Acute Ischemic Events After COVID-19 Infection in Patients Undergoing Maintenance Hemodialysis

Introduction: Patients undergoing maintenance hemodialysis have unique risk factors that render them prone to ischemia. To what extent coronavirus infectious disease 2019 (COVID-19) increases this risk is unknown.

Methods: This retrospective cohort study included incident patients undergoing maintenance hemodialysis from one city in Turkey. A comparison was made between those who developed COVID-19 and those who did not for clinical variables. Independent predictors of acute ischemic complications in the total cohort were assessed using the logistic regression analysis.

Findings: By the start of the pandemic in Turkey, 33 of 154 (21.4%) patients developed COVID-19. During the 15 months of median follow-up after the start of the pandemic, 16 (10.4%) patients developed acute ischemic complications. These included acute myocardial infarction (n = 10), acute ischemic stroke (n = 4), acute peripheral artery thrombosis (n = 1), and pulmonary thromboembolism (n = 1). Overall, acute ischemic events occurred more commonly in those who experienced COVID-19 (24.2% vs. 6.6%, p = 0.007). Ischemia-free survival was significantly shorter in the COVID-19 group (p = 0.001). In the eight patients with COVID-19, ischemic complications emerged at a median 185 (range 21-306) days after the diagnosis of COVID-19. While age, dialysis vintage, and experience of COVID-19 were found as factors significantly associated with the development of acute ischemic events in univariate analysis, the association between COVID-19 and acute ischemia remained significant in the multivariate regression model (odds ratio 3.99, 95% CI [1.3, 12.13], p = 0.016). During the pandemic, 23 (14.9%) patients died. Overall survival was significantly shorter among those who developed acute ischemic event (p < 0.001). The hazard ratio of acute ischemic event for death was 6.76 (95% CI [2.92, 15.66], p < 0.001).

Discussion: A considerable number of patients undergoing maintenance hemodialysis developed acute ischemic complications weeks to months after the resolution of COVID-19. Hemodialysis patients appear to require specific interventions in order to prevent subsequent acute ischemic events after the resolution of COVID-19.