Protected: Frail nephropathic patients: maximum conservative therapy or dialysis? Results from a retrospective observational study

Abstract

Background and objectives: Chronic dialysis in frail nephropathic patients can worsen the symptom load and their functional autonomy, increasing the risk of early mortality. It is key to evaluate if dialysis treatment represents a real advantage for these patients; Maximum Conservative Therapy (MCT) associated with palliative care, could improve their residual quality of life, avoiding dialysis. The aim of this work is to describe the application and the relative terms of MCT in a complete series of cases followed in our Nephrological Clinic.

Study design and setting: This is a retrospective observational study on a cohort of 48 frail nephropathic patients in MCT and 58 on dialysis, in the period between January 2013 and December 2019. The place of death, Incidence Rate (IR) and Incidence Rate Ratio (IRR) related to survival and hospitalization rates were studied.

Results: The average duration of MCT was 9.7 months vs 13.5 months of dialysis treatment. One-year probability of survival of dialysis patient was 0.52 [CI 0.38-0.64] vs 0.48 [CI 0.33-0.62] in MCT patients; however, dialysis patients had higher rates of hospitalization (IR 2.780 vs 1.269 in MCT patients), IRR 2.19 [CI 1.66-2.89], according to literature. 67% of dialysis patients died in hospital versus 35% of MCT patients. 34% of MCT patients are still alive at the time of data analysis (January 31, 2020); no dialysis patients are still alive on the same date.

Conclusions: The use of dialysis has shown a marginal, even though significant, effect on the average survival of frail nephropathic patients; however, they present a higher hospitalization rate, with consequent impact on the quality of life. The choice of the treatment (MCT vs dialysis) should not be merely based on the presence of comorbidities, but rather on the type of comorbidity found, which represents each time an element in favor of MCT or dialysis.

 

Keywords: conservative therapy, dialysis, survival, fragility

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Extracorporeal renal replacement therapies in lithium intoxication

Abstract

Drug poisoning is a significant source of morbidity, mortality and health care expenditure worldwide. Lithium, methanol, ethylene glycol and salicylates are the most important ones, included in the list of poisons, that may require extracorporeal depuration. Lithium is the cornerstone of treatment for bipolar disorders, but it has a narrow therapeutic window. The therapeutic range is 0.6-1.2 mEq/L and toxicity manifestations begin to appear as soon as serum levels exceed 1.5 mEq/L. Severe toxicity can be observed when plasma levels are more than 3.5 mEq/L. Lithium poisoning can be life threatening and extracorporeal renal replacement therapies can reverse toxic symptoms. Currently, conventional intermittent hemodialysis (IHD) is the preferred extracorporeal treatment modality. Preliminary data with prolonged intermittent renal replacement (PIRRT) therapies – hybrid forms of renal replacement therapy (RRT) such as sustained low efficiency dialysis (SLED) – seem to justify their role as potential alternative to conventional IHD. Indeed, SLED allows rapid and effective lithium removal with resolution of symptoms, also minimizing rebound phenomenon.

 

Keywords: lithium, drug toxicity, dialysis, sustained low efficiency dialysis (SLED)

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Introduzione

Le intossicazioni sono un vasto gruppo di patologie di differente gravità determinate da esposizione ad un ampio numero di agenti causali, i cosiddetti veleni o tossici. Tale esposizione può avvenire per vie e con modalità diverse. Con il termine farmaco si indica qualsiasi sostanza che induca in un organismo, attraverso la propria attività chimica, modificazioni delle funzioni biologiche e quindi della funzionalità cellulare e degli organi. Se la modificazione indotta dal farmaco è positiva per la salute esso viene definito medicamento, se invece è dannosa si parla di tossico o veleno. La maggior parte dei farmaci presenti in commercio esercitano una funzione terapeutica a determinate dosi e divengono tossici a concentrazioni più elevate.

Le intossicazioni da farmaci rappresentano un’importante causa di morbilità e mortalità ed il loro trattamento richiede notevoli risorse economiche. Negli Stati Uniti, a partire dal 2008, si è registrato un progressivo incremento degli avvelenamenti da farmaci. Tale fenomeno costituisce ad oggi una delle prime cause di mortalità, determinando un numero di morti superiori a quelle attribuibili ad incidenti stradali [1]. Secondo i dati dell’American Association of Poison Control Centers (AAPCC), nel 2017 si sono registrati negli Stati Uniti 7.222 casi di intossicazione da sali di litio, 3.271 dei quali hanno richiesto l’accesso ad una struttura sanitaria, con un tasso di mortalità pari allo 0,03%; circa la metà dei casi riguardava soggetti con età inferiore o uguale a 20 anni [2]. Nel corso degli ultimi decenni, le intossicazioni da sali di litio, insieme a quelle da metanolo, glicole etilenico e salicilati, sono state tra le prime quattro cause di avvelenamenti per cui si è reso necessario il ricorso a trattamenti di depurazione extracorporea (renal replacement therapies o RRT) [3

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Preliminary report on the Covid-19 outbreak in Valle d’Aosta dialysis centers

Abstract

Valle d’Aosta, Italy’s smallest region, faced a Covid-19 epidemic trend of absolute relevance. In line with data concerning the local general population, the predominance of the illness among uremic patients has been high. The authors report here preliminary data on the spread of this disease within the region and on the clinical trend of the infected patients who needed to be hospitalised.

Keywords: Covid-19, outbreak, dialysis

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Introduzione

A fine dicembre 2019, le autorità politiche e sanitarie cinesi riportano un numero crescente di polmoniti e sindromi respiratorie acute nella città di Wuhan, con la successiva identificazione eziologica di un nuovo agente virale appartenente alla famiglia dei Coronavirus, il SARS-CoV-2 (Severe Acute Respiratory Syndrome CoronaVirus 2) [1]. Nelle successive settimane, la diffusione della malattia assume caratteristiche di pandemia mondiale. I primi casi italiani di infezione da Covid-19 (coronavirus disease 2019), due turisti cinesi, vengono confermati dall’Istituto Superiore di Sanità (ISS) il 30 gennaio 2020. Il primo caso autoctono confermato dall’ISS è stato segnalato a Milano il 21 febbraio. Nelle settimane successive, la diffusione della malattia assume caratteristiche epidemiche di particolare rilevanza a partire dalla Lombardia per poi estendersi a tutto il territorio nazionale[2].
 

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Standard procedures in dialysis during the Covid-19 epidemic

Abstract

Scope

The aim of this document has been to define standard procedures for dealing with dialysis patients once the first cases of novel Coronavirus 2019-nCoV (Covid-19) were confirmed among the Italian population.

Applicability

These procedures, that refer exclusively to the hospital’s dialysis rooms, are currently implemented at the ASST Santi Paolo e Carlo in Milan and two smaller centers in the Milan area.

Description

We describe the preemptive measures adopted by the staff at our dialysis unit since 24/02/2020, in order to slow down the transmission of Covid-19. They have allowed us to adopt a uniform approach towards all patients, streamlining the way we identify and deal with suspected, likely and confirmed Coronavirus infections. To start with, all patients coming to the hospital for their dialytic session have been treated as potentially infectious and everybody has been following closely the standard protocols regarding personal protective equipment (PPE).

 

Keywords: Covid-19-positive, dialysis, prevention, personal protective equipment

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1.    Assistenza al paziente dializzato durante l’emergenza Covid-19

 

1.1. Premessa

Con l’apertura di una sala dialisi e la sua preparazione s’intende la messa in atto di una serie di procedure che consentono all’operatore di poter effettuare una seduta dialitica sicura ed in ambiente protetto. Durante l’emergenza da Covid-19 sono state introdotte modifiche organizzative sia nei tempi che nelle modalità, implementando al meglio le competenze del personale. Sono state create nuove postazioni dialisi che hanno permesso di garantire la continuità assistenziale nei diversi reparti Covid-19 dell’Ospedale. Nel momento della sospetta infezione da Covid-19 (iperpiressia, desaturazione di ossigeno), il paziente viene isolato e si esegue il tampone. Se sono presenti segni e sintomi respiratori si segnala il paziente allo specialista infettivologo/pneumologo che attiverà un percorso diagnostico specifico (RX torace, TC torace, etc.). All’arrivo del paziente, l’infermiere e il medico si presentano per farsi riconoscere.

 

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Clinical and social advantages of remote patient monitoring in home dialysis

Abstract

Introduction. Home dialysis (both extracorporeal and peritoneal) can improve the management and the quality of life of patients with chronic disease. In this study we evaluated the possible clinical and social advantages derived from remote patient monitoring using the Doctor Plus® Nephro program, as opposed to the standard of care. Methods. We included in our analysis the patients participating in the remote monitoring program of the Nephrology Center of ASL 3 in Rome from July 2017 to April 2019. Each patient was observed from a minimum of 4 months to a maximum of 22 months. Systolic and diastolic pressure, heart rate, weight and oximetry were monitored. An SF-12 questionnaire was also administered to evaluate the level of satisfaction with the program Doctor Plus® Nephro. Results. 16 patients (56,3% males, mean age 62 years) were observed as part of the analysis. During the program there was a reduction of systolic pressure in 69% of the patients and of diastolic pressure in 62,5%. Mean heart rate decreased from 69,4 bpm to 68,8 bpm (p<0,0046). The answers to the SF-12 questionnaire showed that the perceived health status of all patients had improved. Due to the closer clinical monitoring, the number of patients accessing emergency services also decreased. Conclusion. Doctor Plus® Nephro could improve access to home treatment; the results of this study in fact show it to be a useful tool for Nephrological Centers to monitor patients undergoing home dialysis.

 Keywords: remote patient monitoring, dialysis, home dialysis, blood pressure, quality of life

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Introduzione

Puntare sulle cure domiciliari per migliorare la gestione e la qualità della vita del paziente cronico e della sua famiglia è l’indicazione contenuta nell’ultimo Piano Nazionale della Cronicità (PNC) approvato dal Ministero della Salute Italiano, che dedica una particolare attenzione alla malattia renale cronica e all’insufficienza renale. Nel capitolo del PNC dedicato alle malattie croniche e all’insufficienza renale uno degli obiettivi generali è favorire l’assistenza domiciliare del paziente; una delle linee di intervento proposte a supporto è sperimentare modelli di dialisi domiciliare (dialisi peritoneale e emodialisi domiciliare), utilizzando strumenti di tele-dialisi assistita [1].

La dialisi domiciliare offre numerosi vantaggi se comparata con la dialisi effettuata in ospedale. Gli studi dimostrano diversi benefici per i pazienti in dialisi domiciliare in termini di sopravvivenza, qualità di vita, costi di spostamento, autonomia e benefici clinici, quali aumento del controllo dei valori pressori e del fosforo [28]. Inoltre, nella maggior parte dei paesi, il costo della dialisi domiciliare è inferiore al costo della dialisi effettuata in ospedale [911].

 

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Covid-19 and its impact on nephropathic patients: the experience at Ospedale “Guglielmo da Saliceto” in Piacenza

Abstract

Roberto Scarpioni and colleagues recount their experience with the Covid-19 epidemic at the Nephrology and Dialysis Center of the “Guglielmo da Saliceto” Hospital in Piacenza, where everybody is still fighting to this moment to contain the spread of the disease and face an increasingly unsustainable clinical situation. Piacenza is only 15 km away from the main cluster of cases in the country (Codogno, in the Lodi province) and, after the closure of the Hospital in Codogno, saw an escalation in the number of patients testing positive to Covid-19.

The authors describe their efforts and the practices they adopted to contain the spread of the disease among inpatients visiting the hospital’s Hemodialysis Clinic. They also reflect on some of the data available on the 25/03/2020, such as the number of patients testing positive and the mortality rate, unfortunately very high. Their aim is to help all colleagues that have yet to face this epidemic in its full force.

Keywords: Covid-19, coronavirus, nephropatic patients, dialysis, kidneys, Piacenza, Emilia Romagna

A cluster of cases of a new unknown type of pneumonia was first signalled in Wuhan, China, on the 31st December. Chinese researchers later identified the cause of the infection as a novel coronavirus called SARS-CoV-2 o Covid-19 [1]. Exactly one month later, in Rome, two Chinese tourists from Wuhan were the first to test positive to the virus in Italy. The first Italian case of Covid-19 was hospitalised on the 21st February in Codogno (Lodi province), only 15 km away from Piacenza [2]. The following weeks saw an exponential increase in the number of infections, to the point that Italy is now the country that has been most heavily hit by the pandemic after China. We have more than 57.521 confirmed cases, with more than 8.256 in the Emilia Romagna region alone, where 1.077 patients have died and 721 have recovered [3].

Here we describe our own experience with the Covid-19 epidemic at the Nephrology and Dialysis Center of the “Guglielmo da Saliceto” Hospital in Piacenza, where everybody is still fighting to this moment to contain the spread of the disease and face an increasingly unsustainable clinical situation. We hope this will be useful to all colleagues that have yet to face this epidemic in its full force, as it has already happened in Emilia Romagna and Lombardia. Piacenza is only 15 km away from the main cluster of cases in Codogno and, after the closure of the Hospital there, saw an escalation in the number of patients presenting to the A&E testing positive to Covid-19 (see Fig. 1).

 

Fig. 1: Number of patients presenting to the A&E testing positive to Covid-19

 

The exponential growth in the number of nephropathic patients with a Covid-19 infection forced us straight away to adopt measures to contain the spread of the disease among inpatients visiting the hospital’s Hemodialysis Clinic. Starting from day 3 and 4 we adopted very strict measures, both when dealing with patients and between colleagues. Fortunately to date (25/03/2020) none of the doctors has been found positive to the virus, while three nurses have been found positive and have isolated at home, in good general conditions.

Inpatients’ body temperature was measured before they entered the ward; they were invited to wear face masks, wash their hands with an alcohol-based sanitizer and change their clothes and shoes. The personnel wore face masks, protective glasses and gloves, and disinfected rooms and machinery at the start of each shift [4].

At first, patients needing chronic hemodialysis were treated within the ward using CRRT (Continuous Renal Replacement Therapy) or high-volume hemofiltration (6 L/hr), with adsorbent membranes to remove inflammatory cytokines (IL-6) and endotoxins. In order to avoid contacts as much as possible, we treated two patients at a time, under the supervision of a single nurse and in the same room, separate from the rest and with its own transport system. Later, however, the high volume of patients forced us to move outside the ward to set up a new space devoted to quarantined patients. While waiting for the test results, all patients were treated as positive by medical personnel wearing face masks, goggles, gloves and overcoats. We insured a distance of at least 1-1,5 m between the beds by emptying the room of all that was not immediately necessary. One of the most difficult tasks was organising a separate transportation system, devoted solely to patients positive to Covid-19 and disinfected after each round. As for us, apart from wearing the protective gear describe above, we decided to avoid holding any staff meetings indoors.

As of today, it is extremely clear how dangerous Covid-19 is for fragile nephropathic patients: 41 of our patients on hemodialysis have been infected, 16% of the total (mean age 73±11, range 52-90 years, all white Caucasian, 31 men/10 women). The diagnosis was based on the results of the oro-rino-pharyngeal swab, wherever possible, or on the findings of the pulmonary CT. It is surprising to note that the rate of infection is the same recorded at the Renmin Hospital in Wuhan (16%) [5]; we have to consider, however, that over the first few says only symptomatic patients were tested for the virus.

Of these patients, those with a temperature and/or struggling to breathe were empirically treated with 5-OH-chloroquine and antiretroviral therapies, when considered appropriate by the infectologist. Due to the patients’ age and previous comorbidities, the mortality rate has unfortunately been very high: to date, half of the infected patients have died (18/41, 41% raw mortality). This is way higher than the rate among non-nephropathic patients in Italy (around 10%) – and an unacceptable price to pay [6].

All transplanted patients in home care (118) and those treated with peritoneal dialysis (34) were discouraged from visiting the hospital but were contacted via telephone on a daily basis by our doctors and nurses. We have currently 4 transplanted patients who tested positive to Covid-19; two of them are hospitalised at the Transplant Center in Bologna, while the others are quarantined at home and are being monitored very closely for any pharmacological interactions. Luckily, only one PD patient has tested positive so far and is also at home, closely monitored.

In line with what has been reported by a few other authors, we observed only a small percentage of Covid-19-related cases of acute kidney injury (AKI) (<3%) [7]. To date, we have 5 AKI patients that have required intensive care treatment with CRRT; 4 of them, all men with existing comorbidities whose average age is 60 and age range is 39-71, are still being treated.

Looking back, the strict containment measures that we have adopted early on have certainly helped minimise the spread of the disease, although the mortality rate has remained unacceptably high among nephropathic patents. We are now waiting for new results to shed light on the renin-angiotensin blockade as a potential functional receptor for the virus [8, 9], on the use of immunomodulating drugs inhibiting IL-6 as a mean to reduce the progression of respiratory failure and inflammation, and on the use of other antiviral medications (or perhaps even a vaccine) that may reduce the rate of infection and the prognosis, which is currently extremely negative in 8-10% of cases. While we wait to know more, however, we must invest in preventing the spread of Covid-19. Prevention through social distancing is imperative, especially for older patients with renal disease, but cannot be enforced in all cases as many of them need to come to the Center for life-saving treatment up to three times per week. The low rate of infection among patients in home care further confirms the effectiveness of self-isolation.

 

Bibliography

  1. Zhu N, Zhang D, Wang W, et al. A novel Coronavirus from patients with pneumonia in China, 2019. N Eng J Med 2020; 382(8):727-33. https://doi.org/10.1056/NEJMoa2001017
  2. Carinci F. Covid-19: preparedness, decentralisation, and the hunt for patient zero. BMJ 2020; 368:bmj.m799. https://doi.org/10.1136/bmj.m799
  3. Ministero della Salute (ultimo accesso 25/03/2020).
  4. Center for Disease Control and Prevention. Interim Additional Guidance for Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed COVID-19 in Outpatient Hemodialysis Facilities: (ultimo accesso 15/03/2020).
  5. Naicker S, Yang C-W, Hwang S-J, et al. The Novel Coronavirus 2019 Epidemic and Kidneys. Kidney Int 2020; in press. https://doi.org/10.1016/j.kint.2020.03.001
  6. Xianghong Y, Renhua S, Dechang C. Diagnosis and treatment of COVID-19: acute kidney injury cannot be ignored. Natl Med J China 2020; epub ahead of print. https://doi.org/10.3760/cma.j.cn112137-20200229-00520
  7. Guan W, Ni Z, Yu Hu, Liang W, et al for the China Medical Treatment Expert Group for Covid-19. Clinical Characteristics of Coronavirus Disease 2019 in China. New Engl Journ Med 2020; https://doi.org/10.1056/NEJMoa2002032
  8. Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular System. Nat Rev Cardiol 2020; https://doi.org/10.1038/s41569-020-0360-5
  9. Perico L, Benigni A, Remuzzi G. Should COVID-19 Concern Nephrologists? Why and to What Extent? The Emerging Impasse of Angiotensin Blockade. Nephron. 2020 Mar 23:1-9. https://doi.org/10.1159/000507305

An account of the first hours of the Covid-19 epidemic at the Nephrology Unit in Lodi (Lombardy)

Abstract

Marco Farina and colleagues give us their account of the first days of the Covid-19 epidemic in the Nephrology Unit of the Ospedale Maggiore in Lodi. From the news trickling through from Codogno on the 20th of February to the hospitalization, the following day, of the first dialytic patient with signs of pneumonia, who later tested positive to the virus.

They tell us of how the hospital has been completely restructured in the wake of the epidemic, at remarkable speed and providing an example for others to follow, and the great sense self-sacrifice displayed by all medical personnel. After an overview of the clinical conditions of the 7 patients positive to the virus hospitalised in the following few days, they describe in some detail how symptomatic Covid+ patients are currently managed at the Ospedale Maggiore in Lodi.

Keywords: Covid-19, Ospedale Maggiore di Lodi, nephrology, dialysis

Introduction

The Covid-19 epidemic suddenly hit us on the 20th of February, the day the news started trickling through that the first case of SARS-CoV-2 had been isolated in Codogno, far out in the province. After being all over the news because of a nasty high-speed train accident only a few days before, the Lodi area was once again in the spotlight as the theatre, this time, of a health emergency.

In those first confusing hours we spent plenty of time and energy trying to find the case 1 and case 0, and doing all we could to pinpoint the starting point of the epidemic — apparently a dinner between co-workers, one of which had just returned from China. Both patient 1 and his pregnant wife, for whom we were all particularly worried, had just been hospitalised. It was then clear that the virus had arrived in Italy, in all likelihood destined to spread from our own region to the rest of the country, and that there was no point in trying to find links between infected people and China any longer. We have since been witnessing an exponential growth that, up to this day, has not shown any signs of a slowdown.

 

The first case

When I got to work on the 21st I was told that our Nephrology department had just received a 62-year-old hemodialysis patient showing signs of pneumonia at a chest X-rays. Showing a commendable insight, our local Health Care System had published on the 5th of February a detailed plan on how to identify, signal and manage either potential, probable or confirmed cases of Covid-19. This is not to say we were ready for what was to come – who could have been? – but at least we had criteria in place to recognise and assess the problem. The patient described above, who had arrived from the small town that would soon become the main cluster of cases in the country, was immediately isolated and we all started using the protective equipment described in detail in the management plan. We sent blood samples and a nasopharyngeal swab to the Microbiology Lab at the Sacco Hospital in Milan and we waited the results with apprehension; as it was still early days, we received them the same evening: positive. We alerted the Crisis Unit created by the Region for this purpose and, in the night between the 21st and the 22nd, the patient was transferred to the Infective Disease Unit at S. Anna Hospital in Como. He was then transferred to the Intensive Care Unit not because of any worsening of his conditions (he did not need a ventilator during transfer) but because he needed dialysis, which cannot be administered in Infective Disease wards. However, within a day, we witnessed a sudden worsening of the patient’s respiratory conditions (something we have grown accustomed to seeing in this type of patients), followed by death. This announcement, that reached our Nephrology Unit through mainstream news channels, was met with bewilderment: we all knew that the patient, albeit young, had several comorbidities but we were nonetheless greatly distressed to learn of his death; as a pre-emptive measure we had to quarantine the entire medical personnel, as the very first contacts with the patient had, quite understandably, taken place without the necessary protections.

 

Re-structuring the Hospital

This is our account of the first hours of this ordeal; the rest, the local and national directives that have been published in quick succession and that keep being fine-tuned hour by hour, is well known to all of us. From the creation of the “red zone” in Lodi, later extended to the entire Lombardy area, to the strict quarantine measures required across the entire Region (DPCM 21 February, 8 March and 11 March, respectively).

Since the spike in the infection rate has started (as we write there has been no inversion in this trend, and we wait for it anxiously) our Hospital in Lodi has undergone a complete overhaul and its re-structuring has been used as a model by other institutes. On the 26th of February the “blue area” was created, with 18 hospital beds previously belonging to Neurology, to hold Covid+ patients necessitating ventilation; on the 28th the “yellow area” was opened, allowing for 37 additional beds for Covid+ patients without the need for ventilation or simply requiring oxygen therapy. On the 4th of March we opened an “orange area” (previously General Medicine) with 38 more beds; on the same date we started setting up a hemodialysis room devoted to patients positive to Covid+. On the 6th we opened, within Nephrology, a “red area” with 13 beds and a drywall-delimited space devoted exclusively to the dressing and undressing of healthcare personnel. On the 7th of March Covid+ pneumonia cases started being hospitalised in the Orthopedics Unit, under supervision of the surgeon.

Doctors and nurses have been assigned to any type of duty according to pressing and ever-changing needs, impossible to predict. At the helm, a multi-disciplinary team composed by the Directors of critical care, resuscitation, pneumology and infectiology and by a number of nurses; working closely with the Biochemical and Microbiology Labs, they constituted the Hospital’s Crisis Unit, gathered in a virtually permanent assembly. Everybody has been displaying a great sense self-sacrifice, working incredibly long shifts, often in silence. This same situation seems to repeat in most of Lombardy, but also in Veneto and in many other places.

 

Other cases

By looking at preliminary data, we clearly have yet to see the huge wave of hospitalizations described by initial projections (this, however, may change or might have already changed since I wrote this piece). Patients arriving from the “red zone” have been immediately treated with the utmost care and attention, and all necessary protections have been used both in local health care facilities and in hospitals. Those of them needing dialysis have been treated in a separate room, used exclusively to this purpose, and they have been closely monitored through anamnesis and the measuring of saturation and body temperature. Of the 18 tests administered to all patients who had been in contact with the first Covid+ case deceased at S. Anna Hospital only 3 turned out positive (about 15%); the rate is actually unexpectedly good, although in the present situation it is very difficult to make any statements with an acceptable degree of confidence.

As I write, there are 7 dialytic patients who resulted positive to SARS-CoV-2, although this number is certainly destined to go up; as we have a total of 162 patients in hemodialysis or peritoneal dialysis, the current number of infections accounts for around 4%. In addition to the case described above, where the patient was initially in good conditions but presented several comorbidities, 2 more have died. An 84-year-old patient, also with many underlying conditions, that had been hospitalized for other reasons but started testing positive during his hospital stay; X-rays showed signs of pneumonia, to be added to a recent diagnosis of pulmonary neoplasms. Then a female patient with stage 5 kidney disease who was not in dialysis but presented severe cardiac problems. She also caught the infection during the hospital stay; palliative care was the only viable option, as general conditions were already heavily compromised.

In the table below we try to summarise the clinical characteristics and outcomes of the patients who tested positive to the virus, while we wait to be able to collect and publish more precise data.

 

Table I: Clinical characteristics and outcomes of patients positive to the virus

 

Addendum and conclusions

We have been the first to be hit by the epidemic and, as such, we have also been the first to put in place stringent protocols and regulations. Although we have been doing our absolute best, there is sometimes a mismatch between the regulations and the actual situation on the ground. Until now, all nurses have been using FFP2 masks, counted and distributed at the beginning of the shift. Nurses assisting the dialysis of patients that are not confirmed cases wear single use garments and, in one of the two centers in the “red area”, also a waterproof vest. All nurses wear a hat and, since the FFP2 mask can be an obstacle to the use of the visor, we have equipped each room with goggles that are sanitized with 70% alcohol at the end of each shift. Leaving aside the FFP2 mask and the waterproof vest, these are for the most part standard sanitary measures.

Patients, on the other hand, wear a chirurgical mask that is changed at the beginning of each new shift. Most of them also use it during transportation, although it is probably the same one they were given the night before. While waiting, all patients are invited to stand at least a meter apart from each other and wash thoroughly their hands and the arm where the vascular access is located.

To date, at our Hospital in Lodi, patients testing positive to the virus and showing symptoms are treated in one of the following ways (as decided by the multidisciplinary team we have previously described):

  1. If invasive ventilation is needed, they are transferred to Intensive Care, where CRRT or hemodialysis is started immediately; a portable osmosis filtration system is also available.
  2. If non-invasive ventilation is needed, they are transferred to the “yellow area”, where CPAP is available, as well as water filtration systems.
  3. Regardless of ventilation needs they can also be assigned to the “red area” created within our Nephrology, where we have 3 rooms with 3 beds each that have also been fitted with systems to filtrate water.

We have very recently implemented a new water management system that allows for two patients to undergo dialysis at the same time. Together with the system available in the yellow area, which caters for one patient at the time, is therefore possible to dialyse 3 patients at the time, maintaining the ratio between nurses and patients to 1:3.

If the patient is a suspected case but has no symptoms, the hemodialysis can be carried out in a hospital room specifically set up for this purpose. It now has 2 beds that could easily become 6 with very minor changes to the set-up.

All considered, the system we have put in place seems currently up to the task. However, as the epidemiological landscape keeps changing, this evaluation could suddenly turn out to be wrong.

Managing patients in dialysis and with kidney transplant infected with Covid-19

Abstract

We are in the midst of a health emergency that is totally new for us all and that requires a concerted effort, especially when it comes to safeguarding patients on hemodialysis, and kidney transplant recipients. Brescia is currently a very active cluster of infections (2918 cases on the 17/03/2020), second only to Bergamo. The way our structure is organised has allowed us to treat nephropathic patients directly within the Nephrology Unit, following of course a great deal of reshuffling; at the moment, we are treating 21 transplanted patients and 17 on hemodialysis. This has led us to adopt a systematic approach to handling this emergency, not only in managing inpatients, but also in researching the
new disease. Our approach is mirrored in the guidelines attached to this article, originally intended for internal use only but potentially very useful to our colleagues, as they face the same exact problems.
We have also started collecting data on our positive patients with the aim of understanding better the functioning of this disease and how best to manage it. If anyone is interested, we ask you to please get in touch with us, so we can coordinate our efforts.

 

Keywords: Covid-19, Brescia, nephrology, dialysis, transplants, guidelines

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Introduzione

L’epidemia da Covid-19 in Lombardia richiede la messa a punto di un protocollo nei pazienti nefropatici, in particolare nei pazienti in trattamento dialitico e in quelli portatori di trapianto renale.

Recentemente, il China CDC ha pubblicato la più ampia casistica di Covid-19, che includeva 44672 casi; da questo studio emerge una mortalità totale del 2.3%. I fattori di rischio principali sembrano essere, oltre all’età (mortalità dell’1.3% nella fascia 50-59, 3.6% nella fascia 60-69, 8% nella fascia 70-79 e 14.8% nella fascia ≥80 anni), la presenza di malattie cardiovascolari (mortalità 10.5%), diabete (mortalità 7.3%), malattie respiratorie croniche (mortalità 6.3%), ipertensione arteriosa (mortalità 6%) e neoplasie (mortalità 5.6%) [1,2]. Nella regione Lombardia, tuttavia, la malattia sembra avere una mortalità decisamente maggiore di quella riportata in Cina, e questo deve indurci a studiare con attenzione tutti i fattori potenzialmente responsabili di questo andamento.

Le comorbidità associate ad aumentata mortalità in corso d’infezione da Covid-19 sono molto frequenti nei pazienti affetti da Insufficienza Renale Cronica (IRC) e nei pazienti in corso di terapia sostitutiva della funzione renale mediante emodialisi. Non esistono inoltre, al momento, dati solidi sui pazienti Covid-19 positivi in trattamento dialitico e nei portatori di trapianto di rene in cui, oltre ai vari fattori di rischio cardiovascolare, esiste una condizione di ridotta immunocompetenza.

 

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Monocentric experience of left atrial appendage occlusion among patients with advanced chronic kidney disease and non-valvular atrial fibrillation

Abstract

Atrial fibrillation is the most common cardiac disorder among chronic nephropathic patients. Possible therapeutic approaches include the use of anticoagulants, which are able to reduce the risk of thromboembolism but lead to an increasing bleeding risk, especially in this cohort of patients. Also, novel oral anticoagulant agents (NAO), due to their mainly renal clearance, are a relative contraindication in advanced renal disease. As an alternative to the oral anticoagulant therapy, left atrial appendage occlusion seems a promising opportunity in high risk, difficult to manage patients. Since there is limited evidence of LAAO in advanced chronic renal disease or dialysis patients, we report here a monocenter experience on 12 patients (6 of which in regular dialytic treatment) with a median clinical follow-up of fourteen months (3-22 months).

 

Keywords: left atrial appendage occlusion, LAAO, atrial fibrillation, NAO, advanced chronic kidney disease, dialysis

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Introduzione

Riportiamo qui una valutazione monocentrica prospettica della chiusura percutanea dell’auricola (LAAO) in 12 pazienti nefropatici, di cui 6 in trattamento dialitico regolare, con follow-up complessivo di 14 mesi (3-22 mesi). Abbiamo voluto valutare come end-point primario la sicurezza intra e post procedurale della manovra, le complicanze trombo-emboliche e la mortalità; come end-point secondario le complicanze infettive e l’eventuale peggioramento funzionale secondario all’impiego di mezzo di contrasto.

La fibrillazione atriale (FA) è il disturbo aritmogeno più frequentemente riscontrabile nei pazienti nefropatici affetti da malattia renale cronica (MRC), con prevalenza nel subset di quelli in dialisi del 15-20% circa, anche se probabilmente il fenomeno è sottostimato [12]. Anche nella popolazione generale, tale disturbo si associa ad un rischio di mortalità proporzionale al grado di decurtazione della funzione renale [2]; mentre nella popolazione generale il ricorso alla terapia anticoagulante orale (TAO) con gli antagonisti della vitamina K (VKA) o con le nuove molecole rappresenta il gold standard, riducendo di fatto di 2/3 il rischio trombo-embolico [3], nei pazienti nefropatici, a vari gradi di decurtazione funzionale, l’efficacia della terapia anticoagulante va perlomeno bilanciata rispetto ai potenziali rischi emorragici indotti, essendo tale coorte di pazienti a rischio per entrambe le complicanze [4-5].
 

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L’insufficienza renale acuta nell’anziano

Abstract

L’insufficienza renale acuta (IRA), definita anche come danno renale acuto, è una patologia che sta ricevendo una crescente attenzione negli ultimi anni, vista la sua incidenza, i danni che causa al paziente ed i costi che sono necessari per il suo trattamento. Il soggetto anziano, spesso gravato da numerose pluri-patologie e con una riduzione funzionale para-fisiologica dell’attività renale, risulta essere maggiormente a rischio di sviluppo di un danno renale acuto. La comparsa di IRA è infatti insieme alle sepsi una delle complicanze più frequenti nell’anziano ricoverato in ambiente ospedaliero. Vi sono delle strategie comportamentali che si sono dimostrate efficaci nella prevenzione del danno renale in molte situazioni, come l’idratazione prima dell’utilizzo dei mezzi di contrasto iodati, l’attenzione ai farmaci nefrotossici, la modulazione di concomitanti terapie che impattano sul sistema cardio-vascolare (inibitori del SRA, betabloccanti, ecc.).

Il sovraccarico di liquidi, la riduzione delle masse muscolari, gli stati settici, che si verificano molto più facilmente e rapidamente nel soggetto anziano, possono mascherare l’innalzamento della creatinina plasmatica. Pertanto, nel contesto anziano, modelli previsionali e diagnostici quali i criteri KDIGO, AKIN e RIFLE vanno presi in considerazione con una certa cautela e ripensati. L’IRA nell’anziano ha specifiche peculiarità che la rendono difficoltosa, sia sotto il profilo diagnostico che terapeutico. Le cose si complicano ulteriormente quando sono necessari interventi, come quelli dialitici, che di per sé hanno una loro un-physiology che può risultare destabilizzante in soggetti fragili e con labile compenso emodinamico.

Parole chiave: insufficienza renale acuta, anziani, co-morbidità, deterioramento danno renale acuto, dialisi

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Questo articolo è stato pubblicato sul Giornale Italiano di Nefrologia, Anno 36, Vol. 3 (Maggio Giugno 2019) e viene riproposto qui senza alcun cambiamento.

 

Introduzione

L’insufficienza renale acuta (IRA), definita anche come danno renale acuto, è una patologia che sta ricevendo una crescente attenzione negli ultimi anni, sia per la sua elevata incidenza, che per i danni che causa al paziente nonché per i costi che sono necessari al suo trattamento. L’IRA insorge nella popolazione generale nello 0,3-0,5% degli individui.  

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