Abstract
BackgroundPatients on kidney replacement therapy (KRT) are at very high risk of coronavirus disease 2019 (COVID-19). The triage pathway for KRT patients presenting to hospitals with varying severity of COVID-19 illness remains ill-defined. We studied the clinical characteristics of patients at initial and subsequent hospital presentations and the impact on patient outcomes.MethodsThe European Renal Association COVID-19 Database (ERACODA) was analysed for clinical and laboratory features of 1423 KRT patients with COVID-19 either hospitalized or non-hospitalized at initial triage and those re-presenting a second time. Predictors of outcomes (hospitalization, 28-day mortality) were then determined for all those not hospitalized at initial triage.ResultsAmong 1423 KRT patients with COVID-19 [haemodialysis (HD), n = 1017; transplant, n = 406), 25% (n = 355) were not hospitalized at first presentation due to mild illness (30% HD, 13% transplant). Of the non-hospitalized patients, only 10% (n = 36) re-presented a second time, with a 5-day median interval between the two presentations (interquartile range 2–7 days). Patients who re-presented had worsening respiratory symptoms, a decrease in oxygen saturation (97% versus 90%) and an increase in C-reactive protein (26 versus 73 mg/L) and were older (72 vs 63 years) compared with those who did not return a second time. The 28-day mortality between early admission (at first presentation) and deferred admission (at second presentation) was not significantly different (29% versus 25%; P = 0.6). Older age, prior smoking history, higher clinical frailty score and self-reported shortness of breath at first presentation were identified as risk predictors of mortality when re-presenting after discharge at initial triage.ConclusionsThis study provides evidence that KRT patients with COVID-19 and mild illness can be managed effectively with supported outpatient care and with vigilance of respiratory symptoms, especially in those with risk factors for poor outcomes. Our findings support a risk-stratified clinical approach to admissions and discharges of KRT patients presenting with COVID-19 to aid clinical triage and optimize resource utilization during the ongoing pandemic.
Highlights
The COVID-19 pandemic has caused devastation to human lives and major disruption of health care systems and individual patient care around the world
Clinical triage pathway for kidney replacement therapy patients presenting with COVID19 illness of varying severity has not been well defined
Ongoing pandemic has seen a major strain in hospital resources and clinical pathways affecting overall care
Summary
The COVID-19 pandemic has caused devastation to human lives and major disruption of health care systems and individual patient care around the world. Understanding of the factors associated with progression of symptoms from the asymptomatic- stage through to severe illness is essential for developing efficient and appropriate triage systems. Avoidance of unnecessary hospitalizations, when clinically appropriate and safe, will offer protection of COVID-19 patients from potential exposure to hospital acquired infections, minimize the risk of transmitting COVID-19 infections to others who don’t have the illness, allow continuation of standard and routine care, cause less disruption to patient lives, and avoid overwhelming the healthcare system. As the pandemic is sustained through second and possible future waves, with a simultaneous increase in identification rates from enhanced testing, and continued disruption of routine care, we urgently need to establish optimum triage tools to support decision-making on hospitalization of patients on KRT affected by COVID-19
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