Stratified risk for prolonged self isolation for adults and children who are receiving immunosuppression for disease of their native kidneys arrow_drop_down

A printable pdf of this page is available here.

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

Notes:

  1. Immunosuppressive medications include: Azathioprine, Leflunomide, methotrexate, MMF, ciclosporin, tacrolimus and sirolimus
  2. 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