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Table of Contents
EDITORIAL
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 1-3

Pandemic and practice of pediatric nephrology


Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India

Date of Submission19-Jun-2020
Date of Acceptance19-Jun-2020
Date of Web Publication27-Jun-2020

Correspondence Address:
Arvind Bagga
Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJPN.AJPN_24_20

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How to cite this article:
Bagga A, Sinha A. Pandemic and practice of pediatric nephrology. Asian J Pediatr Nephrol 2020;3:1-3

How to cite this URL:
Bagga A, Sinha A. Pandemic and practice of pediatric nephrology. Asian J Pediatr Nephrol [serial online] 2020 [cited 2020 Oct 1];3:1-3. Available from: http://www.ajpn-online.org/text.asp?2020/3/1/1/288150



The coronavirus disease 2019 (COVID-19), a rapidly evolving pandemic, has placed unprecedented strain on health-care systems across the world. More than 8 million people have been infected worldwide by mid-June, with rising number of patients in south Asia. Significant resources, in terms of infrastructure, health budgets, and health-care personnel, are being utilized for managing these patients. Meta-analyses of cohort studies indicate that patients with pulmonary or cardiac comorbidities, diabetes mellitus, and immunodeficiency show worse outcomes.[1] Children constitute only 1%–5% of diagnosed COVID-19 cases and have milder presentation and considerably better outcomes than adults, with mortality rates <1%.[2] Recently, a multi-inflammatory syndrome, resembling Kawasaki disease, has been described as part of the COVID-19 spectrum in children.[3]

COVID-19 presents unique challenges for the management of patients with acute and chronic kidney diseases (CKD), especially those receiving immunosuppressive medications and those requiring renal replacement therapy. Adult patients with CKD have three-fold risk of severe COVID-19, and mortality rates exceed 50% in the CKD population.[4] Acute kidney injury (AKI), associated with multi-organ dysfunction syndrome or direct viral infection of the kidneys, is observed in 9% (95% confidence interval: 5%–14%) of cases with COVID-19.[5] This incidence is no different than the incidence of AKI in community-acquired pneumonia. Case fatality rate is five-fold higher for solid organ transplant recipients compared to general population (25.6% vs. 5.6%).[6],[7] Information from series comprising 175 kidney allograft recipients with COVID-19 emphasize the lack of typical symptoms, delayed presentation, severe course, high risk of severe AKI, and prolonged viral shedding.[8],[9],[10],[11]

Information on presentation and outcomes of COVID-19 in children with kidney diseases is limited. A recent international survey on 18 children, aged 0–19 years with CKD on immunosuppressive medications, showed a mild clinical course of COVID-19.[12] Data from two countries that had a large number of patients affected with COVID-19 is similar. Only 4 of 1591 intensive care patients admitted to Lombardy (Italy) were children; 3 of these children had comorbidities but satisfactory outcome.[13] A recent survey from Spain reported 16 children with CKD and COVID-19, showed fever and upper respiratory symptoms in all, with little radiological involvement. While renal functions worsened in three patients, recovery was rapid.[14] Experience from these studies suggests that COVID-19 in children with CKD may have similar clinical course as in healthy children. More studies are required to confirm these findings and study the short- and medium-term course of COVID-19 in children with CKD.

Given the pandemic, most academic renal societies and experts have formulated practice guidelines to guide their members regarding principles of managing patients with AKI, CKD, and/or those receiving immunosuppression who are at risk of, or acquire, COVID-19.[15],[16],[17],[18],[19],[20] Management strategies rely on early experience in patients with COVID-19 combined with intuitive extrapolation of evidence from managing other infections in patients with CKD and/or on immunosuppression. Most guidelines refer to standard operating procedures on prevention, mitigation, and containment of COVID-19 in the context of acute and maintenance hemodialysis, such as the use and disposal of personal protective equipment, scheduling, and location of dialysis services, and issues related to housekeeping and disinfection. Based on limited information from patients on long-term immunosuppression exposed to SARS-CoV-2 infection or having COVID-19, recommendations emphasize (i) delaying elective transplantation surgeries, and (ii) minimizing the use of intense immunosuppression, particularly pulse corticosteroids or cyclophosphamide and T- and B-cell depleting biological therapies, during the pandemic. In patients who are immunocompromised and have COVID-19, guidelines underscore the following: (i) restricting kidney biopsies and frequent blood tests; (ii) a low threshold for admission and inpatient monitoring; (iii) reduction of immunosuppression, including withdrawal of antimetabolites and using calcineurin inhibitors in low doses; (iv) close therapeutic drug monitoring and for drug-drug interaction during “cytokine storm” and/or co-administration of antivirals;[21] (v) careful decision-making in balancing risk of allograft rejection/disease activity with need for immunosuppression reduction; and (vi) considering use of tocilizumab and steroid pulses in patients with severe SARS-CoV-2 pneumonia. There have been concerns regarding the use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers, which share their target receptor site with the SARS-CoV-2 virus that may cause ACE-2 receptor upregulation. However, most professional societies recommended their continued use in patients with SARS-CoV-2 infection treated with these agents. Available clinical evidence, including a recent meta-analysis, has failed to indicate increased risk of severe infection and mortality.[22]

Our preparedness for managing children with acute and CKDs is the need of the hour. A Delphi survey from Europe,[23] an international consensus for the management of children on chronic dialysis [24] and guidelines from the British Association of Pediatric Nephrology [25] and Indian Society of Pediatric Nephrology [26] on managing children with renal diseases, were published during this pandemic, and are based on the current literature and expert views. Such advice should supplement regional or national guidance on standard care of patients with COVID-19.[27]

As with other infections, these recommendations must be individualized based on the patient needs, available resources and clinical judgment when taking decisions regarding medication changes and inpatient management. While children constitute a small proportion of patients with COVID-19, those with chronic disorders constitute a high-risk group and at-risk for adverse outcomes. Data need to be accrued from across the world regarding the risk, clinical course, therapies, and outcomes in patients with kidney diseases who are also afflicted with COVID-19. Therapeutic guidelines are likely to change as evidence emerges from large case series and randomized controlled trials.



 
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