Development and validation of the MMCD score to predict kidney replacement therapy in COVID-19 patients

Background: Acute kidney injury (AKI) is frequently associated with COVID–19 and the need for kidney replacement therapy (KRT) is considered an indicator of disease severity. This study aimed to develop a prognostic score for predicting the need for KRT in hospitalized COVID–19 patients. Methods: This study is part of the multicentre cohort, the Brazilian COVID–19 Registry. A total of 5,212 adult COVID–19 patients were included between March/2020 and September/2020. We evaluated four categories of predictor variables: (1) demographic data; (2) comorbidities and conditions at admission; (3) laboratory exams within 24 h; and (4) the need for mechanical ventilation at any time during hospitalization. Variable selection was performed using generalized additive models (GAM) and least absolute shrinkage and selection operator (LASSO) regression was used for score derivation. The accuracy was assessed using the area under the receiver operating characteristic curve (AUCROC). Risk groups were proposed based on predicted probabilities: non-high (up to 14.9%), high (15.0 to 49.9%), and very high risk (≥ 50.0%). Results: The median age of the model–derivation cohort was 59 (IQR 47–70) years, 54.5% were men, 34.3% required ICU admission, 20.9% evolved with AKI, 9.3% required KRT, and 15.1% died during hospitalization. The validation cohort had similar age, sex, ICU admission, AKI, required KRT distribution and in–hospital mortality. Thirty–two variables were tested and four important predictors of the need for KRT during hospitalization were identified using GAM: need for mechanical ventilation, male gender, higher creatinine at admission, and diabetes. The MMCD score had excellent discrimination in derivation (AUROC = 0.929; 95% CI 0.918–0.939) and validation (AUROC = 0.927; 95% CI 0.911–0.941) cohorts an good overall performance in both cohorts (Brier score: 0.057 and 0.056, respectively). The score is implemented in a freely available online risk calculator (https://www.mmcdscore.com/). Conclusion: The use of the MMCD score to predict the need for KRT may assist healthcare workers in identifying hospitalized COVID–19 patients who may require more intensive monitoring, and can be useful for resource allocation.

The impact of vaccination on incidence and outcomes of SARS-CoV-2 infection in patients with kidney failure in Scotland

Background Patients with kidney failure requiring kidney replacement therapy (KRT) are at high risk of complications and death following SARS-CoV-2 infection with variable antibody responses to vaccination reported. We investigated the effects of COVID-19 vaccination on incidence of infection, hospitalization and death of COVID-19 infection. Methods Study design was an observational data linkage cohort study. Multiple healthcare datasets were linked to ascertain all SARS-CoV-2 testing, vaccination, hospitalization, and mortality data for all patients treated with KRT in Scotland, from the start of the pandemic over a period of 20 months. Descriptive statistics, survival analyses and vaccine effectiveness were calculated. Results As of 19th September 2021, 93% (n=5281) of the established KRT population in Scotland had received two doses of an approved SARS-CoV-2 vaccine. Over the study period, there were 814 cases of SARS-CoV-2 infection (15.1% of the KRT population). Vaccine effectiveness against infection and hospitalization was 33% (95% CI 0-52) and 38% (95% CI 0-57) respectively. 9.2% of fully vaccinated individuals died within 28 days of a SARS-CoV-2 positive PCR test (7% dialysis patients and 10% kidney transplant recipients). This compares to <0.1% of the vaccinated Scottish population being admitted to hospital or dying death due to COVID19 during that period. Conclusions These data demonstrate a primary vaccine course of two doses has limited impact on COVID-19 infection and its complications in patients treated with KRT. Adjunctive strategies to reduce risk of both COVID-19 infection and its complications in this population are urgently required.

Extraskeletal Calcifications in Children with Maintenance Peritoneal Dialysis

Chronic kidney disease (CKD)-mineral and bone disorder (CKD-MBD) is a common complication of CKD, often accompanied by extra-skeletal calcification in adult patients. As increased vascular calcification is predicted to increase cardiovascular mortality and morbidity, the revised Kidney Disease: Improving Global Outcomes guidelines recommend avoiding calcium-containing phosphate chelators. However, extra-skeletal calcification is less commonly noticed in pediatric patients. Here, we report our experience of such a complication in pediatric patients receiving maintenance peritoneal dialysis. Extra-skeletal calcification was noticed at the corneas, pelvic cavity, and soft tissues of the lower leg in 4 out of 32 patients on maintenance peritoneal dialysis. These patients experienced the aggravation of extra-skeletal calcifications during peritoneal dialysis, and 2 of them underwent excisional operations. It is required to monitor extra-skeletal calcifications in children on kidney replacement therapy.

How is Exercise Prescribed for Hemodialysis Patients? A Scoping Review Protocol

Objective: The objective of this scoping review is to describe how exercise has been prescribed for hemodialysis patients. Introduction: Exercise interventions have received more attention from the nephrology community in the last few years. Despite some limitations in the findings, there is currently robust evidence suggesting that exercise is clinically important and provides benefits to hemodialysis patients. Even so, there is little evidence precisely detailing and describing how exercise can be prescribed and delivered for this population. Inclusion criteria: Based on the PCC framework, we will review and include evidence from hemodialysis patients (Participants); describing exercise interventions (Concept); in all settings and designs (Context). The evidence that included any other kidney replacement therapy other than hemodialysis will be excluded. Methods: This review will follow the JBI methodology for scoping reviews and the PRISMA-ScR. We will perform a comprehensive literature search using MEDLINE, EMBASE, SPORTDiscuss, CINAHL, and LILACS databases without date or language restrictions from inception until December 2021. Websites, books, and guidelines from prominent societies and associations will also be searched. Experimental, quasi-experimental, observational, and protocol evidence from adults with chronic kidney disease (≥18 years) undergoing hemodialysis that prescribed exercise as an intervention will be considered. Two independent reviewers will screen title and abstract and perform the full-text review. Data extraction will be done by the main reviewer and checked by a second reviewer. Data characterizing the exercise interventions (e.g., type, setting, frequency, duration, intensity, volume, progression, periodization, professionals involved, etc.) will be extracted from selected evidence. The qualitative and quantitative results will be synthesized and presented in tables and figures along with a narrative summary.

Controlled Study of Decision-Making Algorithms for Kidney Replacement Therapy Initiation in Acute Kidney Injury

Background: Acute kidney injury (AKI) requiring kidney replacement therapy (KRT) is associated with high mortality and utilization. We evaluated the use of an AKI-Standardized Clinical Assessment and Management Plan (SCAMP) on patient outcomes including mortality, hospital and ICU length of stay. Methods: We conducted a 12-month controlled study in the ICUs of a large academic tertiary medical center. We alternated use of the AKI-SCAMP with use of a "sham" control form in 4-6-week blocks. The primary outcome was risk of inpatient mortality. Pre-specified secondary outcomes included 30-day mortality, 60-day mortality and hospital and ICU length of stay. Generalized estimating equations were used to estimate the impact of the AKI-SCAMP on mortality and length of stay. Results: There were 122 patients in the AKI-SCAMP group and 102 patients in the control group. There was no significant difference in inpatient mortality associated with AKI-SCAMP use (41% vs 47% control). AKI-SCAMP use was associated with significantly reduced ICU length of stay (mean 8 (95% CI 8-9) vs 12 (95% CI 10-13) days; p = <0.0001) and hospital length of stay (mean 25 (95% CI 22-29) vs 30 (95% CI 27-34) days; p = 0.02). Patients in the AKI-SCAMP group less likely to receive KRT in the context of physician-perceived treatment futility than those in the control group (2% vs 7%, p=0.003). Conclusions: Use of the AKI-SCAMP tool for AKI-KRT was not significantly associated with inpatient mortality but was associated with reduced ICU and hospital length of stay and use of KRT in cases of physician-perceived treatment futility.

Pregnancy and delivery in women treated with renal replacement therapy: A literature review

The problem of pregnancy and delivery in women with end-stage kidney disease is becoming increasingly important, and the number of such women who are pregnant, receiving kidney replacement therapy, is growing every year. Improvements in dialysis therapy have led to improved obstetric and perinatal outcomes, but the risk of various obstetric and perinatal complications remains extremely high. In this review, we analyzed recently published data on management and outcomes of pregnancy in women with end-stage kidney disease receiving dialysis.

Safety of Bedside Placement of Tunneled Hemodialysis Catheters in the Intensive Care Unit: Translating from the COVID-19 Experience

Background: Critically ill patients with coronavirus disease 2019 (COVID-19) and kidney dysfunction often require tunneled hemodialysis catheter (TDC) placement for kidney replacement therapy, typically under fluoroscopic guidance to minimize catheter-related complications. This entails transportation of patients outside the intensive care unit to a fluoroscopy suite, which may potentially expose many healthcare providers to COVID-19. One potential strategy to mitigate the risk of viral transmission is to insert TDCs at the bedside, using ultrasound and anatomic landmarks only, without fluoroscopic guidance. Methods: We reviewed all COVID-19 patients in the intensive care unit who underwent right internal jugular TDC insertion at the bedside between April and December 2020. Outcomes included catheter placement-related complications such as post-procedural bleeding, air embolism, dysrhythmias, pneumothorax/hemothorax, and catheter tip malposition. TDC insertion was considered successful if the catheter was able to achieve blood flow sufficient to perform either a single intermittent or 24 h of continuous hemodialysis treatment. Results: We report a retrospective, single-center case series of 25 patients with COVID-19 who had right internal jugular TDCs placed at the bedside, 10 of whom underwent simultaneous insertion of small-bore right internal jugular tunneled central venous catheters for infusion. Continuous veno-venous hemodialysis was utilized for kidney replacement therapy in all patients, and a median catheter blood flow rate of 200 mL/min (IQR: 200–200) was achieved without any deviation from the dialysis prescription. No catheter insertion-related complications were observed, and none of the catheter tips were malpositioned. Conclusions: Bedside right internal jugular TDC placement in COVID-19 patients, using ultrasound and anatomic landmarks without fluoroscopic guidance, may potentially reduce the risk of COVID-19 transmission among healthcare workers without compromising patient safety or catheter function. Concomitant insertion of tunneled central venous catheters in the right internal jugular vein for infusion may also be safely accomplished and further help limit personnel exposure to COVID-19.

Peritoneal dialysis in very low and extremely low birthweight infants: A pooled analysis

Background: Peritoneal dialysis (PD) represents an important therapeutic option in neonatal acute kidney injury (AKI), although evidence regarding its effects in preterm neonates remains unclear. The present study aims to evaluate the feasibility of PD in very low birthweight (VLBW) and extremely low birthweight (ELBW) infants and clarify the association of catheter choice with clinical outcomes. Methods: Medline, Scopus, Web of Science, Clinicaltrials.gov and CENTRAL databases were systematically searched from inception to 15 January 2021. Studies reporting individual participant data of VLBW and ELBW infants treated with PD were selected. Results: Overall, 20 studies were included comprising 101 patients. Catheter-related complications were significantly more frequent among ELBW infants (odds ratio: 5.18, 95% confidence intervals (CI): 1.23–29.09). After inverse probability treatment weighting, compared to drainage catheters, death risk was significantly lower with the use of PD (hazard ratio: 0.42, 95% CI: 0.19–0.90) but not vascular catheters (hazard ratio: 0.58, 95% CI: 0.28–1.20). Similarly, kidney function loss was significantly lower only with the implementation of PD catheters (hazard ratio: 0.44, 95% CI: 0.21–0.94). Conclusions: PD is a feasible kidney replacement therapy modality in VLBW and ELBW infants with AKI. The use of drainage catheters may be linked to significantly worse kidney recovery and overall survival rates, compared to PD catheters. Future cohorts should confirm the most appropriate catheter type and contribute to the standardisation of PD procedures.

A propensity-score matched observational study of remdesivir in patients with COVID-19 and severe kidney disease

Background: Remdesivir is not currently approved for patients with estimated glomerular filtration rate (eGFR) < 30mL/min/1.73m2. We aimed to determine the safety of remdesivir in patients with kidney failure. Methods: Retrospective cohort study of patients with COVID-19 hospitalized between May 2020 to January 2021 with eGFR <30 mL/min/1.73m2 who received remdesivir and historical controls with COVID-19 hospitalized between March 1, 2020 - April 30, 2020 prior to Emergency Use Authorization of remdesivir within a large healthcare system. Patients were 1:1 matched by propensity scores accounting for factors associated with treatment assignment. Adverse events and hospital outcomes were recorded by manual chart review. Results: The overall cohort included 34 hospitalized patients who initiated remdesivir within 72 hours of hospital admission with eGFR <30 mL/min/1.73m2 and 217 COVID-19 controls with eGFR <30 mL/min/1.73m2. The propensity score-matched cohort included 31 remdesivir treated cases and 31 non-remdesivir-treated controls. The mean age was 74.0 (SD: 13.8), 56.6% female, 67.7% white. A total of 25.5% had end-stage kidney disease. Among patients who were not on dialysis prior to initiating remdesivir, one developed worsening kidney function (defined ≥ 50% increase in creatinine or initiation of kidney replacement therapy) compared to three in the historical control group. There was no increased risk of cardiac arrythmia, cardiac arrest, altered mental status, or clinically significant anemia or liver function test abnormalities. There was a significantly increased risk of hyperglycemia, which may be partly explained by the increased use of dexamethasone in the remdesivir-treated population. Conclusion: In this propensity-score matched study, remdesivir was well tolerated in patients with eGFR < 30 mL/min/1.73m2.