COVID-19 and Kidney Disease.

COVID-19 can cause acute kidney injury and may cause or exacerbate chronic kidney diseases, including glomerular diseases. SARS-CoV-2 infection of kidney cells has been reported, but it remains unclear if viral infection of kidney cells causes disease. The most important causes of kidney injury in patients with COVID-19 include impaired renal perfusion and immune dysregulation. Chronic kidney disease, especially kidney failure with kidney replacement therapy and kidney transplant, is associated with markedly increased COVID-19 mortality. Persons with severe kidney disease have been excluded from most clinical trials of COVID-19 therapies, so therapeutic approaches must be extrapolated from studies of patients without kidney disease. Some medications used to treat COVID-19 should be avoided or used at reduced dosages in patients with severe kidney disease and in kidney transplant recipients. Additional research is needed to determine the optimal strategies to prevent and treat COVID-19 in patients with kidney disease.

Vitamin D in chronic kidney disease: is there a role outside of PTH control?

PURPOSE OF REVIEW: Vitamin D deficiency is common in patients with kidney disease and many patients receive vitamin D supplementation. Several large, well-designed clinical trials have been published in the last few years evaluating the effects of vitamin D supplementation on important outcomes for patients with kidney disease including effects on cardiovascular disease, secondary hyperparathyroidism, and kidney disease progression. RECENT FINDINGS: Several negative trials have been published showing no effect of cholecalciferol supplementation on cardiovascular events, kidney disease progression, and albuminuria. Long-term supplementation does not appear to be associated with kidney stone disease. Vitamin D supplementation decreases parathyroid hormone (PTH) levels and high levels of 25-hydroxyvitamin D may be required for maximal suppression. SUMMARY: There appear to be no effects of vitamin D supplementation on noncalcemic outcomes including progression of kidney disease, albuminuria, or cardiovascular disease. The primary reason to use vitamin D in kidney disease remains to lower PTH levels.

The Impact of Chronic Kidney Disease on Outcomes of Patients with COVID-19 Admitted to the Intensive Care Unit.

CONTEXT: Coronavirus disease 2019 (COVID-19) disproportionately impacts patients with chronic kidney disease (CKD), especially those with kidney failure requiring replacement therapy (KFRT). Patients with KFRT have increased risk of developing COVID-19, and though initial reports suggested that mortality of these patients in the intensive care unit (ICU) setting is prohibitively high, those studies suffered from significant limitations. Subject of Review: The Study of the Treatment and Outcomes in Critically Ill Patients With COVID-19 (STOP-COVID) is a multicenter cohort study that enrolled adults with COVID-19 admitted to ICUs in 68 medical centers across the USA. STOP-COVID investigators compared characteristics at the time of ICU admission and clinical outcomes in 143 patients with KFRT, 521 with nondialysis-dependent CKD (ND-CKD), and 3,600 patients without CKD. Patients with KFRT were less likely to have typical COVID-19 symptoms but more likely to have altered mental status at the time of ICU admission and were less likely to require mechanical ventilation during hospitalization than those without kidney disease. Approximately, 50% of patients with KFRT and ND-CKD died within 28 days of ICU admission, and in fully adjusted models, patients with KFRT and ND-CKD had 1.41- and 1.25-fold higher risk of 28-day mortality than those without CKD. Patients with KFRT and ND-CKD were also less likely to receive emerging therapies for COVID-19 than those without CKD. Second Opinion: This study provides important new data demonstrating differences in clinical presentation in patients with KFRT and ND-CKD with COVID-19. Alhough patients with severe CKD had higher mortality than those without CKD, approximately half survived after 28 days, demonstrating that patients with COVID-19 and severe CKD can benefit from ICU care. The markedly lower use of emerging COVID-19 treatments in patients with severe CKD highlights the need to include these patients in clinical trials of new COVID-19 therapies and for clinicians to ensure equal access to care in patients with severe CKD and COVID-19.

Associations of Dysnatremia with COVID-19 Status and Mortality.

Background: In patients without COVID-19, dysnatremia is associated with mortality. These relationships are not well established in patients with COVID-19. We tested the hypotheses that patients with COVID-19 were more likely to have dysnatremia than those without COVID-19 and that, among those with COVID-19, dysnatremia is associated with mortality. Methods: We conducted a retrospective observational study of patients admitted to a tertiary care center in the Bronx, New York, during the COVID-19 surge from March 11 to April 26, 2020. Using multinomial logistic regression models, we compared the prevalence of hypernatremia (serum sodium ≥150 mEq/L) and hyponatremia (serum sodium <130 mEq/L) on admission between patients with and without COVID-19. Among patients with COVID-19, we used Cox proportional hazards models to examine the association of dysnatremia with mortality. Results: Compared with those without COVID-19 (n=1265), patients with COVID-19 (n=3345) had a higher prevalence of hypernatremia (7% versus 4%, P<0.001) and hyponatremia (7% versus 6%, P=0.04). In adjusted models, COVID-19-positive patients had a higher likelihood of having hypernatremia (adjusted odds ratio=1.87, 95% CI, 1.3 to 2.57, P=0.001) compared with COVID-19-negative patients, whereas the association between hyponatremia and COVID-19 status was no longer significant (P=0.06). Among patients with COVID-19, 775 (23%) died after a median follow-up of 17 days (IQR 7-27 days). Among nonsurvivors, 15% had hypernatremia and 8% had hyponatremia on admission. Hypernatremia was associated with a higher risk of mortality (adjusted hazard ratio=1.28, 95% CI, 1.01 to 1.63, P=0.04) compared with patients with eunatremia. Conclusions: In patients hospitalized during the spring 2020 COVID-19 surge, COVID-19 status was associated with hypernatremia on admission. Among patients with COVID-19, hypernatremia was associated with higher mortality. Hypernatremia may be a potential prognostic marker for mortality in COVID-19 patients.

Thiazide-induced severe hypercalcemia: a case report and review of literature.

Most common causes of hypercalcemia are hyperparathyroidism, malignancy, vitamin D-mediated conditions such as sarcoidosis, and vitamin D toxicity. Less commonly, hypercalcemia can be caused by drugs such as thiazide diuretics and lithium. Mild hypercalcemia is usually asymptomatic but severe hypercalcemia is associated with nausea, vomiting, abdominal pain, excessive thirst, muscle weakness, lethargy, confusion, and fatigue. We are reporting a case of abdominal pain and altered mental status caused by thiazide-induced severe hypercalcemia of 19.8 mg/dL. This is the most severe case of thiazide-induced hypercalcemia that we have seen reported. Patients on thiazide diuretics should have their electrolytes frequently checked, especially patients on calcium supplements. Management usually includes hydration and discontinuation of drugs causing hypercalcemia.

Freebie Rhabdomyolysis: A Public Health Concern. Spin Class-Induced Rhabdomyolysis.

BACKGROUND: Rhabdomyolysis is a pathologic condition in which intracellular muscle constituents leak into the blood circulation. It is usually caused by muscle trauma. "Spinning" is an indoor form of cycling where participants use a special stationary exercise bicycle with a weighted flywheel and undergo high-intensity cycling classes focusing on endurance. There have been several case reports in the literature of exertional rhabdomyolysis following spin class. METHODS: Our nephrology practices have diagnosed a number of cases of symptomatic patients presenting to our emergency departments following their first spin classes, with histories and creatinine phosphokinase levels diagnostic of exertional rhabdomyolysis. RESULTS: We present 3 unusual cases of exertional rhabdomyolysis, each occurring after a first spin class. In the first case, rhabdomyolysis developed following 15 minutes of spin class. In the second case, it occurred in a young individual who exercises regularly. In the third case, the patient developed biopsy-proved acute kidney injury secondary to exertional rhabdomyolysis and required hemodialysis. CONCLUSION: The high-intensity exercise associated with "spin class" comes with significant risks to newcomers.

Hiring a nurse practitioner: What's in it for the physician?

A solution to the increased demand for primary care providers is to hire a nurse practitioner (NP). Hiring an NP in a primary care practice has numerous advantages for physicians. This article will discuss those advantages and clarify perceived disadvantages to hiring an NP in the primary care setting.

Mitigating contrast-induced acute kidney injury associated with cardiac catheterization.

Contrast-induced nephropathy, also referred to as contrast-induced acute kidney injury (CIAKI), is among the most common causes of AKI, especially in patients with underlying chronic kidney disease. In addition to the increased cost engendered by the development of CIAKI, several studies have suggested the occurrence of AKI after cardiac procedures is associated with an increase in both morbidity and mortality. This increase in morbidity and mortality occurs after both intravenous and intra-arterial studies. This review focuses on relevant proposed pathophysiological mechanisms, risk factors, and current prophylactic strategies, which may reduce the incidence of CIAKI during cardiac angiographic imaging studies.