Clinical Profile and Outcome of Hemodialysis Patients with SARS COV2 Infection in a Tertiary Care Centre in Mumbai, India

Introduction

A novel virus SARS COV 2 surfaced in China December 2019 and has spread across the globe affecting millions of patients and causing havoc to the normal order of the world. WHO declared COVID 19 as a pandemic in March 2020. India saw its first case on 30^th January 2020 in Kerala.[1] Ever since the disease has spread all over the country with Maharashtra having more than 4,00,000 cases as of 29^th July 2020 and Mumbai emerging as an infection hotspot in India.[2] To tackle this unprecedented situation, in Mumbai, two multi-speciality hospitals were converted into Dedicated COVID Hospitals to care for COVID 19 patients. Ours, T.N. Medical College & BYL Nair Ch Hospital was one of these.

The current data suggests that this virus although affecting all age groups, causes greater morbidity and mortality in patients with comorbidities like hypertension, diabetes, obesity, lung disease and heart disease.[3] The presentation can range from asymptomatic infection to bilateral pneumonia with severe acute respiratory syndrome. It can affect various organs like cardiovascular, gastrointestinal tract, nervous system, blood and kidneys.[4]

Chronic Kidney Disease (CKD) patients have a high proportion of co-morbidities and are immunocompromised, making them more susceptible to infections.[5] The first COVID 19 death reported in USA was an ESRD patient on Haemodialysis.[6] Home isolation is not an option as patients on maintenance haemodialysis (MHD) have to visit their dialysis centre two to three times a week. Studies have shown mortality rate ranging from 16% to 30.5%.[78] Also, analysis of CKD5D patients on MHD of Wuhan revealed that upto 21.4% patients can be asymptomatic carriers and haemodialysis centres can be high risk settings for spread of infection.[9]

In this study, we focus on hemodialysis patients with COVID19 infection with emphasis on epidemiology, including clinical features & outcome & its corelation to presenting features.

Methods

This was an prospective observational single centre study to assess clinical profile, and outcome of hemodialysis patients with SARS COV2 infection during pandemic in a tertiary care hospital in a Metro city, from 23^rd April 2020 to 30^th June 2020.Permission from Institutional Ethics Committee was obtained.

Results

A total of 4324 patients with SARS COV2 infection were admitted in the hospital, of which 203 patients were dialysed from 23^rd April to 30^th June 2020 at our center [Table 1]. Of these 21 patients were AKI, 16 were acute on CKD, 7 were CKD5 who were initiated on dialysis and they were excluded from the study. 159 were CKD5D already on maintenance haemodialysis out of which 28 were still admitted at time of writing this manuscript and were also excluded from the study. Outcomes were available for 131 MHD patients. Of the 131 patients, a total of 104 patients turned RT PCR negative and were discharged (Survivors) and 27 patients died (Deceased). Median time from onset of symptoms to discharge was 21 days (8 to 43 days) while from onset of symptoms to death was 12 days (range 4-41 days). The mortality of ESRD patients with COVID 19 was found to be 20.61%.

Discussion

Our institute is a Public Health Institute and was designated as Dedicated COVID Hospital from 18^th April 2020. The COVID pandemic came with lockdown, cessation of public transport, fear factor (patients as well as Health Care Workers), closure of many dialysis centres, no known definitive treatment for COVID & resources crunch in the beginning. In addition, visiting dialysis center 2 to 3 times in a week for MHD increased the exposure risk of patients. In 36% of our cohort, regular MHD was less than thrice in a week HD. This coupled with missing one or more regular HDs during the lockdown period [before reporting to us] made these patients as one of the worst affected subgroups. This subset; is overburdened with co morbidities; as in our study population: Hypertension 76%, Diabetes 29%, Coronary Artery Disease 22% & underlying respiratory illness (COPD, post pulmonary koch's sequelae) 8%, & when COVID 19 infection (pneumonia with ARDS) complicates the course further, outcome is expected to be not favorable when compared with general population with COVID 19 infection.

Total 4324 patients with COVID 19 disease were admitted to our hospital during this period, with 203 requiring HD, of which 159 were ESRD & of these, outcome was noted in 131 during the study period. ESRD was reported in 3.2% at admission in 5,700 patients with COVID 19, admitted to 12 hospitals in New York.[11] CKD in 3% at admission was noted in cohort study with 1,591 patients with laboratory-confirmed COVID-19 admitted to intensive care units in Lombardy, Italy.[12] The Treatment protocols were evolving, changing, largely guided by the evidence at that time and hence cannot be co related with outcome. All ESRD patients were admitted & dialysed till their RT PCR turned negative. The average duration taken by patients to turn negative was 14 days (range 3-40 days).

One fourth of our study population was Asymptomatic. Asymptomatic patients have been reported to range from 1.6% to 56.5% in different studies.[13] Most notably, they took almost the same amount of time to convert to RT PCR negative as symptomatic patients. Since asymptomatic patients have the same infectivity,[14] if undetected, this subgroup of patients could potentially cause rapid spread of infection at dialysis centres. In a study from United Kingdom, clustering of cases in shifts and specific dialysis centres was commonly seen,[15] reiterating how dialysis centre could quickly turn into hotspots. Hence, strict social distancing, testing of all healthcare personnel and patients when clustering of cases occurs is advisable.

The management of COVID 19 disease in patients with CKD is more challenging given the immunosuppressed state & severe co morbidities. It is a severe disease in dialysis population. Overall mortality in China was reported at 2.3%.[1617] In Italy, the overall mortality & case fatality ratio, reported are, 20 per 1,00,000 & 12 respectively.[18] On the other hand, the mortality in dialysis population with COVID 19 infection has been reported at 31%[19] in New York and 30.5%[8] in Spain. The ESRD subgroup in our study group had a mortality rate of 20.61%. Comparing deceased vs survivors [Table 2 and Figure 1]: Age [56 vs 49 yrs], diabetes [56% vs 22%], Duration of symptoms at admission [5 vs 4 days] Dyspnea [85% vs 40%], oxygen requirement [93% vs 29%] and encephalopathy [30% vs 1%] at admission and high leucocyte count 11059 ± 5,929 vs 7,022 ± 2,935/cmm], Xray Chest with bilateral opacities [93% vs 20%] were statistically significant variables associated with mortality. Other factors like hypertension, coronary artery disease, underlying respiratory illness, dialysis vintage, dialysis frequency and access were not associated with increased mortality in our group.

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Figure 1

Weekwise mortality. Among the deceased, 6 of 27 patients died within 1 week, 18 of 27 patients within 2 weeks, 21 of 27 patients within 3 weeks and 25 of 27 patients within 4 weeks. 1 patient died on day 37 and 1 patient on day 41 of disease

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As compared to other countries, our ESRD patient population was younger with average age being 50 years & the likelihood of death with age more than 50 years, 60 yrs and 80 years was 19.28%, 28.96% and 54.31% respectively. The median Age was above 70 yrs in Italy[20] and Spain[8] and 63 yrs in a study from New york.[19] Their mortality rate was also much higher i.e., about 30% in European populations. High prevalence of hypertension (98%) and diabetes (69%) have been reported from New York[19] study.

Patients in the mortality group presented late to the centre for admission with higher number of patients having advanced symptoms like dyspnea, fever and altered sensorium. Happy hypoxia was another phenomenon commonly seen wherein patients had hypoxia requiring oxygen therapy but patient were relatively complain free or had mild symptoms only. Other factors like social stigma around the disease, difficulty in accessing healthcare and testing centres due to lockdown contributed to the late presentation.[21] Two third of the patients who died had ARDS on presentation.

An initial study from Wuhan[22] of 201 COVID19 patients from general population 93% patients had fever, 81% cough, 39.8% dyspnea and 41.8% patients developed ARDS, of whom 52.4% died. Subsequently, a meta-analysis[23] which included 19 studies and 39 case reports showed that fever was seen in 88.7%, cough in 57.6%, dyspnea in 45.6% patients and ARDS in 32.8%. Shock was seen only in 6.2%. Symptomatic fever (40%) and cough (33%) was seen much lesser in our ESRD population. Patients were at higher risk of developing ARDS. In our study 42% patients developed ARDS of whom 45.5% died. ARDS was also the most common cause of death. Diarrhoea was reported to be a common presenting symptom of covid19 in dialysis population in initial case reports,[24] however it was found in only 14.5% of our ESRD population.

Regular haemodialysis was also a challenge in initial days due to increasing number of patients needing emergency HD due to the reluctance of many outpatient dialysis centres to treat patients with COVID-19. The first 39 patients admitted with us were planned to be given twice weekly haemodialysis. However one third patients of these had to be shifted back to thrice weekly schedule due fluid overload and/or hyperkalaemia. One Hundred & four ESRD patients have been discharged after median of 21 days from onset of symptoms. Municipal Corporation of Greater Mumbai has created a software application & war rooms, wherein ESRD patients are registered by Nephrologists and COVID 19 infected patients are ensured vacant slots.

Conclusion

COVID 19 infection in hemodialysis population is severe disease. All due precautions should be taken to prevent infection in this vulnerable group.