical variables were expressed in the form of percentages. Independent samples t test for parametric distribution was used to compare the mean values between the groups. A chi-square test was used to compare the categorical variables between the groups. Patients with mild-moderate categories and severe categories with and without ARDS were clubbed together for analysis purposes. We Mortality was higher among patients on twice-weekly MHD compared to those on thrice-weekly dialysis (p = 0.001) and those getting dialysis through the central venous catheter as compared to those with an arteriovenous fistula (p = 0.001). The basic demography of the patients according to the severity is shown in Table 2 On univariate Cox regression analysis ( The clinical characteristics of the COVID in MHD patients are not different from the COVID in the general population in our cohort of patients, with fever, cough, and breathlessness being the most common manifestations. We also found that patients with severe disease were more likely to die, with the relative risk of mortality being 7.37 times higher in patients with severe COVID than those with mild/moderate disease. The presence of comorbidities also increased the risk of severe COVID and mortality. This observation was not different from the death pattern reported in nondialysis patients. 28, 29 The elderly or patients with comorbidities were more susceptible to COVID-19, and the incidence of severe cases and the risk of death were high. 30 The relatively high mortality in the present study could be due to 14, 17, 20 In such a scenario, any degree of cytokine storm may indicate severe COVID, worsening condition, and death. 20 In our study, 19.01% of patients received glucocorticoids, and the majority in severe categories, and those died. It suggests that glucocorticoids had been used only in desperate situations in our patients. While a number of agents have been tried, the RECOVERY trial showed that glucocorticoids reduce mortality in patients with severe disease. 31 However, the systematic review and meta-analysis did not show any mortality benefit. 32 Given the immunosuppressed state, the use of steroids should be considered carefully. 31, 32 More data are needed to make a conclusive recommendation about the benefit of glucocorticoids in MHD patients with COVID-19. Another reason for the higher mortality in our cohort could be an association with comorbidities, which had been independently associated with COVID-related mortality. In our study, 97% of those who died had some associated comorbidities. The multicentric nature of the study is the major strength of the study. 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COVID 19 and acute kidney injury Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study Clinical features of patients infected with 2019 novel coronavirus in Wuhan Role of corticosteroid in the management of COVID-19: a systemic review and a Clinician's perspective Outcomes of symptomatic coronavirus disease 19 in maintenance hemodialysis patient in India We acknowledge all dialysis nurses and technicians to collect data on the patients on dialysis. The authors declared none. The results presented in this paper have not been published previously in whole or part. https://orcid.org/0000-0001-9801-0474Manas Ranjan Behera https://orcid.org/0000-0002-2756-117XUrmila Anandh https://orcid.org/0000-0003-3298-8642Vivekanand Jha https://orcid.org/0000-0002-8015-9470