key: cord-0833985-4xicmewt authors: Chawki, Sylvain; Buchard, Albert; Sakhi, Hamza; Dardim, Karim; El Sakhawi, Karim; Chawki, Mokhtar; Boulanger, Henri; Kofman, Tomek; Dahmane, Djamal; Rieu, Philippe; Attaf, David; Ahriz-Saksi, Salima; Masoumi, Afshin; Diddaoui, Ali Zineddine; Fromentin, Luc; Michaut, Patrick; Nebbad, Rachida; Desassis, Jean-François; Nicolet, Laurence; Sohier-Attias, Julie; Besson, Frederic; Boula, Remy; Hafi, Ali; Ghazali, Abderrahmane; Lamriben, Larbi; Arezki, Adem; Dupuis, Emmanuel; Rifard, Mohamad-Khair; Joly, Dominique; Attias, Philippe; El Karoui, Khalil title: Long-term Impact of COVID-19 amongst maintenance hemodialysis patients date: 2021-09-27 journal: Clin Kidney J DOI: 10.1093/ckj/sfab166 sha: e56a382a8d72156c9272e47dfe5bc0c0426a1f29 doc_id: 833985 cord_uid: 4xicmewt BACKGROUND: Maintenance hemodialysis (MHD) patients have a high risk of initial mortality from COVID-19. However, long-term consequences of this disease in the MHD population are poorly described. We report the clinical presentation, outcome and long-term follow-up of MHD patients affected by COVID-19, in a multicentric cohort from the Paris, France area. METHODS: Retrospective analysis of clinical presentation and long-term follow-up of MHD patients affected by COVID-19 in 19 MHD centers in the Paris, France area. RESULTS: In this cohort of 248 patients with an initial mortality rate of 18%, age, comorbidities, dyspnea and previous immunosuppressive treatment were associated with death <30d. Among the 203 surviving patients following the acute phase, long-term follow-up (median 180d) was available for 189 (93%) patients. Major adverse events occurred in 30 (16%) patients during follow-up, including 12 deaths (6%) after a median of 78d from onset of symptoms. Overall, cardiovascular events, infections and gastrointestinal bleeding were the main major adverse events. Post-COVID-19 cachexia was observed in 25/189 (13%) patients. Lower initial albuminemia was significantly associated with this cachexia. No reinfection with SARS-CoV-2 was observed. CONCLUSION: This work demonstrates the long-term consequences of COVID-19 in MHD patients, highlighting both initial and long-term severity of the disease, including severe cachexia. Diagnostics Vitros IgG assay (targeting the spike antigen). 104 We defined post-COVID-19 cachexia by non-edematous weight loss >10% at last follow-up, 105 and /or extreme muscle weakness 9,10 . Major adverse events included cardiovascular events 106 (myocardial infarction, stroke, acute peripheral artery disease, pulmonary embolism or cardiac 107 arrest), or severe infections needing hospitalization or prolonged antibiotherapy, or other event 108 requiring hospitalization. Severe forms of COVID-19 were defined according to the need for 109 oxygen therapy. 110 Data collection was declared to the French "Commission Nationale de l'Informatique et des 111 Libertés" (CNIL), registration N°2218583. This protocol was submitted to the approbation of 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 7 125 Patient presentation and initial outcome 128 Two hundred and forty-eight consecutive patients were included. A previous report described 129 the initial evolution and treatment impact of these patients 11 . Given an overall population of 130 1790 patients managed in the 19 centers, the proportion of patients diagnosed with COVID-19 131 was 13.8%. Patients were mostly men (n=165; 67%), with a mean age of 67 (±27) and a mean 132 MHD vintage of 5 years (±5). The most frequent comorbidities included hypertension (94%; 133 n=232), diabetes (59%; n=147), history of coronary disease (30%; n=74) and cardiac failure 134 (16%; n=40). Of the 248 patients, COVID-19 was detected by real time RT-PCR in 88% of 135 cases (n=196). Hospitalization rate was 58% (n=145), after a mean of 3.5 days (±6) after the 136 first symptoms. Most frequent presenting features were fever (n=152; 61%), cough (n=122; 137 49%) and fatigue (n=101; 40%), 29 patients being asymptomatic (11%). Mean levels of hemoglobin, lymphocyte count and C-reactive protein (CRP) were 10.7g/dL 139 (±1.8), 915/mm 3 (±1,046) and 92mg/L (±98), respectively. Chest CT was performed in 62% of 140 cases (n=153). Detailed patient characteristics are provided in Table 1 . Hospital admission was associated with a history of hypertension, previous immunosuppressive 142 treatment as well as the presence of cough and confusion (Table S1) . 143 Treatments and initial outcome has been previously reported 11 . Most hospitalized patients 144 received oxygen therapy (n=114; 79%). A total of 14% (n=20) patients required ICU 145 hospitalization. ARDS requiring invasive mechanical ventilation was observed in 9% patients 146 (n=13). Overall initial mortality (<30d) was 18% (n=45), after a mean of 14 days (median 9 147 days) since the onset of symptoms (Supplementary Figure S1 ). Characteristics of survivors and 148 non-survivors (<30d) are detailed in Table S2 , and the predictors of mortality has been 149 previously reported, including the favorable effect of previous RAS blockers 11 in this cohort. Among the 203 surviving patients after acute phase, follow-up to month 6 was available for 153 189 (93%) patients. Major adverse events occurred in 30 (16%) patients during follow-up, and 154 12/189 died (6% of the whole population) after a median of 78d post-diagnosis ( Figure S1 ). 155 Characteristics of overall 6-month survivors and non survivors are presented in Table S3 . No 156 impact of RAS blockade was detected in overall mortality. Cardiovascular events (n=3), severe 9 them, 5/65 patients had no initial seroconversion. Among 60 patients with initial 178 seroconversion, a progressive decline in antibody titers was observed. Moreover, 15/60 (25%) 179 patients had negative anti-nucleocapsid titer at month 6. However, only 3/60 (5%) patients had 180 both negative anti-nucleocapsid and anti-spike antibodies. Cellular immunity was not evaluated 181 in these patients. No symptomatic reinfection was observed in these patients. Overall, post-COVID-19 cachexia was seen in 25 patients (13.2%), defined as a loss of more 183 than 10% of dry weight (n=16, 8.5%) or extreme muscle weakness (n=9, 4.8%). After multiple 184 testing correction, low initial albuminemia remained a significant predictor of cachexia 185 (t(16.87)=4.91, p=0.005; d=1.39) (see Table S5 ). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 DISCUSSION 188 We report the long-term follow-up of a large series of MHD patients affected by COVID-19. 189 In our cohort, < 30d mortality rate was 18%, which is in line with previously reported cohorts 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 hemodialysis patients have long-term immunity against SARS-CoV-2 and low risk of 214 symptomatic reinfection after 6-month follow-up. 215 Lastly, in this survivor population, we identified post-COVID-19 cachexia in 13% patients, 216 which included patients with very severe weight loss (> 10% after 6 months). We used the 217 threshold of >10% dry weight loss after 6-month follow-up to stratify patients with an Although the incidence of these symptoms is unknown in the MHD population and warrants 224 further studies, our report shows that MHD patients may also present with severe long-term 225 consequences of COVID-19. Conversely, we did not detect any impact of initial severity, age In conclusion, this work describes the deleterious consequences of COVID-19 in MHD patients, 238 highlighting the initial and long-term severity of the disease in this population, including a high 239 rate of severe cachexia. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 21 329 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Clinical course and risk factors for mortality of adult inpatients 20 All authors had no conflict of interest.