|Year : 2021 | Volume
| Issue : 1 | Page : 9-13
COVID-19 Infection in Children and Young Adults with Chronic Kidney Disease: A Single Center Experience
Swarnim Swarnim, Madhavi Bharadwaj, Mukta Mantan, Onkar Singh Bhinder, Urmila Jhamb
Department of Paediatrics, Maulana Azad Medical College, New Delhi, India
|Date of Submission||24-Feb-2021|
|Date of Decision||27-Feb-2021|
|Date of Acceptance||11-Mar-2021|
|Date of Web Publication||28-Apr-2021|
Dr. Mukta Mantan
Professor and Incharge, Division of Pediatric Nephrology, Department of Pediatrics, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi 110002
Source of Support: None, Conflict of Interest: None
Background: Coronavirus has affected millions of people worldwide and its severity is more pronounced in those with comorbidities; there is paucity of literature on its presentation and course in children and young adults suffering from chronic kidney disease (CKD). Aims: The aim of the study was to describe the clinico-epidemiological, biochemical, and radiological profile of children and young adults (up to 25 years of age) having CKD with coronavirus disease 2019 (COVID-19). Methods: This retrospective study was done at a tertiary care “dedicated COVID” hospital between May 1, 2020 and August 30, 2020. Ten children and young adults (up to 25 years of age) with underlying CKD who tested positive by reverse transcription polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 infection and were hospitalized during this period were included; their clinical presentation, outcomes, biochemical, and hematological parameters were recorded and analyzed. Results: All 10 patients (seven males and three females) were in stage 5 of CKD and were undergoing maintenance hemodialysis at admission. Fever and cough were the most common presenting symptoms of COVID-19, while anemia (100%), leukopenia (50%), lymphopenia (30%), and thrombocytopenia (30%) were the hematological findings. Radiological abnormalities on chest radiography were seen in 50% patients with a majority having bilateral lesions. The median (range) duration of hospital stay was 21.5 (10–46) days; five (50%) patients needed intensive care support and one patient required mechanical ventilation who eventually expired. Conclusion: The presenting features of COVID-19 were similar in children and young adults with underlying CKD compared to their healthy counterparts; however, the mortality rate and intensive care requirement were higher and duration of hospital stay too was longer.
Keywords: Children, chronic kidney disease, coronavirus disease 2019, severe acute respiratory syndrome coronavirus 2
|How to cite this article:|
Swarnim S, Bharadwaj M, Mantan M, Bhinder OS, Jhamb U. COVID-19 Infection in Children and Young Adults with Chronic Kidney Disease: A Single Center Experience. MAMC J Med Sci 2021;7:9-13
|How to cite this URL:|
Swarnim S, Bharadwaj M, Mantan M, Bhinder OS, Jhamb U. COVID-19 Infection in Children and Young Adults with Chronic Kidney Disease: A Single Center Experience. MAMC J Med Sci [serial online] 2021 [cited 2021 Aug 1];7:9-13. Available from: https://www.mamcjms.in/text.asp?2021/7/1/9/314882
| Introduction|| |
Coronavirus disease 2019 (COVID-19) is a novel viral disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and has affected people of all the age groups, but its impact on children has been typically of milder intensity, even for infants., The limited data on children with chronic kidney disease (CKD) having COVID-19 infection showed the morbidity and morbidity to be lower than their adult counterparts.,,,, Among adult CKD patients, the prevalence of severe cases has been reported to be as high as 83.9% with a reported mortality from 31% to 53.3%.,, This retrospective study was done to evaluate the clinico-epidemiological profile and outcomes of children and young adults with CKD hospitalized for COVID-19 infection.
| Material and Methods|| |
The study was done between May 1, 2020 and August 30, 2020 in the Department of Pediatrics of a tertiary care “dedicated COVID-19” hospital located in the northern part of India. All hospitalized children, adolescents, and young adults (till 25 years of age) having underlying CKD and who tested positive for SARS-CoV-2 infection by the reverse transcription polymerase chain reaction (RT-PCR) on nasopharyngeal and oropharyngeal swab were included. Case records of these patient were retrieved and data pertaining to the clinical presentation, medications, dialysis requirement, laboratory and radiological profile, treatment, complications, and outcome was collected. The data was compiled in MS excel sheet and analyzed using descriptive statistics. The categorical responses were expressed by the percentages and the continuous variables were reported as mean and standard deviation. The study was reviewed and approved by the Institutional Ethics Committee.
| Results|| |
A total of 10 (seven males and three females) patients with CKD admitted to our facility with RT-PCR positive for SARS-CoV-2 were identified during the study period. The median (range) age of study subjects was 18 (6–25) years. The cause of underlying CKD was known in three patients, while the rest were incidentally detected. All patients at the time of enrollment were dialysis dependent and in CKD stage 5 with median estimated glomerular filtration rate (eGFR) of 8.75 (5.5–12.5) mL/min/1.73 m2. The eGFR was calculated by the modified Schwartz formula for those below 18 years and Chronic Kidney Disease Epidemiology Collaboration (CKD EPI) creatinine-based equation (2009) for those above 18 years of age.,
Prior to admission, they were receiving maintenance hemodialysis and were visiting the dialysis facility twice (six patients) or thrice (four patients) a week. None of the patients were on any immunosuppressants or cytotoxic drugs; one patient was suffering from pulmonary tuberculosis and was on antitubercular drugs, one had hepatitis C infection (not on antivirals), and another had a history of substance abuse.
A history of contact with a known COVID-19 patient or a relevant travel history was present in none of the patients. Fever was the most common symptom, seen in seven (70%), followed by cough in five (50%), and three patients (30%) were asymptomatic and two (20%) developed loose stools. Hypertension and anemia were present in all and three (30%) patients presented with hypertensive emergency; fluid overload was present in two (20%), acidosis and encephalopathy in one (10%) each, and five (50%) patients required packed red blood cell transfusion. The hematological investigations showed leukopenia (defined as total leukocyte count <4000/mm3) in five (50%) patients, lymphopenia in three (30%) patients, and thrombocytopenia (platelet counts <105/mm3) in three patients (30%), while coagulopathy was seen in two patients (20%). Details of investigations are provided in [Table 1] and [Table 2]. The chest radiography was done for all patients, with abnormalities seen in five (50%). The most common radiological abnormality seen was bilateral diffuse opacities (80%).
The median duration of hospital stay was 21.5 (10–46) days with five (50%) patients requiring intensive care support. Oxygen therapy with mask was given to five (50%) patients, through high-flow nasal cannula to two (20%), and one (10%) patient required mechanical ventilation. The specific medications used for COVID-19 infection were hydroxychloroquine in seven patients (70%), azithromycin in seven patients (70%), and ivermectin in four patients (40%). Intravenous antibiotics were administered to five (50%) patients. Intravenous steroids and enoxaparin were used in two (20%) patients and one (11.1%) patient, respectively. We could discharge all but one patient who expired of COVID-19 pneumonia with multi-organ dysfunction within 72 hours of admission. On repeat COVID-19 testing (by RT-PCR), six (60%) became COVID-19 negative before 2 weeks, while three (33.3%) stayed positive for more than 2 weeks, and the longest time taken was 5 weeks in a single patient.
| Discussion|| |
The spectrum of SARS-CoV-2 in children and young adults has been found to be of a milder severity compared to adults.,, Over 90% of cases in children are mild to moderate in intensity with only 5.9% becoming critical compared to 18.5% in adults. CKD has been identified to be a major risk factor associated with severe COVID-19 disease in adults., However, data regarding the spectrum of SARS-CoV-2 in children with end-stage renal disease is sparse.
We enrolled 10 SARS-CoV-2 positive children and young adults having an underlying CKD during the study period. All these patients had CKD stage 5 and were on maintenance hemodialysis. None of our patients had a history of contact with a person positive for SARS-CoV-2 in the family or a significant travel history. They were identified as a result of mandatory screening of patients for SARS-CoV-2 prior to dialysis. This is in contrast to the findings of Ding et al., who did a metanalysis on the clinical characteristics of children with COVID-19 (n = 396) and reported that 86.4% (95% CI 75.5–94.9) of the children with COVID-19 had close contact with family members with COVID-19. Sarangi et al. did a study on the epidemiological and clinical characteristics of COVID-19 in Indian children (n = 50) in the initial phase of the pandemic and found a history of positive household contact in 45 (90%) children, with 42 having family members with mild illness and three with severe illness, while travel history to the affected area was documented in one child. The possible source of exposure in our patients could have been from the dialysis centers they were visiting for their maintenance hemodialysis.
Majority of the patients at presentation had fever (70%) and cough (50%), with 30% being asymptomatic. In a Spanish study by Melgosa et al. on 16 children with chronic kidney pathologies, fever and cough were present in 50% and 37.5% of the cases, respectively, and 18.7% cases were asymptomatic. The incidence of diarrhea in our patients was 20%, which was similar to the frequency of gastrointestinal symptoms (25%) reported by Melgosa et al. A similar observation was made in other pediatric series with nonrenal patients. Ding et al. had 6.1% children with comorbidity in their study and reported fever to be the commonest symptom (51.2%) followed by cough (37%),with asymptomatic cases constituting 17.4%.
The frequency of lymphopenia was 30% in our study, which was identical to the incidence (33.3%) reported by Melgosa et al. However, Patel in her systematic review of 2914 normal pediatric COVID-19 patients reported leukopenia in 31.5% with lymphopenia in only 9.1%. The damage to the cytoplasm of lymphocytes by the direct invasion by SARS-CoV viral particles and apoptosis induced by cytokine storm are some of the proposed mechanisms causing destruction of lymphocytes in these patients., The neutrophil/lymphocyte ratio (NLR) has been identified as an important predictor of COVID-19 pneumonia progression to severe forms; this was 2.2 (1–5) in our study with the higher value of 5 seen in the critically ill patient who expired within few hours of admission. Yang et al. found the optimal threshold of 3.3 for NLR for predicting progression to more severe disease. Liu et al. reported a higher incidence (50%) of critical illness in patients with ages ≥ 50 and NLR ≥ 3.13 compared to an incidence of 9.1% in similar ages with an NLR <3.13.
Radiological abnormalities were found in 50% of patients in the present study, with bilateral diffuse opacities being the commonest finding (80%), followed by ground-glass opacity (10%) and pleural effusion (10%). Melgosa et al. found radiological abnormalities in six out of 10 (60%) patients with four (66.6%) having diffuse infiltrates and two (33.3%) with focal infiltrates. Bilateral involvement was also seen on chest computed tomography in 86.7% of patients in the study by Xiong et al. on 131 adult hemodialysis patients with COVID- 19, and ground-glass or patchy opacity (82.1%) was the most common finding. Valeri et al. in their study on 59 adult patients on dialysis admitted with COVID-19 also found multifocal or bilateral opacities (59%) in most patients. Most pediatric nonrenal studies too have reported bilateral radiological abnormalities in a majority of patients, with the commonest pattern being ground-glass opacities.,
The median duration of hospital stay in this study of 22.5 days was significantly longer than the 3 ± 0.5 days of mean duration of admission reported by Melgosa et al. The need for intensive care support (50%), mechanical ventilation (10%), and mortality rate (10%) was also higher in our study compared to the Spanish (n=16) and UK series (n=5) on pediatric CKD patients, where none of the children required intensive care unit (ICU) support and there were no deaths., The reason for the higher severity of illness documented in our study could be the inclusion of young adults (18–25 years); the mortality rate (31–53.3%) reported in the adult CKD patients, however, was much higher.,, An additional contributor towards a more severe course of COVID-19 could be the presence of additional morbidities like pulmonary tuberculosis, hepatitis C, and substance abuse in 30%. Among the nonrenal pediatric patients reported previously, the average length of hospital stay ranged from 6.5 to 14 days, 6.8% patients received intensive care, mortality rate was 0.18%, and 2.1% needed intubation.The median duration to achieve RT-PCR negativity was 21.5 (10–40) days in this study; in the study by Hu et al. on 59 adult non-CKD patients, the median duration of communicable period, that is, the duration from the first day of positive RT-PCR test to the first day of showing consecutive negative results, was 14 days, ranging from 4 to 25 days. They also reported age >45 years and chest tightness to be independently associated with negative conversion of SARS-CoV-2 RNA. The time taken from symptoms onset to negative RT-PCR test result was 20 days in the study by Xiao et al. on 301 COVID-19 patients from Wuhan, China. The longer duration of time taken for negative conversion in our study is suggestive of longer duration of viral shedding in CKD patients.
The management of COVID-19 was instituted in accordance with the national recommendations of Ministry of Health and Family Welfare, Government of India and Indian Society of Pediatric Nephrology guidelines. Hydroxychloroquine (in GFR corrected doses), azithromycin, and ivermectin were the drugs used. No significant adverse reactions were seen and remdesivir was not used in any patient as it is contraindicated below a GFR of 30 mL/min/1.73 m2. We began the use of steroids in patients requiring supplemental oxygen towards the end of the month of June, following the benefits reported in the interim analysis of the Randomized Evaluation of Covid-19 Therapy (RECOVERY) trial of dexamethasone in patients hospitalized with Covid-19. Therefore, it was used in only 20% of the patients, as most were enrolled in the study prior to that period. The usage of tocilizumab and convalescent plasma therapy was limited to the ICU and was not administered to any of our patients as the only critical patient in our study succumbed within a short duration of admission.
To conclude, we observed that the children and young adults with CKD presented with a similar spectrum of symptoms and radiological findings as their healthy counterparts. The mortality rate was substantially lower than that reported in adult CKD patients. It was also observed that parameters such as lymphopenia and neutrophil/lymphocyte ratio can be used to predict the progression of illness at an early stage of the disease. Besides, these patients took a longer time for RT-PCR negative conversion, suggesting a longer duration for viral clearance in the pediatric CKD patients. However, a better understanding of the impact of COVID-19 on the pediatric CKD patients requires more data possibly from multicentric studies.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]