Severe acute respiratory SARS-CoV-2 infection in dialysis patients in northern Italy: a single-centre experience
Francesco Fontana, Francesco Giaroni, Monica Frisina, Gaetano Alfano, Giacomo Mori, Leonardo Lucchi, Riccardo Magistroni, Gianni Cappelli
Clinical Kidney Journal, doi:10.1093/ckj/sfaa084
Background. Dialysis patients are considered at high risk for COVID-19 and the infection can easily spread in dialysis units. Methods. We conducted an observational single-centre cohort study to describe clinical characteristics, treatments and outcomes of dialysis patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We tested patients who presented symptoms or had contact with a confirmed case. We enrolled 15 patients positive for SARS-CoV-2. Results. We tested 37 of 306 dialysis patients. Patients with SARS-CoV-2 infection were older (mean age 75.96 6 11.09 years) and all had comorbidities. At presentation, most had interstitial infiltrates on chest X-ray, three-quarters had leucopenia and none had respiratory insufficiency. During follow-up, there was an increase in serum C-reactive protein and interleukin-6. Eighty percent of patients received supplemental oxygen; none received non-invasive ventilation, one was intubated. Most patients (80%) were treated with oral hydroxychloroquine for a median time of 6.5 days [interquartile range (IQR) 5-14.5] and 40% received azithromycin; two patients received a short course of antivirals and one received a single dose of tocilizumab. Only two patients did not require hospitalization. Of the nine survivors, eight still tested positive for SARS-CoV-2 a median of 19 days (IQR 9.25-23) after diagnosis. Six patients died (case fatality rate 40%) a median of 5.5 days (IQR 1.75-9.75) after diagnosis. The main reported cause of death was respiratory failure related to COVID-19 (five patients). Conclusions. We report a single-centre experience of SARS-CoV-2 infection in dialysis patients. The disease showed a high case fatality rate and most patients required hospitalization. Survivors show prolonged viral shedding.
AUTHORS' CONTRIBUTIONS F.F. conceived the study, collected and analysed the data and wrote the manuscript. F.G., M.F. and L.L. collected the data. G.A. and G.M. collected the data and contributed to the analysis. R.M. and G.C. critically revised the manuscript.
CONFLICT OF INTEREST STATEMENT None declared.
References
Basile, Combe, Pizzarelli, Recommendations for the prevention, mitigation and containment of the emerging SARS-CoV-2 (COVID-19) pandemic in haemodialysis centres, Nephrol Dial Transplant,
doi:10.1093/ndt/gfaa069Betjes, Immune cell dysfunction and inflammation in end-stage renal disease, Nat Rev Nephrol
Burgner, Ikizler, Dwyer, COVID-19 and the inpatient dialysis unit: managing resources during contingency planning pre-crisis, Clin J Am Soc Nephrol,
doi:10.2215/CJN.03750320Cao, Wang, Wen, A trial of lopinavir-ritonavir in adults hospitalized with severe Covid-19, N Engl J Med,
doi:10.1056/NEJMoa2001282Clinicaltrials, Tocilizumab in COVID-19 Pneumonia (TOCIVID-19
Gautret, Lagier, Parola, Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial, Int J Antimicrob Agents,
doi:10.1016/j.ijantimicag.2020.105949Grasselli, Zangrillo, Zanella, Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy, JAMA,
doi:10.1001/jama.2020.5394Guan, Ni, Hu, Clinical characteristics of coronavirus disease 2019 in China, N Engl J Med
Kliger, Silberzweig, Mitigating risk of COVID-19 in dialysis facilities, Clin J Am Soc Nephrol,
doi:10.2215/CJN.03340320Li, Xu, Lessons from the experience in Wuhan to reduce risk of COVID-19 infection in patients undergoing long-term hemodialysis, Clin J Am Soc Nephrol,
doi:10.2215/CJN.03420320Liu, Xu, Zhang, Patients of COVID-19 may benefit from sustained lopinavir-combined regimen and the increase of eosinophil may predict the outcome of COVID-19 progression, Int J Infect Dis,
doi:10.1016/j.ijid.2020.03.013Naicker, Yang, Hwang, The novel coronavirus 2019 epidemic and kidneys, Kidney Int
Onder, Rezza, Brusaferro, Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy, JAMA,
doi:10.1001/jama.2020.4683Onder, Rezza, Brusaferro, Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy, JAMA,
doi:10.1001/jama.2020.4683Wu, Chen, Cai, Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China, JAMA Intern Med,
doi:10.1001/jamainternmed.2020.0994Zhou, Yu, Du, Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study, Lancet
{ 'indexed': {'date-parts': [[2023, 1, 21]], 'date-time': '2023-01-21T03:59:09Z', 'timestamp': 1674273549339},
'reference-count': 21,
'publisher': 'Oxford University Press (OUP)',
'license': [ { 'start': { 'date-parts': [[2020, 6, 22]],
'date-time': '2020-06-22T00:00:00Z',
'timestamp': 1592784000000},
'content-version': 'vor',
'delay-in-days': 0,
'URL': 'http://creativecommons.org/licenses/by-nc/4.0/'}],
'content-domain': {'domain': [], 'crossmark-restriction': False},
'abstract': '<jats:title>Abstract</jats:title>\n'
' <jats:sec>\n'
' <jats:title>Background</jats:title>\n'
' <jats:p>Dialysis patients are considered at high risk for COVID-19 and the '
'infection can easily spread in dialysis units.</jats:p>\n'
' </jats:sec>\n'
' <jats:sec>\n'
' <jats:title>Methods</jats:title>\n'
' <jats:p>We conducted an observational single-centre cohort study to '
'describe clinical characteristics, treatments and outcomes of dialysis patients with severe '
'acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We tested patients who '
'presented symptoms or had contact with a confirmed case. We enrolled 15 patients positive for '
'SARS-CoV-2.</jats:p>\n'
' </jats:sec>\n'
' <jats:sec>\n'
' <jats:title>Results</jats:title>\n'
' <jats:p>We tested 37 of 306 dialysis patients. Patients with SARS-CoV-2 '
'infection were older (mean age 75.96\u2009±\u200911.09\u2009years) and all had comorbidities. '
'At presentation, most had interstitial infiltrates on chest X-ray, three-quarters had '
'leucopenia and none had respiratory insufficiency. During follow-up, there was an increase in '
'serum C-reactive protein and interleukin-6. Eighty percent of patients received supplemental '
'oxygen; none received non-invasive ventilation, one was intubated. Most patients (80%) were '
'treated with oral hydroxychloroquine for a median time of 6.5\u2009days [interquartile range '
'(IQR) 5–14.5] and 40% received azithromycin; two patients received a short course of '
'antivirals and one received a single dose of tocilizumab. Only two patients did not require '
'hospitalization. Of the nine survivors, eight still tested positive for SARS-CoV-2 a median '
'of 19\u2009days (IQR 9.25–23) after diagnosis. Six patients died (case fatality rate 40%) a '
'median of 5.5\u2009days (IQR 1.75–9.75) after diagnosis. The main reported cause of death was '
'respiratory failure related to COVID-19 (five patients).</jats:p>\n'
' </jats:sec>\n'
' <jats:sec>\n'
' <jats:title>Conclusions</jats:title>\n'
' <jats:p>We report a single-centre experience of SARS-CoV-2 infection in '
'dialysis patients. The disease showed a high case fatality rate and most patients required '
'hospitalization. Survivors show prolonged viral shedding.</jats:p>\n'
' </jats:sec>',
'DOI': '10.1093/ckj/sfaa084',
'type': 'journal-article',
'created': {'date-parts': [[2020, 4, 23]], 'date-time': '2020-04-23T03:22:20Z', 'timestamp': 1587612140000},
'source': 'Crossref',
'is-referenced-by-count': 5,
'title': 'Severe acute respiratory SARS-CoV-2 infection in dialysis patients in northern Italy: a '
'single-centre experience',
'prefix': '10.1093',
'author': [ { 'ORCID': 'http://orcid.org/0000-0003-0762-0942',
'authenticated-orcid': False,
'given': 'Francesco',
'family': 'Fontana',
'sequence': 'first',
'affiliation': [ { 'name': 'Struttura Complessa di Nefrologia e Dialisi, Azienda '
'Ospedaliero-Universitaria di Modena, Modena, Italy'}]},
{ 'given': 'Francesco',
'family': 'Giaroni',
'sequence': 'first',
'affiliation': [ { 'name': 'Surgical Medical and Dental Department of Morphological '
'Sciences, University of Modena and Reggio Emilia, Modena, '
'Italy'}]},
{ 'given': 'Monica',
'family': 'Frisina',
'sequence': 'first',
'affiliation': [ { 'name': 'Surgical Medical and Dental Department of Morphological '
'Sciences, University of Modena and Reggio Emilia, Modena, '
'Italy'}]},
{ 'given': 'Gaetano',
'family': 'Alfano',
'sequence': 'first',
'affiliation': [ { 'name': 'Struttura Complessa di Nefrologia e Dialisi, Azienda '
'Ospedaliero-Universitaria di Modena, Modena, Italy'},
{ 'name': 'Surgical Medical and Dental Department of Morphological '
'Sciences, University of Modena and Reggio Emilia, Modena, '
'Italy'}]},
{ 'given': 'Giacomo',
'family': 'Mori',
'sequence': 'first',
'affiliation': [ { 'name': 'Struttura Complessa di Nefrologia e Dialisi, Azienda '
'Ospedaliero-Universitaria di Modena, Modena, Italy'}]},
{ 'given': 'Leonardo',
'family': 'Lucchi',
'sequence': 'first',
'affiliation': [ { 'name': 'Struttura Complessa di Nefrologia e Dialisi, Azienda '
'Ospedaliero-Universitaria di Modena, Modena, Italy'}]},
{ 'given': 'Riccardo',
'family': 'Magistroni',
'sequence': 'first',
'affiliation': [ { 'name': 'Struttura Complessa di Nefrologia e Dialisi, Azienda '
'Ospedaliero-Universitaria di Modena, Modena, Italy'},
{ 'name': 'Surgical Medical and Dental Department of Morphological '
'Sciences, University of Modena and Reggio Emilia, Modena, '
'Italy'}]},
{ 'given': 'Gianni',
'family': 'Cappelli',
'sequence': 'first',
'affiliation': [ { 'name': 'Struttura Complessa di Nefrologia e Dialisi, Azienda '
'Ospedaliero-Universitaria di Modena, Modena, Italy'},
{ 'name': 'Surgical Medical and Dental Department of Morphological '
'Sciences, University of Modena and Reggio Emilia, Modena, '
'Italy'}]}],
'member': '286',
'published-online': {'date-parts': [[2020, 6, 22]]},
'reference': [ { 'key': '2020062210233507500_sfaa084-B1',
'doi-asserted-by': 'crossref',
'first-page': '1708',
'DOI': '10.1056/NEJMoa2002032',
'article-title': 'Clinical characteristics of coronavirus disease 2019 in China',
'author': 'Guan',
'year': '2020',
'journal-title': 'N Engl J Med'},
{ 'key': '2020062210233507500_sfaa084-B2',
'doi-asserted-by': 'crossref',
'DOI': '10.1001/jama.2020.4683',
'article-title': 'Case-fatality rate and characteristics of patients dying in relation to '
'COVID-19 in Italy',
'author': 'Onder',
'year': '2020',
'journal-title': 'JAMA'},
{ 'key': '2020062210233507500_sfaa084-B3',
'doi-asserted-by': 'crossref',
'first-page': '255',
'DOI': '10.1038/nrneph.2013.44',
'article-title': 'Immune cell dysfunction and inflammation in end-stage renal disease',
'volume': '9',
'author': 'Betjes',
'year': '2013',
'journal-title': 'Nat Rev Nephrol'},
{ 'key': '2020062210233507500_sfaa084-B4',
'doi-asserted-by': 'crossref',
'DOI': '10.1093/ndt/gfaa069',
'article-title': 'Recommendations for the prevention, mitigation and containment of the '
'emerging SARS-CoV-2 (COVID-19) pandemic in haemodialysis centres',
'author': 'Basile',
'year': '2020',
'journal-title': 'Nephrol Dial Transplant'},
{ 'key': '2020062210233507500_sfaa084-B5',
'doi-asserted-by': 'crossref',
'DOI': '10.2215/CJN.03340320',
'article-title': 'Mitigating risk of COVID-19 in dialysis facilities',
'author': 'Kliger',
'year': '2020',
'journal-title': 'Clin J Am Soc Nephrol'},
{ 'key': '2020062210233507500_sfaa084-B6',
'doi-asserted-by': 'crossref',
'first-page': '824',
'DOI': '10.1016/j.kint.2020.03.001',
'article-title': 'The novel coronavirus 2019 epidemic and kidneys',
'author': 'Naicker',
'year': '2020',
'journal-title': 'Kidney Int'},
{ 'key': '2020062210233507500_sfaa084-B7',
'doi-asserted-by': 'crossref',
'DOI': '10.2215/CJN.03750320',
'article-title': 'COVID-19 and the inpatient dialysis unit: managing resources during '
'contingency planning pre-crisis',
'author': 'Burgner',
'year': '2020',
'journal-title': 'Clin J Am Soc Nephrol'},
{ 'key': '2020062210233507500_sfaa084-B8',
'doi-asserted-by': 'crossref',
'DOI': '10.2215/CJN.03420320',
'article-title': 'Lessons from the experience in Wuhan to reduce risk of COVID-19 '
'infection in patients undergoing long-term hemodialysis',
'author': 'Li',
'year': '2020',
'journal-title': 'Clin J Am Soc Nephrol'},
{'key': '2020062210233507500_sfaa084-B9', 'author': 'Ma', 'year': '2019'},
{'key': '2020062210233507500_sfaa084-B10', 'year': '2020'},
{ 'key': '2020062210233507500_sfaa084-B11',
'doi-asserted-by': 'crossref',
'DOI': '10.1001/jama.2020.5394',
'article-title': 'Baseline characteristics and outcomes of 1591 patients infected with '
'SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy',
'author': 'Grasselli',
'year': '2020',
'journal-title': 'JAMA'},
{'key': '2020062210233507500_sfaa084-B12', 'year': '2020'},
{ 'key': '2020062210233507500_sfaa084-B13',
'doi-asserted-by': 'crossref',
'first-page': '1054',
'DOI': '10.1016/S0140-6736(20)30566-3',
'article-title': 'Clinical course and risk factors for mortality of adult inpatients with '
'COVID-19 in Wuhan, China: a retrospective cohort study',
'volume': '395',
'author': 'Zhou',
'year': '2020',
'journal-title': 'Lancet'},
{ 'key': '2020062210233507500_sfaa084-B14',
'doi-asserted-by': 'crossref',
'DOI': '10.1016/j.ijantimicag.2020.105949',
'article-title': 'Hydroxychloroquine and azithromycin as a treatment of COVID-19: results '
'of an open-label non-randomized clinical trial',
'author': 'Gautret',
'year': '2020',
'journal-title': 'Int J Antimicrob Agents'},
{ 'key': '2020062210233507500_sfaa084-B15',
'article-title': 'Patients of COVID-19 may benefit from sustained lopinavir-combined '
'regimen and the increase of eosinophil may predict the outcome of '
'COVID-19 progression',
'author': 'Liu',
'year': '2020',
'journal-title': 'Int J Infect Dis'},
{ 'key': '2020062210233507500_sfaa084-B16',
'doi-asserted-by': 'crossref',
'DOI': '10.1056/NEJMoa2001282',
'article-title': 'A trial of lopinavir-ritonavir in adults hospitalized with severe '
'Covid-19',
'author': 'Cao',
'year': '2020',
'journal-title': 'N Engl J Med'},
{ 'key': '2020062210233507500_sfaa084-B17',
'doi-asserted-by': 'crossref',
'DOI': '10.1001/jamainternmed.2020.0994',
'article-title': 'Risk factors associated with acute respiratory distress syndrome and '
'death in patients with coronavirus disease 2019 pneumonia in Wuhan, '
'China',
'author': 'Wu',
'year': '2020',
'journal-title': 'JAMA Intern Med'},
{'key': '2020062210233507500_sfaa084-B18', 'year': '2020'},
{ 'key': '2020062210233507500_sfaa084-B19',
'article-title': 'Viral dynamics in mild and severe cases of COVID-19',
'author': 'Liu',
'year': '2020',
'journal-title': 'Lancet Infect Dis'},
{ 'key': '2020062210233507500_sfaa084-B20',
'doi-asserted-by': 'crossref',
'DOI': '10.1001/jama.2020.4683',
'article-title': 'Case-fatality rate and characteristics of patients dying in relation to '
'COVID-19 in Italy',
'author': 'Onder',
'year': '2020',
'journal-title': 'JAMA'},
{ 'key': '2020062210233507500_sfaa084-B21',
'doi-asserted-by': 'crossref',
'DOI': '10.1001/jama.2020.4894',
'article-title': 'The importance of addressing advance care planning and decisions about '
'do-not-resuscitate orders during novel coronavirus 2019 (COVID-19)',
'author': 'Curtis',
'year': '2020',
'journal-title': 'JAMA'}],
'container-title': 'Clinical Kidney Journal',
'original-title': [],
'language': 'en',
'link': [ { 'URL': 'http://academic.oup.com/ckj/advance-article-pdf/doi/10.1093/ckj/sfaa084/33415235/sfaa084.pdf',
'content-type': 'application/pdf',
'content-version': 'vor',
'intended-application': 'syndication'},
{ 'URL': 'http://academic.oup.com/ckj/advance-article-pdf/doi/10.1093/ckj/sfaa084/33415235/sfaa084.pdf',
'content-type': 'unspecified',
'content-version': 'vor',
'intended-application': 'similarity-checking'}],
'deposited': { 'date-parts': [[2020, 6, 22]],
'date-time': '2020-06-22T14:23:48Z',
'timestamp': 1592835828000},
'score': 1,
'resource': { 'primary': { 'URL': 'https://academic.oup.com/ckj/advance-article/doi/10.1093/ckj/sfaa084/5860798'}},
'subtitle': [],
'short-title': [],
'issued': {'date-parts': [[2020, 6, 22]]},
'references-count': 21,
'URL': 'http://dx.doi.org/10.1093/ckj/sfaa084',
'relation': {},
'ISSN': ['2048-8505', '2048-8513'],
'subject': ['Transplantation', 'Nephrology'],
'published': {'date-parts': [[2020, 6, 22]]}}
