Redefying the therapeutic strategies against cardiorenal morbidity and mortality:Patient phenotypes

Chronic kidney disease(CKD)patients face an unacceptably high morbidity and mortality,mainly from cardiovascular diseases.Diabetes mellitus,arterial hypertension and dyslipidemia are highly prevalent in CKD patients.Established therapeutic protocols for the treatment of diabetes mellitus,arterial hypertension,and dyslipidemia are not as effective in CKD patients as in the general population.The role of non-traditional risk factors(RF)has gained interest in the last decades.These entail the deranged clinical spectrum of secondary hyperparathyroidism involving vascular and valvular calcification,under the term“CKDmineral and bone disorder”(CKD-MBD),uremia per se,inflammation and oxidative stress.Each one of these non-traditional RF have been addressed in various study designs,but the results do not exhibit any applied clinical benefit for CKD-patients.The“crusade”against cardiorenal morbidity and mortality in CKD-patients is in some instances,derailed.We propose a therapeutic paradigm advancing from isolated treatment targets,as practiced today,to precision medicine involving patient phenotypes with distinct underlying pathophysiology.In this regard we propose two steps,based on current stratification management of corona virus disease-19 and sepsis.First,select patients who are expected to have a high mortality,i.e.,a prognostic enrichment.Second,select patients who are likely to respond to a specific therapy,i.e.,a predictive enrichment.

Siblings with coronavirus disease 2019 infection and opposite outcome—the hemodialysis’s better outcome paradox:Two case reports

BACKGROUND Coronavirus disease 2019(COVID-19)is a highly contagious infection caused by the severe acute respiratory syndrome coronavirus 2 virus and has a unique underlying pathogenesis.Hemodialysis(HD)patients experience high risk of contamination with COVID-19 and are considered to have higher mortality rates than the general population by most but not all clinical series.We aim to highlight the peculiarities in the immune state of HD patients,who seem to have both immune-activation and immune-depression affecting their outcome in COVID-19 infection.CASE SUMMARY We report the opposite clinical outcomes(nearly asymptomatic course vs death)of two diabetic elderly patients infected simultaneously by COVID-19,one being on chronic HD and the other with normal renal function.They were both admitted in our hospital with COVID-19 symptoms and received the same treatment by protocol.The non-HD sibling deteriorated rapidly and was intubated and transferred to the Intensive Care Unit,where he died despite all supportive care.The HD sibling,although considered more“high-risk”for adverse outcome,followed a benign course and left the hospital alive and well.CONCLUSION These cases may shed light on aspects of the immune responses to COVID-19 between HD and non-HD patients and stimulate further research in pathophysiology and treatment of this dreadful disease.

Emperor’s syndrome in the COVID-19 era:Time for patient-centered nephrology?

The coronavirus disease-19(COVID-19)pandemic has been a wake-up call in which has forced us to react worldwide.Health policies and practices have attracted particular attention in terms of human and financial cost.Before COVID-19,chronic kidney disease was already considered a risk multiplier in patients with diabetes and hypertension,the two now being the major risk factors for COVID-19 infection and adverse outcome.In contrast to the urgent need for action,the nephrology field is considered to be in a state of stagnation regarding the management of chronic kidney disease patients who still experience unacceptably high morbidity and mortality.Ironically and paradoxically in a field lacking robust clinical trials,clinical practice is driven by guidelines-based medicine on weak evidence.The Emperor’s syndrome,referring to Hans Christian Andersen’s fairy tale,has been described in medicine as voluntary blindness to an obvious truth,being a weak evidence-based therapeutic intervention or weak health care.A promising positive example of improving heart and kidney outcomes is the emerging treatment with sodium-glucose cotransporter 2 inhibitors.COVID-19 could boost actions for patient-centered care as a positive shift in nephrology care.

COVID-19 presenting with persistent hiccup and myocardial infarction in a peritoneal dialysis patient:A case report

BACKGROUND Persistent hiccups,lasting more than 48 h,have been described as an atypical presentation of coronavirus disease 19(COVID-19)in the general population.To the best of our knowledge,this is the first report of persistent hiccups and non-ST elevation myocardial injury(NSTEMI)as an atypical presentation of COVID-19 in a peritoneal dialysis(PD)patient.CASE SUMMARY A 70-year old man,who had been on PD for 3 years with a history of ischemic heart failure and reduced ejection fraction,presented for a scheduled radionuclide myocardial scan.Upon arrival,he complained of anorexia,nausea for 5 d,and unremitting hiccups for the previous 48 h.Clinical and laboratory examinations revealed an NSTEMI plus a positive nasopharyngeal reverse transcriptase polymerase chain reaction testing for severe acute respiratory syndrome coronavirus 2.COVID-19 lung involvement was mild and was resolved without specific treatment.Myocardial injury was managed by coronary catheterization and stenting,while hiccups responded only to baclofen per os.CONCLUSION Persistent hiccups and NSTEMI can be atypical presentations of COVID-19 in peritoneal dialysis patients,which may be due to involvement of the central nervous system and myocardial injuries.

Clinical presentation and outcomes of chronic dialysis patients with COVID-19:A single center experience from Greece

BACKGROUND Coronavirus disease 2019(COVID-19)is still a menacing pandemic,especially in vulnerable patients.Morbidity and mortality from COVID-19 in maintenance hemodialysis(MHD)patients are considered worse than those in the general population,but vary across continents and countries in Europe.AIM To describe the clinical course and outcomes of hospitalized MHD patients with COVID-19 in a retrospective observational single center study in Greece.METHODS We correlated clinical,laboratory,and radiological data with the clinical outcomes of MHD patients hospitalized with COVID-19 during the pandemic.The diagnosis was confirmed by real-time polymerase chain reaction.Outcome was determined as survivors vs non-survivors and“progressors”(those requiring oxygen supplementation because of COVID-19 pneumonia worsening)vs“non-progressors”.RESULTS We studied 32 patients(17 males),with a median age of 75.5(IQR:58.5-82)years old.Of those,12 were diagnosed upon screening and 20 with related symptoms.According to the World Health Organization(WHO)score,the severity on admission was mild disease in 16,moderate in 13,and severe in 3 cases.Chest computed tomography(CT)showed 1-10%infiltrates in 24 patients.Thirteen“progressors”were recorded among included patients.The case fatality rate was 5/32(15.6%).Three deaths occurred among“progressors”and two in“non-progressors”,irrespective of co-morbidities and gender.Predictors of mortality on admission included frailty index,chest CT findings,WHO severity score,and thereafter the increasing values of serum LDH and D-dimers and decreasing serum albumin.Predictors of becoming a“progressor”included increasing number of neutrophils and neutrophils/lymphocytes ratio.CONCLUSION Patients on MHD seem to be at higher risk of COVID-19 mortality,distinct from the general population.Certain laboratory parameters on admission and during follow-up may be helpful in risk stratification and management of patients.