key: cord-0254964-j69xmgg3 authors: VENEGAS JUSTINIANO, J. Y.; LOZA MUNARRIZ, C.; HURTADO ARESTEGUI, A. N. title: Epidemiological profile of patients with stage 5 chronic kidney disease on dialysis with Covid 19 infection in a Public Hospital-Peru date: 2021-10-01 journal: nan DOI: 10.1101/2021.09.30.21264132 sha: 1e5270be07b180826315d965b19ba82fd968ff97 doc_id: 254964 cord_uid: j69xmgg3 Introduction: Chronic kidney disease (CKD) in Covid 19 is relevant, however, there are few descriptions and fewer in Peru. Our goal was to describe the epidemiological profile and the factors related to mortality and survival of patients with stage 5 (CKD) on chronic dialysis hospitalized for Covid-19 in a public hospital. Methods: Retrospective case series. Patients with stage 5 CKD, older than 18 years, hospitalized for Covid-19 infection were included. The primary data source was medical records. The clinical and epidemiological profile of the study sample and the factors related to mortality and survival are described. Results: 105 medical records of patients with CKD 5 were evaluated. 57 (54,29%) were male, with a mean age of 58,59 +/- 14,3 years. 84 (80%) patients survived and 21 (20%) died. The main cause of admission to hospitalization was respiratory failure in (80) 76,2%. The hospital stay was 11,76 +/- 7,8 days. In the bivariate analysis: the increase in leukocytes, D dimer, ferritin, CRP, LDH and the decrease in lymphocytes, pH, bicarbonate and PaO2/FiO2 were related to mortality. In the multivariate analysis, only CRP> 10 mg/dl [HR: 10.72 (95% CI 1,4-81,58)] and a PaO2/FiO2 [≤] 150 mmHg [HR: 44,40 (95% CI 5,86-336,06)] they were factors related to poor survival. Conclusions: CRP levels> 10mg/dl and PaO2/FiO2 [≤] 150 mmHg are the main factors related to mortality and poor survival in patients with stage 5 CKD hospitalized for Covid-19. Keywords: Renal Insufficiency, renal dialysis, Coronavirus infections, Covid- 19, survival. (MeSH) The World Health Organization (WHO) declared a pandemic to the infection for coronavirus in March 2020, initially this was identified in a group of patients with respiratory compromise in December 2019 in Wuhan. The infection spread quickly in Asia, Europe and the rest of the continents, in Peru, the first case was identified in March 6 of 2020 and to date numerous cases and a high mortality rate have been reported, putting it in the fifth most affected country in Latin America 1-7 . According to reports, the infection is more frequent in the elderly population, men, comorbidities like diabetes mellitus and other immunosuppression conditions. The clinic presentation is known by sustained fever, lymphopenia, hyperferritinemia, pulmonary involvement in more than 50% of cases and other findings in relation to increased interleukins 8-12 . Chronic kidney disease (CKD) characterized by the progressive loss of renal function, it has a progressive increase in frequency and the need of replacement therapy in any of its modalities is increasingly demanding 2 . The population with CKD both in pre-dialysis and renal replacement therapy, as well as in renal transplant recipients have multiple comorbidities associated with higher mortality during COVID-19 infection. It is known that the immune response of the chronic renal patient is diminished with less possibility of presenting cytokine storm, which explains why some series show a low percentage of severe manifestations. However, it should be considered that the chronic state of these patients, associated comorbidities, nutritional level and hospital admissions make them more prone to severe respiratory infections 12-15 . Up to now, existing studies show different findings, some of them include that hemodialysis patients with COVID-19 experiment a minor illness with mild pneumonia, associated with a reduced immune response and decreased cytokine storm 15, 16 . On the contrary, other series report a mortality of 28% in patients on hemodialysis, with hospital admission and severe clinical manifestations 17 . The most important finding is the fact that factors such as advanced age, diabetes, cardiovascular disease, pulmonary disease, and a less efficient immune system with the need for dialysis treatment in overcrowded environments, together with years of dialysis, lead to an increase in the prevalence and mortality rate 18-21 . . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint In Latin America and Peru, little has been described about the burden of Covid 19 infection in hospitalized patients with stage 5 chronic kidney disease on dialysis; characteristics, behavior, evolution and complications, these data are important to optimize care strategies and clinical outcomes. The main objective of the study is to describe the epidemiological and clinical characteristics and factors related to mortality and survival of patients with stage 5 in chronic kidney disease on dialysis with Covid 19 infection in a public hospital in Lima-Peru. The present study is a retrospective case series, conducted at the National Hospital Arzobispo Loayza (HNAL). Lima-Peru, between April and December 2020. The study population was selected by non-probabilistic sampling; hospitalized patients with stage 5 CKD on renal replacement therapy (RRT) and Covid-19 infection were evaluated. Inclusion criteria were hospitalized patients older than 18 years, patients with stage 5 CKD in a chronic hemodialysis or chronic peritoneal dialysis program, renal transplant patients with functioning kidney; clinical diagnosis of Covid-19 infection by their treating physician and/or diagnosis of Covid-19 in the discharge summary. Exclusion criteria were patients with a diagnosis of Acute Kidney Injury (AKI), episode of AKI superadded to CKD and incomplete data in the clinical history records, database, or laboratory record. All were new cases of Covid 19. During the study period, 107 patients with a diagnosis of stage 5 CKD and COVID 19 infection were registered; 105 met the inclusion criteria. The primary source of data was the medical records of each patient, and the data were recorded retrospectively, assigning sequential numbering, evaluated only by the investigator. The independent variables considered for the study were: Age, sex, BMI, hypertensive and non-hypertensive etiology of CKD, symptomatologic profile on admission, smoking history, cause of hospitalization, comorbidities (Charlson Score), inflammatory parameters (CRP, ferritin, D-dimer, DHL, lymphocyte and leukocyte counts), blood gas values (pH, bicarbonate, pO2 and PaO2/FiO2), urea, creatinine, type of vascular access, hospital stay, renal replacement therapy (RRT) modality: chronic hemodialysis (HDC) or is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 1, 2021. ; https://doi.org/10.1101/2021.09.30.21264132 doi: medRxiv preprint chronic peritoneal dialysis (CPD) and associated complications to COVID-19. Dependent variables were high vital status and survival time. The Institutional Ethics and Research Committee of the Cayetano Heredia Peruvian University approved the study under the number 039-01-21 and since it is a retrospective study, it is exempt from informed consent. Descriptive statistics: Descriptive statistics were used to describe numerical variables with means ± SD for variables with normal distribution and with medians and interquartile range (IQR) for variables without normal distribution. Categorical variables were described in proportions (%). We report the crude mortality rate and frequency tables that include clinical and demographic characteristics, laboratory alterations and variables related to hospitalization, treatments, and complications of patients with stage 5 CKD on dialysis and Covid 19 infection. A survival analysis is realized presenting the curve and the general survival table of the study sample. Inferential Statistics: Bivariate analysis was performed to compare clinical and demographic characteristics and laboratory data between survivors and deceased. Variables with a p ≤ 0.2 were selected to be evaluated in the multivariable model. To compare categorical variables or proportions, the "Chi2 exact" test was used. To compare two means of independent samples with normal distribution, the "ttest" (Student's t-test) was used and to compare two means of independent samples without normal distribution, the "Wilcoxon rank sum" test was used. To compare more than two means for data with normal distribution, ANOVA and/or One-way was used. The tables and the overall survival curve of patients with stage 5 CKD on dialysis and Covid-19 infection in the study period were obtained. Survival by groups was also described. The survival curves were compared with the Log Rank test. To evaluate the variables that were independently related to the overall survival of CKD stage 5 patients and Covid 19 infection, a multivariate analysis was performed with Cox regression using the Hazard Ratio (HR). The data were analyzed with State vs. 17 software. For the analysis, p ≤0.05 was considered statistically significant. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 1, 2021. ; https://doi.org/10.1101/2021.09.30.21264132 doi: medRxiv preprint In the study period were evaluated 105 patients with a diagnosis of stage 5 CKD and Covid-19 infection, the average age was 58.59 ± 14.3 years, 57 (54.29%) patients were male, respiratory failure 80 (76.2%) was the main cause of hospitalization; the most frequent etiology of CKD was arterial hypertension in 57 (54.28%) patients and diabetic nephropathy in 26 (24.76%); the hospital stay was reported as 11.76±7.8 days ( Table 1) . In the bivariate analysis, the increase in leukocytes, D-dimer, ferritin, CRP, LDH, as well as the decrease in pH, bicarbonate, lymphocytes and PaO2/FiO2, were related to higher mortality ( Table 2 Figure 1 and 2) . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 1, 2021. ; https://doi.org/10.1101/2021.09.30.21264132 doi: medRxiv preprint It is known that the prevalence of CKD has increased in recent years in relation to the aging of the population and due to the increased prevalence of diabetes mellitus and hypertension. According to 2015 data from the Ministry of Health of Perú, kidney disease (chronic and acute) ranks seventh among the main specific causes of general mortality, with 3.3% of the total, with diabetes mellitus and arterial hypertension being the etiologies responsible for approximately 70% of the cases of Kidney Disease at the national level. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint There is evidence that the factors related to greater mortality are age, male sex, comorbidities such as arterial hypertension, diabetes mellitus and obesity, inflammatory markers, and respiratory compromise 25-32 , in the present investigation as well as in a Spanish study, no relationship was found with age, sex and comorbidities 33 . The severity of Covid-19 infection has not been evaluated, but it is implicitly considered that a patient hospitalized with Covid-19 is generally considered a severe infection, therefore, our study sample is made up of patients with stage 5 CKD with multiple comorbidities in addition to severe Covid-19 infection, conditions that make them a vulnerable population with high mortality. Regarding laboratory markers, there are reports of the relationship between increased leukocytes, CRP, LDH, ferritin, D-dimer and decreased lymphocytes with mortality, data that relate the exaggerated inflammatory response in patients with Covid-19 with increased mortality, such findings are congruent with our findings 30-33 , in relation to the gasometrical characteristics it is described that SatO2<90% persistent despite increased oxygen support, pO2 < 68 mmHg and decreased pO2/FiO2 are related to higher mortality in the context of the severity of respiratory compromise 34 , in this series it was found that most patients needed oxygen support and showed a significantly decreased PaO2/FiO2. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 1, 2021. The main limitations of the study lie in the type of design; it is a retrospective case series whose primary source of data is the hospital medical records, which implicitly may entail a series of errors in the validity and reliability of the data recorded. The biochemical and blood gas variables were processed by the hospital laboratory; they could also have a great intrinsic variability of the values since the variability of the observers and of the equipment used to process the blood samples is unknown. CRP levels >10 mg/dl and PaO2/FiO2≤ 150 mmHg are the main factors related to mortality and lower survival in patients with stage 5 CKD hospitalized for Covid-19. All the authors declared no competing interests. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 1, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 1, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 1, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 1, 2021. ; https://doi.org/10.1101/2021.09.30.21264132 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 1, 2021. ; https://doi.org/10.1101/2021.09.30.21264132 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 1, 2021. ; https://doi.org/10.1101/2021.09.30.21264132 doi: medRxiv preprint Delivering Dialysis During the COVID-19 Outbreak: Strategies and Outcomes Mortality caused by sepsis in patients with end-stage renal disease compared with the general population Caring for Dialysis Patients in a Time of COVID-19 COVID-19 in Patients with Kidney Disease Management of Patients on Dialysis and With Kidney Transplantation During the SARS-CoV-2 (COVID-19) Pandemic in Clinical features of patients infected with 2019 novel coronavirus in Wuhan Worldwide Early Impact of COVID-19 on Dialysis Patients and Staff and Lessons Learned: A DOPPS Roundtable Discussion Kidney diseases in the time of COVID-19: major challenges to patient care COVID-19 in dialysis patients: outlasting and outsmarting a pandemic UK Renal Registry (2020) Weekly COVID-19 Surveillance Report For Renal Centres in the UK; London -up to 22 Management of hemodialysis patients with suspected or confirmed COVID-19 infection: perspective of two nephrologists in the United States A report from the Brescia Renal COVID Task Force on the clinical characteristics and short-term outcome of hemodialysis patients with SARSCoV-2 infection Chronic hemodialysis patients hospitalized with COVID-19: short-term outcomes in the Bronx Mortality analysis of COVID-19 infection in chronic kidney disease, haemodialysis and renal transplant patients compared with patients without kidney disease: a nationwide analysis from Turkey COVID-19 and dialysis: why we should be worried Epidemiology of COVID-19 in an urban dialysis center COVID-19 and chronic renal disease: clinical characteristics and prognosis Clinical Features of Maintenance Hemodialysis Patients with 2019 Novel Coronavirus-Infected