covid 19 and kidney disease insights from epidemiology to inform clinical practice CORD-Papers-2022-06-02 (Version 1)

Title: COVID-19 and kidney disease: insights from epidemiology to inform clinical practice
Abstract: Over the course of the COVID-19 pandemic numerous studies have aimed to address the challenges faced by patients with kidney disease and their caregivers. These studies addressed areas of concern such as the high infection and mortality risk of patients on in-centre haemodialysis and transplant recipients. However the ability to draw meaningful conclusions from these studies has in some instances been challenging owing to barriers in aspects of usual care data limitations and problematic methodological practices. In many settings access to SARS-CoV-2 testing differed substantially between patient groups whereas the incidence of SARS-CoV-2 infection varied over time and place because of differences in viral prevalence targeted public health policies and vaccination rates. The absence of baseline kidney function data posed problems in the classification of chronic kidney disease and acute kidney injury in some studies potentially compromising the generalizability of findings. Study findings also require attentive appraisal in terms of the effects of confounding collider bias and chance. As this pandemic continues and in the future the implementation of sustainable and integrated research infrastructure is needed in settings across the world to minimize infection transmission and both prevent and plan for the short-term and long-term complications of infectious diseases. Registries can support the real-world evaluation of vaccines and therapies in patients with advanced kidney disease while enabling monitoring of rare complications.
Published: 2022-04-13
Journal: Nat Rev Nephrol
DOI: 10.1038/s41581-022-00570-3
DOI_URL: http://doi.org/10.1038/s41581-022-00570-3
Author Name: Mahalingasivam Viyaasan
Author link: https://covid19-data.nist.gov/pid/rest/local/author/mahalingasivam_viyaasan
Author Name: Su Guobin
Author link: https://covid19-data.nist.gov/pid/rest/local/author/su_guobin
Author Name: Iwagami Masao
Author link: https://covid19-data.nist.gov/pid/rest/local/author/iwagami_masao
Author Name: Davids Mogamat Razeen
Author link: https://covid19-data.nist.gov/pid/rest/local/author/davids_mogamat_razeen
Author Name: Wetmore James B
Author link: https://covid19-data.nist.gov/pid/rest/local/author/wetmore_james_b
Author Name: Nitsch Dorothea
Author link: https://covid19-data.nist.gov/pid/rest/local/author/nitsch_dorothea
sha: e30941ddb6f1329eb57355b8b6cdb2f2a71cdf90
license: no-cc
license_url: [no creative commons license associated]
source_x: Medline; PMC; WHO
source_x_url: https://www.medline.com/https://www.ncbi.nlm.nih.gov/pubmed/https://www.who.int/
pubmed_id: 35418695
pubmed_id_url: https://www.ncbi.nlm.nih.gov/pubmed/35418695
pmcid: PMC9006492
pmcid_url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9006492
url: https://www.ncbi.nlm.nih.gov/pubmed/35418695/ https://doi.org/10.1038/s41581-022-00570-3
has_full_text: TRUE
Keywords Extracted from Text Content: people body Ad26.COV2.S Kidney SGLT2 Single-centre baricitinib SARS-CoV-2 antibodies serum creatinine fluids convalescent plasma COVID-19 epidemiology 2 tocilizumab cellular graft Colombia most-part lowresource non-steroidal anti-inflammatory drugs 116, 117 Fig. 1 graft biopsy ACE inhibitors [109] [110] [111] [112] [113 hydroxychloroquine liver recipients donors blood COVID-19 peritoneal COVID- 19 Kidney transplant recipients SARS-CoV-2 monoclonal antibody ERACODA organ solid organ lockdowns venous serum creatinine-based GFR BK polyomavirus ACE inhibitors 108 COVID-19 vaccines Sweden 10 UK corticosteroids lower-income ReF. 59 São Paulo EHRs Urine ACE adenoviral cardiovascular anti-HLA liver kidney biopsies UK ISARIC RECOVERY arterial participants calcineurin kidney recipients recipients gastrointestinal Mogamat Razeen Davids 6 azithromycin transplants COVID-19 diagnosis 1 cytomegalovirus Wuhan, glomerular Guobin Su 2 heart Supplementary Table 1 KRT 79 angiotensin-converting enzyme ( Renal Patients intravenous immunoglobulin renal SARS-CoV-2 solid organs biopsy vascular citrate BNT162b2 individuals kidney SARS-CoV-2 antibodies 8 London, France Fig. 1c lopinavir-ritonavir post-COVID-19 solid organ recipients tubular prednisolone ACE2 patients patient www.nature.com/nrneph solid organ transplants ISARIC Flanders CKD stage 5 seroresponse CKD biopsies Serum creatinine casirivimab-imdevimab oxygen arterial thromboembolic KRT patients 90,91 line ReF. 107 KRT cell CKD stage 4-5 Dexamethasone survivors Patients cells dexamethasone Dorothea Nitsch 1,11 ✉ https://doi.org/10.1038/s41581-022-00570-3 Priya Vart Al-Aly
Extracted Text Content in Record: First 5000 Characters:The abrupt arrival of the COVID-19 pandemic in early 2020 posed unforeseen challenges for patients with kidney disease and their care providers. Day-to-day priorities shifted towards the rapid reconfiguration of services to protect patients on in-centre haemodialysis who were unable to strictly adhere to social distancing policies due to their need to attend treatment. Concerns also existed that transplantation might place new recipients at a heightened risk of postoperative death. There were instances during the pandemic in which some critical care units became overwhelmed with an unprecedented demand for acute kidney replacement therapy (KRT). Despite the rapid development of vaccines and identification of effective treatments for severe disease, many of these challenges persist with the continuing emergence of novel SARS-CoV-2 variants. Lessons from learned experiences and the published literature must, therefore, be rapidly applied to better cope with ongoing challenges and similar crises that may arise in the future. To best inform clinical care, epidemiological studies -ranging from small single-centre case series to large registry and population-wide cohorts -have been conducted across a range of settings. However, the COVID-19 pandemic has presented unique challenges, and many of these studies have encountered methodological difficulties arising from barriers in aspects of usual care, limitations in data collection and challenges in study design ( Table 1; Supplementary Table 1 ). For example, such studies should ideally investigate and account for variations in health-care delivery, temporal trends and geographical factors that arose as a consequence of the pandemic. These methodological challenges have also hindered comparisons between epidemiological studies. Meta-analyses that use aggregated outcomes from studies that have not investigated and/or accounted for these variables may be limited in their conclusions -a fact that has been well-acknowledged 1 . Collider bias is an important problem encountered in COVID-19 epidemiology 2 (Fig. 1 , Table 1; Supplementary Table 1 ). Collider bias occurs when both the risk factor or exposure of interest (for example, kidney transplantation) and the factors on the pathway to the COVID-19 and kidney disease: insights from epidemiology to inform clinical practice Viyaasan Mahalingasivam 1 , Guobin Su 2, 3, 4 , Masao Iwagami 1, 5 , Mogamat Razeen Davids 6, 7, 8 , James B. Wetmore 9, 10 and Dorothea Nitsch 1,11 ✉ Abstract | Over the course of the COVID-19 pandemic, numerous studies have aimed to address the challenges faced by patients with kidney disease and their caregivers. These studies addressed areas of concern such as the high infection and mortality risk of patients on in-centre haemodialysis and transplant recipients. However, the ability to draw meaningful conclusions from these studies has in some instances been challenging, owing to barriers in aspects of usual care, data limitations and problematic methodological practices. In many settings, access to SARS-CoV-2 testing differed substantially between patient groups, whereas the incidence of SARS-CoV-2 infection varied over time and place because of differences in viral prevalence, targeted public health policies and vaccination rates. The absence of baseline kidney function data posed problems in the classification of chronic kidney disease and acute kidney injury in some studies, p ot en ti ally compromising the generalizability of findings. Study findings also r e q u i re a t t e n tive a p p ra isal i n t e r ms o f t h e effects of confounding, collider bias and chance. As this pandemic continues and in the future, the implementation of sustainable and integrated research infrastructure is needed in settings across the world to minimize infection transmission and both prevent and plan for the short-term and long-term complications of infectious diseases. Registries can support the real-world evaluation of vaccines and therapies in patients with advanced kidney disease while enabling monitoring of rare complications. Nature reviews | Nephrology outcome of interest (for example, disease severity on the pathway to death) influence the mechanisms behind selection into a study sample population. Causal inference based on analyses of such a selected study sample cannot then be generalized to a wider population of interest and, depending on the circumstances, may not be internally valid due to selection bias. Epidemiological studies therefore require well-defined study populations in which outcome events (for example, SARS-CoV-2 infection and its consequences) are determined as accurately as possible for every study participant. Although individuals on long-term KRT are generally included in national registries, a lack of baseline kidney function data makes it difficult to define populations with chronic kidney disease (CKD) and acute kidney injury (AKI) for prospective outcome assessment. In this R
Keywords Extracted from PMC Text: comorbidities60 ICU65,66 participants126 SARS-CoV-2 positivity69 azithromycin121–123 well-acknowledged1 SARS-CoV-2 settings47 Sweden10,28,61 graft biopsy all30 membranous nephropathy94 SARS-CoV-2 antibodies8 pandemic120 kidney recipients28,35 dexamethasone 39%118 discharge20 UK63 ERACODA ISARIC Colombia Dexamethasone COVID-19 epidemiology2 solid organ transplants serology testing36 prognosis57,58 organ COVID-19 seroresponse BNT162b2 Pfizer discharge19 intravenous immunoglobulin people vasculitis93 limited73 ACE inhibitors109–113 kidney diseases128 cardiovascular list45 COVID-19 diagnosis1,15,16 patients unavailable8 solid organ recipients Fig. 1c serum creatinine-based GFR vascular heart angiotensin-converting enzyme ( England14 solid organs individuals venovenous health-care providers10,28 disease95 solid organ COVID-19 vaccines State13 prednisolone China3 hydroxychloroquine Patients liver eGFR101,104 population10 Serum creatinine citrate KRT79 Ad26.COV2.S lopinavir patient kidney diseases139 shortages87 IgA nephropathy92 convalescent plasma donors64 Single-centre tubular refs59,118,119 body status21 Kidney transplant recipients cytomegalovirus venous Wuhan, multi-morbidity77 respectively)102 Renal Patients population10,28 16–49 KRT liver recipients biopsy care78 participants ICU101 lockdowns UK CKD tocilizumab blood consumables86 SARS-CoV-2 antibodies graft RECOVERY ACE inhibitors108 BNT162b2 ACE baricitinib CKD status82 kidney biopsies calcineurin arterial SARS-CoV-2 monoclonal antibody KRT89 casirivimab France Wuhan kidney function60 corticosteroids AKI76 kidney recipients line capacity90,91 adenoviral COVID-19 pandemic65 CKD stages serum creatinine cell USA110 arterial thromboembolic ritonavir glomerular peritoneal most-part London, refs70,71 setting74 survivors gastrointestinal treatment114,115 cells non-steroidal anti-inflammatory drugs116,117 dexamethasone85 BK polyomavirus kidney response87 regions12 graft function26 UK85 discharge81 oxygen pandemic18 cellular São Paulo tocilizumab52,53,56 anti-HLA Supplementary Table 1 Flanders biopsies groups125 fluids safely6,9 haemodialysis15 mild3 ref.59 CKD itself77 post-COVID-19 regions111–113 ACE2 CKD stage 5 recipients settings9 Fig. 1 transplants 16–60
Extracted PMC Text Content in Record: First 5000 Characters:The abrupt arrival of the COVID-19 pandemic in early 2020 posed unforeseen challenges for patients with kidney disease and their care providers. Day-to-day priorities shifted towards the rapid reconfiguration of services to protect patients on in-centre haemodialysis who were unable to strictly adhere to social distancing policies due to their need to attend treatment. Concerns also existed that transplantation might place new recipients at a heightened risk of postoperative death. There were instances during the pandemic in which some critical care units became overwhelmed with an unprecedented demand for acute kidney replacement therapy (KRT). Despite the rapid development of vaccines and identification of effective treatments for severe disease, many of these challenges persist with the continuing emergence of novel SARS-CoV-2 variants. Lessons from learned experiences and the published literature must, therefore, be rapidly applied to better cope with ongoing challenges and similar crises that may arise in the future. To best inform clinical care, epidemiological studies — ranging from small single-centre case series to large registry and population-wide cohorts — have been conducted across a range of settings. However, the COVID-19 pandemic has presented unique challenges, and many of these studies have encountered methodological difficulties arising from barriers in aspects of usual care, limitations in data collection and challenges in study design (Table 1; Supplementary Table 1). For example, such studies should ideally investigate and account for variations in health-care delivery, temporal trends and geographical factors that arose as a consequence of the pandemic. These methodological challenges have also hindered comparisons between epidemiological studies. Meta-analyses that use aggregated outcomes from studies that have not investigated and/or accounted for these variables may be limited in their conclusions — a fact that has been well-acknowledged1. Collider bias is an important problem encountered in COVID-19 epidemiology2 (Fig. 1, Table 1; Supplementary Table 1). Collider bias occurs when both the risk factor or exposure of interest (for example, kidney transplantation) and the factors on the pathway to the outcome of interest (for example, disease severity on the pathway to death) influence the mechanisms behind selection into a study sample population. Causal inference based on analyses of such a selected study sample cannot then be generalized to a wider population of interest and, depending on the circumstances, may not be internally valid due to selection bias. Epidemiological studies therefore require well-defined study populations in which outcome events (for example, SARS-CoV-2 infection and its consequences) are determined as accurately as possible for every study participant. Although individuals on long-term KRT are generally included in national registries, a lack of baseline kidney function data makes it difficult to define populations with chronic kidney disease (CKD) and acute kidney injury (AKI) for prospective outcome assessment. In this Review, we discuss a range of epidemiological challenges posed by the COVID-19 pandemic — a unique situation in which timely, reliable research was needed in the face of an unprecedented public health challenge. We discuss some of the major obstacles encountered when conducting epidemiological research in populations with kidney disease in a pandemic setting (Table 1; Supplementary Table 1), including challenges in ascertaining COVID-19-related outcomes in the dialysis and transplant populations, confounding factors such as barriers to health care, and the challenges in identifying and defining people with CKD or AKI (the 'denominators'). We focus particularly on studies that have relevance for public health and their ability to inform future research endeavours and study design. Data on the incidence of COVID-19 among patients receiving in-centre haemodialysis is generally of high quality. The first cases of COVID-19 among patients receiving in-centre haemodialysis were from Wuhan, China3, with additional reports emerging as the pandemic spread to other parts of the world4–7.Throughout the pandemic, patients on in-centre haemodialysis were more likely than members of the general population to be exposed to SARS-CoV-2, as a consequence of the requirement to attend dialysis centres three times weekly, even during lockdowns. Often, attendance would involve shared patient transportation to and from home and interactions with other patients and dialysis staff. Despite the implementation of infection control procedures, these interactions increased exposure risk, especially in the early phases of the pandemic when asymptomatic screening was unavailable8 and personal protective equipment was lacking in some settings9. It is therefore unsurprising that the incidence of COVID-19 is higher in patients on in-centre haemodialysis than in the general
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