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JSM Renal Medicine

Seven Hemodialysis Patients with Covid-19 Pneumonia in a Thertiary Hospital, Istanbul, Turkey

Case Series | Open Access Volume 4 | Issue 1 |

  • 1. Infectious Diseases and Clinical Microbiology, Bakirkoy Dr. Sadi Konuk Training Research Hospital, Istanbul, Turkey
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Corresponding Authors
Hayat kumbasar, Infectious Diseases and Clinical Microbiology, Haseki Training and Research Hospital, Istanbul, Turkey
Abstract

Objective: We aimed to summarize the clinical data from seven hemodialysis patients with COVID-19 pneumonia.

Methods: For this retrospective, single center study, we recruited 539 hospitalized patients who were diagnosed with COVID-19 pneumonia from March 27 to April 15, 2020 in Bak?rkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul. Seven hemodialysis patients with Covid-19 pneumonia were analyzed.

Results: This study included seven hemodialysis patients of 539 cases with confirmed COVID-19, with an average age of 64 years (range, 42-83 years), including 3 females and 4 males. Among the seven patients, two cases were asymptomatic, five patients had fever and respiratory symptoms on admission . Asymptomatic patients were exposed to the virus via infected adults in their household.

Conclusion: All cases had high fever, low oxygen saturation (SO2 <93% ), high CRP, elevated ferritin and cytopenia at the seventh day of hospitalization. This suggests that cytokine storm may be more common in hemodialysis cases and the disease may progress more progressively.

Citation

Karaosmanoglu HK (2021) Seven Hemodialysis Patients with Covid-19 Pneumonia in a Thertiary Hospital, Istanbul, Turkey. JSM Renal Med 4(1): 1017.

INTRODUCTION

In late December 2019, an outbreak of COVID-19 was reported in Wuhan, a city in the Hubei Province of China. It rapidly spread, resulting in an epidemic throughout China, followed by an increasing number of cases in other countries throughout the world.

On March 11, 2020, the World Health Organization declared the COVID-19 outbreak a pandemic [1].

After the first case was reported on the 11 March 2020, The Turkish Government reported that 107,773 cases of COVID-19 had been confirmed, and 2,706 patients had died as of 25 April, 2020 [2].

The case fatality rate so far has ranged widely from 1% to 7.2% overall reaching up to 49% among the critically ill [3,4].

Risk factors for severe disease are older age and the presence of comorbidities such as diabetes, hypertension, chronic kidney disease, morbid obesity, coronary heart disease and chronic lung disease [5].

With the spread of the epidemic, the etiology, epidemiology, and clinical characteristics of COVID-19 have gradually been recognized, but the clinical and epidemiological characteristics of COVID-19 in hemodialysis (HD) patients is still limited, with only sporadic literature reported [6,7].

Here, we aimed to summarize the clinical data from seven hemodialysis patients with COVID-19 pneumonia.

METHODS

For this retrospective, single center study, we recruited 539 hospitalized patients who were diagnosed with COVID-19 pneumonia from March 27 to April 15, 2020 in Bak?rkoy Dr. Sadi Konuk Training and Research Hospital located in the centre of Istanbul. Seven hemodialysis patients with COVID-19 pneumonia were analyzed.

Information recorded includes epidemiological and demographic information, signs and symptoms on admission, laboratory results, CT findings, treatment measures, and outcome data from patients’ medical records. Clinical outcomes were followed up to April 15, 2020. A confirmed case of COVID-19 was defined as a positive result on high-throughput sequencing or real-time RT-PCR of nasal and pharyngeal swab specimens.

RESULTS

Demographic and clinical characteristics

This study included seven hemodialysis patients of 539 cases with confirmed COVID-19, with an average age of 64 years (range, 42-83 years), including 3 females and 4 males. Among the seven patients, two cases were asymptomatic, four patients had fever, fatique and respiratory symptoms (dispnea, dry cough) in admission . Asymptomatic patients were exposed to the virus via infected adults in their household.

All of the patients had lymphopenia, anemia, hyperferritinemia, elevated CRP in the seventh day of admission. The detailed clinical and laboratory features of patients are shown in (Table 1) .

Table 1. Characteristics of HD Patients with Covid-19 Pneumonia.

Characteristics Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7
Age (year) 59 71 79 78 52 42 69
Gender female male female female male female male
Lenght of stay (day) 16 17 14 19 22 15 Still ICU
Oxymetry saturation (At admission)) 98 95 93 96 93 96 91
Oxymetry saturation (7. day of admission) 92 90 92 91 89 92 88

Signs and symptoms at admission


Fever
Dispnea
Dry cough
Fatique
Nausea-vomiting

-
-
-
-
-
+
+
+
+
+
+
+
-
+
-
-
-
-
-
-
+
+
-
+
-
+
-
+
+
-
+
+
+
+
-

Laboratory Findings
(7.day)


Lymphocyte count (×?109 cells per L); (normal range 
0.8–4.0)


C reactive protein (mg/L); (normal range 0.0–5.0)


Ferritin (ng/mL); (normal range 4.63–204.0)

410

 

 


114

 

 

 


4850

610

 

 


157

 

 

 


2134

900

 

 


102

 

 

 


1684

780

 

 


210

 

 

 

 


1093

870

 

 


170

 

 

 


1484

560

 

 


134

 

 

 


1100

401

 

 


215

 

 

 


3220

CT Findings
Ground-glass opacity
+ + + + + + +

Treatment

All of the patients were treated with oseltamivir+ hydroksichlorokine+ azytromycine. Favipravir was added to treatment in four patients who had low oksigene saturation in the room air ( <%90). IVIG treatment was added in one critically ill patient who transferred to intensive care unit in ninth day of hospitalization.

CT Findings

CT images of six patients showed multiple ground-glass opacities were shown in (figure 1).

 Characteristics of HD Patients with Covid-19 Pneumonia.

Figure 1 Characteristics of HD Patients with Covid-19 Pneumonia.

DISCUSSION

Currently, there are few reports of hemodialysis patients with COVID-19. We describe seven HD patients with COVID-19 pneumonia in our hospital, representing 1,5 % of our hospitalized COVID-19 cases at the time.

The dominant clinical features of COVID-19 were fever, cough, and fatigue, while congestion, rhinorrhea, sore throat and diarrhea are rare [8-11].

The most frequently reported finding on CT imaging was ground-glass opacities, particularly bilateral opacities impacting three or more lobes [12,13].

In our study, HD patients had similar symptoms, signs and the radiological findings on admission.

Lymphopenia is the most common laboratory finding in COVID-19 and is found in as many as 83% of hospitalized patients and lymphopenia, high CRP, and high ferritin levels may be associated with greater illness severity [14,15].

Bataille S et al reported that high ferritin levels may be associated with COVID-19 in HD patients, and that even ferritin levels can be used in COVID-19 screening in HD patients [16].

In all our cases, the level of Ferritin is over 1000 ng/mL .

Previous studies have revealed that severe illness predominantly occurs in adults with advanced age or underlying medical comorbidities. and hyperinflammation and cytokine storm may played an important role in the disease progression [17,18].

Most of our HD cases are of advanced age and the disease has been severe.

All of the patients were hospitalized for more than 2 weeks, one case was transferred to the intensive care unit.

Previous studies on COVID-19 associate fever, hypoxia, high CRP, elevated ferritin and presence of cytopenia with MAS / sHLH-like cytokine storm syndrome [19-21].

All HD cases had high fever, low oxygen saturation (SO2 <93% ), high CRP, elevated ferritin and cytopenia at week one.

This suggests that cytokine storm may be more common in HD cases and the disease may progress more progressively.

Antiviral treatments were given to our cases and none of them were given IL-6 or IL-2 inhibitors (tocilizumab or anakinra), but only a critically ill case was given intravenous immunoglobulin (IVIG) in intensive care.

CONCLUSIONS

It is clear that in HD COVID-19 patients, immunomodulating agents can be put on the agenda more in the treatment, but in cases where the presence of bacterial infection cannot be fully eradicated, immunosuppressive effects will cause reservations.

We think that larger series are needed in this regard.

REFERENCES

1. World Health Organization. Coronavirus disease 2019 (COVID-19) situation report–51. Geneva, Switzerland: World Health Organization; 2020.

2. https://covid19.saglik.gov.tr/https://covid19.saglik.gov.tr.

3. Wu, Z. and J.M. McGoogan. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020; 13: 1239-1242.

4. Onder, G., G. Rezza, and S. Brusaferro, Case-Fatality Rate and Characteristics of Patients

5. Dying in Relation to COVID-19 in Italy. JAMA. 2020; 18: 1775-1776.

6. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al., Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet, 2020. 395: 1054-1062.

7. Tang B, Li S, Xiong Y, Tian M, Yu J, Xu L, et al. Coronavirus Disease 2019 (COVID-19) Pneumonia in a Hemodialysis Patient. Kidney Med. 2020.

8. Ferrey AC, Grace C, Hanna RM, Chang Y, Tantisattamo E, Ivaturi K, et al. A Case of Novel Coronavirus Disease 19 in a Chronic Hemodialysis Patient Presenting with Gastroenteritis and Developing Severe Pulmonary Disease. Am J Nephrol. 2020: 51: 337-342.

9. Chen N, Zhou M, Dong X. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020; 395: 507–513.

10. Chen L, Liu H.G, Liu W. [Analysis of clinical features of 29 patients with 2019 novel coronavirus pneumonia] Zhonghua Jie He He Hu Xi Za Zhi. 2020;43: E005.

11. Zhang M Q, Wang X H, Chen Y L. [Clinical features of 2019 novel coronavirus pneumonia in the early stage from a fever clinic in Beijing]. Zhonghua Jie He He Hu Xi Za Zhi. 2020;43: E013.

12. Xu X W., Wu X X., Jiang X.G. Xu K.J., Ling Y J, Ma C L., et al. Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARSCov-2) outside of Wuhan, China: retrospective case series. BMJ. 2020; 368.

13. Pan Y, Guan H, Zhou S, Wang Y, Li Q, Zhu T, et al. Initial CT findings and temporal changes in patients with the novel coronavirus pneumonia (2019-nCoV): a study of 63 patients in Wuhan, China. 2020. Eur Radiol. 2020;30: 3306-3309.

14. https://pubmed.ncbi.nlm.nih.gov/32053470/

15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7266766/

16. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet, 2020;395: 497-506.

17. Bataille S, Pedinielli N, Bergougnioux JP. Could ferritin help the screening for COVID-19 in hemodialysis patients? Kidney Int. 2020; 98: 235-236.

18. CDC COVID-19 Response Team. Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 — United States, February 12–March 28, 2020. MMWR Morb Mortal Wkly Rep. 2020; 69: 382-386.

19. Lighter J, Phillips M, Hochman S, Sterling S, Jhonson D, Francois F, et al. Obesity in patients younger than 60 years is a risk factor for Covid-19 hospital admission. Clin Infect Dis. 2020; 9; 896-897.

20. Zhang C, Wu Z, Li JW, Zhao H, Wang GQ. The cytokine release syndrome (CRS) of severe COVID-19 and Interleukin-6 receptor (IL-6R) antagonist Tocilizumab may be the key to reduce the mortality. Int J Antimicrob Agents. 2020; 105954.

21. Cron R Q, Chatham W W. The Rheumatologist’s Role in Covid-19. J. Rheumatol. 2020; 47: 639-642.

22. McGonagle D, Sharif K, O’Regan A, Bridgewood C. The Role of Cytokines including Interleukin-6 in COVID-19 induced Pneumonia and Macrophage Activation Syndrome-Like Disease. Autoimmun. Rev. 2020; 19: 102537.

Karaosmanoglu HK (2021) Seven Hemodialysis Patients with Covid-19 Pneumonia in a Thertiary Hospital, Istanbul, Turkey. JSM Renal Med 4(1): 1017

Received : 24 Apr 2021
Accepted : 07 Jun 2021
Published : 09 Jun 2021
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