Clinical triage of patients on kidney replacement therapy presenting with COVID-19: an ERACODA registry analysis
Authors: Mitra Sandip , Jayanti Anuradha , Vart Priya , Coca Armando , Gallieni Maurizio , Øvrehus Marius Altern , Midtvedt Karsten , Abd ElHafeez Samar , Gandolfini Iliaria , Büttner Stefan , Franssen Casper F M , Hemmelder Marc H ,   ERACODA Collaborators, van der Net Jeroen B , Essig Marie , du Buf-Vereijken Peggy W G , van Ginneken Betty , Vogt Nanda Maas Liffert , van Jaarsveld Brigit C , Jager Kitty J , Bemelman Frederike J , Klingenberg-Salahova Farah , Heenan-Vos Frederiek , Vervloet Marc G , Nurmohamed Azam , Abramowicz Daniel , Maoujoud Sabine Verhofstede Omar , Malfait Thomas , Fialova Jana , Melilli Edoardo , Favà Alexandre , Cruzado Josep M , Perez Nuria Montero , Lips Joy , Krepel Harmen , Adilovic Harun , Hengst Maaike , Rydzewski rzej , Gellert Ryszard , Oliveira João , Alferes Daniela G , Zakharova Elena V , Ambuehl Patrice Max , Walker rea , Winzeler Rebecca , Lepeytre Fanny , Rabaté Clémentine , Rostoker Guy , Marques Sofia , Azasevac Tijana , Katicic Dajana , Dam Marc ten , Krüger Thilo , Brzosko Szymon , Zanen Adriaan L , Logtenberg Susan J J , Fricke Lutz , Slebe Jeroen J P , Kemlin Delphine , van de Wetering Jacqueline , Reinders Marlies E J , Eiselt Jaromir , Kielberger Lukas , El-Wakil Hala S , Verhoeven Martine A M , Canal Cristina , Facundo Carme , Ramos Ana M , Debska-Slizien Alicja , Veldhuizen Nicoline M H , Tigka Eirini , Konsta Maria Anna Polyzou , Panagoutsos Stylianos , Mallamaci Francesca , Postorino Adele , Cambareri Francesco , Covic Adrian , Matceac Irina , Nistor Ionut , Cordos Monica , Groeneveld J H M , van Buren Jolanda Jousma Marjolijn , Pereira Fritz Diekmann Tiago Assis , Santos Augusto Cesar S , Arias-Cabrales Carlos , Crespo Marta , Llinàs-Mallol Laura , Buxeda Anna , Tàrrega Carla Burballa , Redondo-Pachon Dolores , Jimenez Maria Dolores Arenas , Hofstra Julia M , Franco Antonio , Arroyo David , Rodríguez-Ferrero Maria Luisa , Manzanos Sagrario Balda , Haridian Sosa Barrios R , Ávila Gonçalo , Laranjinha Ivo , Mateus Catarina , Lemahieu Wim , Bartelet Karlijn , Dirim Ahmet Burak , Sever Mehmet Sukru , Demir Erol , Şafak Seda , Turkmen Aydin , Hollander Daan A M J , Büttner Stefan , de Vries Aiko P J , Meziyerh Soufian , van der Helm Danny , Mallat Marko , Bouwsma Hanneke , Sridharan Sivakumar , Petruliene Kristina , Maloney Sharon-Rose , Verberk Iris , van der Sande Frank M , Christiaans Maarten H L , MohanKumar N , Di Luca Marina , Tuğlular Serhan Z , Beerenhout Andrea Kramer Charles , Luik Peter T , Kerschbaum Julia , Watschinger Bruno , Adema Aaltje Y , Stepanov Vadim A , Zulkarnaev Alexey B , Turkmen Kultigin , Fliedner Anselm , Åsberg Anders , Mjoen Geir , de Fijter Hitoshi Miyasato Carola W H , Mongera Nicola , Pini Stefano , de Biase Consuelo , Duivenvoorden Raphaël , Hilbrands Luuk , Kerckhoffs Angele , van de Logt Anne-Els , Maas Rutger , Lebedeva Olga , Lopez Veronica , Verhave Jacobien , Reichert Louis J M , Titov Denis , Parshina Ekaterina V , Zanoli Luca , Marcantoni Carmelita , van Gils-Verrij Liesbeth E A , Harty John C , Meurs Marleen , Myslak Marek , Battaglia Yuri , Lentini Paolo , den Deurwaarder Edwin , Stendahl Maria , Rahimzadeh Hormat , Schouten Marcel , Rychlik Ivan , Cabezas-Reina Carlos J , Roca Ana Maria , Nauta Ferdau , Goffin Eric , Kanaan Nada , Labriola Laura , Devresse Arnaud , Diaz-Mareque Anabel , Meijers Björn K I , Naesens Maarten , Kuypers Dirk , Desschans Bruno , Tonnelier Annelies , Wissing Karl M , de Arriba Gabriel , Dedinska Ivana , Pessolano Giuseppina , Maggiore Umberto , Malik Shafi , Papachristou Evangelos , Gansevoort Ron T , Noordzij Marlies , Berger Stefan P , Meijer Esther , Özyilmaz Akin , Ponikvar Jadranka Buturović , Arnol Miha , Pernat Andreja Marn , Kovac Damjan , Ekart Robert , Abrahams Alferso C , Molenaar Femke M , van Zuilen Arjan D , Meijvis Sabine C A , Dolmans Helma , Tantisattamo Ekamol , Esposito Pasquale , Krzesinski Jean-Marie , Barahira Jean Damacène , Sabiu Gianmarco , Martin-Moreno Paloma Leticia , Guglielmetti Gabriele , Guzzo Gabriella , Toapanta Nestor , Soler Maria Jose , Luik Antinus J , van Kuijk Willi H M , Stikkelbroeck Lonneke W H , Hermans Marc M H , Rimsevicius Laurynas , Righetti Marco , Islam Mahmud , Braak Nicole Heitink-ter 
Published: June 2021

Abstract

Background
Patients on kidney replacement therapy (KRT) are at very high risk of coronavirus disease 2019 (COVID-19). The triage pathway for KRT patients presenting to hospitals with varying severity of COVID-19 illness remains ill-defined. We studied the clinical characteristics of patients at initial and subsequent hospital presentations and the impact on patient outcomes.

Methods
The European Renal Association COVID-19 Database (ERACODA) was analysed for clinical and laboratory features of 1423 KRT patients with COVID-19 either hospitalized or non-hospitalized at initial triage and those re-presenting a second time. Predictors of outcomes (hospitalization, 28-day mortality) were then determined for all those not hospitalized at initial triage.

Results
Among 1423 KRT patients with COVID-19 [haemodialysis (HD), n = 1017; transplant, n = 406), 25% (n = 355) were not hospitalized at first presentation due to mild illness (30% HD, 13% transplant). Of the non-hospitalized patients, only 10% (n = 36) re-presented a second time, with a 5-day median interval between the two presentations (interquartile range 2–7 days). Patients who re-presented had worsening respiratory symptoms, a decrease in oxygen saturation (97% versus 90%) and an increase in C-reactive protein (26 versus 73 mg/L) and were older (72 vs 63 years) compared with those who did not return a second time. The 28-day mortality between early admission (at first presentation) and deferred admission (at second presentation) was not significantly different (29% versus 25%; P = 0.6). Older age, prior smoking history, higher clinical frailty score and self-reported shortness of breath at first presentation were identified as risk predictors of mortality when re-presenting after discharge at initial triage.

Conclusions
This study provides evidence that KRT patients with COVID-19 and mild illness can be managed effectively with supported outpatient care and with vigilance of respiratory symptoms, especially in those with risk factors for poor outcomes. Our findings support a risk-stratified clinical approach to admissions and discharges of KRT patients presenting with COVID-19 to aid clinical triage and optimize resource utilization during the ongoing pandemic.