BackgroundApproximately 30% of adult patients with immunoglobulin A (IgA) nephropathy (IgAN) or IgA vasculitis with nephritis (IgAVN) develop end-stage renal disease during long-term follow-up. In particular, patients with nephritic–nephrotic syndrome have an increased risk of rapid progression. Conventional immunosuppressive therapy with corticosteroids (CSs) may be insufficient for disease control and is associated with a number of side effects. Rituximab (RTX) has been shown to be well tolerated and effective in a range of glomerular diseases, but there is little information on its therapeutic potential in IgAN. The humanized anti-CD20 monoclonal antibody ofatumumab (OFAB) may be an alternative drug for patients intolerant or unresponsive to RTX, but so far there is no report on its use in IgAVN or IgAN.MethodsWe describe clinical outcomes after 17–22 months in four adult patients with biopsy-confirmed IgAVN or IgAN treated with RTX or OFAB as well as CS soon after diagnosis. All presented with nephritic–nephrotic syndrome and one had crescentic IgAN. Rebiopsy was performed in two cases.ResultsRTX and OFAB were well tolerated. Albuminuria was <250 mg/day in three patients at last evaluation and two regained normal renal function. In all cases, renal function improved after therapy. In one patient with severe IgA vasculitis, rebiopsy showed disappearance of subendothelial but not mesangial immune complexes. In the case with crescentic IgAN, rebiopsy after 9 months showed no active necrotic lesions.ConclusionsB cell–depleting therapy may be an alternative treatment for patients with IgAN or IgAVN and nephritic–nephrotic syndrome. A possible CS-sparing effect should be further evaluated in randomized controlled clinical trials.
<b><i>Background:</i></b> The COVID-19 outbreak has been associated with a high morbidity, mortality, and a risk of long-term sequelae, and patients with severe COVID-19 are at increased risk of acute kidney injury. CKD patients are at high risk of being exposed to COVID-19 and suffer complications and poor outcome. In Sweden, mitigation strategies did not include lockdown. During March–April of 2020, wide-spread infection occurred in Stockholm. <b><i>Methods:</i></b> Management and outcomes in forty hemodialysis (HD) patients and 4 peritoneal dialysis (PD) patients, with symptomatic COVID-19 in greater Stockholm during March and April of 2020 are reported. <b><i>Results:</i></b> Twenty-four HD patients (60%) required medical care and hospitalization, whereas 16 patients (40%) were treated at home. Nine patients died (mortality rate of 22.5%), of whom 8 were men. The median age in non-survivors (78 years) was significantly higher than in survivors (<i>p</i> = 0.003). The median time in dialysis (11.5 years) was also significantly longer in non-survivors (<i>p</i> = 0.01). C-reactive protein (CRP) at diagnosis in 7 of non-survivors (median 213 mg/L, range 86–329 mg/L) was significantly higher than the CRP in 25 survivors (median 87 mg/L, range 1–328 mg/L) (<i>p</i> = 0.0003). Maximum CRP also indicated poorer outcome among hospitalized patients (<i>p</i> = 0.0004). The gender imbalance was striking with only men dying apart from 1 elderly woman. Only 4 PD patients were hospitalized with symptomatic COVID-19. One patient died, 2 were discharged, and 1 was treated at the intensive care unit and survived. <b><i>Conclusion:</i></b> HD patients >70 years were reported with longer dialysis vintage, higher CRP, and males were at an increased risk of dying from COVID-19, whereas those <70 years seemed to have a milder disease. Mitigation strategies to reduce rates of infection in high-risk populations remain essential. Follow-up focusing on long-term prognosis for extrapulmonary manifestations is likely to be important also in dialysis patients.
BACKGROUND AND AIMS Acute kidney injury (AKI), frequently with concurrent albuminuria and haematuria, is common and increases mortality in COVID-19 infection. We present the clinical course and long-term outcomes of COVID-19 survivors with AKI and continuous kidney replacement therapy (CKRT) with follow-up of kidney function at 6 and 12 months. METHOD A total of 29 non-CKD COVID-19 infected patients with AKI required mechanical ventilation and CKRT at the intensive care unit (ICU). Of those, 15 died (52%) and 14 survived. Written informed consent to collect and publish data was obtained from 13 survivors. We estimated eGFR with CKD-EPI creatinine in population-based healthy controls (n = 80, median age 62 years) for comparison. RESULTS A total of 13 survivors, median age 58 years, 85% male, 15% diabetes and median BMI 30 kg/m2. None had CKD before admission or at admission following rehydration. The typical scenario was a normal or slightly elevated creatinine level at admission, normalizing after IV fluids, but rising creatinine from day 8 (median) and the start of CKRT on day 10 (median). Urine analysis was available in 7 patients, of which only 1 had no urinary findings, 6 had albuminuria and/or haematuria and/or leukocyturia. Dialysis could be weaned in all 13 survivors after a median time of 16 days in dialysis (range 1–40 days). The median length of stay at the ICU was 41 days (range 10–72 days) and the median weight loss was 16 kg (range 8–27 kg). The survivors had a median eGFR of 100 mL/min/1.73 m2 (range 66–113) at baseline and a median eGFR of 69 mL/min/1.73 m2 (range 49–97) at 12 months estimated with CKD-EPI creatinine. Population-based control subjects had a median eGFR of 85 mL/min/1.73 m2 estimated CKD-EPI creatinine. Urine analysis was available in 11 patients at 12 months, of which 5 had no urinary findings, 3 had microalbuminuria and 3 had haematuria and/or leukocyturia. Since the weight loss was accompanied by a decline in creatinine, we used both creatinine-based, and cystatin C-based eGFR to evaluate kidney function at 6 month follow-up. At 6 months, the survivors had a median eGFR of 70 mL/min/1.73 m2 (range 44–111) estimated with CKD-EPI creatinine as compared with 46 mL/min/1.73 m2 (range 36–65) estimated with cystatin C eGFR, suggesting that cystatin C-based formulae are clinically more useful after COVID-19 associated critical illness. CONCLUSION The AKI mortality in COVID-19 despite CKRT is high, but a substantial number of patients survive and can be weaned off dialysis. Kidney function at 12 months did improve substantially but did not return to its baseline values and was lower compared with healthy age-matched population-based control subjects. Kidney outcome follow-up after COVID-19 and AKI is likely to be important for assessing long-term CKD prognosis and is proposed to be evaluated with both creatinine and cystatin C as well as urinalysis.
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