High Dependency Renal Unit for COVID-19, KEMH Mumbai- Dataset

Background: COVID-19 in patients on dialysis for acute or chronic kidney disease is associated with high mortality. We evaluated the effect of high dependency renal unit (HDRU) with nephrologists as primary care physicians for management of these patients. Methods: This was an observational, cohort study conducted at a tertiary care teaching hospital in western India. Patients needing dialysis for COVID-19 associated Acute Kidney Injury (AKI-D) and patients with End-Stage-Renal-Disease (ESRD) hospitalized for COVID-19 were included in the study. After 2 months into the pandemic (28 March to 28 May 2020), HDRU was commissioned for management of these patients. With nephrologists as primary care physicians, the components of care included completion of care bundle focusing on key nephrology and COVID-19 related issues, checklist-based clinical monitoring, integration of multispecialty care, and training of nurses and doctors. Primary outcome of the study was in hospital mortality compared between pre-HDRU and HDRU cohorts. Secondary outcomes were- dialysis dependence in AKI-D, and predictors of death. Results: 238 of 4254 (5.59%) patients with COVID-19 admitted from 28th March to 30th September had severe renal impairment (116 AKI-D and 122 ESRD). 145 (62%) had severe COVID-19. HDRU care was delivered from 28th May to 30th August. Kaplan-Meier survival analysis showed significant improvement in survival after implementation of HDRU [19 of 52 (36.5%) in pre-HDRU versus 35 of 160 (21.9%) in HDRU died, p=<0.01]. 44 (67.7%) AKI-D survivors were dialysis dependent at discharge. Breathlessness and altered mental status at presentation, development of shock during hospital stay and leukocytosis predicted mortality. Conclusions: HDRU managed by nephrologists as primary care physicians is a feasible and potentially effective approach to improve the outcomes of patients with COVID-19 and severe renal impairment.

背景：接受透析治疗的急性或慢性肾病患者合并COVID-19感染时，死亡率显著升高。本研究评估了以肾病学家（nephrologists）作为首诊医师的高依赖肾内科病房（high dependency renal unit, HDRU）对这类患者的管理效果。
方法：本研究为一项观察性队列研究，于印度西部一所三级教学医院开展。研究纳入两类患者：因COVID-19相关急性肾损伤需接受透析治疗的患者（COVID-19 associated Acute Kidney Injury, AKI-D），以及因COVID-19住院的终末期肾病（End-Stage-Renal-Disease, ESRD）患者。疫情暴发2个月后（2020年3月28日至5月28日），高依赖肾内科病房正式启用，用于此类患者的管理。在肾病学家作为首诊医师的诊疗模式下，护理内容涵盖：落实聚焦肾病学与COVID-19核心相关问题的集束化护理方案、基于核查表的临床监测、多学科诊疗整合，以及医护人员专项培训。本研究的主要结局为对比高依赖肾内科病房启用前后队列的住院死亡率；次要结局包括AKI-D患者的透析依赖情况及死亡预测因素。
结果：2020年3月28日至9月30日期间入院的4254例COVID-19患者中，238例（5.59%）合并重度肾功能损害，其中116例为AKI-D患者，122例为ESRD患者。145例（62%）患者为重型COVID-19。高依赖肾内科病房的护理服务开展于2020年5月28日至8月30日。Kaplan-Meier生存分析显示，启用高依赖肾内科病房后患者的生存率显著提升：启用前队列的52例患者中19例（36.5%）死亡，高依赖肾内科病房队列的160例患者中35例（21.9%）死亡，p<0.01。44例（67.7%）AKI-D幸存者出院时仍需依赖透析。入院时的呼吸困难、意识改变，住院期间出现休克及白细胞增多症为死亡的预测因素。
结论：以肾病学家作为首诊医师管理的高依赖肾内科病房，是改善COVID-19合并重度肾功能损害患者预后的可行且潜在有效的方案。