High Dependency Renal Unit (HDRU) for the management of COVID-19 in patients with severe acute or chronic kidney disease

Abstract Background: COVID-19 in patients on dialysis for acute or chronic kidney disease is associated with high mortality. We evaluated the effect of high dependency renal unit (HDRU) with nephrologists as primary care physicians for management of these patients. Methods: This was an observational, cohort study conducted at a tertiary care teaching hospital in western India. Patients needing dialysis for COVID-19 associated Acute Kidney Injury (AKI-D) and patients with End-Stage-Renal-Disease (ESRD) hospitalized for COVID-19 were included in the study. After 2 months into the pandemic (28 March to 28 May), HDRU was commissioned for management of these patients. With nephrologists as primary care physicians, the components of care included completion of care bundle focusing on key nephrology and COVID-19 related issues, checklist-based clinical monitoring, integration of multispecialty care, and training of nurses and doctors. Primary outcome of the study was in hospital mortality compared between pre-HDRU and HDRU cohorts. Secondary outcomes were- dialysis dependence in AKI-D, and predictors of death. Results: 238 of 4052 (5.87%) patients with COVID-19 admitted from 28th March to 30th September had severe renal impairment (116 AKI-D and 122 ESRD). 133 of 238 (56.8%) has severe COVID-19. HDRU care was delivered from 28th May to 30th August. Kaplan-Meier survival analysis showed significant improvement in survival after implementation of HDRU [19 of 52 (36.5%) in pre-HDRU versus 35 of 160 (21.9%) in HDRU died, p=<0.01]. 44 (67.7%) AKI-D survivors were dialysis dependent at discharge. Male sex, breathlessness and altered mental status at presentation, development of shock during hospital stay and leukocytosis predicted mortality. Conclusions: HDRU managed nephrologists as primary care physicians is feasible and potentially effective approach to improve the outcomes of patients with COVID-19 and severe renal impairment.