Clinical Characteristics and Short- term outcomes of chronic dialysis patient

admitted for COVID-19 IN Metro Manila, Philippines

Principal investigator :

Group 2
IMD Batch 2
Brokenshire College School of Medicine

ADVISOR :

DR. BAI SHARIFFAH B. PANDITA REYES, MD, MPM

26 OCT 2023
INTRODUCTION
 INTRODUCTION
BACKGROUND

Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus. Most
people infected with the virus will experience mild to moderate respiratory illness and recover
without requiring special treatment. However, some will become seriously ill and require medical
attention. Older people and those with underlying medical conditions like cardiovascular disease,
diabetes, chronic respiratory disease, or cancer are more likely to develop serious illness. Anyone
can get sick with COVID-19 and become seriously ill or die at any age.


Chronic kidney disease, also called chronic kidney failure, involves a gradual loss of kidney
function. Your kidneys filter wastes and excess fluids from your blood, which are then removed in
your urine. Advanced chronic kidney disease can cause dangerous levels of fluid, electrolytes and
wastes to build up in your body.
 INTRODUCTION

Since its emergence in China, the novel coronavirus (COVID-19) caused by the severe acute respiratory
syndrome coronavirus 2 has rapidly become a global pandemic.

COVID-19 presents a unique challenge to patients with end stage kidney disease (ESKD) on kidney
replacement therapy.

Continuous dialysis treatments in outpatient dialysis centers pose the risk of spread of infection among
patients and healthcare staff since these closed spaces may cause easy transmission.

A steep rise in the prevalence of chronic kidney disease has been reported, with a 400% increase in the
number of patients on some form of kidney replacement therapy over the last 10 years.

The Nephrology Division provides care to over 400 patients with ESKD on chronic HD from all over the
country every year.

Data published on COVID-19 in the Filipino population, particularly those with ESKD are still lacking.
 INTRODUCTION
 Patients who have survived COVID-19 face
an increased risk of worse kidney outcomes
in the post-acute phase of the disease. Of
clinical significance, COVID-19 may
predispose surviving patients to chronic
kidney disease, independently of clinically
apparent acute kidney injury (AKI).
 INTRODUCTION
SIGNIFICANCE


Studies describing local experience are currently limited

This study aims to determine the clinical profiles and short-term outcomes of chronic
dialysis patients admitted for COVID-19 in Metro Manila, Philippines during the first few
months of the pandemic.

To have an understanding on the effect of COVID-19 on chronic dialysis patients
 INTRODUCTION
RESEARCH QUESTION

What are the effective strategies for reducing the complexity and mortality of the end stage
kidney disease (ESKD) among in-patients and out-patients, among filipino COVID-19 patients ?
METHODOLOGY
 METHODOLOGY

STUDY DESIGN


This is a single-center, retrospective, observational study conducted at the Philippine
General Hospital from April 1, 2020 to July 31, 2020

a tertiary state-owned hospital administered and operated by the University of the Philippines
Manila.
 METHODOLOGY
Research Participants


Data included all patients 18 years old and above, undergoing maintenance peritoneal dialysis
(PD) or HD, hospitalized for COVID-19 disease confirmed by at least one positive result for
SARS-CoV-2 on real-time polymerase chain reaction (RT-PCR) testing of nasopharyngeal
samples.

Exclusion
 Kidney transplant recipients and patients who expired or were discharged prior to completion
of baseline imaging and laboratory tests were excluded.
 METHODOLOGY
Data gathering


Data was collected through chart review of both paper and electronic medical records. This
included demographicinformation on patients’ age, sex, dialysis vintage, cause of kidney
failure, and comorbidities.

Comorbidities
 Hypertension
 Cardiovascular disease
 Diabetes melitus
 Chronic lung disease

 Presence of malignancy
 METHODOLOGY
Data gathering


History of hypertension was determined by history of intake or oral antihypertensive agents and/or with
records of blood pressure monitoring ≥140/90 mmHg on more than 2 occasions

Cardiovascular disease was determined by history of ischemic heart disease and/or by evidence of
coronary artery disease by cardiac catheterization reports

History of diabetes mellitus was determined by fasting blood sugar ≥126 mg/dL or HBa1c ≥6.5% or if
by history was being treated by oral hypoglycemic agents and/or insulin formulations.

History of heart failure by history,clinical symptoms, or by evidence on 2D echocardiography was also
included.

Malignancy was defined as any evidence of active malignancy in any organ either by history or
documentation in medical records.
 METHODOLOGY
Statistical Analysis


Descriptive statistics were used in the analysis of this study. Continuous variables are expressed as
median with interquartile range (IQR) as appropriate.

Baseline characteristics, clinical and radiologic findings between survivors and mortalities were compared
using Student’s t-test or Mann–Whitney U-test for quantitative variables, and chi-square test or Fisher
exact test for qualitative variables, as appropriate.

Box-and-whiskers graphs were constructed for factors with significant differences.

Variables included age, sex,comorbidities (hypertension and diabetes mellitus), dialysis vintage,
hemoglobin level, white blood count, absolute lymphocyte count, platelet count, inflammatory
markers (procalcitonin, ferritin, CRP, and LDH) and ventilatory support.

Survival analysis was done using length of hospital stay in days as time function and mortality as failure
function in analysis of interventions received during admission.
 METHODOLOGY
Data handling and analysis

Descriptive statistics were used in the analysis of this study. Continuous variables are
expressed as median with interquartile range (IQR) as appropriate.

Baseline characteristics, clinical and radiologic findings between survivors and mortalities were
compared using Student’s t-test or Mann–Whitney U-test for quantitative variables, and chi-
square test or Fisher exact test for qualitative variables, as appropriate. Box-and-whiskers
graphs were constructed for factors with significant differences when grouped according to
survival.

Variables included age, sex, comorbidities (hypertension and diabetes mellitus), dialysis
vintage, hemoglobin level, white blood count, absolute lymphocyte count, platelet count,
inflammatory markers (procalcitonin, ferritin, CRP, and LDH) and ventilatory support.
 METHODOLOGY
Data handling and analysis


Survival analysis was done using length of hospital stay in days as time function and
mortality as failure function in analysis of interventions received during admission.

Log rank test for equality of survival functions was done to interventions which have
differences in survivor functions.

Univariate logistic regression model was created to determine the risk factors for mortality
from COVID-19 in our study population.
Research Question:

•1.What type of research study is this ?

•2.Who were excluded from the Research?
•3.How was the data gathered?
•4.what were included in the data collection?
DUMMY RESULTS
 DUMMY RESULTS

We identified 68 patients with ESKD on dialysis admitted with COVID-19 at the PGH from April
1 to July 31, 2020.

The mean age was 54.5 years, with a higher prevalence being male (66%). The most common
comorbidities were hypertension (74.6% of survivors and 25.5% of non-survivors) and
diabetes (74.1% of survivors and 25.9% of non-survivors). It followed that the cause of ESKD
among these patients were also hypertension and diabetes.

All patients were on maintenance HD, while none were on PD. The median dialysis vintage
was 2 years. There were no statistically significant differences in clinical and demographic
characteristics between those who survived and those who died.
 DUMMY RESULTS

Table 1 Baseline Characteristics of ESKD Patients on Dialysis Admitted for COVID-19 Infection
 DUMMY RESULTS

Table 2 Clinical Characteristics and Laboratory Findings of COVID-19 Among ESKD Patients on
Dialysis
DUMMY RESULTS

Statistically significant differences in

admission PF ratio and some inflammatory
markers were seen between the survivors
and non-survivors. Those who died had
lower PF ratios (162 versus 356;
p=0.0009, Figure 1A), higher
procalcitonin (6.07 ng/mL versus 0.73
ng/mL; p=0.02; Figure 1B), higher LDH
(396 U/L versus 282 U/ L; p=0.03; Figure
1C), and higher white blood cell counts
(10 x 109 /L versus 6.3 x 109 /L; p=
0.0039; Figure 1D) on
admission, compared to those who
survived.
 DUMMY RESULTS

Treatment Interventions Given for COVID-19

During the course of the admission, a total of 46 (67.7%) ESKD patients received
azithromycin, 1 (1.5%) received antivirals (lopinavir/ritonavir), 8 (11.76%) received
hydroxychloroquine or chloroquine, 6 (8.82%) received tocilizumab, 6 (8.82%) received
corticosteroids, and 1 (1.47%) received convalescent plasma therapy
 DUMMY RESULTS

Risk factor for mortality feom COVID-19


There are several controversies regarding the clinical course of COVID-19 in ESKD patients.
Early in the pandemic, it was thought that they may present with mild,atypical symptoms.

Treatment strategies also varied throughout the duration of this study. From March to May
2020, the use ofchloroquine and hydroxychloroquine, azithromycin, as well as the antiviral
(Lopinavir/Ritonavir) were included in the investigational therapies used by our infectious
disease specialists. By June, the use of these medications was stopped, and the
interleukin-6 inhibitor, Tocilizumab, was given judiciously in a select number of patients.
Corticosteroid use increased towards the end of our study, in July, when reports of its
benefits among those on ventilatory support were released
 DUMMY RESULTS
Conclusion

ESKD patients on chronic HD are a vulnerable population at increased risk of mortality from
COVID-19 infection.n.

The severity of acute respiratory failure, measured by low PF ratio on admission and need for
invasive ventilatory support, are independently associated with inhospital mortality.

Need for designated outpatient hemodialysis units for ESKD patients with COVID-19 and
mitigating limited resources are some local challenges that remain to be addressed.
REFERENCE
 REFERENCES

1. Naicker S, Yang CW, Hwang SJ, Liu BC, Chen JH, Jha V. The novelcoronavirus 2019 epidemic and kidneys. Kidney Int. 2020;1–5.doi:10.1016/j.kint.2020.03.001
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2. Coronavirus disease (COVID-19) situation reports. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/ situation-reports. Accessed
August 15, 2020.

3. Cheng Y, Luo R, Wang K, et al. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int. 2020;97 (5):829–838.
doi:10.1016/j.kint.2020.03.005
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4. Li J, Xu G. Lessons from the experience in Wuhan to reduce risk of COVID-19 infection in patients undergoing long-term hemodialysis. Clin J Am Soc Nephrol.
2020;15:717–719.
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5. Clarke C, Prendecki M, Dhutia A, et al. High prevalence of asymptomatic COVID-19 infection in hemodialysis patients detected using serologic screening. J Am Soc
Nephrol. 2020;31:1960–1975.
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6. Prasad N, Bhatt M, Agarwal SK, et al. The adverse effect of COVID pandemic on the care of patients with kidney diseases in India. Kidney Int Reports.
2020;5(9):1545–1550. doi:10.1016/j.ekir.2020.06.034
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7. United States Renal Data System. 2017 USRDS Annual Data Report: epidemiology of kidney disease in the United States. Am J KidneyDis. 2018;71(3):S461–S500.
doi:10.1053/j.ajkd.2018.01.024
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8. Department of Health website. Available from: https://www.doh.gov.ph/2019-nCov. Accessed August 15, 2020.

9. PGH. Jose Rodriguez Memorial designated as exclusive COVID-19 hospitals – health dept. Available from:
https://www.cnnphilippines.com/news/2020/3/20/Lung-Center-Jose-Rodriguez-MemorialCaloocan COVID-exclusive-hospitals-DOH.html. Accessed August 15, 2020.
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10. 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.
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12. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21 (3):335–337. doi:10.1016/S1470-
2045(20)30096-6
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13. Lighter J, Phillips M, Hochman S, et al. Obesity in patients younger than 60 years is a risk factor for Covid-19 hospital admission. ClinInfect Dis. 2020;71(15):896–
897. doi:10.1093/cid/ciaa415
 BUDGET
PARTICULARS Source of Funds And Amount (Php)

Name of Sponsor Department Other Sources

1.Personnel Services(PS)
a.Salaries
b.Honoraria

PS SUBTOTAL
2.Maintenance and Other
Operating Expenses(MOOE)
a.Traveling Expenses
b.Supplies and materials
expenses

MOOE SUBTOTAL
3.Capital Outlay

GRAND TOTAL
APPENDIX E. Research Budget .

Resource Requirement Cost (Php)

Office Supplies
• Bond Paper 500
• Printer Ink 2,000
• Storage Device/s 1,600
• Envelopes/Folders 500
• Ballpens/Markers 200

Honorarium
• Statistician 10,000
• Clerks 2,000

Meals/Snacks 5,000
Transportation 1,000
TOTAL 22,500
TIME TABLE
 MEMBERS – GROUP 2

BHOLA 
MADHU NOEL YASWATH ROSHAN

MUHAMMED HARSHIN •
MANIKANDAN ANJANA

SAAD MOHAMED RAFFI 
MERUGUMALA CAROL PAUL

SHAIKH AMRIN 
MURUGESHAN VISHNU

AMALRAJ DIVINITABIYA 
PANWAR AISHWARYA

BABU ELSA GRACE 
SAKTHIVEL DINESHRAM

BHADUGULE RAM VASANT 
SATHEESH SRAVYA

BIRARI AARYA BHARAT 
SHANMUGAM AVINASH

BUDHWANI ROHAN SACHIN 
SOUMYA ILAN KEERTHI CHEZIAN

CHINAVATH AKHILA 
THULASIMOHAN THARUNPRASAD

DASARI KIRAN KUMAR 
DILLI BABU ASHWITHA

DESALE SHANTANU VINOD 
PRAKASH APARNA

GEDELA SAIROHIT 
MISHRA NISHANT RAKESH

JAVALAGIRI VISHNU VARDHAN SINGH 
THEVAR VALLI ARUMUGAM

KASAGONI VARSHITHA 
MALI PRADEEP DATTARAY

KOORARATH SWETHAPRABHA 
LAGAD GANESH POPAT
THANK YOU