Hispanic Ethnicity and Mortality Among Critically Ill Patients With Covid-19

BACKGROUND: Hispanic persons living in the United States (U.S.) are at higher risk of infection and death from coronavirus disease 2019 (COVID-19) compared with non-Hispanic persons. Whether this disparity exists among critically ill patients with COVID-19 is unknown. OBJECTIVE: To evaluate ethnic disparities in mortality among critically ill adults with COVID-19 enrolled in the Study of the Treatment and Outcomes in Critically Ill Patients with COVID-19 (STOP-COVID). METHODS: Multicenter cohort study of adults with laboratory-confirmed COVID-19 admitted to intensive care units (ICU) at 67 U.S. hospitals from March 4 to May 9, 2020. Multilevel logistic regression was used to evaluate 28-day mortality across racial/ethnic groups. RESULTS: A total of 2153 patients were included (994 [46.2%] Hispanic and 1159 [53.8%] non-Hispanic White). The median (IQR) age was 62 (51-71) years (non-Hispanic White, 66 [57-74] years; Hispanic, 56 [46-67] years), and 1462 (67.9%) were men. Compared with non-Hispanic White patients, Hispanic patients were younger; were less likely to have hypertension, chronic obstructive pulmonary disease, coronary artery disease, or heart failure; and had longer duration of symptoms prior to ICU admission. During median (IQR) follow-up of 14 (7-24) days, 785 patients (36.5%) died. In analyses adjusted for age, sex, clinical characteristics, and hospital size, Hispanic patients had higher odds of death compared with non-Hispanic White patients (OR, 1.44; 95% CI, 1.12-1.84). CONCLUSIONS: Among critically ill adults with COVID-19, Hispanic patients were more likely to die than non-Hispanic White patients, even though they were younger and had lower comorbidity burden. This finding highlights the need to provide earlier access to care to Hispanic individuals with COVID-19, especially given our finding of longer duration of symptoms prior to ICU admission among Hispanic patients. In addition, there is a critical need to address ongoing disparities in post hospital discharge care for patients with COVID-19

Cardiac stunning during haemodialysis: the therapeutic effect of intra-dialytic exercise

Background Cardiovascular risk is elevated in end-stage renal disease. Left ventricular (LV) dysfunction is linked to repetitive transient ischaemia occurring during haemodialysis (HD). Cardiomyocyte ischaemia results in ‘cardiac stunning’, evidenced by regional wall motion abnormalities (RWMAs). Ischaemic RWMA have been documented during HD resulting in maladaptive cardiac remodelling and increased risk of heart failure. Intra-dialytic exercise is well tolerated and can improve quality of life and functional capacity. It may also attenuate HD-induced cardiac stunning. Methods This exploratory study aimed to assess the effect of intra-dialytic cycle ergometry on cardiac stunning. Twenty exercise-naïve participants on maintenance HD (mean ± SD, 59 ± 11 years) underwent resting echocardiography and maximal cardiopulmonary exercise testing. Subsequently, cardiac stunning was assessed with myocardial strain-derived RWMAs at four time points during (i) standard HD and (ii) HD with 30 min of sub-maximal intra-dialytic cycle ergometry at a workload equivalent to 90% oxygen uptake at the anaerobic threshold (VO2AT). Central haemodynamics and cardiac troponin I were also assessed. Results Compared with HD alone, HD with intra-dialytic exercise significantly reduced RWMAs after 2.5 h of HD (total 110 ± 4, mean 7 ± 4 segments versus total 77 ± 3, mean 5 ± 3, respectively; P = 0.008). Global cardiac function, intra-dialytic haemodynamics and LV volumetric parameters were not significantly altered with exercise. Conclusions Intra-dialytic exercise reduced cardiac stunning. Thirty minutes of sub-maximal exercise at 90% VO2AT was sufficient to elicit acute cardio-protection. These data potentially demonstrate a novel therapeutic effect of intra-dialytic exercise

Thrombosis, Bleeding, and the Observational Effect of Early Therapeutic Anticoagulation on Survival in Critically Ill Patients With COVID-19

This article is made available for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.Background: Hypercoagulability may be a key mechanism of death in patients with coronavirus disease 2019 (COVID-19). Objective: To evaluate the incidence of venous thromboembolism (VTE) and major bleeding in critically ill patients with COVID-19 and examine the observational effect of early therapeutic anticoagulation on survival. Design: In a multicenter cohort study of 3239 critically ill adults with COVID-19, the incidence of VTE and major bleeding within 14 days after intensive care unit (ICU) admission was evaluated. A target trial emulation in which patients were categorized according to receipt or no receipt of therapeutic anticoagulation in the first 2 days of ICU admission was done to examine the observational effect of early therapeutic anticoagulation on survival. A Cox model with inverse probability weighting to adjust for confounding was used. Setting: 67 hospitals in the United States. Participants: Adults with COVID-19 admitted to a participating ICU. Measurements: Time to death, censored at hospital discharge, or date of last follow-up. Results: Among the 3239 patients included, the median age was 61 years (interquartile range, 53 to 71 years), and 2088 (64.5%) were men. A total of 204 patients (6.3%) developed VTE, and 90 patients (2.8%) developed a major bleeding event. Independent predictors of VTE were male sex and higher D-dimer level on ICU admission. Among the 2809 patients included in the target trial emulation, 384 (11.9%) received early therapeutic anticoagulation. In the primary analysis, during a median follow-up of 27 days, patients who received early therapeutic anticoagulation had a similar risk for death as those who did not (hazard ratio, 1.12 [95% CI, 0.92 to 1.35]). Limitation: Observational design. Conclusion: Among critically ill adults with COVID-19, early therapeutic anticoagulation did not affect survival in the target trial emulation

Diabetic Kidney Disease: Pathophysiology and Therapeutic Targets

Diabetes is a worldwide epidemic that has led to a rise in diabetic kidney disease (DKD). Over the past two decades, there has been significant clarification of the various pathways implicated in the pathogenesis of DKD. Nonetheless, very little has changed in the way clinicians manage patients with this disorder. Indeed, treatment is primarily centered on controlling hyperglycemia and hypertension and inhibiting the renin-angiotensin system. The purpose of this review is to describe the current understanding of how the hemodynamic, metabolic, inflammatory, and alternative pathways are all entangled in pathogenesis of DKD and detail the various therapeutic targets that may one day play a role in quelling this epidemic

Proton Pump Inhibitors and Kidney Disease—GI Upset for the Nephrologist?

Widely regarded as safe and effective, PPIs are among the most commonly used medications in the world today. However, a spate of observational studies suggest an association between PPI use and adverse events, including infection, bone fracture, and dementia. This review details evidence linking the use of PPI therapy to the development of kidney disease, including early case reports of acute interstitial nephritis and subsequent large observational studies of AKI, CKD, and ESRD. The majority of studies showed higher risk of kidney outcomes among persons prescribed PPI medications, with effect sizes that were slightly higher for AKI (∼2- to 3-fold) compared with CKD and ESRD (1.2- to 1.8-fold). Although observational pharmacoepidemiology studies are limited by the possibility of residual confounding and confounding by indication, many of the described studies conducted rigorous sensitivity analyses aimed at minimizing these biases, including new-user design, comparison to similar agents (e.g., histamine2 receptor antagonists), and evaluation for a dose response, with robust results. Given the widespread use of PPIs, even a small effect on kidney outcomes could result in large public health burden. Timely cessation of PPI therapy when there is no clear indication for use might reduce the population burden of kidney disease

COVID-19 vaccination hesitancy among health care workers, communication, and policy-making

Background: Coronavirus disease 2019 (COVID-19) vaccine hesitancy in healthcare workers (HCWs) contributes to personal and patient risk in contracting COVID-19. Reasons behind hesitancy and how best to improve vaccination rates in HCWs are not clear. Methods: We adapted a survey using the Health Belief Model framework to evaluate HCW vaccine hesitancy and reasons for choosing for or against COVID-19 vaccination. The survey was sent to three large academic medical centers in the Chicagoland area between March and May 2021. Results: We received 1974 completed responses with 85% of HCWs receiving or anticipating receiving COVID-19 vaccination. Multivariable logistic regression found HCWs were less likely to receive COVID-19 vaccination if they were Black (OR 0.34, 95% CI 0.15-0.80), Republican (OR 0.54, 95% CI 0.31-0.91), or allergic to any vaccine component (OR 0.27, 95% CI 0.10-0.70) and more likely to receive if they believed people close to them thought it was important for them to receive the vaccine (OR 5.2, 95% CI 3-8). Conclusions: A sizable number of HCWs remain vaccine hesitant one year into the COVID-19 pandemic. As HCWs are positively influenced by colleagues who believe COVID-19 vaccination, development of improved communication across HCW departments and roles may improve vaccination rates

Residual Kidney Function: Implications in the Era of Personalized Medicine

The association of residual kidney function (RKF) with improved outcomes in peritoneal dialysis and hemodialysis patients is now widely recognized. RKF provides substantial volume and solute clearance even after dialysis initiation. In particular, RKF provides clearance of non-urea solutes, many of which are potential uremic toxins and not effectively removed by conventional hemodialysis. The presence of RKF provides a distinct advantage to incident dialysis patients and is an opportunity for nephrologists to individualize dialysis treatments tailored to their patients' unique solute, volume, and quality of life needs. The benefits of RKF present the opportunity to personalize the management of uremi