COVID-19 in Hemodialysis Patients: A Report of 5 Cases
Identifieur interne : 000941 ( Pmc/Corpus ); précédent : 000940; suivant : 000942COVID-19 in Hemodialysis Patients: A Report of 5 Cases
Auteurs : Rui Wang ; Cong Liao ; Hong He ; Chun Hu ; Zimeng Wei ; Zixi Hong ; Chengjie Zhang ; Meiyan Liao ; Hua ShuiSource :
- American Journal of Kidney Diseases [ 0272-6386 ] ; 2020.
Abstract
In December 2019, an outbreak of coronavirus disease (COVID-19) due to the novel SARS-CoV-2 virus began in China and spread rapidly worldwide. It is unknown whether hemodialysis patients represent a distinct group of patients with certain characteristics that may make them susceptible to infection or severe disease. In this Case Report, we describe the clinical and epidemiological features of COVID-19 in 201 maintenance hemodialysis patients in Zhongnan Hospital of Wuhan university, including 5 maintenance hemodialysis patients who contracted COVID-19 disease. Of the 5 patients with COVID-19, one had a definite history of contact with an infected person. The age range of the patients was 47–67 years. Diarrhea (80%), fever (60%), and fatigue (60%) were the most common symptoms. Lymphopenia occurred in all patients.Chest computerized tomography (CT) scans showed ground glass opacity in the lungs of all patients. Up to February 13, 2020, none of the patients had developed severe complications (acute respiratory distress syndrome, shock, multiple organ dysfunction) or died.
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DOI: 10.1053/j.ajkd.2020.03.009
PubMed: 32240718
PubMed Central: 7118604
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">COVID-19 in Hemodialysis Patients: A Report of 5 Cases</title><author><name sortKey="Wang, Rui" sort="Wang, Rui" uniqKey="Wang R" first="Rui" last="Wang">Rui Wang</name><affiliation><nlm:aff id="aff1">Department of Nephrology, Zhongnan Hospital, Wuhan University, Wuhan, 430071,China</nlm:aff></affiliation></author><author><name sortKey="Liao, Cong" sort="Liao, Cong" uniqKey="Liao C" first="Cong" last="Liao">Cong Liao</name><affiliation><nlm:aff id="aff2">Laboratory Medicine, Zhongnan Hospital, Wuhan University, Wuhan, 430071, China</nlm:aff></affiliation></author><author><name sortKey="He, Hong" sort="He, Hong" uniqKey="He H" first="Hong" last="He">Hong He</name><affiliation><nlm:aff id="aff1">Department of Nephrology, Zhongnan Hospital, Wuhan University, Wuhan, 430071,China</nlm:aff></affiliation></author><author><name sortKey="Hu, Chun" sort="Hu, Chun" uniqKey="Hu C" first="Chun" last="Hu">Chun Hu</name><affiliation><nlm:aff id="aff1">Department of Nephrology, Zhongnan Hospital, Wuhan University, Wuhan, 430071,China</nlm:aff></affiliation></author><author><name sortKey="Wei, Zimeng" sort="Wei, Zimeng" uniqKey="Wei Z" first="Zimeng" last="Wei">Zimeng Wei</name><affiliation><nlm:aff id="aff3">Department of Immunology, School of Basic Medical Sciences, Wuhan University, Wuhan, 430071, China</nlm:aff></affiliation></author><author><name sortKey="Hong, Zixi" sort="Hong, Zixi" uniqKey="Hong Z" first="Zixi" last="Hong">Zixi Hong</name><affiliation><nlm:aff id="aff3">Department of Immunology, School of Basic Medical Sciences, Wuhan University, Wuhan, 430071, China</nlm:aff></affiliation></author><author><name sortKey="Zhang, Chengjie" sort="Zhang, Chengjie" uniqKey="Zhang C" first="Chengjie" last="Zhang">Chengjie Zhang</name><affiliation><nlm:aff id="aff3">Department of Immunology, School of Basic Medical Sciences, Wuhan University, Wuhan, 430071, China</nlm:aff></affiliation></author><author><name sortKey="Liao, Meiyan" sort="Liao, Meiyan" uniqKey="Liao M" first="Meiyan" last="Liao">Meiyan Liao</name><affiliation><nlm:aff id="aff4">Imaging Department, Zhongnan Hospital, Wuhan University, Wuhan, 430071 China</nlm:aff></affiliation></author><author><name sortKey="Shui, Hua" sort="Shui, Hua" uniqKey="Shui H" first="Hua" last="Shui">Hua Shui</name><affiliation><nlm:aff id="aff1">Department of Nephrology, Zhongnan Hospital, Wuhan University, Wuhan, 430071,China</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">32240718</idno><idno type="pmc">7118604</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7118604</idno><idno type="RBID">PMC:7118604</idno><idno type="doi">10.1053/j.ajkd.2020.03.009</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000941</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000941</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">COVID-19 in Hemodialysis Patients: A Report of 5 Cases</title><author><name sortKey="Wang, Rui" sort="Wang, Rui" uniqKey="Wang R" first="Rui" last="Wang">Rui Wang</name><affiliation><nlm:aff id="aff1">Department of Nephrology, Zhongnan Hospital, Wuhan University, Wuhan, 430071,China</nlm:aff></affiliation></author><author><name sortKey="Liao, Cong" sort="Liao, Cong" uniqKey="Liao C" first="Cong" last="Liao">Cong Liao</name><affiliation><nlm:aff id="aff2">Laboratory Medicine, Zhongnan Hospital, Wuhan University, Wuhan, 430071, China</nlm:aff></affiliation></author><author><name sortKey="He, Hong" sort="He, Hong" uniqKey="He H" first="Hong" last="He">Hong He</name><affiliation><nlm:aff id="aff1">Department of Nephrology, Zhongnan Hospital, Wuhan University, Wuhan, 430071,China</nlm:aff></affiliation></author><author><name sortKey="Hu, Chun" sort="Hu, Chun" uniqKey="Hu C" first="Chun" last="Hu">Chun Hu</name><affiliation><nlm:aff id="aff1">Department of Nephrology, Zhongnan Hospital, Wuhan University, Wuhan, 430071,China</nlm:aff></affiliation></author><author><name sortKey="Wei, Zimeng" sort="Wei, Zimeng" uniqKey="Wei Z" first="Zimeng" last="Wei">Zimeng Wei</name><affiliation><nlm:aff id="aff3">Department of Immunology, School of Basic Medical Sciences, Wuhan University, Wuhan, 430071, China</nlm:aff></affiliation></author><author><name sortKey="Hong, Zixi" sort="Hong, Zixi" uniqKey="Hong Z" first="Zixi" last="Hong">Zixi Hong</name><affiliation><nlm:aff id="aff3">Department of Immunology, School of Basic Medical Sciences, Wuhan University, Wuhan, 430071, China</nlm:aff></affiliation></author><author><name sortKey="Zhang, Chengjie" sort="Zhang, Chengjie" uniqKey="Zhang C" first="Chengjie" last="Zhang">Chengjie Zhang</name><affiliation><nlm:aff id="aff3">Department of Immunology, School of Basic Medical Sciences, Wuhan University, Wuhan, 430071, China</nlm:aff></affiliation></author><author><name sortKey="Liao, Meiyan" sort="Liao, Meiyan" uniqKey="Liao M" first="Meiyan" last="Liao">Meiyan Liao</name><affiliation><nlm:aff id="aff4">Imaging Department, Zhongnan Hospital, Wuhan University, Wuhan, 430071 China</nlm:aff></affiliation></author><author><name sortKey="Shui, Hua" sort="Shui, Hua" uniqKey="Shui H" first="Hua" last="Shui">Hua Shui</name><affiliation><nlm:aff id="aff1">Department of Nephrology, Zhongnan Hospital, Wuhan University, Wuhan, 430071,China</nlm:aff></affiliation></author></analytic><series><title level="j">American Journal of Kidney Diseases</title><idno type="ISSN">0272-6386</idno><idno type="eISSN">1523-6838</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>In December 2019, an outbreak of coronavirus disease (COVID-19) due to the novel SARS-CoV-2 virus began in China and spread rapidly worldwide. It is unknown whether hemodialysis patients represent a distinct group of patients with certain characteristics that may make them susceptible to infection or severe disease. In this Case Report, we describe the clinical and epidemiological features of COVID-19 in 201 maintenance hemodialysis patients in Zhongnan Hospital of Wuhan university, including 5 maintenance hemodialysis patients who contracted COVID-19 disease. Of the 5 patients with COVID-19, one had a definite history of contact with an infected person. The age range of the patients was 47–67 years. Diarrhea (80%), fever (60%), and fatigue (60%) were the most common symptoms. Lymphopenia occurred in all patients.Chest computerized tomography (CT) scans showed ground glass opacity in the lungs of all patients. Up to February 13, 2020, none of the patients had developed severe complications (acute respiratory distress syndrome, shock, multiple organ dysfunction) or died.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Liu, Y C" uniqKey="Liu Y">Y.C. Liu</name></author><author><name sortKey="Liao, C H" uniqKey="Liao C">C.H. Liao</name></author><author><name sortKey="Chang, C F" uniqKey="Chang C">C.F. Chang</name></author><author><name sortKey="Chou, C C" uniqKey="Chou C">C.C. Chou</name></author><author><name sortKey="Lin, Y R" uniqKey="Lin Y">Y.R. Lin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bastola, A" uniqKey="Bastola A">A. Bastola</name></author><author><name sortKey="Sah, R" uniqKey="Sah R">R. Sah</name></author><author><name sortKey="Rodriguez Morales, A J" uniqKey="Rodriguez Morales A">A.J. Rodriguez-Morales</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Lu, R" uniqKey="Lu R">R. Lu</name></author><author><name sortKey="Zhao, X" uniqKey="Zhao X">X. Zhao</name></author><author><name sortKey="Li, J" uniqKey="Li J">J. Li</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Chen, N" uniqKey="Chen N">N. Chen</name></author><author><name sortKey="Zhou, M" uniqKey="Zhou M">M. Zhou</name></author><author><name sortKey="Dong, X" uniqKey="Dong X">X. Dong</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Zhou, J" uniqKey="Zhou J">J. Zhou</name></author><author><name sortKey="Li, C" uniqKey="Li C">C. Li</name></author><author><name sortKey="Zhao, G" uniqKey="Zhao G">G. Zhao</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wong, P N" uniqKey="Wong P">P.N. Wong</name></author><author><name sortKey="Mak, S K" uniqKey="Mak S">S.K. Mak</name></author><author><name sortKey="Lo, K Y" uniqKey="Lo K">K.Y. Lo</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pesanti, E L" uniqKey="Pesanti E">E.L. Pesanti</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Wang, D" uniqKey="Wang D">D. Wang</name></author><author><name sortKey="Hu, B" uniqKey="Hu B">B. Hu</name></author><author><name sortKey="Hu, C" uniqKey="Hu C">C. Hu</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="case-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Am J Kidney Dis</journal-id><journal-id journal-id-type="iso-abbrev">Am. J. Kidney Dis</journal-id><journal-title-group><journal-title>American Journal of Kidney Diseases</journal-title></journal-title-group><issn pub-type="ppub">0272-6386</issn><issn pub-type="epub">1523-6838</issn><publisher><publisher-name>Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">32240718</article-id><article-id pub-id-type="pmc">7118604</article-id><article-id pub-id-type="publisher-id">S0272-6386(20)30612-0</article-id><article-id pub-id-type="doi">10.1053/j.ajkd.2020.03.009</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>COVID-19 in Hemodialysis Patients: A Report of 5 Cases</article-title></title-group><contrib-group><contrib contrib-type="author" id="au1"><name><surname>Wang</surname><given-names>Rui</given-names></name><xref rid="aff1" ref-type="aff">1</xref><xref rid="fn1" ref-type="fn">∗</xref></contrib><contrib contrib-type="author" id="au2"><name><surname>Liao</surname><given-names>Cong</given-names></name><xref rid="aff2" ref-type="aff">2</xref><xref rid="fn1" ref-type="fn">∗</xref></contrib><contrib contrib-type="author" id="au3"><name><surname>He</surname><given-names>Hong</given-names></name><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author" id="au4"><name><surname>Hu</surname><given-names>Chun</given-names></name><degrees>PhD</degrees><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author" id="au5"><name><surname>Wei</surname><given-names>Zimeng</given-names></name><xref rid="aff3" ref-type="aff">3</xref></contrib><contrib contrib-type="author" id="au6"><name><surname>Hong</surname><given-names>Zixi</given-names></name><xref rid="aff3" ref-type="aff">3</xref></contrib><contrib contrib-type="author" id="au7"><name><surname>Zhang</surname><given-names>Chengjie</given-names></name><xref rid="aff3" ref-type="aff">3</xref></contrib><contrib contrib-type="author" id="au8"><name><surname>Liao</surname><given-names>Meiyan</given-names></name><degrees>PhD</degrees><xref rid="aff4" ref-type="aff">4</xref></contrib><contrib contrib-type="author" id="au9"><name><surname>Shui</surname><given-names>Hua</given-names></name><degrees>PhD</degrees><email>shuihua@whu.edu.cn</email><xref rid="aff1" ref-type="aff">1</xref><xref rid="cor1" ref-type="corresp">∗∗</xref></contrib></contrib-group><aff id="aff1"><label>1</label>Department of Nephrology, Zhongnan Hospital, Wuhan University, Wuhan, 430071,China</aff><aff id="aff2"><label>2</label>Laboratory Medicine, Zhongnan Hospital, Wuhan University, Wuhan, 430071, China</aff><aff id="aff3"><label>3</label>Department of Immunology, School of Basic Medical Sciences, Wuhan University, Wuhan, 430071, China</aff><aff id="aff4"><label>4</label>Imaging Department, Zhongnan Hospital, Wuhan University, Wuhan, 430071 China</aff><author-notes><corresp id="cor1"><label>∗∗</label>Corresponding author: Hua Shui, PhD Department of Nephrology, Zhongnan Hospital, Wuhan University, No.169, Road East lake, Wuhan, Hubei, P.R. China. Postal code: 430071； <email>shuihua@whu.edu.cn</email></corresp><fn id="fn1"><label>∗</label><p id="ntpara0010">R.W. and C.L. contributed equally to this work.</p></fn></author-notes><pub-date pub-type="pmc-release"><day>31</day><month>3</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>31</day><month>3</month><year>2020</year></pub-date><elocation-id></elocation-id><history><date date-type="received"><day>28</day><month>2</month><year>2020</year></date><date date-type="accepted"><day>26</day><month>3</month><year>2020</year></date></history><permissions><copyright-statement>© 2020 Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder></copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="abs0010"><p>In December 2019, an outbreak of coronavirus disease (COVID-19) due to the novel SARS-CoV-2 virus began in China and spread rapidly worldwide. It is unknown whether hemodialysis patients represent a distinct group of patients with certain characteristics that may make them susceptible to infection or severe disease. In this Case Report, we describe the clinical and epidemiological features of COVID-19 in 201 maintenance hemodialysis patients in Zhongnan Hospital of Wuhan university, including 5 maintenance hemodialysis patients who contracted COVID-19 disease. Of the 5 patients with COVID-19, one had a definite history of contact with an infected person. The age range of the patients was 47–67 years. Diarrhea (80%), fever (60%), and fatigue (60%) were the most common symptoms. Lymphopenia occurred in all patients.Chest computerized tomography (CT) scans showed ground glass opacity in the lungs of all patients. Up to February 13, 2020, none of the patients had developed severe complications (acute respiratory distress syndrome, shock, multiple organ dysfunction) or died.</p></abstract><kwd-group id="kwrds0010"><title>Key words</title><kwd>Hemodialysis</kwd><kwd>COVID-19</kwd><kwd>coronavirus</kwd></kwd-group></article-meta></front><body><sec id="sec1"><title>Introduction</title><p id="p0010">In December 2019, an outbreak of coronavirus disease (COVID-19) due to infection with the novel SARS-CoV-2 virus began in Wuhan, China, and spread rapidly to other areas of China and other countries (<xref rid="bib1" ref-type="bibr">1</xref>, <xref rid="bib2" ref-type="bibr">2</xref>, <xref rid="bib3" ref-type="bibr">3</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib6" ref-type="bibr">6</xref>). Phylogenetic analysis suggests that SARS-CoV-2 is a new human-infecting betacoronavirus, closely similar to bat coronaviruses, suggesting that bats might have been the original host of this virus (<xref rid="bib7" ref-type="bibr">7</xref>). There are no antiviral drugs of proven efficacy or applicable vaccines. Supportive therapy is the main method for the management of symptomatic patients, many of whom require mechanical ventilation and other intensive care services. There is limited information regarding the epidemiology of COVID-19 in maintenance hemodialysis (MHD) patients. MHD patients may be at increased risk of COVID-19 because of many comorbid conditions(8). In this report we describe our experience with five MHD patients who developed COVID-19 disease at Zhongnan Hospital of Wuhan University.</p><sec id="sec1.1"><title>Case Reports</title><p id="p0015">Among 201 long-term hemodialysis patients in the dialysis center at Zhongnan Hospital of Wuhan University, five patients were diagnosed with COVID-19 pneumonia according to the criteria of the Chinese Centers for Disease Control, which included positive real time reverse transcriptase PCR testing for SARS-CoV-2 (rRT-PCR). Characteristics of the five patients are presented in <xref rid="tbl1" ref-type="table">Table 1</xref>. The age range of patients was 47 to 67 years and two of five patients were female. None of the patients had known exposure to the Huanan seafood market that appeared to be the epicenter of this infection. One had known exposure to an infected family member. The most common symptom of the five infected patients was diarrhea (4/5), followed by fever (3/5), fatigue (3/5) dyspnea (2/5) and abdominal pain (2/5). Only one patient had dry cough. No patients had rhinorrhea, sore throat, myalgia or other upper respiratory tract infection symptoms. All of the five patients had lymphopenia (<1.0 ×10⁹/L). Only one patient had white blood cell and neutrophil cell count slightly above normal.<table-wrap position="float" id="tbl1"><label>Table 1</label><caption><p>Patient clinical and laboratory characteristics</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th>Case 1</th><th>Case 2</th><th>Case 3</th><th>Case 4</th><th>Case 5</th></tr></thead><tbody><tr><td>Clinical characteristics</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Age (years)</td><td>61</td><td>62</td><td>47</td><td>67</td><td>51</td></tr><tr><td>Sex</td><td>Male</td><td>Male</td><td>Female</td><td>Female</td><td>Male</td></tr><tr><td>Contact history with infected person</td><td>No</td><td>No</td><td>No</td><td>Yes</td><td>No</td></tr><tr><td>Other family members affected</td><td>No</td><td>No</td><td>No</td><td>Yes</td><td>No</td></tr><tr><td>Duration of dialysis (years)</td><td>7</td><td>3</td><td>5</td><td>1</td><td>1</td></tr><tr><td>Causes of renal failure</td><td>Hypertensive Nephropathy</td><td>Hypertensive Nephropathy</td><td>Chronic nephritis</td><td>Hypertensive Nephropathy</td><td>Hypertensive Nephropathy</td></tr><tr><td>Diabetes</td><td>No</td><td>No</td><td>No</td><td>Yes</td><td>No</td></tr><tr><td>Signs and symptoms</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Fever</td><td>Yes</td><td>No</td><td>Yes</td><td>Yes</td><td>No</td></tr><tr><td>Dry cough</td><td>No</td><td>Yes</td><td>No</td><td>No</td><td>No</td></tr><tr><td>Dyspnea</td><td>No</td><td>No</td><td>Yes</td><td>Yes</td><td>No</td></tr><tr><td>Fatigue</td><td>Yes</td><td>No</td><td>No</td><td>Yes</td><td>Yes</td></tr><tr><td>Diarrhea</td><td>Yes</td><td>No</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>Abdominal pain</td><td>No</td><td>No</td><td>Yes</td><td>Yes</td><td>No</td></tr><tr><td>Laboratory characteristics</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>White blood cell count, x10<sup>9</sup>/L</td><td>6.84</td><td>7.50</td><td>7.73</td><td>10.76</td><td>5.03</td></tr><tr><td>Neutrophil count, x 10⁹/ L</td><td>5.69</td><td>5.65</td><td>6.28</td><td>9.24</td><td>4.29</td></tr><tr><td>Lymphocyte count, x10⁹/ L</td><td>0.63</td><td>0.84</td><td>0.80</td><td>0.92</td><td>0.49</td></tr></tbody></table></table-wrap></p><p id="p0020">As shown in <xref rid="fig1" ref-type="fig">Figure 1</xref>, ground glass opacities on chest CT were the most common radiologic findings, followed by consolidation. All of the five patients were transferred to a designated hospital after diagnosis to continue hemodialysis. Two of them received intermittent nasal catheter oxygen inhalation as well as treatment with daily 40 mg methylprednisolone and intravenous immunoglobulin. Two patients were given antiviral treatment with abidol and ribavirin injection, respectively. Up to the end of this study, none of them had developed acute respiratory distress syndrome, shock, or other serious complications.<fig id="fig1"><label>Figure 1</label><caption><p>Chest computerized tomography (CT) scans (transverse plane) of Patient 1 and Patient 3. (A) Patient 1: Bilateral ground glass opacity, mainly in the lower lobes of both lungs, with air bronchogram sign. (B) Patient 3: Bilateral ground glass opacity of lower lung lobes and round shape consolidation opacity with air bronchogram sign in the right lower lung lobe.</p></caption><graphic xlink:href="gr1_lrg"></graphic></fig></p></sec></sec><sec id="sec2"><title>Discussion</title><p id="p0025">We describe five adult MHD patients in our dialysis center who were diagnosed with mild COVID-19 disease, representing 2.5% of our dialysis population at the time. In addition one patient had respiratory symptoms and abnormal CT but negative rRT-PCR. All patients presented with lymphopenia, and the most common chest radiograph abnormality was ground glass opacity, which bears some resemblance to previous reports (<xref rid="bib9" ref-type="bibr">9</xref>). Of note the prevalence of 2.5% may underestimate the actual prevalence of infected patients. Screening of all MHD patients began after the first patient was identified on Feb. 9, and screening consisted of a chest CT; rRT-PCR testing was only performed in those with an abnormal CT. In addition all patients had temperature measured prior to dialysis and those patients who had temperature exceeding 37.3⁰ C or with respiratory symptoms had a chest CT and, if abnormal, testing for rRT-PCR. Therefore, some patients may have developed COVID-19 prior to screening and patients without an abnormal CT at the time of screening would have been missed, although no symptomatic patients were identified prior to Feb. 9.</p><p id="p0030">It has been confirmed that T-cell immunity plays a key role in recovery from SARS-CoV infection (<xref rid="bib10" ref-type="bibr">10</xref>). Because the uremia status is associated with extensive impairment of lymphocyte and granulocyte function, an abnormal immune system may alter their response to SARS-CoV infection(10). This is of particular concern given the densely populated and busy nature of dialysis facilities, creating a high risk of exposure. However, in our dialysis center, it does not seem to have spread widely. Since the outbreak of COVID-19 occurred in Wuhan, the city our dialysis center is located, we have taken a number of measures to avoid infection of patients and staff by the SARS-CoV2 virus beginning on Jan. 9. Patients were required to wear surgical masks or N95 masks throughout the hemodialysis treatment. No visitors were allowed. The staff members who conducted the dialysis treatments wore face shields, N95 face masks, eye shields, disposable gowns, caps, and gloves. In addition, chlorine disinfectants were used daily by staff to disinfect items and floors in the dialysis center. The circulating air UV air sterilizer disinfects 4 times a day for 2 hours each time.</p><p id="p0035">In a retrospective study of 1099 patients with COVID-19 acute respiratory disease, fever and cough were the dominant symptoms, whereas vomiting and diarrhea were rare (<xref rid="bib13" ref-type="bibr">13</xref>). Wang <italic>et al.</italic> found that the common symptoms of COVID-19 were fever, fatigue, and dry cough although many patients also presented with gastrointestinal symptoms, such as nausea and diarrhea (<xref rid="bib14" ref-type="bibr">14</xref>). Of note the typical triad of fever, cough, and dyspnea was not present in any of the patients we report here and diarrhea was a common presenting symptom. Some symptoms of dialysis patients with COVID-19 disease may be difficult to distinguish from other symptoms common among patients on dialysis.</p><p id="p0040">In summary, we describe five MHD patients who developed mild COVID-19 disease. In addition to fever and fatigue, diarrhea was also common in our dialysis patients. Further observations will be needed to more fully understand the full spectrum of clinical features and optimal diagnostic and treatment approached for of COVID-19 disease in hemodialysis patients.</p><p id="p0045">Article Information</p><p id="p0050">Support: There was no funding for this work.</p><p id="p0055">Financial Disclosure: The authors declare that they have no relevant financial interests.</p><p id="p0060">Patient Consent for Publication: The authors declare that they have obtained consent from each patient reported in this article for publication of the information about him/her that appears within this Case Report.</p><p id="p0065">Peer Review: Peer Review: Received February 28, 2020. Evaluated by 2 external peer reviewers, with direct editorial input from an Associate Editor and a Deputy Editor. 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