Case Report
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Nephrol. Mar 25, 2021; 10(2): 21-28
Published online Mar 25, 2021. doi: 10.5527/wjn.v10.i2.21
Siblings with coronavirus disease 2019 infection and opposite outcome—the hemodialysis’s better outcome paradox: Two case reports
Dimitra Bacharaki, Evangelia Chrysanthopoulou, Sotiria Grigoropoulou, Panagiotis Giannakopoulos, Panagiotis Simitsis, Frantzeska Frantzeskaki, Aikaterini Flevari, Minas Karagiannis, Aggeliki Sardeli, Dimitra Kavatha, Anastasia Antoniadou, Demetrios Vlahakos
Dimitra Bacharaki, Panagiotis Giannakopoulos, Minas Karagiannis, Aggeliki Sardeli, Demetrios Vlahakos, Department of Nephrology, B Propaideutiki Internal Medicine Clinic, Attikon University Hospital, Chaidari 12064, Greece
Evangelia Chrysanthopoulou, Panagiotis Simitsis, Frantzeska Frantzeskaki, Aikaterini Flevari, Intensive Care Unit, Attikon University Hospital, Chaidari 12064, Greece
Sotiria Grigoropoulou, Dimitra Kavatha, Anastasia Antoniadou, D Internal Medicine Clinic, Attikon University Hospital, Chaidari 12064, Greece
Author contributions: Bacharaki D treated the HD patient as Consultant Nephrologist, reviewed the literature, and drafted the manuscript; Chrysanthopoulou E, Simitsis P, Frantzeskaki F and Flevari A contributed to acquisition, selection, interpretation, revision and recording of the data and contributed to the treatment of the critically ill patient in the ICU; Grigoropoulou S, Giannakopoulos P, Karagiannis M and Sardeli A contributed to the treatment of the patients in the clinic and during hemodialysis and contributed to the preparation of the table and figure of the manuscript; Kavatha D and Antoniadou A as Infectious Disease Specialists in the COVID-19 department and Vlahakos D as Head of the Nephrology department supervised the patients’ care and the manuscript.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: No conflict of interest from none of the authors.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Dimitra Bacharaki, MD, PhD, Doctor, Department of Nephrology, B Propaideutiki Internal Medicine Clinic, Attikon University Hospital, Rimini 1, Chaidari 12064, Greece.
Received: October 1, 2020
Peer-review started: October 1, 2020
First decision: November 12, 2020
Revised: December 5, 2020
Accepted: December 27, 2020
Article in press: December 27, 2020
Published online: March 25, 2021

Coronavirus disease 2019 (COVID-19) is a highly contagious infection caused by the severe acute respiratory syndrome coronavirus 2 virus and has a unique underlying pathogenesis. Hemodialysis (HD) patients experience high risk of contamination with COVID-19 and are considered to have higher mortality rates than the general population by most but not all clinical series. We aim to highlight the peculiarities in the immune state of HD patients, who seem to have both immune-activation and immune-depression affecting their outcome in COVID-19 infection.


We report the opposite clinical outcomes (nearly asymptomatic course vs death) of two diabetic elderly patients infected simultaneously by COVID-19, one being on chronic HD and the other with normal renal function. They were both admitted in our hospital with COVID-19 symptoms and received the same treatment by protocol. The non-HD sibling deteriorated rapidly and was intubated and transferred to the Intensive Care Unit, where he died despite all supportive care. The HD sibling, although considered more “high-risk” for adverse outcome, followed a benign course and left the hospital alive and well.


These cases may shed light on aspects of the immune responses to COVID-19 between HD and non-HD patients and stimulate further research in pathophysiology and treatment of this dreadful disease.

Keywords: Case report, Hemodialysis, Siblings, COVID-19, Host response, Immune-activation, Immune-depression

Core Tip: The pandemic of novel severe acute respiratory syndrome coronavirus 2 is life threatening only for a limited subgroup of patients who manifest severe respiratory failure (SRF). Hemodialysis (HD) patients are in a paradox state of immune-activation and immune-depression, and it is not yet clear if they are more or less vulnerable to SRF. We report the case of two siblings with coronavirus disease 2019 (COVID-19) infection at the same time and opposite outcome, death of the brother with normal renal function and rather indolent course of the brother on HD. This case challenges the relevance of HD as an independent risk factor for COVID-19 associated mortality.