Background Renal involvement in COVID-19 leads to severe disease and higher mortality. We study renal parameters in COVID-19 patients and their association with mortality and length of stay in hospital. Methods A retrospective study (n=340) of confirmed COVID-19 patients with renal involvement determined by the presence of acute kidney injury. Multivariate analyses of logistic regression for mortality and linear regression for length of stay (LOS) adjusted for relevant demographic, comorbidity, disease severity, and treatment covariates. Results Mortality was 54.4% and mean LOS was 12.9 days. For mortality, creatinine peak (OR:35.27, 95% CI:2.81, 442.06, p<0.01) and persistent renal involvement at discharge (OR:4.47, 95% CI:1.99,10.06, p<0.001) were each significantly associated with increased odds for mortality. Increased blood urea nitrogen peak (OR:0.98, 95%CI:0.97,0.996, p<0.05) was significantly associated with decreased odds for mortality. For LOS, increased blood urea nitrogen peak (B:0.001, SE:<0.001, p<0.01), renal replacement therapy (B:0.19, SE:0.06, p<0.01), and increased days to acute kidney injury (B:0.19, SE:0.05, p<0.001) were each significantly associated with increased length of stay. Conclusion Our study emphasizes the importance in identifying renal involvement parameters in COVID-19 patients. These parameters are associated with LOS and mortality, and may assist clinicians to prognosticate COVID-19 patients with renal involvement.
Introduction. COVID-19 affects the hematologic system. We evaluate the impact of hematologic involvement of different blood cell line parameters of white blood cells including absolute neutrophil count (ANC), hemoglobin, and platelets in COVID-19 patients and their association with hospital mortality and length of stay (LOS). Methods. This is a retrospective study of 475 patients with confirmed positive COVID-19 infection and hematologic abnormalities in the metropolitan New York City area. Results. Increased (ANC) (OR:1.20; 95% CI:1.02-1.42, p<0.05) increased days to hematologic involvement (OR:4.44, 95% CI:1.42-13.90; p<0.05), and persistence of hematologic involvement at discharge (OR:2.87, 95% CI:1.20, 6.90, p<0.05) were associated with higher mortality. Higher hemoglobin at admission (OR:0.77, 95% CI:0.60-0.98, p<0.001) and platelets peak (OR:0.995, 95% CI 95%:0.992-0.997, p<0.001) were associated with decreased mortality. Patients with higher white blood cell peak (B=0.46, SE=0.07, p<0.001) and higher hemoglobin at admission (B=0.05, SE=0.01, p<0.001) were associated with higher LOS. Those with higher hemoglobin nadir (B=-0.06, SE=0.01, p<0.001), higher platelets nadir (B=-0.001, SE=<0.001, p<0.001), and hematologic involvement at discharge/death (B=-0.06, SE=0.03, p<0.05) were associated with lower LOS. Conclusions. These findings can be used by clinicians to better risk-stratify patients with hematologic involvement in COVID-19 and tailor therapies to potentially improve patient outcomes.
Figure 1. A: CT scan with markedly dilated intrahepatic and extrahepatic biliary ductal dilation, distended gallbladder, and markedly dilated duodenum with abrupt transition point in proximal jejunum.
A 64 y/o man with history of hiatal hernia and reflux disease, presented with persistent heartburn. He had history of smoking and alcohol abuse. Labs were unremarkable. Abdominal CT showed distal esophageal mass with hepatic metastases. EGD revealed necrotic, distal esophageal ulcer (Figure B). He passed away 3 months after initial presentation. Pathology findings (esophageal tumor biopsy) in both cases showed undifferentiated tumor cells in solid sheets (Figure C) and adjacent mucosa consistent with Barrett's esophagus (BE). SMARCA4 was lost within the tumor cells (Figure D). Discussion: The SMARCA4 gene encodes the BRG1 protein which has a tumor suppressor role. Loss of SMARCA4 gene has been associated with undifferentiated highly aggressive tumors .SMARCA4-deficient UEC is extremely rare and has been predominantly reported in elderly men. While our 64 y/o male patient fits the commonly reported demographics with risk factors for esophageal carcinoma, our 39 y/o patient did not have any potential risk factors and is the youngest reported patient. Additionally, the positive family history in the younger patient highlights the possibility of a germline mutation, which has been previously described in literature. Histologically, the observed BE in the background of tumor cells in our cases, was also observed in most reported cases. The presence of BE and the distal esophageal location in these tumors suggest the possibility of this tumor arising from progressive de-differentiation of BE. Our patients had evidence of metastatic disease on presentation, rapidly progressed and passed away within 1.5-3 months. The rapid mortality rate and the limited utility of SMARCA4 immunostaining could explain the underreporting of this disease.[2285] Figure 1. A: EGD in case 1, showing a large, non-obstructing, circumferential, ulcerating mass in the lower third of the esophagus. B: EGD in case 2, showing a fungating, circumferential, necrotic, distal esophageal ulcer with stigmata of recent bleeding. C: Both tumor biopsies showed undifferentiated tumor cells consisting of epithelioid cells arranged in solid sheets with adjacent intestinal metaplasia (low magnification, H&E). D: Loss of SMARCA4/BRG1 within the tumor cells, while retained within inflammatory cells (internal control).
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