Just a month ago, I was on call at North Shore University Hospital in Manhasset and covering a census of >50 patients. It was a great mix of cases from AL amyloidosis, Anca vasculitis, Anti GBM, cardio renal syndromes, check pt inhibitor induced AIN, and several onconephrology electrolyte disorders. In addition, our center had also just done their first heart-kidney transplant recently and it was an amazing feeling.
Fast forward, a month later, I am on call again and I sense a census >60 and over 80% of those cases are COVID-19+ with either AKI or ESRD. What just happened here????
As the pandemic knocked the doors of NY, the hospital I have worked for 10 years now had turned into a different place. In the last 3 weeks, all surgeries were cancelled, all non elective admissions postponed... outpatient clinics slowing down.. and what do I see now..
I walk in and I can't recognize people. The make up and gel that people used to have is replaced by N95s and surgical masks. Nice suits,dresses all gone and replaced by scrubs and surgical gowns.
CT ICU, NS ICU, SICU, CCU and transplant ICU - are now all medical ICU beds.
ER is overflowing with COVID-19 patients.
ICU has vented patients from ages 31-83y of age, both males and females.
CRRT machines being deployed at almost every floor.
Surgical floors converted to medical COVID-19 floors. Only 4-5 floors remain as non COVID floors in the hospital...
Hallways are empty, cafe empty since no family is allowed....
This transformation -- just in 3 weeks. What a change.. Shock is an understatement.
What is more clear was the fear and anxiety in the eyes of the providers. People I used to see always joking around, making Trump Jokes, and laughing and smiling -- you could now sense fear in their voice.
Fatigue was evident in the nurses and ICU docs... but they were not giving up.
Renal consultations came every hour and it was all COVID-19 intubated patient in AKI, needing CRRT. It was pre renal, ATN, AIN, who knows-- we were just trying to save whoever we could...
The fellow and I scared to enter rooms, no time to even take a bathroom break and not sure how to even eat at the cafeteria.
Sadness, fear and anxiety was evident everywhere....1/3 of admitted COVID-19 patients end up in ICU, staying longer and longer stays ( 2 weeks) on a ventilator.. and what happens after that.. renal failure, cardiac failure.
But....what also was evident and most inspiring to me was...
Never before seen- working together of teams of residents and attendings ever imagined.
One of the covid-19 ICUS was headed by a surgical intensivists, vascular surgery attending, medicine residents, and pulmonary team helping out-- what amazing team work..
Then comes the NSICU, another converted COVID-19 unit- intensivists out of their comfort zone providing amazing medical ICU care to these COVID patients.
Finally, pediatric ICU docs coming to help the adult ICU patients- working hand in hand with pulmonary fellows, medical residents, neurology residents... amazing amazing!!
Kudos to the hospital management, CEO, CMOs, and department chairs to get this together in 2 weeks and creating this team work environment.
While the hospital is now a COVID-19 hospital and increasing number of ICU beds, everyone has stepped up outside their comfort zone and created history at our institution.
There are some wins-some patients coming extubated and many getting discharged.. While we may loose many, we are also saving many lives.. Kudos to our ER, hospital medicine and ICU staff and amazing nurses and health care providers...
Consults have become real, people are not calling "non needed' consults
Note writing has been minimized... and communication has improved.
While there is fear in everyone's eyes, we also sensed and felt a sense of pride to battle this war with our invisible enemy...
One of my Nephrology friends said it perfectly "This is literally a battle zone which we are dealing with. Quite honestly, for the most part could exhilarating. You are living history. Nothing has prepared us for this. Soak it in.... Hopefully, 40 years from now, you will be telling your grandkids how you served on the front lines of the great 2020 pandemic. You may never again have the opportunity to be involved in something more meaningful again."
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Sunday, March 29, 2020
Wednesday, March 11, 2020
Topic Discussion: COVID-19 and hemodialysis patients
As we all learn more and more about COVID-19, the burning question in many nephrologists is the risk to patients on dialysis mainly in-center HD? While we all are developing guidelines of how to triage and place patients on in-center HD who have symptoms of COVID-19, what is their risk of severe infection vs. death from this virus compared to the general population?
So far, while we are still learning about the Italian, South Korean, Japanese experience, the only pre published data is from Wuhan, China dialysis units. Ma et al describe their experience and it is quite interesting what they found.
Brief summary of the study
1. It is a single HD unit epidemic course of infected patients compared to non infected and staff that were effected.
2. Of 230 HD patients, 37 were infected( 37%) and 2 medical staff of 33 staff members. During that time frame, the HD center had 7 deaths, 6 were COVID-19 positive patients. This made the mortality of 3%( higher than usual for that dialysis unit)
3. Presumed cause of death was hyperkalemia and cardiac events and not pulmonary cause
4. 62% were men, mean age 66 years.
5. 59% patients had bilateral CT scan involvement, 41% had unilateral findings
6. Serum levels of all cytokines measured( Il-4,6,10, TNF .etc) were lower levels compared to non HD patients with COVID-19
7. In their discussion, they do mention that the deaths were due to under-dialysis and hyperkalemia given the fear of contracting the virus-- interesting analysis.
8. Interestingly, none of the 37 patients in their center were admitted to the ICU due to severe PNA
9. The authors think that the HD patients don't mount a severe immune response and don't have that cytokine storm as seen in healthy adults leading to the "itis" leading to less organ damage.
This study is a start. More data from S.Korea, USA, Japan and Italy might help us in better information to decide on the care of the HD patient with COVID-19
Recently also, there is a case report published on HD patient treated successfully with anti virals in China in Kidney Medicine
So far, while we are still learning about the Italian, South Korean, Japanese experience, the only pre published data is from Wuhan, China dialysis units. Ma et al describe their experience and it is quite interesting what they found.
Brief summary of the study
1. It is a single HD unit epidemic course of infected patients compared to non infected and staff that were effected.
2. Of 230 HD patients, 37 were infected( 37%) and 2 medical staff of 33 staff members. During that time frame, the HD center had 7 deaths, 6 were COVID-19 positive patients. This made the mortality of 3%( higher than usual for that dialysis unit)
3. Presumed cause of death was hyperkalemia and cardiac events and not pulmonary cause
4. 62% were men, mean age 66 years.
5. 59% patients had bilateral CT scan involvement, 41% had unilateral findings
6. Serum levels of all cytokines measured( Il-4,6,10, TNF .etc) were lower levels compared to non HD patients with COVID-19
7. In their discussion, they do mention that the deaths were due to under-dialysis and hyperkalemia given the fear of contracting the virus-- interesting analysis.
8. Interestingly, none of the 37 patients in their center were admitted to the ICU due to severe PNA
9. The authors think that the HD patients don't mount a severe immune response and don't have that cytokine storm as seen in healthy adults leading to the "itis" leading to less organ damage.
This study is a start. More data from S.Korea, USA, Japan and Italy might help us in better information to decide on the care of the HD patient with COVID-19
Recently also, there is a case report published on HD patient treated successfully with anti virals in China in Kidney Medicine
Wednesday, March 4, 2020
Topic Discussion: COVID-19 and the Kidney
Coronavirus disease 2019 (COVID-19) causes a severe acute respiratory syndrome. Similar to SARS outbreak, this virus has caused the 2019-2020 outbreak. It presents with a dry cough, fever, running nose, fatigue and shortness of breath. The elderly, hx of pulmonary disease, immunocompromised are at risk. Mortality rate is around 2-3% from ongoing outbreaks.
How does this virus affect the Kidney. First and foremost, what is the data on transmission via dialysis units and infection in dialysis patients. Wuhan, China was where the outbreak occurred and started. In a single center study under open access review, 37 cases ( 16%) of HD patients were infected. 7 HD patients died and 6 had COVID-19 during this epidemic. The precaution measures taken by HD units prevented further cases. For some unclear reason, while HD patients were more likely to get this infection, the cases were milder than non HD counterparts.
Here is the ASN suggestions for HD units for COVID-19 screening and precautions.
What about AKI? Is it common? Again from Wuhan, in the month of the major outbreak in China, < 20 patients showed mild elevations in BUN and crt and trace albuminuria. 5 patients required CRRT.
All patients that had CKD after this survived. Moreover, SARS-CoV-2 RNA in urine sediments was positive only in 3 patients from 48 cases without renal illness before, and one patient had a positive for SARS-CoV-2 from 5 cases with CKD. Interpretation Acute renal impairment was uncommon in COVID-19. SARS-CoV-2 infection does not significantly cause obvious acute renal injury, or aggravate CKD in the COVID-19 patients.
Interestingly, another center reported a different finding. A large tertiary center in China studied 710 consecutive COVID19 patients, 89 (12.3%) of whom died in hospital. On admission, 44% of patients have proteinuria hematuria and 26.9% have hematuria, and the prevalence of elevated serum creatinine and blood urea nitrogen were 15.5% and 14.1% respectively. During the study period, AKI occurred in 3.2% patients. Kaplan-Meier analysis demonstrated that patients with kidney impairment have higher risk for in-hospital death. Cox proportional hazard regression confirmed that elevated serum creatinine, elevated urea nitrogen, AKI, proteinuria and hematuria was an independent risk factor for in-hospital death after adjusting for age, sex, disease severity, leukocyte count and lymphocyte count. Conclusion: The prevalence of kidney impairment (hematuria, proteinuria and kidney dysfunction) in hospitalized COVID-19 patients was high. After adjustment for confounders, kidney impairment indicators were associated with higher risk of in-hospital death. This was in strike contrast to the prior study.
Finally, hypokalemia was a common electrolyte finding in these patients. One would think GI cause as the cause, but GI symptoms were not associated with hypokalemia among 108 hypokalemia patients. Body temperature, CK, CK-MB, LDH, and CRP were significantly associated with the severity of hypokalemia. 93% of severe and critically ill patients had hypokalemia which was most common among elevated CK, CK-MB, LDH, and CRP. Urine K+ loss was the primary cause of hypokalemia.
How does this virus affect the Kidney. First and foremost, what is the data on transmission via dialysis units and infection in dialysis patients. Wuhan, China was where the outbreak occurred and started. In a single center study under open access review, 37 cases ( 16%) of HD patients were infected. 7 HD patients died and 6 had COVID-19 during this epidemic. The precaution measures taken by HD units prevented further cases. For some unclear reason, while HD patients were more likely to get this infection, the cases were milder than non HD counterparts.
Here is the ASN suggestions for HD units for COVID-19 screening and precautions.
What about AKI? Is it common? Again from Wuhan, in the month of the major outbreak in China, < 20 patients showed mild elevations in BUN and crt and trace albuminuria. 5 patients required CRRT.
All patients that had CKD after this survived. Moreover, SARS-CoV-2 RNA in urine sediments was positive only in 3 patients from 48 cases without renal illness before, and one patient had a positive for SARS-CoV-2 from 5 cases with CKD. Interpretation Acute renal impairment was uncommon in COVID-19. SARS-CoV-2 infection does not significantly cause obvious acute renal injury, or aggravate CKD in the COVID-19 patients.
Interestingly, another center reported a different finding. A large tertiary center in China studied 710 consecutive COVID19 patients, 89 (12.3%) of whom died in hospital. On admission, 44% of patients have proteinuria hematuria and 26.9% have hematuria, and the prevalence of elevated serum creatinine and blood urea nitrogen were 15.5% and 14.1% respectively. During the study period, AKI occurred in 3.2% patients. Kaplan-Meier analysis demonstrated that patients with kidney impairment have higher risk for in-hospital death. Cox proportional hazard regression confirmed that elevated serum creatinine, elevated urea nitrogen, AKI, proteinuria and hematuria was an independent risk factor for in-hospital death after adjusting for age, sex, disease severity, leukocyte count and lymphocyte count. Conclusion: The prevalence of kidney impairment (hematuria, proteinuria and kidney dysfunction) in hospitalized COVID-19 patients was high. After adjustment for confounders, kidney impairment indicators were associated with higher risk of in-hospital death. This was in strike contrast to the prior study.
Finally, hypokalemia was a common electrolyte finding in these patients. One would think GI cause as the cause, but GI symptoms were not associated with hypokalemia among 108 hypokalemia patients. Body temperature, CK, CK-MB, LDH, and CRP were significantly associated with the severity of hypokalemia. 93% of severe and critically ill patients had hypokalemia which was most common among elevated CK, CK-MB, LDH, and CRP. Urine K+ loss was the primary cause of hypokalemia.