Physicians at the University of California Irvine have described what they believe is one of the first cases of COVID-19 infection in a hemodialysis patient in the United States.

The case involves a 56-year-old man from southern California with end-stage kidney disease due to IgA nephropathy. Kamyar Kalantar-Zadeh, MD, PhD, MPH, Chief of the Division of Nephrology, Hypertension, and Kidney Transplantation, the corresponding author of the case report, said the man had an unusual manifestation of COVID-19: gastrointestinal symptoms, nausea, vomiting, and diarrhea accompanied by fever but without initial respiratory symptoms. The case report, whose first author is Antoney J. Ferrey, MD, was published in the American Journal of Nephrology.

Although the patient does not have diabetes, he has hypertension and coronary artery disease.

During the first 5 days of the patient’s febrile disease, he presented to an urgent care facility, 3 emergency departments, a cardiology clinic, and 2 dialysis centers, one in California and another in Utah as he was travelling, said Dr Kalantar-Zadeh, who is the medical director of nephrology for Renal & Urology News.


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 “During this interval he reported nausea, vomiting, diarrhea and low-grade fevers but was not suspected of COVID-19 infection until he developed respiratory symptoms and was admitted to the hospital,” Dr Kalantar-Zadeh and his coauthors wrote in the case report.

The man initially was diagnosed with suspected food poisoning. Imaging studies performed upon admission were consistent with bilateral interstitial pneumonia, the authors noted. A positive result on a COVID-19 test was reported on hospital day 3.

The patient had been receiving high-dose angiotensin receptor blocker (ARB) therapy (losartan 100 mg/day) in the year leading up to COVID-19, Dr Kalantar-Zadeh said. The drug was discontinued upon hospitalization because he had low blood pressure and was in septic shock.

Severe acute respiratory distress syndrome (ARDS) developed, and he was intubated. He showed no improvement after 10 days in an intensive care unit. The man remains in critical condition and is being treated with hydroxychloroquine and tocilizumab in addition to standard medical management for septic shock and ARDS.

“Our case is unique in its atypical initial presentation and highlights the importance of early testing if possible,” Dr Kalantar-Zadeh said.

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It is hypothesized that prior renin-angiotensin-aldosterone (RAAS) inhibitor therapy can cause angiotensin-converting enzyme-2 (ACE2) receptor upregulation, which in turn may have unfavorable effects on COVID-19. However, if these same patients contract COVID-19 infection, then giving even higher doses of ACE inhibitors or ARBs may help block these highly upregulated ACE2 receptors. Clinical trials are underway to test this hypothesis, he said.

Dr Kalantar-Zadeh noted that the current recommendation of the Council on Hypertension of the European Society of Cardiology and most other cardiovascular societies is not to stop RAAS blockade due to the potential for harm.

Reference

Ferrey AJ, Choi G, Hanna RM, et al. A case of novel coronavirus disease 19 in a chronic hemodialysis patient presenting with gastroenteritis and developing severe pulmonary disease [published online March 28, 2020]. Am J Nephrol. 2020. doi: 10.1159/000507417

https://www.karger.com/Article/FullText/507417