Clinical triage of patients on kidney replacement therapy presenting with COVID-19: An ERACODA registry analysis

Mitra, S.; Jayanti, A.; Vart, P.; Coca, A.; Gallieni, M.; Ovrehus, M. A.; Midtvedt, K.; Abd Elhafeez, S.; Gandolfini, I.; Buttner, S.; Franssen, C. F. M.; Hemmelder, M. H.; Van Der Net, J. B.; Essig, M.; Du Buf-Vereijken, P. W. G.; Van Ginneken, B.; Maas, N.; Vogt, L.; Van Jaarsveld, B. C.; Jager, K. J.; Bemelman, F. J.; Klingenberg-Salahova, F.; Heenan-Vos, F.; Vervloet, M. G.; Nurmohamed, A.; Abramowicz, D.; Verhofstede, S.; Maoujoud, O.; Malfait, T.; Fialova, J.; Melilli, E.; Fava, A.; Cruzado, J. M.; Perez, N. M.; Lips, J.; Krepel, H.; Adilovic, H.; Hengst, M.; Rydzewski, A.; Gellert, R.; Oliveira, J.; Alferes, D. G.; Zakharova, E. V.; Ambuehl, P. M.; Walker, A.; Winzeler, R.; Lepeytre, F.; Rabate, C.; Rostoker, G.; Marques, S.; Azasevac, T.; Katicic, D.; Dam, M. T.; Kruger, T.; Brzosko, S.; Zanen, A. L.; Logtenberg, S. J. J.; Fricke, L.; Slebe, J. J. P.; Kemlin, D.; Van De Wetering, J.; Reinders, M. E. J.; Eiselt, J.; Kielberger, L.; El-Wakil, H. S.; Verhoeven, M. A. M.; Canal, C.; Facundo, C.; Ramos, A. M.; Debska-Slizien, A.; Veldhuizen, N. M. H.; Tigka, E.; Konsta, M. A. P.; Panagoutsos, S.; Mallamaci, F.; Postorino, A.; Cambareri, F.; Covic, A.; Matceac, I.; Nistor, I.; Cordos, M.; Groeneveld, J. H. M.; Jousma, J.; Marjolijn Van Buren,; Diekmann, F.; Tiago Assis Pereira,; Santos, A. C. S.; Arias-Cabrales, C.; Crespo, M.; Llinas-Mallol, L.; Buxeda, A.; Tarrega, C. B.; Redondo-Pachon, D.; Jimenez, M. D. A.; Hofstra, J. M.; Franco, A.; Arroyo, D.; Rodriguez-Ferrero, M. L.; Manzanos, S. B.; Barrios, R. H. S.; Avila, G.; Laranjinha, I.; Mateus, C.; Lemahieu, W.; Bartelet, K.; Dirim, A. B.; Sever, M. S.; Demir, E.; Safak, S.; Turkmen, A.; Hollander, D. A. M. J.; De Vries, A. P. J.; Meziyerh, S.; Van Der Helm, D.; Mallat, M.; Bouwsma, H.; Sridharan, S.; Petruliene, K.; Maloney, S. -R.; Verberk, I.; Van Der Sande, F. M.; Christiaans, M. H. L.; Mohankumar, N.; Di Luca, M.; Tuglular, S. Z.; Kramer, A.; Beerenhout, C.; Luik, P. T.; Kerschbaum, J.; Tiefenthaler, M.; Watschinger, B.; Adema, A. Y.; Stepanov, V. A.; Zulkarnaev, A. B.; Turkmen, K.; Fliedner, A.; Asberg, A.; Mjoen, G.; Miyasato, H.; De Fijter, C. W. H.; Mongera, N.; Pini, S.; De Biase, C.; Duivenvoorden, R.; Hilbrands, L.; Kerckhoffs, A.; Van De Logt, A. -E.; Maas, R.; Lebedeva, O.; Lopez, V.; Verhave, J.; Reichert, L. J. M.; Titov, D.; Parshina, E. V.; Zanoli, L.; Marcantoni, C.; Van Gils-Verrij, L. E. A.; Harty, J. C.; Meurs, M.; Myslak, M.; Battaglia, Y.; Lentini, P.; Den Deurwaarder, E.; Stendahl, M.; Rahimzadeh, H.; Schouten, M.; Rychlik, I.; Cabezas-Reina, C. J.; Roca, A. M.; Nauta, F.; Goffin, E.; Kanaan, N.; Labriola, L.; Devresse, A.; Diaz-Mareque, A.; Meijers, B. K. I.; Naesens, M.; Kuypers, D.; Desschans, B.; Tonnelier, A.; Wissing, K. M.; De Arriba, G.; Dedinska, I.; Pessolano, G.; Maggiore, U.; Malik, S.; Papachristou, E.; Gansevoort, R. T.; Noordzij, M.; Berger, S. P.; Meijer, E.; Ozyilmaz, A.; Sanders, J. S. F.; Ponikvar, J. B.; Arnol, M.; Pernat, A. M.; Kovac, D.; Ekart, R.; Abrahams, A. C.; Molenaar, F. M.; Van Zuilen, A. D.; Meijvis, S. C. A.; Dolmans, H.; Tantisattamo, E.; Esposito, P.; Krzesinski, J. -M.; Barahira, J. D.; Sabiu, G.; Martin-Moreno, P. L.; Guglielmetti, G.; Guzzo, G.; Toapanta, N.; Soler, M. J.; Luik, A. J.; Van Kuijk, W. H. M.; Stikkelbroeck, L. W. H.; Hermans, M. M. H.; Rimsevicius, L.; Righetti, M.; Islam, M.; Braak, N. H. -T.

doi:10.1093/ndt/gfab196

Background: Patients on kidney replacement therapy (KRT) are at very high risk of coronavirus disease 2019 (COVID-19). The triage pathway for KRT patients presenting to hospitals with varying severity of COVID-19 illness remains ill-defined. We studied the clinical characteristics of patients at initial and subsequent hospital presentations and the impact on patient outcomes. Methods: The European Renal Association COVID-19 Database (ERACODA) was analysed for clinical and laboratory features of 1423 KRT patients with COVID-19 either hospitalized or non-hospitalized at initial triage and those re-presenting a second time. Predictors of outcomes (hospitalization, 28-day mortality) were then determined for all those not hospitalized at initial triage. Results: Among 1423 KRT patients with COVID-19 [haemodialysis (HD), n = 1017; transplant, n = 406), 25% (n = 355) were not hospitalized at first presentation due to mild illness (30% HD, 13% transplant). Of the non-hospitalized patients, only 10% (n = 36) re-presented a second time, with a 5-day median interval between the two presentations (interquartile range 2-7 days). Patients who re-presented had worsening respiratory symptoms, a decrease in oxygen saturation (97% versus 90%) and an increase in C-reactive protein (26 versus 73 mg/L) and were older (72 vs 63 years) compared with those who did not return a second time. The 28-day mortality between early admission (at first presentation) and deferred admission (at second presentation) was not significantly different (29% versus 25%; P = 0.6). Older age, prior smoking history, higher clinical frailty score and self-reported shortness of breath at first presentation were identified as risk predictors of mortality when re-presenting after discharge at initial triage. Conclusions: This study provides evidence that KRT patients with COVID-19 and mild illness can be managed effectively with supported outpatient care and with vigilance of respiratory symptoms, especially in those with risk factors for poor outcomes. Our findings support a risk-stratified clinical approach to admissions and discharges of KRT patients presenting with COVID-19 to aid clinical triage and optimize resource utilization during the ongoing pandemic.