# COVID-19 et rein : épisode 2

Stéphane Burtey

► To cite this version:

Stéphane Burtey. COVID-19 et rein : épisode 2. Doctorat. COVID néphrologique, France. 2020. hal-02529846

HAL Id: hal-02529846

https://amu.hal.science/hal-02529846v1

Submitted on 2 Apr 2020

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Distributed under a Creative Commons CC BY 4.0 - Attribution - International License
# COVID-19 et Rein
## Episode 2

Pr S. Burtey

Centre de néphrologie et transplantation rénale

AMU

AP-HM

Marseille
# Nouvelles du front

395 647 cas

17 241 morts

## L'épidémie de Covid-19 en France

MIS À JOUR LE 24 MARS

Survolez les régions pour obtenir plus d'informations.

<figure><img src="image_2.png" /></figure>

## Coronavirus deaths in Italy, Spain and the UK are increasing much more rapidly than they did in China

Cumulative number of deaths, by number of days since 10th death

Nationwide lockdowns: ⭐

<figure><img src="image_3.png" /></figure>

<figure><img src="image_4.png" /></figure>

FT graphic: John Burn-Murdoch / @jburnmurdoch

Source: FT analysis of Johns Hopkins University, CSSE; Worldometers; FT research. Data updated March 23, 21:00 GMT

© FT
# Un risque, la surchauffe informationnelle

* 1367 articles dans Pubmed (23/03/2020)
[https://www.ncbi.nlm.nih.gov/pubmed/?term=covid-19](https://www.ncbi.nlm.nih.gov/pubmed/?term=covid-19)

* 699 preprints dans BioRxiv [https://connect.biorxiv.org/relate/content/181](https://connect.biorxiv.org/relate/content/181)

* Vous êtes le reviewer... Nécessite une lecture attentive voir très attentive.

* 102 preprints dans arXiv [https://arxiv.org/search/?query=covid-19](https://arxiv.org/search/?query=covid-19)

* 125 études dans ClinicalTrials [https://clinicaltrials.gov/ct2/results?cond=covid-19&term=&cntry=&state=&city=&dist=](https://clinicaltrials.gov/ct2/results?cond=covid-19&term=&cntry=&state=&city=&dist=

* Impossible de faire une revue exhaustive

* Question sur la qualité:

Editorial

March 16, 2020

ONLINE FIRST

FREE

## Editorial Concern—Possible Reporting of the Same Patients With COVID-19 in Different Reports

Howard Bauchner, MD¹; Robert M. Golub, MD¹; Jody Zylke, MD¹

» Author Affiliations | Article Information

JAMA. Published online March 16, 2020. doi:10.1001/jama.2020.3980
# Des conseils pour l'éviter

* Ne culpabilisez pas et sachez vous déconnecter.

* Des sources d'informations fiables

* LitCovid: https://www.ncbi.nlm.nih.gov/research/coronavirus/

* Living map of evidence: http://eppi.ioe.ac.uk/COVID19_MAP/covid_map_v3.html

* Consortium REACTING: https://reacting.inserm.fr/literature-review/

* DocCismef: https://doccismef.chu-rouen.fr/dc/#env=basic&q=covid-19.sr%20ET%202020-03-22.ins&p=1&n=50

* Un MOOC: https://www.fun-mooc.fr/courses/course-v1:UPEC+169003+cv_01/about

* NephJC: http://www.nephjc.com/covid19

* ERA-EDTA: https://www.era-edta.org/en/covid-19-news-and-information/# toggle-id-11

* Ne pas trop regarder et écouter les médias et les réseaux sociaux
Mode de transmission

•Gouttelette (direct et manuporté)

• Selles https://doi.org/10.1038/s41591-020-0817-4

• Le SARS-COV2 pourrait survivre dans les aérosols (3 hrs) et sur les surfaces (jusqu'à 3 jours sur le plastique et l'acier, jusqu'à 24 hrs sur le carton)

• L'homme ne fait pas d'aérosol

• Capital pour éviter les contaminations des soignants

• Maitres mots protéger les équipes soignantes en permettant un soin de qualité.
ckj

CLINICAL
KIDNEY
JOURNAL

# What lessons can we learn from the Milan experience on coronavirus management in dialysis centers?

## General hygienic measures

<figure><img src="image_5.png" /></figure>

- Have alcohol dispensers available for use in waiting rooms

<figure><img src="image_6.png" /></figure>

- Patients should wash their hands thoroughly before starting dialysis

<figure><img src="image_7.png" /></figure>

- Healthcare staff assisting in dialysis rooms should wear surgical masks

<figure><img src="image_8.png" /></figure>

- Healthcare staff should regularly wash their hands with soap and water

## Dialysis patients in contact with confirmed cases

<figure><img src="image_9.png" /></figure>

Asymptomatic

Wear a surgical mask for the duration of time in the dialysis unit

<figure><img src="image_10.png" /></figure>

Symptomatic on arrival

Be assessed in the emergency department; dialyse in isolation, treat as if a carrier for SARS-CoV-2

<figure><img src="image_11.png" /></figure>

Coronavirus positive

Dialyse in isolation. Staff in contact wear a disposable gown, glasses/visor, FFP3 mask, overshoes and double gloves

**Conclusion:** Specific prophylactic measures can be adopted to help reduce the spread of coronavirus in dialysis units. There should be specific pathways for patients who have been in contact with confirmed cases of coronavirus.

Cozzolino, M.
Clinical Kidney Journal (2020)
@CKJsocial
# Un virus et une maladie

* SARS-CoV-2 est le virus

* COVID-19 est la maladie

* Virus de la famille des coronavirus des chauves souris.

* Le virus n'a pas été créé par l'homme https://www.nature.com/articles/s41591-020-0820-9

* 80% des cas asymptomatiques ou peu sévères

* 20% des cas plus sévères avec un tableau de pneumopathie interstitielle.

* 5% nécessitant la réanimation

<figure><img src="image_12.png" /></figure>
# Symptomatologie

<figure><img src="image_13.png" /></figure>
# Symptomatologie

* La fièvre n'est pas forcément inaugurale

* Tableau de gastroentérite, y penser

* L'anosmie pourrait être un signe clinique

https://www.sforl.org/wp-content/uploads/2020/03/Alerte-anosmie-COVID-19.pdf

* Pour l'instant pas d'article référencé

* Une période à risque d'aggravation entre J7 et J10

* La durée d'incubation médiane est de 5 jours
(10.7326/M20-0504)

<figure><img src="image_14.png" /></figure>
# Symptomatologie

a

<figure><img src="image_15.png" /><figcaption>Probabilité de mourir en Chine après avoir des symptômes</figcaption></figure>

b

<figure><img src="image_16.png" /><figcaption>Risque relatif en Chine d'avoir des symptômes</figcaption></figure>
# Mortalité

<table><caption>Table. Case-Fatality Rate by Age Group in Italy and Chinaª</caption><thead><tr><th rowspan="2"></th><th colspan="2">Italy as of March 17, 2020</th><th colspan="2">China as of February 11, 2020</th></tr><tr><th>No. of deaths (% of total)</th><th>Case-fatality rate, %<sup>b</sup></th><th>No. of deaths (% of total)</th><th>Case-fatality rate, %<sup>b</sup></th></tr></thead><tbody><tr><td>All</td><td>1625 (100)</td><td>7.2</td><td>1023 (100)</td><td>2.3</td></tr><tr><td>Age groups, y</td><td></td><td></td><td></td><td></td></tr><tr><td>0-9</td><td>0</td><td>0</td><td>0</td><td>0</td></tr><tr><td>10-19</td><td>0</td><td>0</td><td>1 (0.1)</td><td>0.2</td></tr><tr><td>20-29</td><td>0</td><td>0</td><td>7 (0.7)</td><td>0.2</td></tr><tr><td>30-39</td><td>4 (0.3)</td><td>0.3</td><td>18 (1.8)</td><td>0.2</td></tr><tr><td>40-49</td><td>10 (0.6)</td><td>0.4</td><td>38 (3.7)</td><td>0.4</td></tr><tr><td>50-59</td><td>43 (2.7)</td><td>1.0</td><td>130 (12.7)</td><td>1.3</td></tr><tr><td>60-69</td><td>139 (8.6)</td><td>3.5</td><td>309 (30.2)</td><td>3.6</td></tr><tr><td>70-79</td><td>578 (35.6)</td><td>12.8</td><td>11,9% de la cohorte</td><td>312 (30.5)</td><td>8.0</td></tr><tr><td>≥80</td><td>850 (52.3)</td><td>20.2</td><td>208 (20.3)</td><td>14.8</td></tr></tbody></table>

37,6% de la cohorte

Sur 355 patients décédés en Italie (Age moyen 79,5 ans, 30% de femmes)

0,8% sans comorbidité

25,1% avec une comorbidité

25,6% avec deux comorbidités

48,5% avec 3 ou plus comorbidités

<footnote>ª Data from China are from Chinese Center for Disease Control and Prevention. ª Age was not available for 1 patient.</footnote>

<footnote>ᵇ Case-fatality rate calculated as number of deaths/number of cases.</footnote>
Insuffisance rénale aigue et COVID-19

* Des séries chinoises entre 2 et 5% d'insuffisance rénale aigue. (peu de détails)

* Dans les séries réanimatoires fréquence plus importante (25%)

* Impact de l'IRA sur le pronostic est difficile à préciser devant la médiocrité des données.

* Une série de 700 patients: 4,5% IRA et pronostic vital corrélé à la fonction rénale (créat et protéinurie) à l'entrée. https://www.kidney-international.org/article/S0085-2538(20)30255-6/fulltext

* Protéinurie 4 articles: 20 à 60% de protéinurie souvent dès le diagnostic suggérant une atteinte inaugurale

* Conforte une atteinte rénale directe reflet de la sévérité et d'une virémie https://www.medrxiv.org/content/10.1101/2020.03.04.20031120v2
# Insuffisance rénale aigue et COVID-19

<figure><img src="image_17.png" /></figure>

Y Cheng et al, 2020
# HTA et COVID-19

* Aucune raison d'arrêter les IEC et sartans quand l'indication est là

* Aucune raison de les commencer sans indication

<table><thead><tr><td>Society</td><td>Summary of recommendations</td><td>Last Statement Update</td></tr></thead><tbody><tr><td>European Society of Hypertension</td><td>Recommend continuing ACEIs/ARBs due to lack of evidence to support differential use in COVID-19 patients. In those with severe symptoms or sepsis, antihypertensive decisions should be made on a case-by-case basis taking into account current guidelines</td><td>March 12, 2020</td></tr><tr><td>European Society of Cardiology Council on Hypertension</td><td>Strongly encourage continuing ACEIs/ARBs due to lack of evidence to support discontinuing</td><td>March 13, 2020</td></tr><tr><td>Hypertension Canada</td><td>Recommend continuing ACEIs/ARBs due to lack of evidence that patients with hypertension or those treated with ACEIs/ARBs are at higher risk of adverse outcomes from COVID-19 infection</td><td>March 13, 2020</td></tr><tr><td>Canadian Cardiovascular Society</td><td>Strongly encourage continuing ACEIs/ARBs and Angiotensin Receptor Neprilysin Inhibitors due to a lack of clinical evidence to support withdrawal of these agents</td><td>March 15, 2020</td></tr><tr><td>The Renal Association, United Kingdom</td><td>Strongly encourage continuing ACEIs/ARBs due to unconvincing evidence that these medications increase risk</td><td>March 15, 2020</td></tr><tr><td>International Society of Hypertension</td><td>Strongly recommend that the routine use of ACEIs/ARBs to treat hypertension should not be influenced by concerns about COVID-19 in the absence of compelling data that ACEIs/ARBs either improve or worsen susceptibility to COVID-19 infection nor do they affect the outcomes of those infected</td><td>March 16, 2020</td></tr><tr><td>American College of Physicians</td><td>Encourage continuing ACEIs/ARBs because there is no evidence linking them to COVID-19 disease severity, and discontinuation of antihypertensive therapy without medical indication could in some circumstances result in harm</td><td>March 16, 2020</td></tr><tr><td>Spanish Society of Hypertension</td><td>Recommend that ACEIs/ARBs should not be empirically stopped in patients who are already taking them; in seriously ill patients, changes should be made on a case-by-case basis</td><td>March 16, 2020</td></tr><tr><td>American Heart Association, Heart Failure Society of America, American College of Cardiology</td><td>Recommend continuing ACEIs/ARBs for all patients already prescribed them</td><td>March 17, 2020</td></tr><tr><td>European Renal Association - European Dialysis and Transplant Association</td><td>Recommend continuing ACEIs/ARBs in COVID-19 infection patients due to a lack of evidence to support differential use and the discontinuation of ACEIs/ARBs in COVID-19 patients</td><td>March 17, 2020</td></tr><tr><td>American Society of Pediatric Nephrology</td><td>Strongly recommend continuing ACEIs/ARBs until new evidence to the contrary becomes available</td><td>March 17, 2020</td></tr><tr><td>High Blood Pressure Research Council of Australia</td><td>Recommend continuing routine use of ACEIs/ARBs. Patients should not cease blood pressure lowering medications unless advised to do so by their physician</td><td>March 18, 2020</td></tr></tbody></table>
# Dialyse et COVID-19

* Expérience Lombarde

* Deux centres touchés

* Centre 1: 18 patients sur 60 dans structure périphérique en une semaine, isolement immédiat, un patient grave et pas de soignant touché

* Sur 200 patients pas d'autre contamination

* Centre 2: 4 sur 170 patients, isolement immédiat et pas de nouveau cas.

* L'isolement est capital.

https://sinitaly.org/wp-content/uploads/2020/03/JN2020Rombola.pdf
# Dialyse et COVID-19

* Nous avons besoin de plus de données.

* Surtout des recommandations

* https://www.ajkd.org/article/S0272-6386(20)30608-9/fulltext

* https://academic.oup.com/ndt/advance-article/doi/10.1093/ndt/gfaa069/5810637

* https://cjasn.asnjournals.org/content/early/2020/03/20/CJN.03340320.long

* https://doi.org/10.1016/j.kint.2020.03.001

## How can we reduce transmission of COVID-19 in haemodialysis centres?

This review from the Eudial Working Group of ERA-EDTA provides recommendations for the prevention, mitigation and containment of the emerging SARS-CoV-2 (COVID-19) pandemic in haemodialysis centres

### Recommendations for the healthcare team

<figure><img src="image_18.png" /></figure>

Be trained in use of personal protective equipment

<figure><img src="image_19.png" /></figure>

Inform your team leader if symptomatic or in contact with a case

<figure><img src="image_20.png" /></figure>

Stay home if unwell

<figure><img src="image_21.png" /></figure>

Use full personal protective equipment when caring for confirmed cases

### Recommendations for dialysis patients

<figure><img src="image_22.png" /></figure>

Be provided with clear instructions on appropriate hand and respiratory hygiene

<figure><img src="image_23.png" /></figure>

Should inform staff of symptoms in advance of arrival at the dialysis unit

<figure><img src="image_24.png" /></figure>

Should perform hand hygiene on arrival and departure from the dialysis unit

<figure><img src="image_25.png" /></figure>

Should be instructed to self-isolate

<figure><img src="image_26.png" /></figure>

Body temperature should be checked before the start and end of dialysis sessions

<figure><img src="image_27.png" /></figure>

Symptomatic patients should be dialyzed in a separate isolation room
# Dialyse et covid-19

* Screening: important d'identifier pour trier

* Isoler les positifs

* Des masques pour les patient(e)s

* Protéger les soignant(e)s: air et surface (charlotte, lunette, masque FFP2, surblouse/tablier et gants)

* Nettoyer, nettoyer et nettoyer

* Marseille: 7 patients
# Traitement

* Inefficacité de Lopinavir-Ritonavir 10.1056/NEJMoa2001282

* Protocole marseillais: Hydroxychloroquine/azithromycine

* Essai chinois HCQ (30 patients 400 mg vs placebo 5 j): J7 PCR neg 86,7% HCQ+ vs 93,3% Placebo http://www.zjujournals.com/med/EN/10.3785/j.issn.1008-9292.2020.03.03

* 115 essais en cours dans le monde

<figure><img src="image_28.png" /></figure>

<table><tbody><tr><th rowspan="3" scope="rowgroup">Study design</th><td>Randomized</td><td>92 (80)</td></tr><tr><td>Non-randomized</td><td>12 (11)</td></tr><tr><td>Single-arm</td><td>11 (10)</td></tr><tr><th rowspan="5" scope="rowgroup">Blinding</th><td>Double-blind</td><td>15 (13)</td></tr><tr><td>Single-blind</td><td>11 (10)</td></tr><tr><td>Open-label</td><td>53 (46)</td></tr><tr><td>Non-applicable†</td><td>6 (5)</td></tr><tr><td>Unspecified</td><td>30 (26)</td></tr></tbody></table>

<figure><img src="image_29.png" /></figure>
# Traitement

<figure><img src="image_30.png" /></figure>
En conclusion

* Plus de questions que de réponses

* Le rein est une cible du SARS-COV2

* Conséquences rénales à long terme?

* Importance de protéger les soignants et les soignés.

* Nous allons avoir des réponses sur les thérapeutiques

* Méfiez vous des informations non validées, croisez vos sources, doutez et critiquez

* Une autre façon de visualiser : http://shinyapps.org/apps/corona/