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American Journal of Kidney Diseases

Corticosteroids and COVID-19: What Could Be the Best Bet in Treating Active Glomerular Diseases in Patients With Concomitant Early COVID-19?

Published:September 25, 2020DOI:https://doi.org/10.1053/j.ajkd.2020.09.006
      To the Editor:
      Patients with early mild or asymptomatic coronavirus disease 2019 (COVID-19) who require intense immunosuppression for underlying immune-mediated diseases pose a dilemma to physicians. In severe COVID-19, organ salvaging measures may not seem a top priority. However, because 80% of COVID-19 illnesses are mild, lasting about a week, starting or delaying intense immunosuppression in early mild COVID-19 and active glomerular diseases should be based on informed decision making.
      Corticosteroids, often at high doses, remain the cornerstone of treating most glomerular diseases. Use of high-dose (1 mg/kg per day) but not low-dose (<1 mg/kg per day) corticosteroids (methylprednisolone or equivalent) was found to result in prolonged viral shedding (with possible increased hospital stay)

      Li S, Hu Z, Song X. High-dose but not low-dose corticosteroids potentially delay viral shedding of patients with COVID-19 [published online ahead of print June 26, 2020]. Clin Infect Dis. https://doi.org/10.1093/cid/ciaa829

      and increased risk for mortality
      • Li X.
      • Xu S.
      • Yu M.
      • et al.
      Risk factors for severity and mortality in adult COVID-19 inpatients in Wuhan.
      in patients with COVID-19. The RECOVERY trial

      RECOVERY Collaborative Group; Horby P, Lim WS, et al. Dexamethasone in hospitalized patients with Covid-19 - preliminary report [published online ahead of print July 17, 2020]. N Engl J Med. doi: 10.1056/NEJMoa2021436.

      found low-dose corticosteroid treatment (6 mg of dexamethasone) for up to 10 days to be beneficial among hospitalized patients with severe or critical COVID-19. However, the long-term effect of corticosteroids or longer duration of corticosteroid treatment on outcomes of patients with COVID-19 is currently unknown.
      We suggest that risk stratification of patients, by balancing the risks of severe COVID-19 with that of irreversible kidney injury, should guide treatment decisions. Currently known risk factors for severe COVID-19 illness (presence of comorbid conditions, lymphopenia,
      • Tan L.
      • Wang Q.
      • Zhang D.
      • et al.
      Lymphopenia predicts disease severity of COVID-19: a descriptive and predictive study.
      and high viral load
      • Rao S.N.
      • Manissero D.
      • Steele V.R.
      • Pareja J.
      A narrative systematic review of the clinical utility of cycle threshold values in the context of COVID-19.
      ) could be incorporated. Although antibody-mediated diseases could possibly be managed with low-dose corticosteroid therapy (~0.5 mg/kg per day of prednisolone) and adjunctive plasmapheresis/intravenous immunoglobulins,
      • Kronbichler A.
      • Gauckler P.
      • Windpessl M.
      • et al.
      COVID-19: implications for immunosuppression in kidney disease and transplantation.
      other immune-mediated diseases such as podocytopathy and/or acute tubulointerstitial nephritis would typically need high-dose corticosteroids (1 mg/kg per day). In case high-dose corticosteroids are used, covering with an antiviral agent could be done. We believe that more data with antiviral therapy will emerge as trials include patients with kidney disease. Not least of all, shared decision making with the patient must be done after explaining possible benefits and harms of treatment.

      Article Information

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      Financial Disclosure

      The authors declare that they have no relevant financial interests.

      Peer Review

      Received August 26, 2020. Direct editorial input from an Associate Editor and a Deputy Editor. Accepted in revised form September 15, 2020.

      References

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        Lymphopenia predicts disease severity of COVID-19: a descriptive and predictive study.
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        A narrative systematic review of the clinical utility of cycle threshold values in the context of COVID-19.
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        COVID-19: implications for immunosuppression in kidney disease and transplantation.
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