Clinical triage of patients on kidney replacement therapy presenting with COVID-19: an ERACODA registry analysis

Abstract

Rationale & Objective Patients on kidney replacement therapy (KRT) are at a very high risk of COVID-19. Triage pathway for KRT patients presenting with varying severity of COVID-19 illness remains ill-defined. We studied clinical characteristics of patients at initial and subsequent hospital presentations and its impact on patient outcomes. Study Design, Setting, Participants European Renal Association COVID-19 Database (ERACODA) was analysed for clinical and laboratory features of 1423 KRT patients with COVID-19 either hospitalized or non-hospitalized during first presentation and those representing after non-admission at initial triage. Predictors of outcomes (Hospitalisation, 28-day mortality) were determined for those not hospitalized at first presentation. Results Amongst 1423 KRT patients with COVID-19 (Hemodialysis = 1017/Transplant = 406), 25% (n = 355) were not hospitalized at first presentation (30% Hemodialysis/13% Transplant). Of these non-hospitalized patients, 10% (n = 36) re-presented second time, with a 5-day median interval between two presentations (Interquartile interval 2-7 days). Patients who re-presented had worsening respiratory symptoms, a fall in oxygen saturation (97% vs. 90%) and rise in C-reactive protein between attendances (26 vs. 73 mg/L). Patients on second presentation were older (72 vs. 63 years), had early respiratory symptoms and lung imaging abnormalities compared with those who did not return second time. The 28-day mortality for those admitted at first or second presentations was not significantly different (25% vs. 29%, p = 0.6). Higher age, prior smoking history, higher clinical frailty score and self-reported shortness of breath at first presentation, were identified as predictors of mortality in those discharged at initial triage. Conclusions The study provides evidence that KRT patients with COVID-19 and mild pulmonary abnormalities with lack of pulmonary insufficiency can be safely discharged, with vigilance of respiratory symptoms, especially in those with risk factors for poor outcomes. Our findings support a risk-stratified clinical approach to admissions and discharges of KRT patients presenting with COVID-19, to aid clinical triage and optimise resource utilisation during the ongoing pandemic.

The Longitudinal Evolution of Post–COVID-19 Outcomes Among Hemodialysis Patients in Turkey

“…In another study conducted by the European Renal Association COVID-19 Database, including 1423 end-stage renal disease patients with COVID-19 (HD ¼ 1017 patients/kidney transplant recipients ¼ 406 patients), the higher age, prior smoking history, higher clinical frailty score, and self-reported shortness of breath at first presentation were identified as predictors of mortality in those discharged at initial triage. 15 They also showed that among nonhospitalized patients, 10% (n ¼ 36) were readmitted to the hospital; these patients had worsening respiratory symptoms, a fall in oxygen saturation (97% vs. 90%), and high CRP between attendances (26 vs. 73 mg/l).…”

“Virtual ward” community outreach support for COVID‐19‐positive hemodialysis patients may delay but not prevent subsequent admission to hospital: A single‐center retrospective case–control pilot study

“…We found overall mortality rates in patients receiving HD who are ambulant and not requiring admission at the time of COVID diagnosis (6%) were significantly lower than those recently reported in a large European cohort, where 28-day mortality was around 30%. 6 The majority of the study cohort was White which may contribute to the reduced mortality seen compared to other studies.…”

“…Cumulative time on HD therapy and past medical history of diabetes mellitus, lung disease, and recent (within 30 days of positive swab) immunosuppression did not significantly differ between groups; however, a history of cardiovascular disease was more common in controls (Table 1). There was no difference seen in the overall admission rate (Figure 1a), but there was a significant delay in admission in cases compared to controls (8 [7][8][9][10][11][12][13][14][15][16][17][18] vs. 4 [2][3][4][5][6][7] days after positive swab, p = 0.03). Management through the pathway was not associated with a shorter length of hospital stay in those admitted (cases: 8 [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] days, controls: 8 [6-10], p = 0.81).…”

“…There was no difference seen in the overall admission rate (Figure 1a), but there was a significant delay in admission in cases compared to controls (8 [7][8][9][10][11][12][13][14][15][16][17][18] vs. 4 [2][3][4][5][6][7] days after positive swab, p = 0.03). Management through the pathway was not associated with a shorter length of hospital stay in those admitted (cases: 8 [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] days, controls: 8 [6-10], p = 0.81). There was a trend toward increased 28-day inpatient mortality in controls, although this was limited by low number of events with no deaths amongst cases (Figure 1b).…”