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This risk stratification was created following the CMO initiative to identify the 1.5 million most vulnerable adults in the UK. It was led by the RCP and coordinated with all other specialist societies who also care for patients with autoimmune disease. The guidance for renal was drawn up by a small working group of 4 adult and 4 paediatric nephrologists with expertise in this field. It acknowledges that there is no evidence base in this area and these represent pragmatic guidance to try to offer consistency about who the most vulnerable renal patients are in this group
Cases should be individualised and take into account patient age and overall co-morbidity, current and past immunosuppression and previous clinical manifestations of susceptibility to infection.
Group 1 (highest risk with one of the following should all be advised to self-isolate for at least 12 weeks)
- Those currently receiving intravenous induction immunosuppressive medication for autoimmune disease eg receiving CYCLOPS/Euro lupus regimens or have received cytotoxics/rituximab/other biologic within the last 6 months
- Those who are currently receiving cyclophosphamide orally
- Those who have received a corticosteroid dose of > or = to prednisolone 20mg/day or 35mg/m2/day for more than 4 weeks within the last 6 months.
- Those who have received > 5 mg/day, or >0.25mg/kg/day, prednisolone (or equivalent ) for > 4 weeks plus at least one other immunosuppressive medication within the last 6 months
- Those who have current nephrotic range proteinuria or who have a history of frequently relapsing nephrotic syndrome.
- Those whose overall cumulative burden of immunosuppression (IS) is high over a number of years even if their current IS is in stable maintenance phase e.g. patients who have received repeated courses of cyclophosphamide/biologics /or repeated high dose corticosteroids.
- Those who are currently on stable (possibly modest) maintenance IS but whose additional factors make them vulnerable to a severe course in COVID-19 – e.g.:
- those over 70 years of age
- those whose AI disease has affected their CVS/Respiratory systems such as lung fibrosis
- Those with any non-autoimmune underlying co-morbidity of `respiratory/cardiovascular system, hypertension or diabetes mellitus
- hose with CKD stage 3 or above
- Those who have previously manifested adverse infectious complications of immunosuppression – e.g. those with recurrent CMV or chest infections
Group 2 (intermediate risk :if one of the following risk factors exist: these patients are not currently advised to self-isolate but may be moved in to Group 1 at a later stage, as understanding develops)
- Those with well controlled disease activity and no co-morbidity who are on a single oral immunosuppressive drugs.
- Those known to have low IgG levels even if not currently on immunosuppression.
- Those who despite completing biologic induction treatment more than 6 months previously remain B cell depleted.
- Patients who despite achieving disease remission remain on maintenance low dose prednisolone
Group 3 (may not require self isolation in the first instance but should follow all hygiene measures and social distancing as per standard government guidelines)
- Patients less than 60 years who are generally well and whose disease has been stable for > 6 months who are on Hydroxychloroquine alone
- Immunosuppressive medications include: Azathioprine, Leflunomide, methotrexate, MMF, ciclosporin, tacrolimus and sirolimus
- Biologic/monocolonal includes – Rituximab; all antiTNF drugs – etanercept, adalimumab, infliximab, golimumab, certolizumab and biosimilar variants of all of these; Tociluzimab; Abatacept; Belimumab; Anakinra; Seukinumab; Ixekizumab; Ustekinumab