Faculty Bibliography

Background:The COVID-19 pandemic strained hospital resources in New York City, including those for providing dialysis. New York University Medical Center and affiliations, including New York City Health and Hospitals/Bellevue, developed a plan to offset the increased needs for KRT. We established acute peritoneal dialysis (PD) capability, as usual dialysis modalities were overwhelmed by COVID-19 AKI. Methods:Observational study of patients requiring KRT admitted to Bellevue Hospital during the COVID surge. Bellevue Hospital is one of the largest public hospitals in the United States, providing medical care to an underserved population. There were substantial staff, supplies, and equipment shortages. Adult patients admitted with AKI who required KRT were considered for PD. We rapidly established an acute PD program. A surgery team placed catheters at the bedside in the intensive care unit; a nephrology team delivered treatment. We provided an alternative to hemodialysis and continuous venovenous hemofiltration for treating patients in the intensive-care unit, demonstrating efficacy with outcomes comparable to standard care. Results:From April 8, 2020 to May 8, 2020, 39 catheters were placed into ten women and 29 men. By June 10, 39% of the patients started on PD recovered kidney function (average ages 56 years for men and 59.5 years for women); men and women who expired were an average 71.8 and 66.2 years old. No episodes of peritonitis were observed; there were nine incidents of minor leaking. Some patients were treated while ventilated in the prone position. Conclusions:Demand compelled us to utilize acute PD during the COVID-19 pandemic. Our experience is one of the largest recently reported in the United States of which we are aware. Acute PD provided lifesaving care to acutely ill patients when expanding current resources was impossible. Our experience may help other programs to avoid rationing dialysis treatments in health crises.

Introduction: The dramatic spread of COVID-19 in March 2020 threatened to overwhelm ICU capacity. At the peak we had more than 120 patients in the ICU. About 40% of the ICU patients required RRT due to AKI. Our ability to provide RRT with CVVH and IHD was severely limited by critical shortages of equipment and personnel. We rapidly established an acute PD program at Bellevue hospital for AKI patients. The acute PD program turned out to be instrumental in the BH response to COVID AKI. Case Description: Patients All patients who needed RRT in the ICU were eligible to receive PD catheters except for those with prior abdominal surgery. 36/38 patients who received catheters were Covid (+). Proning was not always planned; we did not use this as a contraindication. We were able to successfully perform adequate PD on patients who were proned with minimal complications. Surgical Support Catheters were placed using a limited cut down to the peritoneal membrane through the rectus muscle at bedside; most of the patients were intubated and sedated. Training and Initial Experience A nurse affiliated with Bellevue's outpatient dialysis unit helped make videos and trained the lead nephrologist on how to perform PD and how to use a Cycler. 25 people were on the PD team and we were able to provide exchanges 24 hours per day. Exchanges were initially performed manually every 1-2 hours. Eventually we acquired 18 cyclers which greatly eased the workload. Outcomes As of May 8, 2020 63 patients were evaluated, 38 PD catheters were placed with 35 used for exchanges. 2 patients had catheters placed but recovered renal function prior to starting PD. 1/38 was nonfunctioning and changed to IHD. 15/35 survived >30 days; 8 recovered renal function; 20 expired <30 days.
Discussion(s): Because of the shortage of our typically used dialysis modalities we were compelled to start an acute PD program. No patient on PD required additional dialytic support with IHD or CVVH. PD was well tolerated by ventilated patients with hemodynamic instability. Acute PD more than adequately filled the gap in treatment options during this unprecedented crisis

Macrophage migration inhibitory factor (MIF), originally identified as a cytokine secreted by T lymphocytes, was found recently to be both a pituitary hormone and a mediator released by immune cells in response to glucocorticoid stimulation. We report here that the insulin-secreting beta cell of the islets of Langerhans expresses MIF and that its production is regulated by glucose in a time- and concentration-dependent manner. MIF and insulin colocalize by immunocytochemistry within the secretory granules of the pancreatic islet beta cells, and once released, MIF appears to regulate insulin release in an autocrine fashion. In perifusion studies performed with isolated rat islets, immunoneutralization of MIF reduced the first and second phase of the glucose-induced insulin secretion response by 39% and 31%, respectively. Conversely, exogenously added recombinant MIF was found to potentiate insulin release. Constitutive expression of MIF antisense RNA in the insulin-secreting INS-1 cell line inhibited MIF protein synthesis and decreased significantly glucose-induced insulin release. MIF is therefore a glucose-dependent, islet cell product that regulates insulin secretion in a positive manner and may play an important role in carbohydrate metabolism.