Clinical and histopathological characteristics of primary focal segmental glomerulosclerosis in Turkish adults.

The data regarding primary FSGS (pFSGS) from different parts of the world differ. While the prevalence of pFSGS has been increasing in Western countries like the USA, it follows an inconsistent trend in Europe and Asia and a decreasing trend in Far Eastern countries such as China in the last two decades. There are undetermined factors to explain those national and geographic discrepancies. Herein, we aimed to reveal the current prevalence with clinical and histopathological characteristics of pFSGS in Turkish adults. This study includes the biopsy-proven pFSGS patients data recorded between 2009 and 2019, obtained from the national multicenter primary glomerulonephritis registry system of the Turkish Society of Nephrology Glomerular Diseases (TSN-GOLD) database. 850 of the 3875 primer glomerulonephritis patients(21.9%) have pFSGS. The mean age is 40.5 ± 14.2 and 435 (51.2%) of patients are male. Nephrotic syndrome is the most common biopsy indication (59.2%). 32.6% of patients have hematuria, 15.2% have leukocyturia and 7.8% have both. Serum creatinine, albumin, and proteinuria are 1.0 mg/dL (IQR = 0.7-1.4) mg/dl, 3.4 ± 0.9 g/dl, 3400 mg/day(IQR, 1774-5740), respectively. Females have lower mean arterial pressure (- 2.2 mmHg), higher eGFR (+ 10.0 mL/min/1.73 m2), and BMI (+ 1.6 kg/m2) than males. Thickened basal membrane(76.6%) and mesangial proliferation (53.5%) on light microscopy are the major findings after segmental sclerosis. IgM (32.7%) and C3 (32.9%) depositions are the most common findings on immunofluorescence microscopy. IgM positivity is related to lower eGFR, serum albumin, and higher proteinuria. The prevalence of pFSGS is stable although slightly increasing in Turkish adults. The characteristics of the patients are similar to those seen in Western countries.

Proton pump inhibitors with calcium acetate on serum phosphorus levels in hemodialysis patients.

Background: The increase in serum phosphorus level is an independent risk factor for mortality in patients with chronic renal failure or undergoing dialysis due to end-stage renal disease. Proton pump inhibitors (PPI) are the general name given to agents used to suppress stomach acid. In this study, the clinical benefit of using PPIs in addition to drugs used for phosphorus control was investigated. Methods: 153 patients with end-stage renal disease were included in the study. The data of the patients who had been on hemodialysis for at least 6 months and using calcium acetate for at least 1 month were recorded in the SPSS 21 program. The patients were analyzed in two groups according to whether they used PPI or not. Anamnesis, patient follow-up, laboratory, and treatment forms collected from hemodialysis centers were used. Results: Of the 153 patients in the study, 49% were males and the mean age was 65.11±11.23. The mean duration of patients on dialysis was 48.5 months. Hypertension was found to be the most common comorbidity with 75.8% prevalence among the patients. The mean phosphorus levels of the patients using calcium acetate together with PPI were found to be approximately 1.2 mg/dl lower (p= 0.000). Conclusion: It should be taken into account that the use of PPI together with calcium acetate, which is still common as a phosphorus binder in developing countries, can contribute to controlling phosphorus levels.

Evaluation of Outcomes of Peritoneal Dialysis Patients in the Post-COVID-19 Period: A National Multicenter Case-Control Study from Turkey.

INTRODUCTION: There are not enough data on the post-CO-VID-19 period for peritoneal dialysis (PD) patients affected from COVID-19. We aimed to compare the clinical and laboratory data of PD patients after COVID-19 with a control PD group. METHODS: This study, supported by the Turkish Society of Nephrology, is a national, multicenter retrospective case-control study involving adult PD patients with confirmed COVID-19, using data collected from April 21, 2021, to June 11, 2021. A control PD group was also formed from each PD unit, from patients with similar characteristics but without COVID-19. Patients in the active period of COVID-19 were not included. Data at the end of the first month and within the first 90 days, as well as other outcomes, including mortality, were investigated. RESULTS: A total of 223 patients (COVID-19 group: 113, control group: 110) from 27 centers were included. The duration of PD in both groups was similar (median [IQR]: 3.0 [1.88-6.0] years and 3.0 [2.0-5.6]), but the patient age in the COVID-19 group was lower than that in the control group (50 [IQR: 40-57] years and 56 [IQR: 46-64] years, p < 0.001). PD characteristics and baseline laboratory data were similar in both groups, except serum albumin and hemoglobin levels on day 28, which were significantly lower in the COVID-19 group. In the COVID-19 group, respiratory symptoms, rehospitalization, lower respiratory tract infection, change in PD modality, UF failure, and hypervolemia were significantly higher on the 28th day. There was no significant difference in laboratory parameters at day 90. Only 1 (0.9%) patient in the COVID-19 group died within 90 days. There was no death in the control group. Respiratory symptoms, malnutrition, and hypervolemia were significantly higher at day 90 in the COVID-19 group. CONCLUSION: Mortality in the first 90 days after COVID-19 in PD patients with COVID-19 was not different from the control PD group. However, some patients continued to experience significant problems, especially respiratory system symptoms, malnutrition, and hypervolemia.

Surveillance of hemodialysis related infections: a prospective multicenter study.

As in many countries, there is neither a surveillance system nor a study to reveal the hemodialysis (HD) related infection rates in Turkey. We aimed to investigate the infection rate among HD outpatients and implement CDC's surveillance system. A multicenter prospective surveillance study is performed to investigate the infection rate among HD patients. CDC National Healthcare Safety Network (NHSN) dialysis event (DE) protocol is adopted for definitions and reporting. During April 2016-April 2018, 9 centers reported data. A total of 199 DEs reported in 10,035 patient-months, and the overall DE rate was 1.98 per 100 patient-months. Risk of blood culture positivity is found to be 17.6 times higher when hemodialysis was through a tunneled catheter than through an arteriovenous fistula. DE rate was significantly lower in patients educated about the care of their vascular access site. Staphylococcus aureus was the most causative microorganism among mortal patients. Outcomes of DEs were hospitalization (73%), loss of vascular access (18.2%), and death (7.7%). This first surveillance study revealed the baseline status of HD related infections in Turkey and showed that CDC National Healthcare Safety Network (NHSN) DE surveillance system can be easily implemented even in a high workload dialysis unit and be adopted as a nationwide DE surveillance program.

Characteristics and Survival Results of Peritoneal Dialysis Patients Suffering from COVID-19 in Turkey: A Multicenter National Study.

INTRODUCTION: We aimed to study the characteristics of peritoneal dialysis (PD) patients with coronavirus disease-19 (COVID-19), determine the short-term mortality and other medical complications, and delineate the factors associated with COVID-19 outcome. METHODS: In this multicenter national study, we included PD patients with confirmed COVID-19 from 27 centers. The baseline demographic, clinical, laboratory, and radiological data and outcomes at the end of the first month were recorded. RESULTS: We enrolled 142 COVID-19 patients (median age: 52 years). 58.2% of patients had mild disease at diagnosis. Lung involvement was detected in 60.8% of patients. Eighty-three (58.4%) patients were hospitalized, 31 (21.8%) patients were admitted to intensive care unit and 24 needed mechanical ventilation. Fifteen (10.5%) patients were switched to hemodialysis and hemodiafiltration was performed for four (2.8%) patients. Persisting pulmonary symptoms (n = 27), lower respiratory system infection (n = 12), rehospitalization for any reason (n = 24), malnutrition (n = 6), hypervolemia (n = 13), peritonitis (n = 7), ultrafiltration failure (n = 7), and in PD modality change (n = 8) were reported in survivors. Twenty-six patients (18.31%) died in the first month of diagnosis. The non-survivor group was older, comorbidities were more prevalent. Fever, dyspnea, cough, serious-vital disease at presentation, bilateral pulmonary involvement, and pleural effusion were more frequent among non-survivors. Age (OR: 1.102; 95% CI: 1.032-1.117; p: 0.004), moderate-severe clinical disease at presentation (OR: 26.825; 95% CI: 4.578-157.172; p < 0.001), and baseline CRP (OR: 1.008; 95% CI; 1,000-1.016; p: 0.040) were associated with first-month mortality in multivariate analysis. DISCUSSION/CONCLUSIONS: Early mortality rate and medical complications are quite high in PD patients with COVID-19. Age, clinical severity of COVID-19, and baseline CRP level are the independent parameters associated with mortality.

Differences in clinical outcomes of COVID-19 among vaccinated and unvaccinated kidney transplant recipients.

INTRODUCTION: The remarkable efficacy and effectiveness of COVID-19 vaccines have been described in healthy individuals, but kidney transplant recipients have been excluded from these studies. Therefore, real-world evidence of these vaccines can guide clinicians in predicting complications in kidney transplant recipients and how many doses of vaccines are protective. In this study, we aimed to investigate the impact of the COVID-19 vaccines on kidney transplant recipients with SARS-CoV-2 infection. MATERIAL AND METHOD: This matched case-control study included vaccinated kidney transplant recipients with COVID-19 from two centers between 1 May and 1 October 2021. All patients in the vaccinated group received a minimum of two doses of the vaccine and were diagnosed with COVID-19 at least one month after the last dose. Each vaccinated patient was matched with an unvaccinated kidney transplant recipient diagnosed with COVID. The endpoints were all-cause mortality, hospitalization, intensive care unit admission, acute kidney injury, cytokine storm, and acute respiratory distress syndrome. RESULTS: The median age of vaccinated seventy-two participants was 45 years, and 41 of the participants were men in the vaccinated group. Four patients in the vaccinated group and nine patients in the control group died during follow-up (p = 0.247). Seventeen patients in the vaccinated group, thirty-four participants in the control group were hospitalized (p = 0.004); five vaccinated patients and ten unvaccinated patients were followed-up in the ICU during follow-up (p = 0.168). Thirteen of the vaccinated and twelve unvaccinated patients developed acute kidney injury (p = 0.16). The occurrence of cytokine storm (n = 4 vs. n = 11; p = 0.061) and acute respiratory distress syndrome (n = 5 vs. n = 10; p = 0.168) was higher in the patient group compared to the control group. CONCLUSION: COVID-19 remains a fatal disease despite advancing treatment modalities and preventive strategies. COVID-19 vaccines can't prevent death in all kidney transplant recipients, but they decrease hospitalization rate and duration in most patients.

The Longitudinal Evolution of Post-COVID-19 Outcomes Among Hemodialysis Patients in Turkey.

Introduction: Hemodialysis (HD) patients have increased risk for short-term adverse outcomes of COVID-19. However, complications and survival at the post-COVID-19 period have not been published extensively. Methods: We conducted a national, multicenter observational study that included adult maintenance HD patients recovered from confirmed COVID-19. A control HD group without COVID-19 was selected from patients in the same center. We investigated the characteristics and outcomes in the follow-up of HD patients and compare them with the non-COVID-19 group. Results: A total of 1223 patients (635 patients in COVID-19 group, 588 patients in non-COVID-19 group) from 47 centers were included in the study. The patients' baseline and HD characteristics were almost similar. The 28th-day mortality and mortality between 28th day and 90th day were higher in the COVID-19 group than non-COVID-19 group (19 [3.0%] patients vs. none [0%]; 15 [2.4%] patients vs. 4 [0.7%] patients, respectively). The presence of respiratory symptoms, rehospitalization, need for home oxygen therapy, lower respiratory tract infection, and arteriovenous (AV) fistula thrombosis was significantly higher in the COVID-19 group in both the first 28 days and between 28 and 90 days. In the multivariable analysis, age (odds ratio [OR] [95% CI]: 1.029 [1.004-1.056]), group (COVID-19 group vs. non-COVID-19 group) (OR [95% CI]: 7.258 [2.538-20.751]), and vascular access type (tunneled catheter/AV fistula) (OR [95% CI]: 2.512 [1.249-5.051]) were found as independent parameters related to 90-day mortality. Conclusion: In the post-COVID-19 period, maintenance HD patients who have had COVID-19 have increased rehospitalization, respiratory problems, vascular access problems, and high mortality compared with the non-COVID-19 HD patients.

Short and mid-term SARS-CoV-2 antibody response after inactivated COVID-19 vaccine in hemodialysis and kidney transplant patients.

The efficacy of the inactivated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine has not been fully elucidated across the whole spectrum of patients on kidney replacement therapy. We aimed to characterize the long-term antibody response of inactivated SARS-CoV-2 vaccine administered in kidney transplant recipients (KTRs) and hemodialysis (HD) patients. We performed this prospective observational study in 50 HD, 64 KTR, and 41 healthy control groups (HG) given two doses of CoronaVac. We measured anti-Spike antibodies after 28 days of every vaccine dose, 3rd and 6th months after the first dose, and compared them between cohorts. After two doses, an anti-spike immunoglobulin G of ≥50 AU/ml was present in HD, KTR, and HG as 44%, 7.2%, and 58.5%, respectively (p < 0.001). Furthermore, the proportion of antibody titers peaked at 86.5%, 23%, and 97.6% (p < 0.001) at the 3rd month and decreased significantly at the 6th month in most HD and HG participants, whereas this effect was not observed in KTRs from basal until the 6th month (p < 0.001). During the follow-up, the incidence of coronavirus disease 2019 disease was higher (p < 0.003) in KTRs compared to the other groups, but there was no requirement for an intensive care unit and no death was recorded. We found a negative correlation between antibody seroconversion and age (p < 0.016). The antibody response following inactivated vaccine in dialysis patients is almost comparable to controls for 6 months. In contrast, kidney transplant patients have a poor response. These findings reinforce the need to discuss the vaccination strategy in immunocompromised patients, including the third dose with homologous or heterologous vaccines.

The effectiveness of dexamethasone on the prognosis of dialysis patients with severe COVID-19.

OBJECTIVE: This study aimed to investigate the effectiveness of dexamethasone in dialysis patients with COVID-19 and whether it predicts mortality. METHODS: This is a comparative cross-sectional study of 113 consecutive patients with COVID-19 with severe pneumonia signs. The patients were divided into two groups according to the use of dexamethasone treatment: group 1 (n=45) included patients who were treated with dexamethasone and group 2 (n=68) who did not receive dexamethasone. RESULTS: The mean age of both groups was 67.0±10.6 and 67.2±13.0 years, respectively (p=0.947). With respect to demographic and laboratory findings, there were no significant differences between the two groups (p>0.05). The hospitalization time of patients in group 1 was longer than that in group 2 (11 [7-17] days vs. 8 [5.3-14] days, p=0.093]. The 28-day survival rate was 54.2% in the group receiving dexamethasone treatment and 79.5% in the group not receiving dexamethasone treatment (p=0.440). CONCLUSION: Dexamethasone did not reduce mortality rates and the requirement for intensive care unit in dialysis patients with COVID-19. Larger prospective randomized clinical trials are required to associate personalized medicine with the corticosteroid treatment to select suitable patients who are more likely to show a benefit.

The relationship between glomerular IgG staining and poor prognostic findings in patients with IgA nephropathy: the data from TSN-GOLD working group.

BACKGROUND: Galactose-deficient IgA1 (Gd-IgA1) has an increased tendency to form immunocomplexes with IgG in the serum, contributing to IgAN pathogenesis by accumulating in the glomerular mesangium. Several studies showed that glomerular IgG deposition in IgAN is an important cause of mesangial proliferation and glomerular damage. This study aims to determine the association of the positivity of IgG and the intensity of IgG staining with a poor renal prognosis. METHODS: A total of 943 IgAN patients were included in the study. Glomerular IgG staining negative and positive patients were compared using Oxford classification scores, histopathological evaluations, proteinuria, eGFR, albumin, blood pressures. IgG positive patients were classified as (+), (++), (+++) based on their staining intensity, and the association with the prognostic criteria was also evaluated. RESULTS: 81% (n = 764) of the patients were detected as IgG negative, while 19% (n = 179) were positive. Age, gender, body mass index, blood pressure, proteinuria, eGFR, uric acid values were similar in IgG positive and negative patients who underwent biopsy (p > 0.05). Intensity of glomerular IgG positivity was not found to be associated with diastolic and systolic blood pressure, urea, uric acid, age, eGFR, albumin, proteinuria (p > 0.05 for all, r = - 0.084, r = - 0.102, r = - 0.006, r = 0.062, r = 0.014, r = - 0.044, r = - 0.061, r = - 0.066, r = 0.150, respectively). There was no difference for histopathological findings between IgG (+), IgG (++), IgG (+++) groups (for all, p > 0.05). CONCLUSION: Glomerular IgG negativity and positivity detected by routine IFM in IgAN patients is not associated with poor renal prognostic risk factors.

Predictors of Mortality in Patients with COVID-19 Infection-associated Acute Kidney Injury.

OBJECTIVE: To determine clinical characteristics, renal replacement therapy (RRT) requirements, and predictors of mortality in critically ill patients with COVID-19 associated AKI. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Sakarya University Education and Training Hospital, Sakarya, Turkey, between April 1 and 30, 2020. METHODOLOGY: The study included 55 patients who were admitted with diagnosis of COVID-19, and whose illnesses showed a critical course that leads to AKI. The variables were studied as per objective. RESULTS: During the follow-up, 43 out of 55 patients (78.2%) died and 12 (21.8%) were discharged with recovery. The mortality was higher in patients at stage 3 (88.9% mortality) compared to stage 2 (53.8% mortality) (p=0.014). In the nonsurvivor group, RDW (red cell distribution width) and albumin levels were lower at admission; whereas, the LDH levels and CRP/albumin ratios were higher. On regression analysis, low albumin level (OR: 12.793, p = 0.010), high LDH level (OR: 8.454, p = 0.026), and presence of stage 3 AKI (OR: 10.268, p = 0.020) were found as independent risk factors for mortality in COVID-19 patients, who developed AKI. CONCLUSION: In critically ill patients with COVID-19 pneumonia, who developed AKI, it was seen that the presence of low albumin, high LDH, and stage 3 AKI at the time of admission could be used as predictors of mortality. Moreover,, it was shown for the first time that in these patients, the high CRP/albumin ratio and low RDW could be associated with mortality. Key Words: Acute kidney injury, Mortality, COVID-19.

The effectiveness of dexamethasone on the prognosis of dialysis patients with severe COVID-19

SUMMARY OBJECTIVE: This study aimed to investigate the effectiveness of dexamethasone in dialysis patients with COVID-19 and whether it predicts mortality. METHODS: This is a comparative cross-sectional study of 113 consecutive patients with COVID-19 with severe pneumonia signs. The patients were divided into two groups according to the use of dexamethasone treatment: group 1 (n=45) included patients who were treated with dexamethasone and group 2 (n=68) who did not receive dexamethasone. RESULTS: The mean age of both groups was 67.0±10.6 and 67.2±13.0 years, respectively (p=0.947). With respect to demographic and laboratory findings, there were no significant differences between the two groups (p>0.05). The hospitalization time of patients in group 1 was longer than that in group 2 (11 [7-17] days vs. 8 [5.3-14] days, p=0.093]. The 28-day survival rate was 54.2% in the group receiving dexamethasone treatment and 79.5% in the group not receiving dexamethasone treatment (p=0.440). CONCLUSION: Dexamethasone did not reduce mortality rates and the requirement for intensive care unit in dialysis patients with COVID-19. Larger prospective randomized clinical trials are required to associate personalized medicine with the corticosteroid treatment to select suitable patients who are more likely to show a benefit.

Correlation between venous blood gas indices and radiological involvements of COVID-19 patients at first admission to emergency department.

BACKGROUND: The purpose of this study was to investigate the relation between venous blood gas and chest computerized tomography findings and the clinical conditions of COVID-19 pneumonia. METHODS: A total of 309 patients admitted to the emergency department and subsequently confirmed COVID-19 cases was examined. Patients with pneumonia symptoms, chest computerized tomography scan, venous blood gas findings, and confirmed COVID-19 on reverse transcription-polymerase chain reaction (PCR) were consecutively enrolled. Multiple linear regression was used to predict computerized tomography and blood gas findings by clinical/laboratory data. RESULTS: The median age of patients was 51 (interquartile range 39-66), and 51.5% were male. The mortality rate at the end of follow-up was 18.8%. With respect to survival status of patients pCO2 and HCO3 levels and total computerized tomography score values were found to be higher in the surviving patients (p<0.001 and p=0.003, respectively), whereas pH and lactate levels were higher in patients who died (p=0.022 and p=0.001, respectively). With logistic regression analysis, total tomography score was found to be significantly effective on mortality (p<0.001). The diffuse and random involvement of the lungs had a significant effect on mortality (p<0.001, 95%CI 3.853-38.769, OR 12.222 and p=0.027; 95%CI 1.155-11.640, OR 3.667, respectively). With linear regression analysis, the effect of pH and lactate results were found to have a positive effect on total tomography score (p=0.003 and p<0.001, respectively), whereas pCO2 was found to have a negative effect (p=0.029). CONCLUSION: There was correlation between venous blood gas indices and radiologic scores in COVID-19 patients. Venous blood gas taken in emergency department can be a fast, applicable, minor-invasive, and complementary test in terms of diagnosing COVID-19 pneumonia and predicting the prognosis of disease.

Does Macrophage Migration Inhibitory Factor predict the prognosis of COVID-19 disease?

INTRODUCTION: The aim of this study is to investigate whether macrophage migration inhibitory factor (MIF) predicts the prognosis of COVID-19 disease. METHODOLOGY: This descriptive and cross-sectional study was conducted on 87 confirmed COVID-19 patients. The patients were separated into two groups according to the admission in the ICU or in the ward. MIF was determined batchwise in plasma obtained as soon as the patients were admitted. Both groups were compared with respect to demographic characteristics, biochemical parameters and prediction of requirement to ICU admission. RESULTS: Forty seven patients in ICU, and 40 patients in ward were included. With respect to MIF levels and biochemical biomarkers, there was a statistically significant difference between the ICU and ward patients (p< 0.024). In terms of ICU requirement, the cut-off value of MIF was detected as 4.705 (AUC:0.633, 95%CI:0.561-0.79, p= 0.037), D-dimer was 789 (AUC:0.779, 95%CI: 0.681-0.877, p= 0.000), troponin was 8.15 (AUC: 0.820, 95%CI:0.729-0.911, p= 0.000), ferritin was 375 (AUC: 0.774, 95%CI:0.671-0.876, p= 0.000), and lactate dehydrogenase (LDH) was 359.5 (AUC:0.843, 95%CI: 0.753-0.933, p= 0.000). According to the logistic regression analysis; when MIF level > 4.705, the patient's requirement to ICU risk was increased to 8.33 (95%CI: 1.73-44.26, p= 0.009) fold. Similarly, elevation of troponin, ferritin and, LDH was shown to predict disease prognosis (p< 0.05). CONCLUSIONS: Our study showed that MIF may play a role in inflammatory responses to COVID-19 through induction of pulmonary inflammatory cytokines, suggesting that pharmacotherapeutic approaches targeting MIF may hold promise for the treatment of COVID-19 pneumonia.

Predicting the outcome of COVID-19 infection in kidney transplant recipients.

BACKGROUND: We aimed to present the demographic characteristics, clinical presentation, and outcomes of our multicenter cohort of adult KTx recipients with COVID-19. METHODS: We conducted a multicenter, retrospective study using data of patients hospitalized for COVID-19 collected from 34 centers in Turkey. Demographic characteristics, clinical findings, laboratory parameters (hemogram, CRP, AST, ALT, LDH, and ferritin) at admission and follow-up, and treatment strategies were reviewed. Predictors of poor clinical outcomes were analyzed. The primary outcomes were in-hospital mortality and the need for ICU admission. The secondary outcome was composite in-hospital mortality and/or ICU admission. RESULTS: One hundred nine patients (male/female: 63/46, mean age: 48.4 ± 12.4 years) were included in the study. Acute kidney injury (AKI) developed in 46 (42.2%) patients, and 4 (3.7%) of the patients required renal replacement therapy (RRT). A total of 22 (20.2%) patients were admitted in the ICU, and 19 (17.4%) patients required invasive mechanical ventilation. 14 (12.8%) of the patients died. Patients who were admitted in the ICU were significantly older (age over 60 years) (38.1% vs 14.9%, p = 0.016). 23 (21.1%) patients reached to composite outcome and these patients were significantly older (age over 60 years) (39.1% vs. 13.9%; p = 0.004), and had lower serum albumin (3.4 g/dl [2.9-3.8] vs. 3.8 g/dl [3.5-4.1], p = 0.002), higher serum ferritin (679 µg/L [184-2260] vs. 331 µg/L [128-839], p = 0.048), and lower lymphocyte counts (700/µl [460-950] vs. 860 /µl [545-1385], p = 0.018). Multivariable analysis identified presence of ischemic heart disease and initial serum creatinine levels as independent risk factors for mortality, whereas age over 60 years and initial serum creatinine levels were independently associated with ICU admission. On analysis for predicting secondary outcome, age above 60 and initial lymphocyte count were found to be independent variables in multivariable analysis. CONCLUSION: Over the age of 60, ischemic heart disease, lymphopenia, poor graft function were independent risk factors for severe COVID-19 in this patient group. Whereas presence of ischemic heart disease and poor graft function were independently associated with mortality.

Predictors of Mortality in Patients with COVID-19 Infection-associated Acute Kidney Injury.

OBJECTIVE: To determine clinical characteristics, renal replacement therapy (RRT) requirements, and predictors of mortality in critically ill patients with COVID-19 associated AKI. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Sakarya University Education and Training Hospital, Sakarya, Turkey, between April 1 and 30, 2020. METHODOLOGY: The study included 55 patients who were admitted with diagnosis of COVID-19, and whose illnesses showed a critical course that leads to AKI. The variables were studied as per objective. RESULTS: During the follow-up, 43 out of 55 patients (78.2%) died and 12 (21.8%) were discharged with recovery. The mortality was higher in patients at stage 3 (88.9% mortality) compared to stage 2 (53.8% mortality) (p=0.014). In the nonsurvivor group, RDW (red cell distribution width) and albumin levels were lower at admission; whereas, the LDH levels and CRP/albumin ratios were higher. On regression analysis, low albumin level (OR: 12.793, p = 0.010), high LDH level (OR: 8.454, p = 0.026), and presence of stage 3 AKI (OR: 10.268, p = 0.020) were found as independent risk factors for mortality in COVID-19 patients, who developed AKI. CONCLUSION: In critically ill patients with COVID-19 pneumonia, who developed AKI, it was seen that the presence of low albumin, high LDH, and stage 3 AKI at the time of admission could be used as predictors of mortality. Moreover,, it was shown for the first time that in these patients, the high CRP/albumin ratio and low RDW could be associated with mortality. Key Words: Acute kidney injury, Mortality, COVID-19.

Impact of hospital-acquired acute kidney injury on Covid-19 outcomes in patients with and without chronic kidney disease: a multicenter retrospective cohort study

Background/aim: Hospital-acquired acute kidney injury (HA-AKI) may commonly develop in Covid-19 patients and is expected to have higher mortality. There is little comparative data investigating the effect of HA-AKI on mortality of chronic kidney disease (CKD) patients and a control group of general population suffering from Covid-19. Materials and methods: HA-AKI development was assessed in a group of stage 3­5 CKD patients and control group without CKD among adult patients hospitalized for Covid-19. The role of AKI development on the outcome (in-hospital mortality and admission to the intensive care unit [ICU]) of patients with and without CKD was compared. Results: Among 621 hospitalized patients (age 60 [IQR: 47­73]), women: 44.1%), AKI developed in 32.5% of the patients, as stage 1 in 84.2%, stage 2 in 8.4%, and stage 3 in 7.4%. AKI developed in 48.0 % of CKD patients, whereas it developed in 17.6% of patients without CKD. CKD patients with HA-AKI had the highest mortality rate of 41.1% compared to 14.3% of patients with HA-AKI but no CKD (p < 0.001). However, patients with AKI+non-CKD had similar rates of ICU admission, mechanical ventilation, and death rate to patients with CKD without AKI. Adjusted mortality risks of the AKI+non-CKD group (HR: 9.0, 95% CI: 1.9­44.2) and AKI+CKD group (HR: 7.9, 95% CI: 1.9­33.3) were significantly higher than that of the non-AKI+non-CKD group. Conclusion: AKI frequently develops in hospitalized patients due to Covid-19 and is associated with high mortality. HA-AKI has worse outcomes whether it develops in patients with or without CKD, but the worst outcome was seen in AKI+CKD patients.

Determinants of mortality in a large group of hemodialysis patients hospitalized for COVID-19.

BACKGROUND: Maintenance hemodialysis (MHD) patients are at increased risk for coronavirus disease 2019 (COVID-19). The aim of this study was to describe clinical, laboratory, and radiologic characteristics and determinants of mortality in a large group of MHD patients hospitalized for COVID-19. METHODS: This multicenter, retrospective, observational study collected data from 47 nephrology clinics in Turkey. Baseline clinical, laboratory and radiological characteristics, and COVID-19 treatments during hospitalization, need for intensive care and mechanical ventilation were recorded. The main study outcome was in-hospital mortality and the determinants were analyzed by Cox regression survival analysis. RESULTS: Of 567 MHD patients, 93 (16.3%) patients died, 134 (23.6%) patients admitted to intensive care unit (ICU) and 91 of the ones in ICU (67.9%) needed mechanical ventilation. Patients who died were older (median age, 66 [57-74] vs. 63 [52-71] years, p = 0.019), had more congestive heart failure (34.9% versus 20.7%, p = 0.004) and chronic obstructive pulmonary disease (23.6% versus 12.7%, p = 0.008) compared to the discharged patients. Most patients (89.6%) had radiological manifestations compatible with COVID-19 pulmonary involvement. Median platelet (166 × 103 per mm3 versus 192 × 103 per mm3, p = 0.011) and lymphocyte (800 per mm3 versus 1000 per mm3, p < 0.001) counts and albumin levels (median, 3.2 g/dl versus 3.5 g/dl, p = 0.001) on admission were lower in patients who died. Age (HR: 1.022 [95% CI, 1.003-1.041], p = 0.025), severe-critical disease clinical presentation at the time of diagnosis (HR: 6.223 [95% CI, 2.168-17.863], p < 0.001), presence of congestive heart failure (HR: 2.247 [95% CI, 1.228-4.111], p = 0.009), ferritin levels on admission (HR; 1.057 [95% CI, 1.006-1.111], p = 0.028), elevation of aspartate aminotransferase (AST) (HR; 3.909 [95% CI, 2.143-7.132], p < 0.001) and low platelet count (< 150 × 103 per mm3) during hospitalization (HR; 1.864 [95% CI, 1.025-3.390], p = 0.041) were risk factors for mortality. CONCLUSION: Hospitalized MHD patients with COVID-19 had a high mortality rate. Older age, presence of heart failure, clinical severity of the disease at presentation, ferritin level on admission, decrease in platelet count and increase in AST level during hospitalization may be used to predict the mortality risk of these patients.

Characteristics and mortality determinants of COVID-19 patients undergoing hemodialysis

Background/aim: The COVID-19 infection, which started in Wuhan City, China, in December 2019, turned into a pandemic in a very short time, affecting mainly the elderly and those with serious chronic illnesses. COVID-19 infections have been observed to have a high mortality rate, especially in patients undergoing maintenance hemodialysis. Materials and methods: Forty-two patients over 18 years of age who underwent a maintenance hemodialysis program at our unit, who tested positive for COVID-19 by PCR from nasopharyngeal swabs, and/or who were observed to have disease-related signs in their CTs were included in the study. Results: In this study, 23 of 42 patients receiving hemodialysis support in our clinic were included. The median age was 67 years old (min: 35; max: 91 years), and all of our patients had primary hypertension and other comorbidities. Their clinical evaluation showed that dry cough (47.8%) and shortness of breath (47.8%) were the most common symptoms. Fever was less pronounced (30.4%). The median time from the onset of symptoms to hospitalization was 1 day (min: 0; max:), and the time from hospitalization to death was 18 days (min: 1; max: 22). Transfer from the inpatient ward to the ICU took a median of 7 days (min: 1; max: 13). Among the 23 patients, 3 died during follow-up, and 20 were discharged with full recovery. Baseline ferritin, procalcitonin levels, and CRP/albumin rates were higher, and neutrophil/lymphocyte levels were lower in patients who eventually died. In these patients, despite being nonsignificant, there were more diabetic patients, and the D-dimer levels were higher than 1000 ugFEU/L. Conclusion: The COVID-19 infection is associated with increased mortality in chronic kidney diseases patients. Despite being nonsignificant, there was a trend towards increased mortality in patient with diabetes, D-dimer levels >1000 ugFEU/L, higher ferritin and prokalsitonin levels, an increased CRP/albumin ratio, and a lower neutrophil/lymphocyte ratio.

Clinical course of COVID-19 disease in immunosuppressed renal transplant patients

Background/aim: We aimed to identify clinical settings of renal transplant patients with COVID-19. Materials and methods: In this retrospective study, we included kidney transplant inpatients with laboratory confirmed COVID-19 who had been discharged or had died by October 1st, 2020. Characteristics of the patients, including basal and last outpatient biochemical parameters were recorded. Discontinuation or dosage reduction of immunosuppressives and other treatment information was documented. Results: Twenty patients were included in this study, of whom 18 were discharged and 2 died in hospital. The mean duration of hospitalization and follow-up were 9.7 ± 6.4 days and 4.5 ± 2.0 months, respectively. Fourteen patients (70%) were male and mean age was 48.0 ± 10.3 years. At admission, all had immunosuppression withdrawn and were started on methylprednisolone 16 mg/ day (50%) or dexamethasone (50%). Tacrolimus/m-TOR inhibitors were reduced by 50% and all antimetabolites were discontinued. Hemodialysis was needed for 10% of patients. Acute kidney injury was detected in 25% of the patients. With respect to hospitalization time and complications, there was no significant difference between patients who used dexamethasone and those who did not (P > 0.05). The discontinued immunosuppressives were resumed within 2 to 4 weeks after discharge according to the severity of disease. No rehospitalization or acute rejection was detected during the follow-up of the patients. Conclusion: Renal transplant patients are considered a high risk group for COVID-19. It can be said that discontinuation or reducing dosages of immunosuppressives may be effective and safe in kidney transplant patients.