Outcomes of COVID-19 among Patients on In-Center Hemodialysis: An Experience from the Epicenter in South Korea

Abstract

Patients with advanced chronic kidney disease (CKD) or who are on hemodialysis (HD) could have increased susceptibility to the 2019 coronavirus disease (COVID-19) given their pre-existing comorbidities, older age, compromised immune system, and regular visits to populated outpatient dialysis centers. This study included 14 consecutive patients on HD or with advanced CKD who initiated HD after being diagnosed with laboratory-confirmed COVID-19 from February to April 2020 in hospitals throughout Daegu, South Korea. The included patients, 42.9% of whom were men, had a mean age of 63.5 years. Four patients had a history of contact with a patient suffering from COVID-19. The most common symptom was cough (50.0%), followed by dyspnea (35.7%). The mean time from symptom onset to diagnosis and admission was 2.6 and 3.5 days, respectively. Patients exhibited lymphopenia and elevated inflammatory markers, including C-reactive protein and ferritin. Chest radiography findings showed pulmonary infiltration in 10 patients. All patients underwent regular HD in a negative pressure room and received antiviral agents. Four patients received mechanical ventilation and continuous renal replacement therapy at a median duration of 14.0 and 8.5 days, respectively. One patient underwent extracorporeal membrane oxygenation for three days. Among the 14 patients included, two died due to acute respiratory distress syndrome, nine were discharged from the hospital, and three remained hospitalized. Despite the high-risk conditions associated with worse outcomes, patients on HD did not exhibit extremely poor overall COVID-19 outcomes perhaps due to early diagnosis, prompt hospitalization, and antiviral therapy.

Keywords: COVID-19; SARS-CoV-2; South Korea; hemodialysis.

Figure 1

Temporal changes in laboratory markers in individual patients with end-stage renal disease and COVID-19. The temporal changes for (A) lymphocyte count, (B) lymphocyte percentage, (C) C-reactive protein, (D) ferritin, (E) lactate dehydrogenase, and (F) creatine phosphokinase. The red symbols and solid red lines indicate the results for patients who died. The dotted red lines indicate the lower limit of normal for lymphocyte count and lymphocyte percentage, while the dotted blue lines indicate the upper limit of normal for each parameter.

Figure 2

Temporal changes in chest imaging studies in one patient with end-stage renal disease and COVID-19. Temporal changes in chest radiography and computed tomography for patient number 2. Initial chest radiography upon admission showed focal consolidations in the right upper and left middle lung zones (A). (B,E) Images obtained on the 16th day of hospitalization showed bilateral worsening of multifocal patchy consolidations and ground glass opacities. (C,F) Images obtained on the 23rd day of hospitalization (the day of discharge) showed improvement of multifocal patchy consolidations and ground glass opacities, as well as organized changes. (D) Image obtained on 14th day after discharge (37 days from admission) showed resolved inflammatory lung lesions.

Figure 3

Clinical courses and outcomes for individual patients with end-stage renal disease and COVID-19. As of 14 April 2020, a total of 2 (14.3%) patients had died, 9 (64.3%) had been discharged, and 3 (21.4%) remained under treatment. Abbreviations: COVID-19, coronavirus disease 2019; HD, hemodialysis; CRRT, continuous renal replacement therapy; MV, mechanical ventilation; ECMO, extracorporeal membrane oxygenation.