COVID-19 in Hemodialysis Patients: A Report of 5 Cases.

In December 2019, an outbreak of coronavirus disease 2019 (COVID-19) due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began in China and spread rapidly worldwide. It is unknown whether hemodialysis patients represent a distinct group of patients with certain characteristics that may make them susceptible to infection or severe disease. In this case report, we describe the clinical and epidemiologic features of COVID-19 infection in 201 maintenance hemodialysis patients in Zhongnan Hospital of Wuhan University, including 5 maintenance hemodialysis patients who contracted COVID-19 infection. Of the 5 patients with COVID-19 infection, one had a definite history of contact with an infected person. The age range of the patients was 47 to 67 years. Diarrhea (80%), fever (60%), and fatigue (60%) were the most common symptoms. Lymphopenia occurred in all patients. Computed tomography of the chest showed ground glass opacity in the lungs of all patients. Up to February 13, 2020, none of the patients had developed severe complications (acute respiratory distress syndrome, shock, or multiple organ dysfunction) or died.

Introduction

In December 2019, an outbreak of coronavirus disease (COVID-19) due to infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began in Wuhan, China, and spread rapidly to other areas of China and other countries.1, 2, 3, 4, 5, 6 Phylogenetic analysis suggests that SARS-CoV-2 is a new human-infecting betacoronavirus, closely similar to bat coronaviruses, suggesting that bats may have been the original host of this virus. There are no antiviral drugs of proven efficacy or applicable vaccines. Supportive therapy is the main method for the management of symptomatic patients, many of whom require mechanical ventilation and other intensive care services. There is limited information regarding the epidemiology of COVID-19 in maintenance hemodialysis (MHD) patients. MHD patients may be at increased risk for COVID-19 infection because of many comorbid conditions. In this report, we describe our experience with 5 MHD patients who developed COVID-19 disease at Zhongnan Hospital of Wuhan University.

Case Reports

Among 201 MHD patients in the dialysis center at Zhongnan Hospital of Wuhan University, 5 patients had COVID-19 pneumonia diagnosed according to criteria of the Chinese Centers for Disease Control, which included positive real-time reverse transcriptase–polymerase chain reaction (rRT-PCR) test results for SARS-CoV-2. Characteristics of the 5 patients are presented in Table 1 . The age range of patients was 47 to 67 years and 2 of 5 patients were women. None of the patients had known exposure to the Huanan seafood market that appeared to be the epicenter of this infection. One had known exposure to an infected family member. The most common symptom of the 5 infected patients was diarrhea (4/5), followed by fever (3/5), fatigue (3/5), dyspnea (2/5), and abdominal pain (2/5). Only 1 patient had dry cough. No patient had rhinorrhea, sore throat, myalgia, or other upper respiratory tract infection symptoms. All 5 patients had lymphopenia (lymphocytes <1.0 ×10⁹/L). Only 1 patient had white blood cell and neutrophil cell counts slightly above normal.

Table 1

Patient Clinical and Laboratory Characteristics

	Case 1	Case 2	Case 3	Case 4	Case 5
Clinical Characteristics
Age, y	61	62	47	67	51
Sex	Male	Male	Female	Female	Male
Contact history with infected person	No	No	No	Yes	No
Other family members affected	No	No	No	Yes	No
Dialysis vintage, y	7	3	5	1	1
Cause of kidney failure	Hypertensive nephropathy	Hypertensive nephropathy	Chronic nephritis	Hypertensive nephropathy	Hypertensive nephropathy
Diabetes	No	No	No	Yes	No
Signs and symptoms
Fever	Yes	No	Yes	Yes	No
Dry cough	No	Yes	No	No	No
Dyspnea	No	No	Yes	Yes	No
Fatigue	Yes	No	No	Yes	Yes
Diarrhea	Yes	No	Yes	Yes	Yes
Abdominal pain	No	No	Yes	Yes	No
Laboratory Characteristics
White blood cell count, ×103/μL	6.84	7.50	7.73	10.76	5.03
Neutrophil count, ×103/μL	5.69	5.65	6.28	9.24	4.29
Lymphocyte count, ×103/μL	0.63	0.84	0.80	0.92	0.49

As shown in Figure 1 , ground glass opacities on computed tomography (CT) of the chest were the most common radiologic findings, followed by consolidation. All 5 patients were transferred to a designated hospital after diagnosis to continue hemodialysis. Two of them received intermittent oxygen inhalation through a nasal catheter and treatment with daily 40 mg of methylprednisolone and intravenous immunoglobulin. Two patients were given antiviral treatment with abidol and ribavirin injection, respectively. Up to the end of this study, none of them had developed acute respiratory distress syndrome, shock, or other serious complications.

Figure 1

Computed tomographic scans (transverse plane) of the chest of patients 1 and 3. (A) Patient 1: bilateral ground glass opacity, mainly in the lower lobes of both lungs, with air bronchogram sign. (B) Patient 3: bilateral ground glass opacity of lower lung lobes and round shape consolidation opacity with air bronchogram sign in the right lower lung lobe.

Discussion

We describe 5 adult MHD patients in our dialysis center diagnosed with mild COVID-19, representing 2.5% of our dialysis population at the time. In addition, 1 patient had respiratory symptoms and abnormal CT results but negative rRT-PCR results. All patients presented with lymphopenia, and the most common chest radiograph abnormality was ground glass opacity, which bears some resemblance to previous reports. Of note, the prevalence of 2.5% may underestimate the actual prevalence of infected patients. Screening of all MHD patients began after the first patient was identified on February 9, and screening consisted of CT of the chest. rRT-PCR testing was performed only in those with abnormal CT results. In addition, all patients had the temperature measured before dialysis and patients who had a temperature > 37.3°C or with respiratory symptoms underwent CT of the chest and, if abnormal results, rRT-PCR testing. Therefore, some patients may have developed COVID-19 infection before screening and patients without an abnormal CT result at the time of screening would have been missed, although no symptomatic patients were identified before February 9.

It has been confirmed that T-cell immunity is a key factor in recovery from SARS-CoV infection. Because uremia status is associated with extensive impairment of lymphocyte and granulocyte function, an abnormal immune system may alter the response to SARS-CoV infection.11, 12 This is of particular concern given the densely populated and busy nature of dialysis facilities, creating a high risk for exposure. However, in our dialysis center, it does not seem to have spread widely.

Because the COVID-19 outbreak began in Wuhan, the city in which our dialysis center is located, by January 9, 2020 we had already begun taking a number of measures to avoid infection of patients and staff by SARS-CoV-2. Patients were required to wear surgical masks or N95 masks throughout the hemodialysis treatment. No visitors were allowed. Staff members who conducted the dialysis treatments wore face shields, N95 face masks, eye shields, and disposable gowns, caps, and gloves. In addition, chlorine disinfectants were used daily by staff to disinfect items and floors in the dialysis center. The circulating air UV air sterilizer disinfects 4 times a day for 2 hours each time.

In a retrospective study of 1,099 patients with COVID-19 acute respiratory disease, fever and cough were the dominant symptoms, whereas vomiting and diarrhea were rare. Wang et al found that the common symptoms of COVID-19 infection were fever, fatigue, and dry cough, although many patients also presented with gastrointestinal symptoms, such as nausea and diarrhea. Of note, the typical triad of fever, cough, and dyspnea was not present in any of the patients we report here, and diarrhea was a common presenting symptom. Some symptoms of dialysis patients with COVID-19 disease may be difficult to distinguish from other symptoms common among patients receiving dialysis.

In summary, we describe 5 MHD patients who developed mild COVID-19 disease. In addition to fever and fatigue, diarrhea was common in our dialysis patients. Further observations will be needed to more fully understand the full spectrum of clinical features and optimal diagnostic and treatment approached for of COVID-19 disease in hemodialysis patients.