New data may provide a clearer picture of the impact of coronavirus disease 2019 (COVID-19) in 2 groups of patients with end-stage kidney disease – kidney transplant (KT) recipients and patients on maintenance hemodialysis (HD), according to recently published reports in the Clinical Journal of the American Society of Nephrology.
In a study of 41 KT outpatients with known or suspected COVID-19, S. Ali Husain, MD, MPH, of Columbia University Medical Center in New York, and colleagues found that only 13 of them (32%) required hospitalization. They were hospitalized a median of 8 days from symptom onset but as late as 16 days after onset.
“This wide interval underscores the need for increased vigilance approximately 1 week following the onset of symptoms and also, the need for continued close outpatient follow-up for the early detection of clinical deterioration during the second week,” the authors wrote.
As in the general population, KT recipients most commonly presented with fever (80%), cough (56%), and dyspnea (39%). Twenty-three patients (56%) had outpatient symptom resolution a median of 12 days after symptom onset, with a maximum of 23 days after onset.
“Clinicians caring for these patients must therefore be aware that a prolonged duration of symptoms does not necessarily portend a poor outcome,” the investigators stated.
Notably, according to the investigators, the hospitalized patients were more likely to have reported dyspnea than patients who had resolution of symptoms (77% vs 21%), “perhaps because of the eventual need for supplemental oxygen that would require hospitalization. As a result, patients with dyspnea at the outset should be monitored closely for the likely eventual need for hospitalization.”
This case series indicate that immunosuppressed patients can be safely monitored and managed as outpatients through telemedicine visits or phone calls every 6, 24, or 48 hours on the basis of symptom severity. “These findings show that patients must be followed until improvement to watch for late worsening of symptoms requiring hospitalization,” Dr Husain said in a news release from the American Society of Nephrology.
In the second study, investigators in China led by Xianyou Li, PhD, of Tongren Hospital of Wuhan University, found that the main symptoms of COVID-19 pneumonia, which include fever and cough, are less common among patients receiving HD, and that these patients are at higher risk for death.
Dr Liand collaborators studied 101 COVID-19 patients (median age 62 years) hospitalized from January to early March. The group included 49 patients with and 52 without kidney failure. Fever (47% vs 90%) and dry cough (49% vs 71%) were less common among HD patients. Dialysis patients most often presented with fatigue (59%) and anorexia (57%), which can be mistaken for uremic symptoms.
Dialysis patients also had prominent laboratory and radiologic abnormalities. Lymphocyte counts were significantly decreased in HD than control patients (0.8×109/L vs 0.9×109/L). Creatine kinase (muscle and brain type), myoglobin, hypersensitive troponin I, B-type natriuretic peptide, and procalcitonin were all increased in dialysis patients. With respect to computed tomography findings, dialysis patients displayed a higher percentage of bilateral lung abnormalities (82% vs 69%) and a significantly lower percentage of unilateral lung abnormalities (10% vs 27%).
With respect to clinical outcomes, HD patients had higher rates of common complications including shock, acute respiratory distress syndrome, arrhythmia, and acute cardiac injury. Significantly more dialysis patients required noninvasive ventilation (25% vs 6%). As of March 19, 2020 (study end), 6% of HD patients were transferred to an intensive care unit and received invasive ventilation. A greater proportion of dialysis than nondialysis patients died (14% vs 7%).
In an accompanying editorial discussing both studies, Maria Ajaimy, MD, and Michal L. Melamed, MD, of Montefiore Medical Center in New York, commented, “Because the presentation of COVID-19 in patients on dialysis and kidney transplant recipients is often atypical (with fewer presenting with fever or respiratory symptoms), it is even more important in this population to rapidly screen for SARS-CoV-2 infection and practice universal respiratory precautions.” Clinicians should also discuss home dialysis modalities with patients, they noted.
Husain SA, Dube G, Morris H, et al. Early outcomes of outpatient management of kidney transplant recipients with coronavirus disease 2019 [published online May 18, 2020]. Clin J Am Soc Nephrol. doi: 10.2215/CJN.05170420
Wu J, Li J, Zhu G, et al. Clinical features of maintenance hemodialysis patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China [published online May 22, 2020]. Clin J Am Soc Nephrol. doi: 10.2215/CJN.04160320
COVID-19 in patients who have received kidney transplants or are undergoing dialysis [news release]. Washington DC: American Society of Nephrology; July 7, 2020.
Ajaimy M and Melamed ML. COVID-19 in patients with kidney disease [published online July 7, 2020]. Clin J Am Soc Nephrol. doi: 10.2215/CJN.09730620
CDC updates, expands list of people at risk of severe COVID-19 illness [news release]. Centers for Disease Control and Prevention; June 26, 2020.