Journal of Clinical & Experimental Nephrology

Keywords

COVID-19; Diabetes mellitus; ESKD; Dialysis

Introduction

Novel coronavirus disease 2019 (COVID-19) is emerging, pandemic and highly infectious, rapidly spreading viral disease with estimating case fatality rate from 3 to 5% [1]. The risk factors for severe presentations are concentrated in patients with chronic kidney disease, particularly patients with end-stage renal disease (ESRD) who are dialysis dependent.

Case Report

\We report a case of a 62-year-old nondiabetic male with ESKD, secondary to hypertensive nephropathy. He had hypertension controlled with calcium channel blocker, amlodipine 5 mg/day and had past history of excessive smoking. During the two years of his dialysis, he has never showed high blood glucose. He is on thrice-weekly maintenance hemodialysis for 2 years in Diaverum-Abu Arish clinic-Saudi Arabia, who developed nausea, vomiting and abdominal pain during his last session on 11th June 2020, he received antispasmodic and felt relieved to complete his session. Blood glucose measured in dialysis treatment area, and reported as 100 mg/dl. Late that day at home, he developed fever, shortness of breath and vomiting, carried to Abu Arish hospital, where he investigated and swabbed for COVID-19 test, investigation showed high blood glucose 513 mg/dl, repeated again after administered isotonic saline, and it was 315 mg/dl. They referred him to Damad hospital as a case of hyperglycemia with possible COVID-19 infection. Blood glucose level repeated again, and it was 315 mg/dl. Four days later, he brought to our clinic by ambulance for hemodialysis session when screened at the ambulance he was evaluated, screened and labeled as vitally stable with high suspicion for COVID-19. He was admitted to king Fahad hospital where he admitted in isolation setting, received hemodialysis session and managed as per COVID-19 infection protocol. Within the first 24 h, he deteriorated quickly and developed acute respiratory distress syndrome (ARDS), requiring intubation and increasing respiratory support; he had two episodes of cardiac arrest at the intensive care unit. The same day, nasopharyngeal swab came positive for COVID-19. Seven days later, he developed cardiac arrest for the third time and failed to recover this time and announced his death.

Discussion

New onset diabetes and severe metabolic complications of preexisting diabetes including diabetic ketoacidosis and hyperosmolarity for which exceptionally high doses of insulin are warranted have been observed in patients with COVID-19 [2,3]. This case is unique in its atypical initial presentation and highlights the possibility of causation relationship between COVID-19 and new onset diabetes and the bad outcome when COVID-19 is associated with hyperglycemia. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, binds to angiotensin-converting enzyme 2 (ACE2) receptors, which are expressed in key metabolic organs and tissues, including pancreatic beta cells, adipose tissue, the small intestine, and the kidneys [4]. Thus, it is plausible that SARS-CoV-2 may cause pleiotropic alterations of glucose metabolism that could complicate the pathophysiology of preexisting diabetes or lead to new mechanisms of disease. Greater incidences of fasting hyperglycaemia and acute-onset diabetes have been reported among patients with SARS coronavirus 1 pneumonia than among those with non-SARS pneumonia [5].

Taken together, these observations provide support for the hypothesis of a potential diabetogenic effect of COVID-19, beyond the well-recognized stress response associated with severe illness. However, whether the alterations of glucose metabolism that occur with a sudden onset in severe COVID-19 persist or remit when the infection resolves is unclear. Several questions are raised and need further documentation, how frequent is the phenomenon of new-onset diabetes, and is it classic type 1, type 2 diabetes, or a new type of diabetes? Do these patients remain at higher risk for diabetes or diabetic ketoacidosis? In patients with preexisting diabetes, does COVID-19 change the underlying pathophysiology and the natural history of the disease? Answering these questions in order to inform the immediate clinical care, follow-up, and monitoring of affected patients is a priority.

Conclusion

In this case, it is clear that COVID-19 induced hyperglycemia in non-diabetic patient have developed in ESKD treated with hemodialysis modality. Given the case scenario, it is also clear that hyperglycemia in COVID 19 infection carries very poor prognosis. To the best of our knowledge, this phenomenon is unique and has not been reported in hemodialysis patient.

Disclosure

The authors have neither conflict of interest nor financial support of any kind related to this work.

References

1. Wu Z, McGoogan JM (2020) Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. Jama 323: 1239-1242.
2. Chee YJ, Ng SJH, Yeoh E (2020) Diabetic ketoacidosis precipitated by Covid-19 in a patient with newly diagnosed diabetes mellitus.Diabetes Res Clin Pract.
3. Li J, Wang X, Chen J, Zuo X, Zhang H, et al. (2020) COVID-19 infection may cause ketosis and ketoacidosis. Diabetes Obes Metab.
4. Hamming I, Timens W, Bulthuis ML, Lely AT, Navis G, et al. (2004) Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus: a first step in understanding SARS pathogenesis. J Pathol 203: 631-637.
5. Yang JK, Lin SS, Ji XJ, Guo LM (2010) Binding of SARS coronavirus to its receptor damages islets and causes acute diabetes. Acta Diabetol 47: 193-199.