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• W3048702451 abstract "Given the high risk of infection-related mortality, patients with end-stage kidney disease (ESKD) may be at increased risk with COVID-19. To assess this, we compared outcomes of patients with and without ESKD, hospitalized with COVID-19. This was a retrospective study of patients admitted with COVID-19 from 13 New York hospitals from March 1, 2020, to April 27, 2020, and followed through May 27, 2020. We measured primary outcome (in-hospital death), and secondary outcomes (mechanical ventilation and length of stay). Of 10,482 patients with COVID-19, 419 had ESKD. Patients with ESKD were older, had a greater percentage self-identified as Black, and more comorbid conditions. Patients with ESKD had a higher rate of in-hospital death than those without (31.7% vs 25.4%, odds ratio 1.38, 95% confidence interval 1.12 - 1.70). This increase rate remained after adjusting for demographic and comorbid conditions (adjusted odds ratio 1.37, 1.09 - 1.73). The odds of length of stay of seven or more days was higher in the group with compared to the group without ESKD in both the crude and adjusted analysis (1.62, 1.27 - 2.06; vs 1.57, 1.22 - 2.02, respectively). There was no difference in the odds of mechanical ventilation between the groups. Independent risk factors for in-hospital death for patients with ESKD were increased age, being on a ventilator, lymphopenia, blood urea nitrogen and serum ferritin. Black race was associated with a lower risk of death. Thus, among patients hospitalized with COVID-19, those with ESKD had a higher rate of in-hospital death compared to those without ESKD. Given the high risk of infection-related mortality, patients with end-stage kidney disease (ESKD) may be at increased risk with COVID-19. To assess this, we compared outcomes of patients with and without ESKD, hospitalized with COVID-19. This was a retrospective study of patients admitted with COVID-19 from 13 New York hospitals from March 1, 2020, to April 27, 2020, and followed through May 27, 2020. We measured primary outcome (in-hospital death), and secondary outcomes (mechanical ventilation and length of stay). Of 10,482 patients with COVID-19, 419 had ESKD. Patients with ESKD were older, had a greater percentage self-identified as Black, and more comorbid conditions. Patients with ESKD had a higher rate of in-hospital death than those without (31.7% vs 25.4%, odds ratio 1.38, 95% confidence interval 1.12 - 1.70). This increase rate remained after adjusting for demographic and comorbid conditions (adjusted odds ratio 1.37, 1.09 - 1.73). The odds of length of stay of seven or more days was higher in the group with compared to the group without ESKD in both the crude and adjusted analysis (1.62, 1.27 - 2.06; vs 1.57, 1.22 - 2.02, respectively). There was no difference in the odds of mechanical ventilation between the groups. Independent risk factors for in-hospital death for patients with ESKD were increased age, being on a ventilator, lymphopenia, blood urea nitrogen and serum ferritin. Black race was associated with a lower risk of death. Thus, among patients hospitalized with COVID-19, those with ESKD had a higher rate of in-hospital death compared to those without ESKD. Editor’s NoteThis is one of several articles we think you will find of interest that are part of our special issue of Kidney International addressing the challenges of dialysis and transplantation during the COVID-19 pandemic. Please also find additional material in our commentaries and letters to the editor sections. We hope these insights will help you in the daily care of your own patients. This is one of several articles we think you will find of interest that are part of our special issue of Kidney International addressing the challenges of dialysis and transplantation during the COVID-19 pandemic. Please also find additional material in our commentaries and letters to the editor sections. We hope these insights will help you in the daily care of your own patients. A novel coronavirus, severe acute respiratory syndrome (SARS-CoV-2), causing coronavirus disease 2019 (COVID-19), emerged in late 2019 in Wuhan, China, and rapidly spread throughout the world.1World Health OrganizationNovel Coronavirus—China.https://www.who.int/csr/don/12-january-2020-novel-coronavirus-china/en/Date accessed: May 17, 2020Google Scholar,2Reese H.E. Wallace M. Wang C. et al.First known person-to-person transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the USA.Lancet. 2020; 395: 1137-1144Abstract Full Text Full Text PDF PubMed Scopus (369) Google Scholar The disease has resulted in a large number of hospitalizations and intensive care unit (ICU) admissions, with now well-described pulmonary, cardiac, vascular, and renal complications.3Izzedine H. Jhaveri K.D. Perazella M.A. Vascular injury and COVID-19-related mortality: What lies below the tip of the iceberg?.Clin Nephrol. 2020; 94: 11-13Crossref PubMed Scopus (9) Google Scholar, 4Madjid M. Safavi-Naeini P. Solomon S.D. Vardeny O. Potential effects of coronaviruses on the cardiovascular system: a review.JAMA Cardiol. 2020; 5: 831-840Crossref PubMed Scopus (1242) Google Scholar, 5Hirsch J.S. Ng J.H. Ross D.W. et al.Acute kidney injury in patients hospitalized with COVID-19.Kidney Int. 2020; 98: 209-218Abstract Full Text Full Text PDF PubMed Scopus (912) Google Scholar, 6Richardson S. Hirsch J.S. Narasimhan M. et al.Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.JAMA. 2020; 323: 2052-2059Crossref PubMed Scopus (6061) Google Scholar, 7Sharma P. Uppal N.N. Wanchoo R. et al.COVID-19-associated kidney injury: a case series of kidney biopsy findings.J Am Soc Nephrol. 2020; 31: 1948-1958Crossref PubMed Scopus (238) Google Scholar To what degree COVID-19 has impacted patients with end-stage kidney disease (ESKD) on dialysis has not been fully elucidated. Understanding the outcomes of COVID-19–infected patients with and without ESKD is important because this information would help risk-stratify patients with ESKD to certain therapies for COVID-19 as they arrive at the hospital. Patients with ESKD have a dysregulated immune system8Kato S. Chmielewski M. Honda H. et al.Aspects of immune dysfunction in end-stage renal disease.Clin J Am Soc Nephrol. 2008; 3: 1526-1533Crossref PubMed Scopus (725) Google Scholar and carry significant comorbid conditions, such as diabetes mellitus (DM), cardiac disease, and obesity, which are now considered risk factors for severe COVID-19 disease.9Docherty A.B. Harrison E.M. Green C.A. et al.Features of 20 133 UK patients in hospital with Covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study.BMJ. 2020; 369: m1985Crossref PubMed Scopus (1923) Google Scholar,10Williamson E.J. Walker A.J. Bhaskaran K. et al.Factors associated with COVID-19-related death using OpenSAFELY.Nature. 2020; 584: 430-436Crossref PubMed Scopus (3560) Google Scholar The ESKD population has higher annual mortality rates compared with the general population, even after adjustment for age, race, and DM. For example, annual mortality secondary to sepsis is 30–45 times higher in the dialysis population compared to the general population.11Sarnak M.J. Jaber B.L. Mortality caused by sepsis in patients with end-stage renal disease compared with the general population.Kidney Int. 2000; 58: 1758-1764Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar A recent study found an association between community influenza-like illness activity and seasonal variation in all-cause mortality among patients with ESKD, with an excess mortality of 1100 deaths per year, or 1.5%–2% of all deaths per influenza season in the ESKD cohort.12Gilbertson D.T. Rothman K.J. Chertow G.M. et al.Excess deaths attributable to influenza-like illness in the ESRD population.J Am Soc Nephrol. 2019; 30: 346-353Crossref PubMed Scopus (23) Google Scholar Despite recent improvements in mortality among patients with ESKD, with a 28% decline over the past 16 years, the ESKD population has a higher mortality rate compared with the general population, even after adjusting for age, race, and DM.13USRDS. Annual Data Report. 2018 ADR Chapters.https://www.usrds.org/annual-data-report/previous-adrs/Google Scholar With COVID-19, either an increased or decreased risk of death related to SARS-CoV-2 infection in ESKD could have been postulated. Severe disease with COVID-19 has been attributed to direct viral damage as well as the body’s exuberant immune response.14Nile S.H. Nile A. Qiu J. et al.COVID-19: pathogenesis, cytokine storm and therapeutic potential of interferons.Cytokine Growth Factor Rev. 2020; 53: 66-70Crossref PubMed Scopus (296) Google Scholar Thus, the diminished immune response in ESKD could potentially protect against the cytokine storm observed with severe COVID-19 infection. In fact, in a preprint study published by Ma et al., measured levels of inflammatory cytokines in dialysis patients with COVID-19 were found to be lower than those in other patients.15Ma Y, Diao B, Lv X, et al. 2019 novel coronavirus disease in hemodialysis (HD) patients: report from one HD center in Wuhan, China [e-pub ahead of print]. medxRiv. https://doi.org/10.1101/2020.02.24.20027201. Accessed October 29, 2020.Google Scholar Another factor to consider is the reduced angiotensin-converting enzyme 2 (ACE2) activity seen in dialysis patients.16Roberts M.A. Velkoska E. Ierino F.L. Burrell L.M. Angiotensin-converting enzyme 2 activity in patients with chronic kidney disease.Nephrol Dial Transplant. 2013; 28: 2287-2294Crossref PubMed Scopus (51) Google Scholar,17Soler M.J. Wysocki J. Batlle D. ACE2 alterations in kidney disease.Nephrol Dial Transplant. 2013; 28: 2687-2697Crossref PubMed Scopus (97) Google Scholar As ACE2 serves as a receptor that allows the novel coronavirus CoV-2 to enter a cell,18Vaduganathan M. Vardeny O. Michel T. et al.Renin-angiotensin-aldosterone system inhibitors in patients with Covid-19.N Engl J Med. 2020; 382: 1653-1659Crossref PubMed Scopus (1516) Google Scholar diminished activity could plausibly mitigate the severity of illness. Alternatively, patients on dialysis may be more susceptible to SARS-CoV-2 infection because of increased transmissibility in dialysis units and diminished ability to fight infection.19Silverstein M.D. Qin H. Mercer S.Q. et al.Risk factors for 30-day hospital readmission in patients ≥65 years of age.Proc (Bayl Univ Med Cent). 2008; 21: 363-372Crossref PubMed Google Scholar,20Corbett R.W. Blakey S. Nitsch D. et al.Epidemiology of COVID-19 in an urban dialysis center.J Am Soc Nephrol. 2020; 31: 1815-1823Crossref PubMed Scopus (157) Google Scholar To date, no large study exists on the outcomes of patients with ESKD who are hospitalized with COVID-19. Recent studies from China and Europe on patients with ESKD who were infected with COVID-19 have been limited to small numbers and single centers.21La Milia V. Bacchini G. Bigi M.C. et al.COVID-19 outbreak in a large hemodialysis centre in Lombardy, Italy.Kidney Int Rep. 2020; 5: 1095-1099Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 22Xiong F. Tang H. Liu L. et al.Clinical characteristics of and medical interventions for COVID-19 in hemodialysis patients in Wuhan, China.J Am Soc Nephrol. 2020; 31: 1387-1397Crossref PubMed Scopus (183) Google Scholar, 23Goicoechea M. Cámara L.A.S. Macías N. et al.COVID-19: clinical course and outcomes of 36 maintenance hemodialysis patients from a single center in Spain.Kidney Int. 2020; 98: 27-34Abstract Full Text Full Text PDF PubMed Scopus (228) Google Scholar, 24Alberici F. Delbarba E. Manenti C. et al.A report from the Brescia Renal COVID Task Force on the clinical characteristics and short-term outcome of hemodialysis patients with SARS-CoV-2 infection.Kidney Int. 2020; 98: 20-26Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar A single-center study from the United States (US) published recently also showed poor outcomes among 59 patients with ESKD—18 (31%) had died within the whole cohort, and 6 (75%) had died within the subset of patients requiring mechanical ventilation.25Valeri A.M. Robbins-Juarez S.Y. Stevens J.S. et al.Presentation and outcomes of patients with ESKD and COVID-19.J Am Soc Nephrol. 2020; 31: 1409-1415Crossref PubMed Scopus (233) Google Scholar In the current study, we compared the outcomes of patients with and without ESKD among those hospitalized with COVID-19, and examined the risk factors associated with death in the non-ESKD group and in the ESKD group. From March 1, 2020, to April 27, 2020, there were 11,635 hospital admissions to 13 health system hospitals with a diagnosis of COVID-19 present on admission or made during the hospitalization. Of these, 10,482 were included in the final cohort (Figure 1) and were followed through May 27, 2020. Of the included cohort, 7624 (72.7%) were discharged home, 2684 (25.6%) died, and 174 (1.7%) were still admitted. Within the cohort, 7346 (73%) patients in the non-ESKD group were discharged home, and 278 (66.3%) in the ESKD group. A total of 419 (4.0%) patients with ESKD were treated in the hospital for COVID-19, of whom 408 (97.4%) were on hemodialysis (HD) and 11 (2.6%) were on peritoneal dialysis (Table 1). Within the HD group, 335 (82.1%) had permanent vascular access with either an arteriovenous graft or arteriovenous fistula, and 73 (17.9%) had an HD catheter. The baseline characteristics comparing patients with and without ESKD at hospital admission are provided in Table 1. Between the 2 groups, patients with ESKD were older, more frequently self-identified as Black, had lower body mass index (BMI), and were more likely to have Medicare as primary insurance. Additionally, patients with ESKD had more home medications, and a greater proportion were on antihypertensives, antiplatelets, anticoagulants, and statins. Patients with ESKD also had a higher proportion of comorbid diagnoses of DM, hypertension (HTN), coronary artery disease, peripheral vascular disease, and heart failure. During the hospital course, the severity of illness in both groups was similar in terms of ICU stay and vasopressor use. The in-hospital medications used to treat COVID-19 in the 2 groups are shown in Supplementary Table S1.Table 1Demographic and clinical characteristics of patients with and without end-stage kidney diseaseVariablesaMissingness is shown if missing data are >2%.Non-ESKD (n = 10,063)ESKD (n = 419)Age at admission, yr66 (54, 77)66 (55, 75)Age, yr <40729 (7.2)25 (6.0) 40–491018 (10.1)35 (8.4) 50–591878 (18.7)74 (17.7) 60–692273 (22.6)123 (29.4) 70–792096 (20.8)104 (24.8) ≥802069 (20.6)58 (13.8)Male5979 (59.4)260 (62.1)Race/Ethnicity Hispanic2096 (20.8)87 (20.8) Non-Hispanic Black1991 (19.8)152 (36.3) Non-Hispanic White3476 (34.5)93 (22.2) Other1783 (17.7)69 (16.5) Unknown717 (7.1)18 (4.3)Insurance Commercial3104 (30.8)37 (8.8) Medicaid2042 (20.3)81 (19.3) Medicare4677 (46.5)299 (71.4) Self-pay121 (1.2)0 (0.0) Other119 (1.2)2 (0.5)Tertiary hospital6783 (67.4)303 (72.3)BMI, kg/m228.3 (25.0, 32.6)26.5 (23.3, 31.2) Missing1101 (10.9)20 (4.8)Tobacco status Never7433 (73.9)308 (73.5) Smoker2013 (20.0)88 (21.0) Missing617 (6.1)23 (5.5)Diabetes3588 (35.7)248 (59.2)Hypertension5966 (59.3)382 (91.2)CAD1299 (12.9)121 (28.9)Heart failure818 (8.1)102 (24.3)PVD235 (2.3)38 (9.1)Asthma828 (8.2)31 (7.4)COPD629 (6.3)34 (8.1)Liver disease277 (2.8)16 (3.8)Cancer778 (7.7)36 (8.6)Chronic kidney disease506 (5.0)—Dialysis modality Hemodialysis—408 (97.4) Peritoneal dialysis—11 (2.6)Dialysis modality access Permanent vascular access—335 (80.0) Dialysis catheter—73 (17.4) Peritoneal dialysis catheter—11 (2.6)No. of medications5.0 (1.0, 9.0)9.0 (7.0, 14.0)Type of medications ACE inhibitor1277 (13.9)38 (9.6) ARB1638 (17.8)59 (14.9) Anticoagulants900 (9.8)63 (15.9) Antiplatelets2442 (26.6)195 (49.2) Missing877 (8.7)23 (5.5)No. of antihypertensives 04064 (40.4)60 (14.3) 1–23881 (38.6)209 (49.9) ≥31241 (12.3)127 (30.3) Missing877 (8.7)23 (5.5)Laboratory test results within 48 h of admission Hemoglobin, g/l13.3 (12.0, 14.5)10.5 (9.3, 11.5) White blood cell count, 1000/μl7.5 (5.6, 10.2)6.3 (4.5, 8.6) Lymphocyte count, 1000/μl0.9 (0.6, 1.3)0.7 (0.5, 1.1) Neutrophil count, 1000/μl5.8 (4.1, 8.4)4.8 (3.2, 7.0) Blood urea nitrogen, mg/dl18.0 (12.0, 29.0)51.0 (33.0, 72.8) Ferritin, ng/ml780.0 (404.2, 1405.0)2491.5 (1266.0, 4751.0) Missing2338 (23.2)115 (27.5) C-reactive protein, mg/dl11.0 (5.8, 18.5)10.4 (5.0, 19.3)Missing2155 (21.4)117 (27.9) D-Dimer assay, ng/ml462.0 (274.0, 989.5)583.0 (392.0, 1090.0)Missing3703 (36.8)174 (41.5)ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; AVF, arteriovenous fistula; AVG, arteriovenous graft; BMI, body mass index; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; ESKD, end-stage kidney disease; PVD, peripheral vascular disease.Values are n (%) or median (interquartile range), unless otherwise indicated.a Missingness is shown if missing data are >2%. Open table in a new tab ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; AVF, arteriovenous fistula; AVG, arteriovenous graft; BMI, body mass index; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; ESKD, end-stage kidney disease; PVD, peripheral vascular disease. Values are n (%) or median (interquartile range), unless otherwise indicated. Patients with ESKD had a higher rate of in-hospital death than those without ESKD (31.7% vs. 25.4%; odds ratio [OR] 1.38, 95% confidence interval [CI] 1.12–1.70). After adjusting for baseline demographics and comorbid conditions, the odds of in-hospital death remained higher in the ESKD group compared to the non-ESKD group (adjusted OR 1.37, 95% CI 1.09–1.73; Table 2). Patient-level characteristics of those who achieved the primary outcome (expired or alive) are shown in Supplementary Table S2.Table 2Odds ratios for in-hospital outcomes among patients with and without end-stage kidney disease (the group without end-stage kidney disease is the reference)OutcomesOR95% CIPIn-hospital death Unadjusted1.381.12–1.700.003 Adjusted for baseline demographicaBasic demographic variables include age, sex, race/ethnicity.1.471.17–1.83<0.001 Adjusted for baseline demographic and comorbid conditionsbComorbid conditions variables include body mass index, diabetes mellitus, hypertension, coronary artery disease, heart failure, peripheral vascular disease, asthma, chronic obstructive pulmonary disease, liver disease, and cancer.1.371.09–1.730.006Mechanical ventilation Unadjusted1.070.84–1.360.60 Adjusted for baseline demographic1.080.84–1.380.56 Adjusted for baseline demographic and comorbid conditions0.970.75–1.250.82Length of stay (<7 vs. ≥7 d)cThe analyses were performed only among those who were discharged alive. Unadjusted1.621.27–2.06<0.001 Adjusted for baseline demographic1.611.27–2.06<0.001 Adjusted for baseline demographic and comorbid conditions1.571.22–2.02<0.001CI, confidence interval; OR, odds ratio.a Basic demographic variables include age, sex, race/ethnicity.b Comorbid conditions variables include body mass index, diabetes mellitus, hypertension, coronary artery disease, heart failure, peripheral vascular disease, asthma, chronic obstructive pulmonary disease, liver disease, and cancer.c The analyses were performed only among those who were discharged alive. Open table in a new tab CI, confidence interval; OR, odds ratio. Patients with ESKD had rates of mechanical ventilation similar to those for patients without ESKD (89 [21.2%] vs. 2076 [20.6%], respectively). In both the crude analysis and the adjusted analysis, the ESKD group did not have significantly higher odds of requiring mechanical ventilation than the non-ESKD group (OR 1.07, 95% CI 0.84–1.36 vs. adjusted OR 0.97, 95% CI 0.75–1.25). The median length of hospital stay for patients discharged alive was higher in the ESKD group compared with the non-ESKD group (7.7 days [interquartile range {IQR} 4.8– 13.4] vs. 6.1 days [IQR 3.4–10.8], respectively). In the crude analysis, the odds of having a length of stay of ≥7 days were higher in the ESKD group compared to the non-ESKD group (OR 1.62, 95% CI 1.27–2.06). After adjusting for baseline demographics and comorbid conditions, the adjusted OR was 1.57, 95% CI 1.22–2.02 (Table 2). We studied various clinical characteristics as potential risk factors of in-hospital death among patients with ESKD and those without ESKD (Tables 3 and 4; Figure 2).Table 3Univariable and multivariable logistic regression analyses of risk factors associated with in-hospital death in patients without ESKDVariablesUnivariableMultivariable (model 1)dModel 1: Adjusted for age, sex, race/ethnicity, BMI, diabetes mellitus, hypertension, cardiovascular disease, cancer, mechanical ventilation, use of vasoactive medication, hemoglobin, lymphocyte, blood urea nitrogen, albumin, C-reactive protein, and ferritin.Multivariable (model 2)eModel 2: Variables included in model 1, excluding laboratory values and inflammatory markers.OR95% CIPAdjusted OR95% CIPAdjusted OR95% CIPAge, yr1.051.05–1.05<0.0011.071.07–1.08<0.0011.081.08–1.09<0.001Male1.241.13–1.36<0.0011.181.03–1.350.021.391.23–1.58<0.001Race/ethnicity Non-Hispanic White————————— Non-Hispanic Black0.710.62–0.80<0.0010.960.80–1.150.671.130.95–1.340.17 Hispanic0.680.60–0.78<0.0010.950.79–1.140.550.940.79–1.120.52 Other0.760.67–0.87<0.0011.040.86–1.260.680.980.81–1.170.79 Unknown0.760.63–0.920.0050.780.60–1.020.070.850.66–1.090.20BMI, kg/m2 18.5–29.9————————— <18.51.671.24–2.26<0.0010.950.64–1.400.791.200.83–1.720.34 ≥30.00.780.71–0.87<0.0011.050.90–1.220.570.980.84–1.130.76Diabetes mellitus1.351.23–1.48<0.0011.060.93–1.220.391.161.02–1.320.02Hypertension1.601.46–1.76<0.0010.800.69–0.930.0040.8450.73–0.980.03Use of ACE inhibitor/ARB1.201.08–1.33<0.0010.830.72–0.970.020.780.67–0.90<0.001Cardiovascular diseaseaCardiovascular diseases include coronary artery disease, heart failure, and peripheral vascular disease.2.242.02–2.49<0.0011.321.14–1.53<0.0011.321.14–1.52<0.001Respiratory diseasebRespiratory diseases include asthma and chronic obstructive pulmonary disease.1.080.95–1.230.24——————Cancer1.621.38–1.89<0.0011.331.09–1.630.0061.301.07–1.570.009Chronic liver disease0.830.62–1.110.20——————Mechanical ventilation16.4014.60–18.50<0.0019.006.48–12.47<0.0017.425.42–10.18<0.001Vasoactive medicationcVasoactive medications include inotropes and vasopressors.16.5514.71–18.61<0.0013.962.89–5.45<0.0015.333.92–7.24<0.001Hemoglobin, g/l0.940.92–0.96<0.0010.980.95–1.010.23———WBC, 1000/μl1.081.07–1.09<0.001——————Lymphocyte, 1000/μl0.830.77–0.89<0.0010.930.86–1.010.07———Neutrophil, 1000/μl1.101.09–1.11<0.001——————BUN, mg/dl1.031.03–1.03<0.0011.021.01–1.02<0.001———Albumin, g/l0.450.42–0.49<0.0010.760.68–0.85<0.001———CRP, mg/dl1.051.05–1.06<0.0011.031.02–1.04<0.001———Log serum ferritin, ng/ml1.371.30–1.45<0.0011.131.04–1.230.004———ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin ii receptor blocker; BMI, body mass index; BUN, blood urea nitrogen; CI, confidence interval; CRP, C-reactive protein; OR, odds ratio; WBC, white blood count.a Cardiovascular diseases include coronary artery disease, heart failure, and peripheral vascular disease.b Respiratory diseases include asthma and chronic obstructive pulmonary disease.c Vasoactive medications include inotropes and vasopressors.d Model 1: Adjusted for age, sex, race/ethnicity, BMI, diabetes mellitus, hypertension, cardiovascular disease, cancer, mechanical ventilation, use of vasoactive medication, hemoglobin, lymphocyte, blood urea nitrogen, albumin, C-reactive protein, and ferritin.e Model 2: Variables included in model 1, excluding laboratory values and inflammatory markers. Open table in a new tab Table 4Univariable and multivariable logistic regression analyses of risk factors associated with death among patients with ESKDVariableUnivariableMultivariable (model 1)dModel 1: adjusted for age, sex, race/ethnicity, BMI, diabetes mellitus, hypertension, cardiovascular disease, cancer, mechanical ventilation, use of vasoactive medication, hemoglobin, lymphocyte, blood urea nitrogen, albumin, C-reactive protein and ferritin.Multivariable (model 2)eModel 2: Variables included in model 1, excluding all the laboratory values and inflammatory markers.OR95% CIPAdjusted OR95% CIPAdjusted OR95% CIPAge, yr1.031.01–1.040.0011.051.02–1.07< 0.0011.051.02–1.07< 0.001Male1.510.97–2.330.070.910.50–1.660.771.120.65–1.940.68Race/ethnicity Non-Hispanic White————————— Non-Hispanic Black0.420.24–0.730.0020.470.22–0.980.040.480.24–0.960.04 Hispanic0.570.30–1.060.070.680.28–1.650.390.680.30–1.530.35 Other1.120.60–2.120.721.620.65–4.040.981.480.66–3.320.34 Unknown0.530.18–1.620.270.560.11–2.730.690.550.13–2.340.42BMI, kg/m2 18.5–29.9————————— <18.51.020.40–2.640.961.010.29–3.500.981.070.35–3.250.92 ≥30.01.010.63–1.610.971.150.58–2.290.690.950.51–1.790.88Diabetes0.870.57–1.330.530.900.49–1.330.740.980.56–1.720.94Hypertension0.750.36–1.560.450.730.26–2.000.530.620.25–1.510.29Use of ACE inhibitor/ARB0.720.43–1.210.220.760.37–1.540.440.820.41–1.610.56Cardiovascular diseaseaCardiovascular diseases include coronary artery disease, heart failure and peripheral vascular disease.1.280.85–1.940.241.320.74–2.370.341.070.63–1.810.81Respiratory diseasebRespiratory diseases include asthma and chronic obstructive pulmonary disease.Cancer1.640.81–3.320.171.960.74–1.150.171.770.72–4.340.21Chronic liver disease1.270.45–3.560.65——————Mechanical ventilation14.668.15–26.35<0.00113.454.34–41.65<0.00110.443.62–30.19<0.001Vasoactive medicationcVasoactive medications include inotropes and vasopressors.12.427.10–21.75<0.0012.090.68–6.400.202.931.06–8.090.04Hemoglobin, g/l1.020.92–1.150.641.150.97–1.370.10———WBC, 1000/μl1.061.01–1.110.01——————Lymphocyte, 1000/μl0.610.39–0.940.030.600.41–0.900.01———Neutrophil, 1000/μl1.091.04–1.160.001——————BUN, mg/dl1.011.00–1.010.031.011.00–1.030.005———Albumin, g/l0.570.42–0.79<0.0010.640.39–1.040.07———CRP, mg/dl1.041.02–1.06<0.0011.020.98–1.010.29———Log serum ferritin, ng/ml1.691.31–2.19<0.0011.471.03–2.110.04———ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin ii receptor blocker; BMI, body mass index; BUN, blood urea nitrogen; CI, confidence interval; CRP, C-reactive protein; OR, odds ratio; WBC, white blood count.a Cardiovascular diseases include coronary artery disease, heart failure and peripheral vascular disease.b Respiratory diseases include asthma and chronic obstructive pulmonary disease.c Vasoactive medications include inotropes and vasopressors.d Model 1: adjusted for age, sex, race/ethnicity, BMI, diabetes mellitus, hypertension, cardiovascular disease, cancer, mechanical ventilation, use of vasoactive medication, hemoglobin, lymphocyte, blood urea nitrogen, albumin, C-reactive protein and ferritin.e Model 2: Variables included in model 1, excluding all the laboratory values and inflammatory markers. Open table in a new tab ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin ii receptor blocker; BMI, body mass index; BUN, blood urea nitrogen; CI, confidence interval; CRP, C-reactive protein; OR, odds ratio; WBC, white blood count. ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin ii receptor blocker; BMI, body mass index; BUN, blood urea nitrogen; CI, confidence interval; CRP, C-reactive protein; OR, odds ratio; WBC, white blood count. For patients without ESKD, the independent risk factors for in-hospital death after adjusting for covariates in model 1 included increased age, male sex, cardiovascular disease, cancer, requiring mechanical ventilation, requiring vasoactive medications, high blood urea nitrogen level, low albumin level, high C-reactive protein level, and high log-transformed serum ferritin level. The diagnosis of hypertension and use of an ACE inhibitor or angiotensin II receptor blocker (ARB) were associated with a lower risk of in-hospital death (Table 3). After adjusting for variables in model 2, the independent risk factors for in-hospital death among patients without ESKD were increased age, male sex, DM, cardiovascular disease, cancer, requiring mechanical ventilation, and requiring vasoactive medications (Table 3). Hypertension and use of ACE inhibitors or ARB were again associated with lower risk of in-hospital death. Among patients with ESKD, independent risk factors for in-hospital death after adjustment in model 1 were increased age, requiring mechanical ventilation and lymphopenia, elevated blood urea nitrogen level, and high log-transformed serum ferritin level. In model 2, the independent risk factors for in-hospital death were increased age, requiring mechanical ventilation, and vasoactive medication use. Black race was associated with a significantly lower risk of death among patients with ESKD in both models (OR 0.47, 95% CI 0.22–0.98 and OR 0.48, 95% CI 0.24–0.96, in models 1 and 2, respectively; Table 4 and Figure 2). In a comparison of the odds of in-hospital death in the ESKD group versus the non-ESKD group, sensitivity analysis incorporating the assumption that those who were still hospitalized either all experienced death or were all discharged alive did not significantly alter the results (Supplementary Table S3). Similarly, sensitivity analyses examining risk factors for mortality in the ESKD and non-ESKD cohorts separately did not substantially alter the results (Supplementary Tables S4 and S5). Supplementary Table S6 shows the odds ratios of in-hospital death of patients with and without ESKD, stratified by mechanical ventilation. We examined the clinical c" @default.
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• W3048702451 date "2020-12-01" @default.
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• W3048702451 title "Outcomes of patients with end-stage kidney disease hospitalized with COVID-19" @default.
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• W3048702451 doi "https://doi.org/10.1016/j.kint.2020.07.030" @default.
• W3048702451 hasPubMedCentralId "https://www.ncbi.nlm.nih.gov/pmc/articles/7428720" @default.
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