REPORTE DE CASOS / CASE REPORTS
COVID-19 infected patients in a Hemodialysis facility in Ecuador, 2020.
Mario Hernández1, Emilio Fors2, Fresia Massuht3, Ingrid Figueredo4, Raúl Caballero5, Christian Berruz6, Yinet Ramirez7, Elsa Bernal8 and Martha Fors9
Available from: http://dx.doi.org/10.21931/RB/2021.06.02.27
We retrospectively analyzed the data of 38 hemodialysis patients with COVID-19, including demographic and clinical characteristics were collected from the medical records of patients from Reynadial center from April to June 2020. Of 125 patients from the clinic, 38 (30.4%) were diagnosed with COVID-19. The third part of patients (12) died, the mortality rate was 31%. The mean (±SD) age of the patients was 61±13 years, 57.9% were men. The most common symptoms were shortness of breath and cough; 80% of patients had fever on admission, and more than 90% had hypertension. No significant differences were observed between survivors and non-survivors in demographic and epidemiological characteristics except for gender. We found statistically significant differences between blood pressure and weight before and after the infection by COVID-19. We found a high COVID-19 prevalence in our hemodialysis patients and a high rate of deaths among them, with non-significant statistical differences between survivors and non-survivors of the disease regarding most of the variables studied.
Keywords: Clinical features; Coronavirus disease; Hemodialysis, COVID-19, epidemiology
Severe acute respiratory syndrome (SARS-CoV-2) emerged in Wuhan, China in December 2019 and was spread mainly by person-to-person transmission 1. Symptoms associated with COVID-19 are nonspecific and may include fever, cough, muscle pain and fatigue among other 2.
One of a severe medical condition is the kidney failure which is associate with a high prevalence of concomitant diseases, such as diabetes and heart disease, severely affecting older adults 3,4.
In a few months, COVID-19 has gone from being a little-known respiratory infectious disease generated in China to a devastating pandemic that threatens the health and has changed action protocols worldwide. There are no health care areas that have not been affected by the COVID-19 pandemic, and the chronic kidney patient's management is no exception. Both healthcare professionals and these patients have been forced to adjust the workflow to minimize exposure to COVID-19 in this type of patient.
A mortality rate in hemodialysis (HD) patients of approximately 16% 5 have been reported internationally, and others report infection rates in the range of approximately 1% 6 to 30% 7. Patients in the dialysis healthcare institutions are relatively mobile, and patients with uremia who require long-term hemodialysis make it more challenging to prevent and control infectious diseases than in general universe 8.
Also, patients in dialysis due to a non very efficient immune system are more likely to develop different and serious infectious diseases than the rest of the population 9,10.
Reynadial clinic in Guayaquil has developed a model for managing kidney patients in pandemic time according to national and international regulations. This institution is a care center dedicated to providing Hemodialysis Service to patients with chronic kidney disease grade V. We have followed recommendations from published interim guidance for the prevention and control of COVID-19 in outpatient hemodialysis facilities by the US Centers for Disease Control and Prevention (CDC) 11.
The clinic began to provide Services in 2016 (11/19/2016) and has been a faithful follower of the Treatment Protocols drawn up by the Ministry of Public Health and concerned about the incorporation of new techniques for the management of these patients. This institution has also taken all precautions and measures to avoid infection due to this disease, but there is always the risk that patients will acquire COVID-19. Since the development of COVID-19 may worsen kidney functions in this type of patient strict management protocols are followed in our institution to prevent the spread of COVID-19 among our patients. The study's objective was to describe the clinical characteristics and outcomes of patients with COVID-19 and determine the percentage of death among them.
MATERIALS AND METHODS
Retrospective observational cross-sectional study. Medical records were reviewed from patients treated from March to June of 2020.
Medical records of patients from both gender and ≥18 years old receiving hemodilysis treatment and with COVID-19 diagnosis.
It was considered a suspected of COVID-19 clinical case a patient fulfilling: 1) a presence of at least one the these symptoms: fever; respiratory symptoms such as cough, fever or dyspnea; or radiographic evidence of pneumonia, 2) a recent close contact with confirmed COVID-19 persons within 14 days before illness onset or qRT-PCR result positive for COVID-19.
Fever was defined as a temperature of at least 37·3°C.
Demographic information, baseline comorbidities, and the use of antibiotics were extracted from electronic medical records and compared between survivors and non-survivors. According to the age, it was divided into the elderly group (≥60 years old) and the young and middle-aged group (<60 years old).
None personally identifiable information was collected and guaranteed anonymity and confidentiality for this study. Informed consent for humans was hence not required as there was no data obtained directly from the subjects. Declaration of Istanbul regarding the traffic of organs and Declaration of Helsinki was observed during this study's performance. We followed STROBE guidelines for the report of the results.
Cuantitative variables were displayed as means and standard deviations. Confidence intervals at 95% were calculated for means. Categorical variables were expressed as number and relative frequencies (%).
Mann-Whitney U test, or Fisher's exact test to compare differences between survivors and non-survivors where appropriate were used (non-parametric methods). Nonparametric Paired T-test was used to compare each variable before and after the disease. A P-value less than 0.05 was considered statistically significant. SPSS, version 24.0 was used for Statistical analysis.
The number of patients of this health institution who are receiving hemodialysis is 125, from them 38 patients were COVID-19 diagnosed for a general prevalence of the disease of 30.4%. Only 10. Real-time PCR confirmed 5%, the rest was clinically diagnosed.
The mean age of the 38 patients was 61.2 with an SD of 13.4 years (range, 18–83), while weight was 61.09 kilograms (range, 35–88.4). No statistical differences were found between survivors and non-survivors for most of the evaluated characteristics (p>0.05), except for the number of days from the beginning of the disease until curation or death. (Table 1).
Table 1. Demographic findings. Comparison between means of the two groups and 95%confidence intervals
The average value of the systolic blood pressure BP, diastolic pressure, and weight before COVID-19 infection was seen to be 160.5 mm/hg, 76.4 mm/hg, and 62.4 kg. At the end of the disease, the average values of blood pressures (BP) and weight were significantly lower when analyzed using the paired t-test (P-value < 0.01). (Table 2)
Table 2. Paired Samples test. Comparison between means in two points of time in the same patient
Among the 38 patients, 57.9% were male. There were significant differences according to gender for non-survivors and survivors (p=0.004). Regarding the group of age (≥60 years old and <60 years old), we did not find any differences between non-survivors and survivors.
Most of the patients presented comorbidities, being hypertension the most common comorbidity, followed by diabetes and chronic kidney disease. There were no patients with chronic obstructive lung disease. Non-statistical differences were found between survivors and non-survivors (p>0.05 (Table 3)
Table 3. Comparison between proportions according comorbidities of the two groups
The most common symptoms at the beginning of the infection were dyspnea (89.4%), fever, and cough with 78%, respectively, followed by diarrhea (23.6%) and headache (10.5%). Less common symptoms included myalgia, fatigue, and convulsions. Non-statistical differences were found between survivors and non-survivors (p>0.05) (Table 4)
Table 4. Comparison between proportions according symptoms of the two groups
Thirty-three patients had an arteriovenous fistula, and 5 patients had a permanent central venous catheter. In each session the convective volume ranged from 22 to 32 liters. All patients were receiving low molecular weight heparin anticoagulation therapy. The most used antibiotic was Cefazoline. (Table 5)
Table 5. Antibiotics used during the disease. Frequencies and percentages of the most used antibotics
To date, this report is the only case series of hemodialyzed patients with COVID‐19 in Ecuador. Data of patients with COVID-19 in hemodialysis facilities are limited. Among 125 patients in the dialysis center Reynadial in Guayaquil, 38 patients had 2019-nCoV infection (30.4%). The mortality rate, 31.6%, was similar to the results obtained by Goicochea et al. 12 but much higher than that observed in the general population.
A university dialysis facility in Renmin Hospital reported that among 230 hemodialysis patients, 37 (16%) COVID-19 cases were diagnosed, and 7 hemodialysis patients died (18.9%) during a short period 13. Another study reported that among 602 subjects receiving hemodialysis as renal replacement therapy, 7 patients (1.1%) were infected with SARS-CoV-2, and none died during the study 14.
Both studies have shown the disease much lower than what we are reporting in the current work.
Albalate at al. reported that from 90 HD patients, 37 (41.1%) had COVID-19 and 6 of them died (16,2%) 15. At the moment of this study, the province of Guayas, where this clinic is located, reported 14728 confirmed cases with 1516 deaths in the general population 16.
We did not find any differences between survivors and non-survivors regarding age, arterial pressure, or weight. There were significant statistical differences between both arterial blood pressures before and after the disease. HD treatment generally reduces BP, and these reductions in BP are associated with intradialytic decreases in both body weight and plasma volume. These mild degrees of hypotension we have seen could be attributed to COVID-19 treatments as high doses of sedatives, positive pressure ventilation with high levels of positive end-expiratory pressure (PEEP), restrictive fluid management, and aggressive diuresis. Generally, weight gain is commonly observed in patients undergoing chronic hemodialysis; nevertheless, we observed decreased patients' weight after the disease.
We observed that more men than women get infected, consistent with some authors who have reported 17,18.
There was a statistically significant difference in the proportion of non survivors and survivors according to gender in our study. Older adults, men, and those with pre-existing comorbidities like hypertension and diabetes mellitus were highly prevalent. A similar pattern is reported from China 19.
We found that the most common symptoms at the beginning of the infection were dyspnea (89.4%), fever, and cough, with 78% consistent with other studies. In a retrospective study performed by Guan et al., including 1,099 patients with COVID19 respiratory disease, fever and cough were the most important symptoms, while vomiting and diarrhea were the less frequent 20. Wang et al. reported that diarrhea (80%), fever (60%), and fatigue (60%) were the most common symptoms in Hemodialysis five cases they studied 21. The most common symptom reported were cough and dyspnea in a study performed by Jung et al. 22.
Some symptoms of COVID-19 disease may be difficult to distinguish from other symptoms common among patients receiving dialysis. According to Borges, hemodialysis patients have disorders of B- and T-cell function patients and they may have atypical presentations of the disease 23. Freitas has appointed the same 24.
Hemodialysis population is vulnerable to COVID-19 pneumonia due to the presence of immunosuppression and the high prevalence of comorbid clinical conditions 25.
All our patients were receiving heparin, the most used anticoagulant during HD procedures, associated with a better prognosis in patients with COVID-19 26.
We initiated empiric therapy with antibiotics for possible co-infection, considering clinical judgment, the bacterial pathogens commonly isolated in our institution.
Our study has some limitations; because it is a cross-sectional study, we cannot identify a causal relationship between the variables we have included in the study. Due to the retrospective study design, laboratory tests for diagnoses were not available in most patients. Small sample of patients.
Patients with SARS-CoV-2 infection were high in our institution as well as the mortality rate. Most of the infected patients were male. Further observational studies are required to clearly understand clinical evolution and the right diagnostic and treatment methods for COVID-19 disease in hemodialysis patients.
MH, EF, MF, and FM worked on the design of the research. MH, FM, IF, YR, RC, CB, and EF were responsible for the data collection. MF, CB, EB, and EF were responsible for analyzing, interpreting, drafting, and revising the work. All authors participated in the interpretation and revision process of the manuscript. All authors gave their final approval of the version to be published
Availability of data and materials
The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.
Conflict of Interest Statement
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
No funds received.
1. Perlman S. Another Decade, Another Coronavirus. N. Engl. J. Med. 2020 doi: 10.1056/NEJMe2001126.
2. Guan WJ, Zhong NS. Clinical Characteristics of Covid-19 in China. Reply.N Engl J Med. 2020 7 May; 382(19):1861-1862.
3. US Renal Data System. https://www.usrds.org/Default.aspx Accessed 3 March, 2020.
4. Saran R, Robinson B, Abbott KC, et al. US Renal Data System 2017 Annual Data Report: Epidemiology of Kidney Disease in the United States [published correction appears in Am J Kidney Dis. 2018 Apr;71(4):501]. Am J Kidney Dis. 2018;71(3 Suppl 1):A7. doi:10.1053/j.ajkd.2018.01.002
5. Meijers B, Messa P, Ronco C. Safeguarding the Maintenance Hemodialysis Patient Population during the Coronavirus Disease 19 Pandemic. Blood Purif. 2020;49(3):259‐264. doi:10.1159/000507537
6. Europa Press. El 1,3% de personas en diálisis o con trasplante renal están infectados de Covid-19. Infosalus (2020).
7. Sánchez-Álvarez JE, Pérez Fontán M, Jiménez Martín C, et al. SARS-CoV-2 infection in patients on renal replacement therapy. Report of the COVID-19 Registry of the Spanish Society of Nephrology (SEN) [published online ahead of print, 2020 16 April]. Situación de la infección por SARS-CoV-2 en pacientes en tratamiento renal sustitutivo. Informe del Registro COVID-19 de la Sociedad Española de Nefrología (SEN) [published online ahead of print, 2020 Apr 16]. Nefrologia. 2020;S0211-6995(20)30040-0. doi:10.1016/j.nefro.2020.04.002
8. Park HC, Lee YK, Lee SH, Yoo KD, Jeon HJ, Ryu DR, Kim SN, Sohn SH, Chun RW, Choi KB; Korean Society of Nephrology MERS-CoV Task Force Team: Middle East respiratory syndrome clinical practice guideline for hemodialysis facilities. Kidney Res Clin Pract 36: 111–116, 2017pmid:28680819
9. Syed-Ahmed M, Narayanan M. Immune dysfunction and risk of infection in chronic kidney disease. Adv Chronic Kidney Dis. 2019;26(1):8–15. [PubMed] [Google Scholar]
10. Betjes MG. Immune cell dysfunction and inflammation in end-stage renal disease. Nat Rev Nephrol. 2013;9(5):255–265
11. Centers for Disease Control and Prevention. Interim guidance for infection prevention and control recommendations for patients with suspected or confirmed COVID-19 in outpatient hemodialysis facilities. CDChttps://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/dialysis.html (2020)
12. Goicoechea M, Sánchez Cámara LA, Macías N, Muñoz de Morales A, González Rojas Á, Bascuñana A, Arroyo D, Vega A, Abad S, Verde E, García Prieto AM, Verdalles U, Barbieri D, Felipe Delgado A, Carbayo J, Mijaylova A, Pérez de José A, Melero R, Tejedor A, Rodriguez Benitez P, de José AP, Rodriguez Ferrero ML, Anaya F, Rengel M, Barraca D, Luño J, Aragoncillo I. COVID-19: Clinical course and outcomes of 36 maintenance hemodialysis patients from a single center in Spain. Kidney Int. 2020 May 10;98(1):27–34. doi: 10.1016/j.kint.2020.04.031. Epub ahead of print. PMID: 32437770; PMCID: PMC7211728.
13. Ma Y, Diao B, Lv X, Zhu J, Liang W, Liu L, Bu W, Cheng H, Zhang S, Yng L, Shi M, Ding G, Shen B, Wang H. 2019 novel coronavirus disease in hemodialysis (HD) patients: Report from one HD center in Wuhan, China. medRxiv preprint 2020, doi: https://doi.org/https://doi.org/10.1101/2020.02.24.20027201-y.
14. Arslan H, Musabak U, Ayvazoglu Soy EH, et al. Incidence and Immunologic Analysis of Coronavirus Disease (COVID-19) in Hemodialysis Patients: A Single-Center Experience. Exp Clin Transplant. 2020;18(3):275-283. doi:10.6002/ect.2020.0194
15. Albalate M, Arribas P, Torres E, Cintra M, Alcázar R, Puerta M, Ortega M, Procaccini F, Martin J, Jiménez E, Fernandez I, de Sequera P; Grupo de Enfermería HUIL; Grupo enfermería HUIL. High prevalence of asymptomatic COVID-19 in haemodialysis: learning day by day in the first month of the COVID-19 pandemic. Nefrologia. 2020 May-Jun;40(3):279-286. English, Spanish. doi: 10.1016/j.nefro.2020.04.005. Epub 2020 Apr 30. PMID: 32456944; PMCID: PMC7190471.
16. Coronavirus COVID-19 – Ministerio de Salud Pública. https://www.salud.gob.ec/coronavirus-covid-19/.
17. Du X, Li H, Dong L, Li X, Tian M, Dong J. Clinical features of hemodialysis patients with COVID-19: a single-center retrospective study on 32 patients. Clin Exp Nephrol. 2020 May 27:1–7. doi: 10.1007/s10157-020-01904-w. Epub ahead of print. PMID: 32462378; PMCID: PMC7252511.
18. Trujillo H, Caravaca-Fontán F, Sevillano Á, Gutiérrez E, Caro J, Gutiérrez E, Yuste C, Andrés A, Praga M. SARS-CoV-2 Infection in Hospitalized Patients with Kidney Disease. Kidney Int Rep. 2020 May 1;5(6):905–9. doi: 10.1016/j.ekir.2020.04.024. Epub ahead of print. PMID: 32363253; PMCID: PMC7194060.
19. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-1062.
20. Guan W-j, Ni Z-y, Hu Y, et al; The China Medical Treatment Expert Group for Covid-19. Clinical characteristics of 2019 novel coronavirus infection in China. N Engl J Med. 2020;382: 1708-1720
21. Wang, Rui, Cong Liao, Hong He, Chun Hu, Zimeng Wei, Zixi Hong, Chengjie Zhang, Meiyan Liao, and Hua Shui. "COVID-19 in Patients: A Report of 5 Cases." American Journal of Kidney Diseases 76, no. 1 (2020): 141–43. https://doi.org/10.1053/j.ajkd.2020.03.009.
22. Jung H-Y, Lim J-H, Kang SH, Kim SG, Lee Y-H, Lee J, et al. Outcomes of COVID-19 among Patients on In-Center Hemodialysis: An Experience from the Epicenter in South Korea. Journal of Clinical Medicine 2020;9:1688.
23. Borges A, Borges M, Fernandes J. Apoptosis of peripheral CD4(+) T-lymphocytes in end-stage renal disease patients under hemodialysis and rhEPO therapies. Ren Fail. 2011;33(2):138–143.
24. Freitas GRR, da Luz Fernandes M, Agena F. Aging and end stage renal disease cause a decrease in absolute circulating lymphocyte counts with a shift to a memory profile and diverge in Treg population. Aging Dis. 2019;10(1):49–61
25. Tang B, Li S, Xiong Y, Tian M, Yu J, Xu L, Zhang L, Li Z, Ma J, Wen F, Feng Z, Liang X, Shi W, Liu S. Coronavirus Disease 2019 (COVID-19) Pneumonia in a Hemodialysis Patient. Kidney Med. 2020 12 March. doi: 10.1016/j.xkme.2020.03.001. Epub ahead of print. PMID: 32292904; PMCID: PMC7103984.
26. Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020;18:1094–9. http://dx.doi.org/10.1111/jth.14851.
Received: 30 December 2020
Accepted: 15 February 2021
Mario Hernández1, Emilio Fors2, Fresia Massuht3, Ingrid Figueredo4, Raúl Caballero5, Christian Berruz6, Yinet Ramirez7, Elsa Bernal8 and Martha Fors9
1. Clinica Reynadial, Guayaquil, Ecuador. Hospital General IESS Babahoyo, Los Ríos, Ecuador. Email email@example.com ORCID 0000-0001-8019-6266
2. Clinica Reynadial, Guayaquil, Ecuador. Hospital General IESS Babahoyo, Los Ríos, Ecuador. Email firstname.lastname@example.org ORCID 0000-0002-3567-2638
3. Clinica Reynadial. Hospital General IESS Sur Valdivia, Guayaquil, Ecuador. Email email@example.com ORCID 0000-0002-0436-9062
4. Clinica Reynadial, Guayaquil, Ecuador. Email firstname.lastname@example.org ORCID 0000-0002-4718-7445
5. Clinica Reynadial, Guayaquil, Ecuador. Email email@example.com ORCID 0000-0003-1750-3424
6. Clinica Reynadial, Guayaquil, Ecuador, Email firstname.lastname@example.org ORCID 0000-0001-6790-7334
7. Clinica Reynadial, Guayaquil, Ecuador. Email email@example.com ORCID 0000-0002-4436-6704
8. Universidad Técnica de Babahoyo, Los Ríos. Email firstname.lastname@example.org ORCID 0000-0002-3463-5923
9. Universidad de las Américas, Quito, Ecuador. Email email@example.com ORCID 0000-0002-0844-199X Corresponding author. firstname.lastname@example.org