The coronavirus 2019 (COVID-19) disease outbreak occurred in Wuhan, Hubei Province, China, in December 2019 and has been declared a global pandemic by World Health Organization (WHO) [1]. COVID-19 is highly contagious by human-to-human transmission and can cause critical conditions and even death [2]. Over 20 million confirmed cases and over 800,000 deaths by the end of August 2020 [3]. Although underlying diseases have been considered a significant risk factor for clinical outcomes such as acute respiratory distress syndrome (ARDS), sepsis, shock, and all-cause mortality, the relationship between specific underlying diseases, for example, renal dysfunction, and these outcomes in patients with Covid-19 is unclear [4,5]. The main clinical features of severe COVID-19 infection are lung destruction and respiratory failure, but some studies have shown that COVID-19 infection also involves other organs, including the kidney a liver [6-8]. Recent clinical evidence has revealed that COVID-19 patients with acute kidney injury (AKI) had fatal outcomes [6,9,10]. This implies that patients with pre-existing chronic kidney disease (CKD), who have functional defects in their innate and adaptive immune cells, may have a higher risk of COVID-19 infection and death [11-13]. Clinicians should take more notice of medical management and prevention of COVID-19 infection in this population. Although several investigations have reported CKD in patients with COVID-19 infection, the data collected were usually restricted to a   single   hospital or country [14,15]. Aim of the study was to find out the Outcome of patients with Chronic Kidney Disease during COVID-19.

This retrospective study was conducted at the department of Medicine in Shaheed Monsur Ali Medical College, Dhaka, Bangladesh. This study was carried out from January 2020 to December 2021 with 115 patients. The Institute's ethics committee granted the permission to study. A significant proportion of the patients admitted were undergoing maintenance dialysis from other centres (government or private). The study's primary objective was to describe the clinical-epidemiological, biochemical and radiological profile of patients with laboratory-confirmed COVID-19 and kidney disease. The diagnostic criteria for COVID-19 infection was a laboratory-confirmed SARS-CoV-2 infection, detected in nasopharyngeal and oral swabs by RT-PCR using methods recommended by the Bangladesh Medical Research Council (BMRC), with or without clinical symptoms. For patients on kidney replacement therapy, especially haemodialysis, most centres adhered to the national guidelines for screening patients for COVID-19 with RT-PCR or rapid antigen test [16]. As per national guidelines, a mandatory quarantine policy for all COVID-19-positive patients was observed until 14 days after infection. Those with underlying comorbidities were advised to be hospitalized rather than in a Covid-care center/isolation facility, especially those undergoing regular hemodialysis. The cases were categorized into mild, moderate and severe based on the following definitions [17].

• Mild COVID-19 infection: Mild COVID-19 infection was defined as cases presenting with fever and/or upper respiratory tract illness with normal respiratory rates (14–16/min).

• Moderate COVID-19 infection: Moderate COVID-19 was defined as Pneumonia with no signs of severe disease (respiratory rates 15 to 30/minute, SpO2 90%–94% on room air).

• Severe COVID-19 infection: Severe disease was defined as fever or suspected respiratory infection, plus one of the following; respiratory rate >30 breaths/min, severe respiratory distress, SpO2 <90% on room air.

All patients on dialysis and detected COVID-19 positive were admitted to the dialysis facility in this Covid-dedicated center. They were discharged once clinically stable and achieved RTPCR negativity so that they were fit to resume their maintenance dialysis requirements in a Covid-negative facility. The case records of patients were retrieved, and data about the demographic details, exposure history, underlying co-morbidities, clinical presentation, previous and present medications, dialysis requirement, laboratory and radiological profile, treatment, complications and outcomes were collected. In addition to inflammatory markers such as C-reactive protein, IL-6, procalcitonin (PCT) and thrombosis, haematological and biochemical parameters including hemogram, total leukocyte count, neutrophil/lymphocyte ratio, kidney function test and liver function test were recorded. Like the D-dimer. Patient outcomes during hospitalization in terms of death or discharge and the proportion of patients developing complications (respiratoryfailure/myocarditis/AKI/thro mbocytopenia/others) were reported. No prospective details were recorded after the patients were discharged. Data were entered in a pre-determined preform and duration of hospital stay, and the proportion of patients requiring respiratory support, i.e., O2 by mask, high flow nasal cannula, non-invasive ventilation, mechanical ventilation and time to RTPCR negativity, was recorded. Data of CKDND patients were compared with the details of CKD5D patients. Likewise, the disease characteristics were compared between those who survived versus those who succumbed.

Inclusion Criteria

• Patients of all ages with CKD were admitted at ……. hospital during the study duration.

• Patients whose RT-PCR test on the nasopharyngeal and oropharyngeal swab is reported as positive for SARS CoV-2.

Exclusion Criteria

• There was no exclusion criterion.

Statistical analysis

All data were presented in a suitable table or graph according to their affinity. A description of each table and graph was given to understand them clearly. All statistical analysis was performed using the statistical package for social science (SPSS) program, and Windows. Continuous parameters were expressed as mean ±SD and categorical parameters as frequency and percentage. Comparisons between groups (continuous parameters) were made by Student’s t-test. Categorical parameters compared by Chi-Square test. The significance of the results as determined by a 95.0% confidence interval and a value of p<0.05 was considered to be statistically significant. 

This is a retrospective observational; 115 patients were enrolled and analyzed in this study. Table 1 shows the age distribution of the participants; most of the 38(33.04%) patients were from the age range 60≥ years, and the lowest 3(2.61%) patients were from the age range ≤18 years. The figure shows the sex distribution of the study; the male patients were 61.74%, and the females were 38.26%. According to the COVID-19 categories, 55(47.83%) patients were from severe categories, 44(38.26%) patients were from mild categories, and 16(13.91%) patients were from moderate categories. Most 70(60.87%) patients had a fever, and only two had diarrhea in Table 2. Table 3 shows study complications and comorbidities; About 42% of patients had pneumonia, 13 (11.30%) patients had encephalopathy, 17 (14.78%) patients had AKI, and only 4 (3.48%) patients had other complications. According to comorbidities, 95(82.61%) patients with hypertension, 40(34.78%) patients with type 2 diabetes mellitus, and only two patients with pulmonary Koch's Table 3. In this study were got 90 patients were alive, and 32 patients were expired. From the investigation, the hemoglobin level of survivors was 11.95±1.83 and expired was 9.35±2.04; lymphocyte count and platelets level were also mentioned in table 4. Table 4 also shows the drugs used in the study; approximately 85% of survivors were treated with Ivermectin, and more than 80% of survivors were treated with HCQ. The crucial part of the study was that most expired patients were treated with multiple drugs like HCQ, azithromycin, Ivermectin, steroid, etc. Table 5 shows the hospital stay of the study populations; most of the 52(45.22%) patients were admitted to the hospital for more than 36 days, 41(35.65%) patients were admitted to the hospital for 19-36 days, and 22(19.13%) patients were admitted to the hospital for 0-18 days. From our study, there were 52(45.22%) patients turned RTPCR negative within 54 days, 40(34.78%) patients needed 36 days, and 23(20.00%) patients needed 18 days to get negative results Table 5. The study's outcome; the survivor's rate was 78.26%, and the mortality rate was 21.74%.

Table 1: Age distribution of the study population (N=115)

 Table 2: Covid-19 categories and symptoms

Table 3: Complications and Co-Morbidities of the Study Populations

The present study looked at the outcomes of patients hospitalized with COVID-19 infection with an underlying CKD. A majority of the patients were already on maintenance hemodialysis at admission. The study population comprised a higher proportion of males (61.74%); the prevalence of diabetes and hypertension was 34.78% and 82.61%, respectively. A multicenter US-based study described the profile and outcomes of 419 ESKD patients (62.1% males), and the prevalence of diabetes and hypertension was 59.2% and 91.2% in that cohort [18]. Similar results had been reported by the ERA-EDTA registry data, too [19]. This reflects the demographic profile of Bangladesh, with a higher proportion of the younger population (only 6% >65 years of age compared to 15.2% in the United States and 19.2% in the European Union). Patients with ESKD are at an increased risk of infections, especially bacterial, predominantly due to a uremic milieu that predisposes to immune dysregulation [20]. The annual mortality due to sepsis is almost 50 times higher in the dialysis population compared to the general population [21]. Most patients in the study were symptomatic for COVID-19, with moderate or severe infection. Another smaller series from India reported a higher number of asymptomatic and mild patients  in  a  similar  group,  especially  at  the start of the pandemic [22]. 

Table 4: Investigations and Treatment Drugs of the Study Populations

Table 5: Days of hospital stay

However, a nationwide study from Turkey has described a higher incidence (43.9%) of severe disease among hospitalized CKD, hemodialysis, and renal transplant patients [23]. A Korean study has also reported more severe disease in CKD5D (78.6%) [24]. The drugs most frequently used for treating COVID-19 infection were HCQS and ivermectin. The use of azithromycin was lower as prolonged QT intervals were seen in at least 20% of patients who were co-administered HCQ. Table 4. Remdesivir could be used only in a single patient as its use is contraindicated in stages 4 and 5 of CKD. Other studies have reported similar usage of these drugs. However, the evidence for the use of antiviral agents is relatively scant for patients with CKD, as most trials on therapy have excluded these patients [23-25]. The usage of steroids (63.8%) and LMWH (59.2%) was higher than in other series, possibly due to the more severe disease and patient admissions after the benefits of steroids had been published by the recovery trial (interim analysis was published in 2020) [23, 24, 26, 27]. The overall mortality was 21.74%, and 78.26% of patients survived. High mortality rates of 11.6% and 31.7% among the CKD population have been reported in China and later from other countries [18- 20, 28-30]. The mortality rates were higher in series, having a more significant proportion of ESKD patients [29, 31]. A metanalysis (n=38,906) on hospitalized COVID-19 patients (from the US, Europe, and China) showed a case fatality rate of 48% (37–63%) for CKD; deaths were more in males and those above 60 years of age [31]. An analysis of our deaths showed that diabetes mellitus, dyspnoea at presentation, encephalopathy, and ground-glass opacities on chest radiographs were associated with a higher mortality risk. Among survivors, the median time to RTPCR negativity was 15 days, and significant shedding was observed even after three weeks implying prolonged viral shedding in patients with CKD. Further, there was an earlier viral clearance for CKD patients. Another study from Korea has made a similar observation [24]. Trained human resources was a significant constraint during the pandemic's peak in many countries, and a pooling of all resources to tide the crisis appeared to be a reasonable solution. This led to our repurposing for managing more adult renal patients at our COVID-19-only facility. Table 5. In the process, we pediatric nephrologists got an opportunity to broaden our horizons and felt grateful for the opportunity to serve during the pandemic. Other pediatric nephrology colleagues have shared similar experiences in developed parts of the world [32]. To conclude, we learned that the severity of COVID-19 infection was higher in patients with CKD, and so was mortality. Besides, they shed the virus for prolonged periods (>2 weeks), thus necessitating more extended hospitalization for dialysis and prevention of viral spread. 

Limitations of the study

Every hospital-based study has some limitations and the present study undertaken is no exception to this fact. The limitations of the present study are mentioned. Therefore, the results of the present study may not be representative of the whole of the country or the world at large. The number of patients included in the present study was less in comparison to other studies. Because the trial was short, it was difficult to remark on complications and mortality.

In conclusion, patients with CKD had a significantly increased risk of all-cause mortality and hospitalization compared with those without CKD. Clinicians should pay more medical attention to this population in COVID-19 infection and apply timely adequate medical strategies to prevent the progression to poor outcomes.

Conflict of Interest

None declared

Funding

No funding sources

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