Report gives perspective on patients with ESKD hospitalized with COVID-19 in New York City
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In a published report, researchers described the characteristics of patients who received in-center hemodialysis before hospitalization for COVID-19, assessing in-hospital mortality and outcomes after mechanical ventilation was required.
“Montefiore Health System has been the largest hospital system in the Bronx providing care to patients hospitalized with COVID-19,” Molly Fisher, DO, of the Albert Einstein College of Medicine, Bronx, New York, and colleagues wrote.
With the first patient admitted to one of its two hospitals with COVID-19 in March, the system has had more than 6,000 patients admitted with the condition as of June 7, according to the researchers. Further, at the end of April, the Bronx had the highest rate of hospitalizations and mortality from COVID-19 compared with other New York City boroughs.
“Early reports identified older age and underlying chronic comorbidities as risk factors for more severe disease and death from COVID-19,” they added. “The Bronx consists of a predominantly Black and Hispanic population with a disproportionate burden of comorbidities including cardiovascular disease, hypertension, diabetic mellitus and end-stage kidney disease.”
The researchers sought to describe the clinical characteristics and short-term outcomes during the first month of the outbreak in the New York City area. They identified patients with ESKD who were hospitalized between March 9 and April 8, 2020 (mean age, 64.5 years; 88.6% were Black or Hispanic patients). Only those receiving hemodialysis treatments were evaluated (n = 114); those receiving perineal dialysis or who were transplanted were excluded. All patients were followed during their hospitalization through April 22, 2020, leading to a 14-day minimum follow-up.
“Early on, during the abrupt rise in COVID-19 admissions to our hospitals, we provided bedside hemodialysis to all COVID-infected patients to mitigate transmission of infection within the hospital,” the researchers noted. “Because this required a 1:1 dialysis nurse to patient ratio, the default frequency of hemodialysis was reduced to twice weekly in patients without hyperkalemia or signs of fluid overload.”
However, patients were regularly assessed to determine if additional dialysis was needed and by the end of March, they were able to open an in-patient hemodialysis unit allowing for most patients to undergo dialysis three times per week.
The analysis showed the most common comorbidities were diabetes mellitus (66.7%), hypertension (89.5%), coronary artery disease (55.2%) and pulmonary disease (35.1%).
In addition, the most common symptoms at initial presentation were shortness of breath (50%) and fever (44.7%; 36% with a temperature 100.4° F). Less common symptoms included cough, chest pain and diarrhea, with many patients presenting signs of sepsis upon admission.
The researchers also determined 30.7% of patients were nursing home residents.
Regarding treatment and subsequent outcomes, the researchers described most patients (86.8%) as being admitted to a general medical floor, with 76.3% receiving hydroxychloroquine and 85.1% being placed on prophylactic or therapeutic anticoagulation. A total of 15 patients (13.2%) required transfer to the ICU, with 16.7% receiving mechanical ventilation and 15.8% receiving vasopressors. Intermittent hemodialysis was the predominant modality for renal replacement therapy in this cohort (two patients required continuous renal replacement therapy).
Looking at mortality, the researchers observed that in-hospital death occurred in 28.1% of patients in the total cohort (19.2% admitted to general medical floor; 86.7% admitted or transferred to ICU). The most common causes of death were cardiac arrest and respiratory failure, with 43.8% of those who died having sudden cardiac arrest requiring cardiopulmonary resuscitation.
A total of 19 patients required mechanical ventilation (14 from ICU) and 18 of 19 of these patients (94.7%) died.
According to the researchers, it is crucial to keep in mind that more than half of the patients also had cardiovascular disease.
Another important finding was that inflammatory markers were higher in the patients who died compared to those who survived.
“Our findings demonstrate elevated inflammatory markers are associated with more severe disease and mortality in ESKD patients on chronic hemodialysis requiring hospitalization for COVID-19,” the researchers wrote.
Therefore, they recommend examining trends in these markers to assess risk for poor outcomes, which could facilitate decisions as to whether aggressive medical treatment or end-of-life care is the better option.
“In-hospital mortality approaches 100% for chronic hemodialysis patients with COVID-19 who require mechanical ventilation and should be considered when addressing goals of care, advance directives and end-of-life discussions in those patients with their health care proxy,” they concluded.
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