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Letter to Editor
32 (
2
); 186-188
doi:
10.4103/ijn.IJN_522_20

COVID-19 Infection in CAPD Patients: A Single-Center Indian Experience

Department of Nephrology, Madras Medical Mission, Chennai, Tamil Nadu, India
Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
Department of Microbiology, Madras Medical Mission, Chennai, Tamil Nadu, India

Address for correspondence: Dr. Georgi Abraham, Nephrology, The Madras Medical Mission, Mogappair, Chennai - 600 004, Tamil Nadu, India. E-mail: Abraham_georgi@yahoo.com

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This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Disclaimer:
This article was originally published by Wolters Kluwer - Medknow and was migrated to Scientific Scholar after the change of Publisher.

Sir,

With more than 8 million cases of COVID-19 (coronavirus disease 2019) infection in India, chronic kidney disease (CKD) patients form a vulnerable high-risk group. Among the CKD patients, COVID 19 prevalence is the highest in transplant recipients followed by maintenance hemodialysis patients and those who are on continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD).[1] CAPD patients are trained to do the dialysis at home, therefore reducing the risk of COVID-19.[2] No data exist on home peritoneal dialysis (PD) and detection of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) in the PD effluent in India. We present a single-center case series on the clinical characteristics and outcomes of chronic PD patients who developed COVID-19 infection in India.

This is a prospective, observational, case series of all CAPD who tested positive for COVID-19 infection between March 1, 2020, and October 31, 2020. The Ethical Committee clearance was obtained for chart review-based data collection. Nasopharyngeal swabs were sent to the laboratory for testing the E gene and Orf1a gene in a single reaction (Truenat Quattro, Molbio Diagnostics). The dialysis effluent collected in the 2-L drainage bag was sent to the laboratory for identification of COVID-19 by RT-PCR. The testing procedure was done from the dialysis effluent in 2-L bag after thorough mixing.

Five among the 56 prevalent CAPD patients developed COVID-19 (8.9%), and none of them died. None of the five patients had any augmented immunosuppressive state. The details of all patients are given in Table 1. Figure 1 illustrates the HRCT (high-resolution computed tomography) chest and chest X-ray findings from two of these patients. PD effluent from all the patients was negative for SARS-CoV-2 by RT-PCR. The most recent patient who was a diabetic with heart failure and contracted COVID-19 was switched over temporarily to slow low-efficiency dialysis in another center and was kept on noninvasive ventilation, and she has recovered now. She needed one re-hospitalization.

(a) Chest X-ray AP (anterior–posterior) view of Patient 2 showing right lower zone consolidation and changes of fluid overload. (b) HRCT (high-resolution computed tomography) chest of Patient 4 showing bilateral ground-glass opacities correlating with CORADS 6
Figure 1
(a) Chest X-ray AP (anterior–posterior) view of Patient 2 showing right lower zone consolidation and changes of fluid overload. (b) HRCT (high-resolution computed tomography) chest of Patient 4 showing bilateral ground-glass opacities correlating with CORADS 6
Table 1 Characteristics of CAPD patients who developed COVID-19
Patient 1 2 3 4 5
Age (years) 74 55 61 60 41
Gender Male Female Female Male Female
Diabetes mellitus Yes YES No Yes No
Hypertension No Yes Yes Yes Yes
Coronary artery disease Yes Yes No No No
Hypothyroidism No No No Yes Yes
EF (%) 39 35 64 57
Smoking No No No No No
CAPD/APD CAPD CAPD CAPD CAPD CAPD
Exchanges 4 (1.5% × 4 L 2.5% × 4 L) 4 (2.5% × 6 L, 7.5% × 2 L) 3 (1.5% × 2 L, 2.5% × 4 L) 3 (7.5% × 4 L, 2.5% × 2 L) 3 (2.5% × 4 L, 1.5% × 2 L)
PD vintage (in months) 48 48 4 72 24
Blood group O A A B B
COVID diagnosis by RT-PCR Positive Positive Positive Positive Positive
Cycle threshold value E Gene 25.5
N2 27.8
E gene 22
Orf1a 22.25
E gene 20.13
Rdrp 21.0
N 23
Orf1a 25
N 20
Orf1a 25
Symptoms
 Fever Yes No No Yes No
 Cough Yes Yes No No No
 Breathlessness Yes Yes No Yes No
 Anosmia No No No Yes No
 Ageusia No No Yes No No
 Diarrhea No No No No No
 Abdominal pain No No Yes No No
 Anorexia Yes Yes No No
Contact history No No No No Yes (spouse)
PD-effluent SARS-CoV-2 RT-PCR Negative Negative Negative Negative Negative
Chest X-ray/CT chest findings Right midzone and lower zone consolidation Right Lower zone consolidation Normal CORADS 6 Normal
Hb (g/dL) 8.2 7.9 10.9 10.7 11
TC (cells/mm3) 13,500 15,000 9,800 5,200 4,800
Lymphocyte (%) 5 14 6.8 16.4 10
CRP (mg/L) 82 46 29.3 85.4 8
LDH (IU/L) 468 561 227 200 198
D Dimer (ng/mL) 1,300 1,234 2,368 2,377 290
Ferritin (ng/ml) 3,000 2,914 601 413 326
Hospitalized Yes Yes Yes Yes No
Oxygen requirement Yes Yes No No No
Ventilation Noninvasive ventilation Noninvasive ventilation No No No
Steroids Yes
IV methylprednisolone 40 mg once a day for 5 days
Yes
IV methylprednisolone 40 mg once a day for 5 days
Oral dexamethasone 4 mg twice a day for 3 days Intravenous methylprednisolone 40 mg once a day for 5 days No
Remdesivir Yes
200 mg loading dose followed by 100 mg once a day for 5 days
Yes
200 mg loading dose followed by 100 mg once a day for 5 days
No Yes
100 mg OD for 5 days
No
Tocilizumab Yes
200 mg subcutaneous one dose
No No No No
Length of hospital stay (days) 10 10 14 6 -
Readmission No Yes No No -
Complications None Lung complications leading to readmission
Needed temporary SLED
Acute pancreatitis (conservatively managed) No No
Outcome Discharged
Alive
Hospitalized
Alive and off ventilator
Discharged
Alive
Discharged
Alive
Alive

CAPD=continuous ambulatory peritoneal dialysis, EF-ejection fraction, APD=automated peritoneal dialysis, PD=peritoneal dialysis, RT-PCR=reverse transcription polymerase chain reaction, SARS-CoV-2=severe acute respiratory syndrome coronavirus 2, CT=computed tomography, Hb=hemoglobin, TC=total count, CRP=C reactive protein, LDH=lactate dehydrogenase, SLED=sustained low-efficiency dialysis, IV=intravenous, OD=once a day

Like all patients with CKD, those on CAPD carry an increased risk of infection due to their immunosuppressed state and comorbid conditions.[3] Our cohort contained patients with a significant comorbidity profile, but none had malignancy or were on immunosuppressive medications. We have trained a number of patients for home PD during the study period. Despite the risk factors, they seemed to do fairly well. The hand washing techniques that are perfected by these patients and social distancing probably mitigated their risk at the peak of the pandemic. Although our patients had a history of fever, at presentation three of them only presented with signs suggestive of fluid overload, which suggests that a high degree of suspicion is needed to identify COVID-19 infection in CAPD.

Sachdeva et al.[4] reported that three out of 11 patients who developed culture-negative peritonitis and postulated that the direct effect of the virus, hematogenous spread, touch contamination, the effect of inflammatory mediators, and superimposed bacterial translocation were due to diarrhea as causative mechanisms. We did not have any PD-related peritonitis in our cohort. One of our patients did develop acute pancreatitis, which was managed conservatively while continuing PD.

Vischini et al.[5] previously reported peritoneal dialysate being positive for SARS-CoV-2 in a COVID-19 patient. However, to the contrary, Candellier and Goffin,[6] in a letter to the editor, reported three patients on PD in whom the virus was not detected in the PD fluid despite the high viral load on the initial nasopharyngeal specimen. This seems to be more in concordance with our findings as we did not detect the virus in any of the PD-effluent samples despite repeated testing.

We describe a small cohort of home PD patients who developed COVID-19 infection with no mortality. There was an absence of detection of the SARS-CoV-2 virus in the dialysis effluent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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