What your doctor reads on Medscape.com:
APRIL 8, 2020 – As the worst-hit countries of Spain and Italy show encouraging signs of a slowdown within the number of latest COVID-19 infections, nephrologists from these and other hard-hit countries are sharing their insights and experiences gained through the pandemic.
Although lung damage is the foremost feature of severe COVID-19 disease, it's becoming increasingly clear that the kidney can be one in all the opposite essential organs affected, explained Dr. Annette Bruchfeld, professor of nephrology at Karolinska University Hospital in Sweden, during a webinar organized last week by the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA).
Bruchfeld discussed findings from the primary wave of the outbreak in China and highlighted that kidney disease at admission or during infection is a serious complication of severe COVID-19 disease and a major risk factor for death.
Meanwhile, Maria Jose Soler, MD, PhD, a nephrologist at Vall d'Hebron University Hospital in Barcelona, Spain, has presented a snapshot of COVID-19 amongst kidney dialysis and transplant patients from a registry maintained by the Spanish Society of Nephrology. As of April 7, that registry included greater than 600 patients, with mortality rates starting from 17% to 23%, depending on whether or not they were transplant or dialysis patients.
“The mortality we see in these [dialysis and transplant] patients because COVID-19 pneumonia/disease can be very aggressive, with severe distress syndrome,” Soler said Medical news from Medscape.
She explained how her team had tried various pharmacological interventions in dialysis and transplant patients, but acknowledged that proper studies are needed for definitive answers. “Nephrologists hope that our patients, who are usually excluded from randomized controlled trials… will be included. We need data on our patients, not just speculation.”
Meanwhile, Dr. Umberto Maggiore from the Department of Nephrology at the University Hospital of Parma (Italy) offered a glimmer of hope.
He reported that his team used the gout drug colchicine, among others, to successfully treat two kidney transplant patients with COVID-19, both of whom recovered. The key, he said, is to start treatment before patients get too sick. “We have started using colchicine as an anti-inflammatory drug and are now starting a randomized controlled trial on it,” he noted.
Developments in China so far: AKI is common in COVID-19 patients
Bruchfeld spoke about a prospective single-center study of 701 patients with COVID-19 in Wuhan, China, published In Kidney International.
Of the patients in the study, 43.9% had proteinuria and 26.7% had hematuria on admission, she noted. The prevalence of elevated serum creatinine, elevated blood urea nitrogen, and an estimated glomerular filtration rate of < 60 ml/min/1.73 m2 were 14.4%, 13.1% and 13.1% respectively.
And during the study period, 5.1% of patients developed acute kidney injury (AKI).
Kidney disease influenced mortality, ranging from a doubling of the risk of death with elevated baseline serum creatinine levels (hazard ratio 2.10) to an almost quadrupling of the risk with elevated baseline blood urea nitrogen levels (HR 3.97).
In patients with acute kidney failure, the risk of death was almost twice as high in stage 1 as in stage 3 and more than four times as high.
A similar pattern was seen for proteinuria and hematuria, with the risks being even higher for the latter.
“Our results show that the prevalence of kidney disease at admission and the development of acute kidney disease during hospitalization is high and is associated with in-hospital mortality,” says Yichun Cheng, MD, Department of Nephrology, Huazhong University of Science and Technology, Wuhan, China.
And in a Meta-analysis Of 30 studies involving 53,000 patients in China – although this is a preprint that has not been peer-reviewed – chronic kidney disease was associated with a six-fold increased risk of severe COVID-19 (odds ratio 6.0).
In comparison, the relative risk for chronic obstructive pulmonary disease is 5.3 and for cerebrovascular disease is 3.2, reported Bruchfeld.
Dialysis/Transplant COVID-19 experiences in Spain
Soler reported that there are currently 405 hemodialysis patients with COVID-19 in their Barcelona registry, including 94 deaths (23%).
There were five deaths (19%) among 26 peritoneal dialysis patients, and there were 35 deaths (17%) among 206 kidney transplant patients with COVID-19.
She also reported on treatments. The most common were hydroxychloroquine (75%), lopinavir/ritonavir (47%), steroids (15%), interferon (11%) and tocilizumab (3%).
Soler noted that lopinavir/ritonavir did not show greater efficacy than standard therapy for COVID-19 in a recent study. randomized clinical trialShe suspects that the drug combination may be more effective if used earlier in the course of the disease.
Given the high mortality rates in this study, “you realize that these were the really sick patients with advanced COVID-19 infection,” Soler said.
“That’s why we administer the drug earlier – not when the patients are in the intensive care unit, but earlier.”
Colchicine for transplant patients before the disease becomes severe?
Maggiore said that Italy is also trying to administer the drugs of choice earlier in the course of the disease.
They describe their experiences with two kidney transplant patients with COVID-19 in a Letter to the editor published last week in American Journal of Transplantation.
They discontinued immunosuppression to promote an antiviral response and maintained steroids as the only antirejection medication. Both patients received hydroxychloroquine 200 mg twice daily in addition to antiviral therapy.
After progressive respiratory deterioration and noninvasive ventilation, patients received colchicine as an anti-inflammatory agent, partly because they did not have tocilizumab.
Neither patient was transferred to intensive care; both recovered.
During the webinar, Maggiore further commented on the treatment of COVID-19 with steroids, noting that while he believes the drugs have no benefit and may even be harmful in COVID-19, he believes they may be important.
“If a patient with respiratory disease deteriorates abruptly inside 24 hours and also you don't have an intensive care bed, I believe steroids must be considered,” he said.