Extracorporeal blood purification with Oxiris® filter in critically ill patients with COVID-19 requiring continuous renal replacement therapy.

INTRODUCTION: Severe COVID-19 is associated with a dysregulated immune response that usually leads to cytokine release syndrome. This study aimed to compare the use of extracorporeal blood purification therapy (Oxiris®) versus standard continuous renal replacement therapy (CRRT) in critically-ill patients with severe COVID-19. METHODS: This was a national, multicenter, retrospective study of patients with COVID-19 admitted to the intensive care unit (ICU) between March and October 2020 who required CRRT. Patients were categorized into two groups: Oxiris® CRRT and standard CRRT. The primary outcome was the number of patients alive and ventilator-free at 30-days post-CRRT treatment. Key secondary endpoints included change in inflammatory markers, Sequential Organ Failure Assessment (SOFA) scores, and PaO2/FiO2 ratio at 24- and 72-h post Oxiris® initiation. RESULTS: Thirty-five patients received Oxiris® CRRT and 23 patients received standard CRRT. The primary outcome was 31.4% in the Oxiris® group versus 4.3% in the standard CRRT group (adjusted odds ratio 5.97, 95% confidence interval [CI], 0.64-55.6; p = 0.117). In the Oxiris® group, interleukin-6 (IL-6) concentrations significantly decreased at 24 and 72-h (p = 0.033) and PaO2/FiO2 ratio significantly increased at 24 and 72 h after Oxiris® initiation (p = 0.001). There was no significant change in SOFA scores at 24- and 72-h after Oxiris® initiation. CONCLUSION: The number of patients alive and ventilator-free at 30-days was higher in the Oxiris® group than that in the standard CRRT group; however, the difference did not reach statistical significance after adjusting for the baseline severity of illness. There was a significant reduction in IL-6 and significant improvement in PaO2/FiO2 ratio after Oxiris® CRRT initiation.

Time-Series Forecasting of Hemodialysis Population in the State of Qatar by 2030.

BACKGROUND: There are few statistics on dialysis-dependent individuals with end-stage kidney disease (ESKD) in Qatar. Having access to this information can aid in better understanding the dialysis development model, aiding higher-level services in future planning. In order to give data for creating preventive efforts, we thus propose a time-series with a definitive endogenous model to predict ESKD patients requiring dialysis. METHODS: In this study, we used four mathematical equations linear, exponential, logarithmic decimal, and polynomial regression, to make predictions using historical data from 2012 to 2021. These equations were evaluated based on time-series analysis, and their prediction performance was assessed using the mean absolute percentage error (MAPE), coefficient of determination (R2), and mean absolute deviation (MAD). Because it remained largely steady for the population at risk of ESKD in this investigation, we did not consider the population growth factor to be changeable. (FIFA World Cup 2022 preparation workforce associated growth was in healthy and young workers that did not influence ESKD prevalence). RESULT: The polynomial has a high R2 of 0.99 and is consequently the best match for the prevalence dialysis data, according to numerical findings. Thus, the MAPE is 2.28, and the MAD is 9.87%, revealing a small prediction error with good accuracy and variability. The polynomial algorithm is the simplest and best-calculated projection model, according to these results. The number of dialysis patients in Qatar is anticipated to increase to 1037 (95% CI, 974-1126) in 2022, 1245 (95% CI, 911-1518) in 2025, and 1611 (95% CI, 1378-1954) in 2030, with a 5.67% average yearly percentage change between 2022 and 2030. CONCLUSION: Our research offers straightforward and precise mathematical models for predicting the number of patients in Qatar who will require dialysis in the future. We discovered that the polynomial technique outperformed other methods. Future planning for the need for dialysis services can benefit from this forecasting.

Risk Factors for Unplanned Initiation of Dialysis in Patients with Advanced Chronic Kidney Disease: A Retrospective Cohort Study.

Many patients with advanced chronic kidney disease (CKD) managed in a specialized multidisciplinary clinic start dialysis urgently during hospitalization rather than electively as outpatients. This study aimed to identify risk factors for starting unplanned dialysis among patients with advanced CKD who attended multidisciplinary low-clearance clinics between January 1, 2020, and December 31, 2021. Of these, 175 patients started dialysis: 101 (26.7%) started it urgently, whereas 74 (19.5%) started it electively. Patients with urgent initiation of dialysis received less education, had fewer clinic visits and follow-up and were seen less often in the vascular clinic. In the univariate regression analysis, congestive heart failure significantly increased the risk of acute dialysis. Moreover, the risk increased in patients who did not receive dialysis education. The risk increased in patients who were not seen in a vascular clinic and did not have a vascular access plan. Moreover, high albumin levels at initial presentation to the clinic had a lower risk for elective initiation of dialysis. In the multivariate regression analysis, use of renin-angiotensin-aldosterone system inhibitors and attending a vascular clinic reduced the risk of unplanned dialysis by 73% and 96%, respectively. Acute unplanned initiation of dialysis is common even in CKD patients followed in low-clearance clinics. Early referral to multidisciplinary low clearance clinics, timely education, compliance with timely follow-up periods, and creation of access in patients at risk may reduce hospital admissions, hospital stays, admission to intensive care units, costs, and morbidity in these patients.

National response to the COVID-19 Omicron variant crisis in the ambulatory hemodialysis service in the State of Qatar.

The coronavirus disease (COVID-19) pandemic has had a significant worldwide impact since its emergence in 2019. End-stage kidney disease patients have been among the most vulnerable population affected and have a higher risk of acquiring infection and developing more severe disease. We have encountered three major COVID-19 waves in Qatar and they have required different strategies to overcome. The most recent wave was due to the Omicron variant characterized by higher transmissibility. The monthly incidence of COVID-19 infection during the Omicron wave in patients with end-stage renal disease peaked at 256 patients compared to 35 and 39 patients during the first and second waves, respectively. In addition, more than one-third of our dialysis staff became infected during this wave. Unlike the previous two waves, COVID-19 due to the Omicron variant was less severe with only 5% of hemodialysis patients requiring admission to the intensive care unit compared to 25% during the previous waves. The Omicron variant wave resulted in a crisis in our country due to the high number of non-hospitalized COVID-19 hemodialysis patients and the severe staff shortage. Several measures were taken to overcome the crisis, such as designating one facility to dialyze all COVID-19 ambulatory patients, reducing dialysis sessions to 3 hours, and introducing a fourth dialysis shift. This article describes the challenges we faced in the ambulatory hemodialysis service during the Omicron wave and the measures taken in the COVID-19 and non-COVID-19 designated facilities to combat the crisis.

Effectiveness of Messenger RNA Vaccines against SARS-CoV-2 Infection in Hemodialysis Patients: A Case-Control Study.

Patients with end-stage kidney disease (ESKD) are at increased risk for SARS-CoV-2 infection and its complications compared with the general population. Several studies evaluated the effectiveness of COVID-19 vaccines in the dialysis population but showed mixed results. The aim of this study was to determine the effectiveness of COVID-19 mRNA vaccines against confirmed SARS-CoV-2 infection in hemodialysis (HD) patients in the State of Qatar. We included all adult ESKD patients on chronic HD who had at least one SARS-CoV-2 PCR test done after the introduction of the COVID-19 mRNA vaccines on 24 December 2020. Vaccinated patients who were only tested before receiving any dose of their COVID-19 vaccine or within 14 days after receiving the first vaccine dose were excluded from the study. We used a test-negative case−control design to determine the effectiveness of the COVID-19 vaccination. Sixty-eight patients had positive SARS-CoV-2 PCR tests (cases), while 714 patients had negative tests (controls). Ninety-one percent of patients received the COVID-19 mRNA vaccine. Compared with the controls, the cases were more likely to be older (62 ± 14 vs. 57 ± 15, p = 0.02), on dialysis for more than one year (84% vs. 72%, p = 0.03), unvaccinated (46% vs. 5%, p < 0.0001), and symptomatic (54% vs. 21%, p < 0.0001). The effectiveness of receiving two doses of COVID-19 mRNA vaccines against confirmed SARS-CoV-2 infection was 94.7% (95% CI: 89.9−97.2) in our HD population. The findings of this study support the importance of using the COVID-19 mRNA vaccine in chronic HD patients to prevent SARS-CoV-2 infection in such a high-risk population.

Minimal change disease following the Moderna COVID-19 vaccine: first case report.

BACKGROUND: There have been cases of minimal change disease (MCD) reported following previous vaccines. During the COVID-19 era, only 3 cases of new-onset MCD and a case of MCD relapse were reported following the Pfizer-BioNTech COVID-19 vaccine. We herein report the first case of MCD after receiving the Moderna COVID-19 vaccine. CASE PRESENTATION: A 43-year-old man presented to hospital 3 weeks after receiving the first dose of the Moderna vaccine, with both bilateral lower extremities and scrotal edema. He initially developed a sudden-onset bilateral lower extremities swelling on day 7 post-vaccine. He, then, developed dyspnea and scrotal swelling over a time span of 2 weeks. On physical examination, his blood pressure was 150/92 mmHg. There was a decreased air entry at lung bases, bilateral lower extremities and scrotal edema. Labs revealed hypoalbuminemia, hyperlipidemia and 15 g of proteinuria. His immunologic and serologic work up was negative. Renal biopsy showed concomitant MCD and IgA nephropathy. Patient was treated with oral steroids and had a good response; his edema resolved, serum albumin improved, and proteinuria decreased to 1 g within 2 weeks of treatment. CONCLUSIONS: To the best of our knowledge, MCD has not been previously reported after receiving the Moderna COVID-19 vaccine. It remains unclear whether the COVID-19 mRNA vaccines are associated with the development of MCD, or it coincided with the mass vaccination. Further studies are needed to determine the incidence of MCD post COVID-19 vaccines and the underlying pathophysiology of glomerular injury post vaccination.

Kidney Transplant Recipients Infected With Coronavirus Disease 2019: Retrospective Qatar Experience.

BACKGROUND: This study aimed to evaluate the incidence of coronavirus disease 2019 (COVID-19) infection on kidney transplant, mortality, and risk factors associated with infection acquisition and severe illness in kidney transplant recipients with COVID-19. METHODS: Of 693 kidney transplant recipients who reported to our center, 249 were tested for COVID-19 by throat and nasal swab reverse transcription polymerase chain reaction. Of these, 43 recipients tested positive and 206 recipients tested negative. Among the 43 positive recipients, 9 were treated within an isolation facility, 25 were admitted to the hospital, and 9 were admitted to the intensive care unit (ICU). Risk factors associated with positive results and ICU admission were evaluated. RESULTS: COVID-19 was found in 6% of transplant recipients. Asian ethnicity (p = .003), history of hypertensive nephropathy (p = .01), AB blood group (P = .04), and higher tacrolimus trough levels (P = .007) were more frequent in the COVID-19 positive than in the COVID-19 negative group. ICU admission was more frequent in recipients presenting with fever, shortness of breath, and acute allograft dysfunction. Renal replacement therapy was required in 3 (7%) of 43 recipients, and mortality was reported in 1 (2.3%) recipient. Acute allograft dysfunction was an independent risk factor for severe COVID-19 (odds ratio, 93.7; 95% confidence interval, 2.37-3710.94; P = .02). CONCLUSIONS: Higher tacrolimus targets may be associated with COVID-19 development. Acute kidney injury during the COVID-19 course may be a sign of severe disease. Prognostication of COVID-19 severity in kidney transplant recipients is crucial for early recognition of critical illness and may ensure early intervention.

Eradication of hepatitis C virus infection in kidney transplant recipients using direct-acting antiviral therapy: Qatar experience.

INTRODUCTION: Hepatitis C virus (HCV) infection has detrimental effects on patient and graft survival after kidney transplantation. In the pre-direct-acting antiviral (DAA) era, treatment of HCV infection was associated with low response rates, poor tolerance, and increased risk of allograft rejection. However, DAAs have revolutionized HCV treatment. The aims of this study were to determine the impact of DAA on the sustained virologic response (SVR), renal function, and calcineurin inhibitor (CNI) levels and assess the tolerability to treatment in kidney transplant recipients with HCV infection in Qatar. METHODS: This retrospective study included the medical records of all kidney transplant recipients with confirmed HCV infection before January 1, 2020. All data were obtained from the patients' electronic medical records; these included patient demographics; virologic responses to treatment; serum creatinine levels during treatment; urine protein to creatinine ratios and CNI levels before, during, and after treatment; and side effects related to DAA therapy. RESULTS: A total of 27 kidney transplant recipients with HCV were identified, 23 of whom received DAA therapy. The length of treatment ranged from 12 to 24 weeks, and 52% of patients had HCV genotype 1 infection. The median log10 HCV RNA was 6.6 copies per milliliter. None of the patients had liver cirrhosis, and all of them achieved SVR. There was no statistically significant difference in the glomerular filtration rate before, during, and after treatment. Most patients had stable CNI trough levels during treatment and did not require dose adjustment. CONCLUSIONS: HCV infection was successfully eradicated by DAA therapy in kidney transplant recipients, with a 100% SVR rate. Moreover, DAA therapy was well-tolerated, and kidney function remained stable without an increased risk of rejection. These results are expected to drive the eradication of hepatitis C from the entire country.

Atypical Anti-Glomerular Basement Membrane Disease With Diffuse Crescentic Membranoproliferative Glomerulonephritis: Case Report and Review of Literature.

Anti-glomerular basement membrane (anti-GBM) disease occurs in fewer than two cases per million population. Patients usually present with features of rapidly progressive glomerulonephritis (RPGN) with or without pulmonary involvement. Anti-GBM disease is classically diagnosed by both demonstrating GBM linear immunofluorescence staining on kidney biopsy and detecting anti-GBM antibodies in serum. More than 90% of patients with anti-GBM disease either become dialysis-dependent or die if left untreated. Here, we report a 37-year-old man who presented with bilateral lower limb edema, hypertension, acute kidney injury (creatinine of 212 µmol/L), microscopic hematuria, and nephrotic range proteinuria (15 g/day). His kidney biopsy showed diffuse crescentic membranoproliferative glomerulonephritis and bright linear staining of GBM by immunoglobulin G consistent with anti-GBM disease; however, serum anti-GBM antibodies were negative. The patient was diagnosed with atypical anti-GBM disease and treated aggressively with intravenous pulse steroids, plasmapheresis, oral cyclophosphamide, and oral prednisolone with significant improvement in kidney function and proteinuria. Atypical anti-GBM disease should be considered in patients presenting with RPGN, even in the absence of serum anti-GBM antibodies. Early diagnosis and aggressive treatment in such cases are warranted to prevent irreversible kidney damage as the course of the disease might not be as benign as previously thought.

Prediabetes and older age increase the risk of post-transplantation diabetes mellitus: Qatar experience.

Post-transplantation diabetes mellitus (PTDM) is a major complication in kidney transplant recipients leading to reduced allograft and patient survival. Given the high prevalence of diabetes in Qatar, which is twice the global average, we were interested in determining the incidence of PTDM, identifying risk factors, and comparing clinical outcomes in kidney transplant recipients with and without diabetes. We retrospectively followed up 191 adult kidney allograft recipients transplanted between January 1, 2012, and December 31, 2016, for a median of 41 months. A total of 76 patients (40%) had pre-existing diabetes. A total of 39 patients developed PTDM during follow-up; they represent 34% of patients who did not have diabetes prior to transplantation. Two thirds of PTDM occurred within 3-6 months post-transplantation. Prediabetes before transplant [OR = 6.07 (1.24-29.74), P = .026] older recipient's age at the time of transplantation [OR = 1.10 (1.00-1.20), P = .039] and average fasting blood sugar during 3-6 months post-transplant [OR = 1.06 (1.01-1.11), P = .010] were independently associated with PTDM. Patient and kidney allograft survival rates exceeded 97% in all groups. The incidence of PTDM in kidney transplant recipients living in Qatar is high. Older age and prediabetes are independent risk factors for developing PTDM.

Dehydration and volume depletion: How to handle the misconceptions.

Dehydration and volume depletion describe two distinct body fluid deficit disorders with differing pathophysiology, clinical manifestations and treatment approaches. However, the two are often confused or equated with each other. Here, we address a number of commonly encountered misconceptions about body-fluid deficit disorders, analyse their origins and propose approaches to overcome them.

Kidney allograft failure in the steroid-free immunosuppression era: A matched case-control study.

We studied the causes and predictors of death-censored kidney allograft failure among 1670 kidney recipients transplanted at our center in the corticosteroid-free maintenance immunosuppression era. As of January 1, 2012, we identified 137 recipients with allograft failure; 130 of them (cases) were matched 1-1 for recipient age, calendar year of transplant, and donor type with 130 recipients with functioning grafts (controls). Median time to allograft failure was 29 months (interquartile range: 18-51). Physician-validated and biopsy-confirmed categories of allograft failure were as follows: acute rejection (21%), glomerular disease (19%), transplant glomerulopathy (13%), interstitial fibrosis tubular atrophy (10%), and polyomavirus-associated nephropathy (7%). Graft failures were attributed to medical conditions in 21% and remained unresolved in 9%. Donor race, donor age, human leukocyte antigen mismatches, serum creatinine, urinary protein, acute cellular rejection, acute antibody-mediated rejection, BK viremia, and CMV viremia were associated with allograft failure. Independent predictors of allograft failure were acute cellular rejection (odds ratio: 18.31, 95% confidence interval: 5.28-63.45) and urine protein ≥1 g/d within the first year post-transplantation (5.85, 2.37-14.45). Serum creatinine ≤1.5 mg/dL within the first year post-transplantation reduced the odds (0.29, 0.13-0.64) of allograft failure. Our study has identified modifiable risk factors to reduce the burden of allograft failure.