Background and Aims SARS-CoV-2 infection has a severe course in immunocompromised (RTR) patients. The aim is to study the clinical course and risk factors for adverse outcomes and results of COVID-19 treatment in RTR. Method At the beginning of the study there were 2580 RTR observed at Moscow Nephrology Center, by the end of it there were 2776 RTR. A retrospective uncontrolled observational study included 279 RTR (M: 172/F: 107, aged 49.9±10.9 yrs.), infected with SARS-CoV-2 from April 1 to November 30, 2020. The period after kidney transplantation before the onset of the disease was 54,0 months (14.0;108.0). After confirmation of COVID-19 by PCR and chest СТ MMF/Аza were canceled, CNI dose was minimized (target blood level was CyA 30-50 ng/ml, Тac 1,5-3 ng/ml), a CS dose was increased to 10-15 ng/day. Observation endpoints: discharge/recovery or death. Results The number of RTR infected with SARS-CoV-2 from April 1 to May 31, 2020 was 108; there were 42 RTR from June 1 to August 31, 2020; and 129 RTR - from September 1 to November 30, 2020. 59 RTR (21,1%) had a mild course of COVID-19. Patients with moderate and severe course (220/78.9%) were treated in the hospital. The period from the onset of the disease to the hospitalization was 7.1 ± 5.1 days. Severe lung damage (> 50%) occurred in 97 of 220 (44.1%); decrease in SpO2 <95% was seen in 128 of 220 (58.2%); 31 patients died. Thus, hospital mortality was 14.1%, overall mortality was 11.1%. Scr during the course increased from 160.9 ± 68.2 μmol/l to 185.4 ± 130.9 μmol/l (p <0.01) with no signs of acute rejection; and after the recovery, it decreased to 158.1 ± 63.2 μmol/l (p <0.01). Risk factors associated with fatal outcome were analyzed among the survivors (group 1; n-189) and the deceased (group 2; n-31). Groups 1 and 2 differed in the frequency of severe lung damage (69/36.9% vs 24/77.4%, p <0.001); the Charlson comorbidity index (4.4 ± 1.7 vs 6.1 ± 2.5, p <0.001); the frequency of IMV use (0 vs 23, p <0.0001), Scr upon admission (160.3 ± 67.1 µmol/l vs 208.9 ± 99.4 µmol/l, p <0.03), Hb levels (116.3 ± 21.8 g/l vs 91.7 ± 23.9 g/l, p <0.001), white blood cell сount (11.1 ± 4.8 × 109/L vs 18.1 ± 7.5 × 109/L, p <0.001), lymphocyte count (0.7 ± 0.4 × 109/l vs 0.4 ± 0.4 × 109/L, p <0.02), albumin (32.4 ± 4.1 g/l vs 25.8 ± 2.8 g/l, p <0.001), glucose (6.1 ± 1.9 mmol/l vs 7.8 ± 2.8 mmol/l, p <0.001), LDG (305.6 ± 135.6 U/l vs 800.8 ± 313.8 U/l, p <0.0001), CRP (74.1 ± 68.4 mg/L vs 160.7 ± 74.4 mg/L, p <0.0001), D-dimer (967.3 ± 949.0 μg/L vs 2810.1 ± 1807.7 μg/L, p <0.0001) and the frequency of procalcitonin increase (29.5 vs 86.4%, p <0.001). The independent factors of adverse outcome (Cox model) were high levels of comorbidity index (p <0.006) and procalcitonin (p <0.006), as well as the IMV use (p <0.0001). It was not possible to establish differences in Groups 1 and 2 depending on the use of individual drugs (Corticosteroids, Baricitinib, Monoclonal Ab IL-6/IL-17/IL-1β, antiCOVID plasma) as well as their combinations. Conclusion The frequency of SARS-CoV-2 infection in RTR was more than 2 times lower in summer compared to spring and autumn, which suggests a seasonal nature of this infection. The course of the disease was characterized by high hospital and general mortality. High values of the comorbidity index, procalcitonin and the IMV use were independent predictors of the fatal outcome.
We herein present our initial report from «ROKKOR-recipient», a national multicenter observational study. The prevalence, risk factors, clinical manifestations and outcomes of the novel coronavirus disease 2019 (COVID-19) in solid organ transplant recipients receiving immunosuppressive therapy were investigated. The study enrolled 251 COVID-19 patients (220 kidney recipients, 7 liver recipients, 1 liver-kidney recipient, and 23 heart recipients). The subjects came from 20 regions in Russia. The symptoms, clinical presentation, imaging and lab test results, therapy and outcomes of COVID-19 were described. It was established that solid organ transplant recipients with COVID-19 have a higher risk of developing adverse events. Predictors of adverse events include associated cardiovascular diseases, pulmonary diseases, diabetes, and kidney failure. Symptoms of the disease include dyspnea, rash and catarrhal signs, as well as initial low blood oxygen saturation (SpO2 <92%), leukocytosis (white blood cell count >10 × 109/L), elevated creatinine levels (>130 μmol/L) and a marked decrease in glomerular filtration rate, requiring hemodialysis. Performing organ transplant surgery in COVID-19 does not increase the risk of adverse events but could save the lives of waitlisted terminally ill patients.
Журнал для непрерывного медицинского образования врачей COVID-19 у больных, получающих лечение программным гемодиализом ОРИГИНАЛЬНЫЕ ИССЛЕДОВАНИЯ 1 Государственное бюджетное учреждение здравоохранения города Москвы «Городская клиническая больница № 52 Департамента здравоохранения города Москвы», 123182, г. Москва, Российская Федерация 2 Федеральное бюджетное учреждение науки «Московский научноисследовательский институт эпидемиологии и микробиологии им. Г.Н. Габричевского» Федеральной службы по надзору в сфере защиты прав потребителей и благополучия человека, 125212, г. Москва, Российская Федерация 3 Филиал федерального государственного бюджетного военного образовательного учреждения высшего образования «Военно-медицинская академия имени С.М. Кирова» Министерства обороны Российской Федерации, 107392, г. Москва, Российская Федерация 4 Федеральное государственное бюджетное образовательное учреждение высшего образования «Московский государственный медикостоматологический университет имени А.И. Евдокимова» Министерства здравоохранения Российской Федерации, 127473, г. Москва, Российская Федерация 5 Федеральное государственное бюджетное учреждение «Главный военный клинический госпиталь им. Н.Н. Бурденко» Министерства обороны Российской Федерации, 105229, г. Москва, Российская Федерация
Introduction. In recent years, the number of patients with autosomal dominant polycystic kidney disease (ADPKD) who undergo kidney transplantation without nephrectomy has increased. The most frequent and adverse complication from your own kidneys is infection of cysts (IC). This dictates the need to predict the probability of IC and determine diagnostic and therapeutic approaches in this category of patients. Materials and methods. The results of observation and treatment of 55 patients with ADPKD who underwent kidney transplantation from 2000 to 2019 without prior nephrectomy were evaluated. Results. Bilateral nephrectomy in connection with IC was performed in 10 (18.1%) patients, and one patient died from sepsis progression. Burdened urological history (kidney operations for suppuration of cysts and recurrent urinary tract infection (UTI)) significantly increased the chances of nephrectomy for IC by 6.8 times (AOR 6.83; 95% CI 1.34-34.8; p=0.021). The median time from kidney transplantation to nephrectomy was 7 months (Q1-Q3: 2-8). Acute graf pyelonephritis was associated with IR (p=0.045) in single-factor analysis. Forty-five patients are under observation, with a median follow-up of 41 months (Q1-Q3: 19-76). Seventeen patients underwent magnetic resonance imaging using diffusely weighted image protocols (MRI-DWI). MR-signs of infection were detected in 5 patients. Given the absence of clinical and laboratory manifestations of inflammation, nephrectomy was not performed. Further followup did not indicate the development of clinical and laboratory signs of UTI in any case. Discussion. As our study and a number of other studies have shown, in patients with ADPKD after kidney transplantation, the most frequent indication for nephrectomy is inflammatory changes in their own kidneys. Patients with a history of severe pyelonephritis or IC who previously had pyelonephritis or IC before kidney transplantation are at risk for developing inflammatory changes after kidney transplantation, and it does not matter how long ago they had a history of pyelonephritis attacks or kidney surgery. This fact should be taken into account before kidney transplantation and offer patients a nephrectomy before kidney transplantation. Our work is consistent with a number of non-numerous publications that have shown that in the diagnosis of IC, the most informative non-invasive, imaging method is MRI of the kidneys, but this method has low specificity, which can lead to an increase in the number of false positive conclusions and an increase in the number of unjustified nephrectomies. Conclusion. The predictor of infection of own kidney cysts after transplantation is a burdened urological history. MRI DWI has high sensitivity and low specificity in the diagnosis of IR in ADPKD. When identifying single cysts with MR-signs of infection in the absence of clinical, laboratory manifestations of UTI, nephrectomy is not indicated.
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