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Revista de la Sociedad Española de Nefrología
www.revistanefrologia.com

Letter to the editor

Treatment of patients with COVID-19 on hemodialysis:
Efficacy of remdesivir
Tratamiento de pacientes con COVID-19 en hemodiálisis:
Eficacia de remdesivir
Dear Editor,
Patients on hemodialysis (HD) are at risk of COVID-19 for several reasons. In previous studies, the mortality rate of HD
patients with COVID-19 was higher (16.3%) than that of thegeneral population (2–3%).1 Most prospective therapeutic trials have excluded patients on HD for safety reasons. Thereis no adequate infection control of COVID-19 for HD patients,
although these patients are one of the most vulnerable groups
to contract SARS-CoV-2 infection.
Remdesivir was approved as the first antiviral agent by
the FDA in 2020. However, at first, remdesivir was not suggested for patients with a low estimated glomerular filtration
rate (eGFR) because its adverse event was renal impairment.
Aiswarya et al. reported the efficacy and safety of remdesivir
in HD patients.2 Since August 2021, the Japanese guidelines
have described the possibility of remdesivir for HD patients.3
We present our clinical experience with remdesivir in 25
patients with COVID-19 on HD and support its efficacy andsafety. According to a previous report,2 remdesivir was administered at a dose of 100 mg/day on day 1, 4 h before HD.
Subsequent doses of up to a maximum of six doses wereadministered 4 h before each HD. Neutralizing antibody (Sotrovimab) was administered intravenously to all patients 48 hafter admission.
The median age of the patients was 78 years (range, 45–92years) and was predominantly male (84%). The median duration of hospitalization was 11 days (range: 7–26 days). A totalof 44% of the patients had mild disease, 36% had moderate-1(pneumonia without oxygen), and 20% had moderate-2 (pneumonia with oxygen). Among them, 88% of the patients werevaccinated and 60% of the patients developed COVID-19 due
to a cluster of facilities.
The most common symptoms were fever (76%), cough(44%), anorexia (16%), flushing (8%), and diarrhea (4%) (Table 1).
The most common comorbidities were renal failure (100%),
hypertension (60%), cardiac disease (44%), diabetes mellitus(40%), cerebrovascular disease (36%), hyperlipidemia (24%),
malignancy (16%), and chronic obstructive pulmonary disease(COPD) (16%).
The most frequent biomarkers were elevated creatinine(100%), followed by C-reactive protein (80%), lymphopenia(76%), D-dimer (68%), ferritin (16%), lactate dehydrogenase(16%), creatinine kinase (16%), KL-6 (12%), and thrombocytopenia (8%).
Two patients experienced deterioration. One patient withpneumonia at admission developed respiratory distress on
day 8 and was started on oxygen therapy. The patient wasstarted on dexamethasone; however, the patient did not
respond to the treatment. He was then switched to steroid plus
(methylprednisolone 1000 mg/day on days 1–3, 125 mg/day ondays 4–5). The patient recovered from respiratory distress andwas discharged on day 22. The remaining patient did not havepneumonia upon admission. He developed pneumonia on day
8 and was started on oxygen therapy. He was treated with dexamethasone and recovered from respiratory distress on day
20. None of the patients developed severe disease. All patients
recovered from COVID-19 and were discharged.
A total of 20% of the patients showed persistent low-grade
fever for 14 days, and 24% of the patients developed aspiration
pneumonia. Various persistent symptoms have been reported.
Swallowing function is damaged due to severe COVID-19 has
been reported.4 In elderly patients, there is a possibility ofdecreased activity of daily living due to long-term hospitalization and decreased swallowing function due to COVID-19.
In our cohort, all patients recovered from the disease;
therefore, there were no factors to evaluate the efficacy ofremdesivir. Upon admission, some biomarkers showed anabnormal range above the standard value. We used thesebiomarkers and compared the data obtained before andafter remdesivir treatment. The most frequent biomarker
was creatinine level. However, we could not use it since
all patients had renal failure; therefore, C-reactive protein
and lymphocyte counts were used. C-reactive protein levels

Please cite this article in press as: Nakaya A, et al. Treatment of patients with COVID-19 on hemodialysis: Efficacy of remdesivir. Nefrologia.
2023. https://doi.org/10.1016/j.nefroe.2022.07.008

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Table 1 – Patients’ characteristics.
Number of patients (n)Median age (range) (y/o)
Male (%)
Median days of hospitalization (range) (days)

2578 (45–92)
84
11 (7–26)

Severity (%)
MildModerate-1
Moderate-2
Severe4436200CI, 0.26–0.80, p = 0.004) compared to those who did not receive
remdesivir.5
Our study had some limitations. First, this study included
a small sample of patients from a single center. We only
included patients with mild to moderate, without severe disease. Second, most of our patients were elderly, as a regional
characteristic of the large elderly population. Data on patients
undergoing HD are required; therefore, regardless of limitations, we believe that it is worth reporting on our practicalexperience.
We hope that our study helps frontline healthcare workers
in the treatment of COVID-19.

Symptoms (%)
FeverCoughAnorexia
Flushing
Diarrhea
Comorbidity (%)
Renal failure
Hypertension
Diabetes mellitus
Cardiac disease
Cerebrovascular disease
Hyperlipidemia
Malignancy
COPD

100
6040
4436241616

Biomarkers (%)
High creatinineHigh C-reactive protein
Lymphopenia
High d-dimer
High ferritin
High lactate dehydrogenase
High CKHigh KL-6
Thrombocytopenia

100
8076
68
161616128

Vaccine (%)

88

Treatment (%)
Neutralizing antibody
Remdesivir

100100references

OutcomeMortality rate (%)
Deterioration rate (%)

08

1. Turgutalp K, Ozturk S, Arici M, Eren N, Gorgulu N, Islam M, et al.
Determinants of mortality in a large group of hemodialysis
patients hospitalized for COVID-19. BMC Nephrol. 2021;22:29,
http://dx.doi.org/10.1186/s12882-021-02233-0 [PMID: 33446135;
PMCID: PMC7808398].
2. Aiswarya D, Arumugam V, Dineshkumar T, Gopalakrishnan N,
Lamech TM, Nithya G, et al. Use of remdesivir in patients with
COVID-19 on hemodialysis: a study of safety and tolerance.
Kidney Int Rep. 2021;6:586–93,
http://dx.doi.org/10.1016/j.ekir.2020.12.003 [PMID: 33354635;
PMCID: PMC7746511; Epub 18.12.20].
3. The Ministry of Health, Labour and Welfare and the National
Institute of Infectious Diseases. Clinical management ofpatients with COVID-19 (version 7.2); 2022.
4. Lagier A, Melotte E, Poncelet M, Remacle S, Meunier P.
Swallowing function after severe COVID-19: early
videofluoroscopic findings. Eur Arch Otorhinolaryngol.
2021;278:3119–23,
http://dx.doi.org/10.1007/s00405-020-06522-6.
5. Kikuchi K, Nangaku M, Ryuzaki M, Yamakawa T, Yoshihiro O,
Hanafusa N, et al. Survival and predictive factors in dialysis
patients with COVID-19 in Japan: a nationwide cohort study.
Ren Replace Ther. 2021;7:59,
http://dx.doi.org/10.1186/s41100-021-00378-0 [PMID: 34697570;
PMCID: PMC8529564; Epub 21.10.21].

76
44
1684Conflict of interest
The authors report no declarations of interest.

Statement of ethics
This study was conducted following the ethical principles of
the Declaration of Helsinki and was approved by the institutional review board of Biwako Ohashi Hospital.

Acknowledgments
We thank Yuu Tochitani, Rika Umeda, Shizuka Morita, Yohei
Takano, Masanori Fujiie, Tsutomu Ito, Ayako Igosaki, andSatomi Ozawa for their assistance.

COPD: chronic obstructive pulmonary disease; CK: creatine kinase.

Table 2 – Bioparameters.

C-reactive protein (mg/dl)
Lymphocyte count (/␮l)

BeforeremdesivirAfterremdesivir

p-Value

3.30
700

1.04
722

<0.001
0.925

were significantly decreased (p < 0.001), whereas lymphocyte
counts did not show differences before and after remdesivir
treatment (p = 0.925) (Table 2). This is consistent with aprevious study.2 C-reactive protein may be an independent
parameter that reflects the efficacy of remdesivir.
Recently, Kikuchi et al. reported data on patients with
COVID-19 on HD in the Japanese population. Among the1010 patients, 98 received remdesivir. Patients treated withremdesivir had shortened hospitalization (16.2 ± 8.1 days vs.
20.9 ± 13.2 days) and better prognosis (Hazard ratio, 0.45; 95%

Please cite this article in press as: Nakaya A, et al. Treatment of patients with COVID-19 on hemodialysis: Efficacy of remdesivir. Nefrologia.
2023. https://doi.org/10.1016/j.nefroe.2022.07.008

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Aya Nakaya ∗ , Morihiro Kondo, Eiji Ogura, Yuki Katayama,
Eiko Yoshino, Kazuya Hozumi, Saori Tago, Yuko Teranishi,
Yuki Minamibashi, Makiko Harada, Yuri Kawano, Yuka Arai,Mika Kobayashi, Airi Kouyama, Keno Yoshida, Shozo
Shimizu, Kazuma Ogura, Katsuaki Iwashita, BOH Covid-19
Team
Internal Medicine, Biwako Ohashi Hospital, 5-1-29 Mano, Otsu
City, Shiga 520-0232, Japan3∗ Corresponding author.

E-mail address: nakaya1016@yahoo.co.jp (A. Nakaya).
2013-2514/© 2022 Sociedad Española de Nefrologı́a. Publishedby Elsevier España, S.L.U. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.nefroe.2022.07.008

Please cite this article in press as: Nakaya A, et al. Treatment of patients with COVID-19 on hemodialysis: Efficacy of remdesivir. Nefrologia.
2023. https://doi.org/10.1016/j.nefroe.2022.07.008