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Budhathoki P, Shrestha DB, Rawal E, Khadka S. Corticosteroids in COVID-19: Is it Rational? A Systematic Review and Meta-Analysis. SN COMPREHENSIVE CLINICAL MEDICINE 2020; 2:2600-2620. [PMID: 33103063 PMCID: PMC7569091 DOI: 10.1007/s42399-020-00515-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 01/08/2023]
Abstract
Due to a lack of definitive treatment, many drugs were repurposed for Coronavirus disease (COVID-19) treatment; among them, corticosteroid is one. However, its benefit or harm while treating COVID-19 is not fully studied. Thus, we conducted this meta-analysis to assess the rationality on the use of corticosteroids in COVID-19. Pubmed, Medline, Clinicaltrials.gov, Cochrane library, and Preprint publisher were searched. In the qualitative syntheses, 41, and quantitative studies, 40, were included using PRISMA guidelines. Assessment of heterogeneity was done using the I-squared (I 2) test and random/fixed effect analysis was done to determine the odds/risk ratio. We found severely ill COVID-19 patients almost 5 (OR 4.78, 2.76-8.26) times higher odds of getting corticosteroids during their treatment. Similarly, the odds for corticosteroids in addition to standard of care (SOC) were approximately 4 (OR 4.09, 1.89-8.84) times higher among intensive care unit (ICU) patients than non-ICU ones. A higher mortality risk with the corticosteroid-receiving group compared with the SOC alone (RR 2.01, 1.12-3.63) was observed. Neither increased discharge rate (RR 0.79, 0.63-0.99) nor recovery/improvement rate was shown among the corticosteroid-receiving group (OR 0.24, 0.13-0.43). Approximately, the overall 4-day longer hospital stay was found among the treatment groups (MD 4.19, 2.57-5.81). For the negative conversion of reverse transcription-polymerase chain reaction (RT-PCR), approximately a 3-day (MD 2.42, 1.31-3.53) delay was observed with corticosteroid treatment cases. Our study concludes that more severe and critically ill patients tend to get corticosteroids, and the mortality risk increases with the use of corticosteroids. With the use of corticosteroids, delayed recovery and a longer hospital stay were observed.
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Affiliation(s)
| | - Dhan Bahadur Shrestha
- Department of Emergency Medicine, Mangalbare Hospital, Morang, Ulrabari, 56600 Nepal
| | - Era Rawal
- Department of Emergency Medicine, Kathmandu Medical College, Kathmandu, 44600 Nepal
| | - Sitaram Khadka
- Department of Pharmacy, Shree Birendra Hospital, Nepalese Army Institute of Health Sciences, Kathmandu, 44600 Nepal
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Almalki ZS, Khan MF, Almazrou S, Alanazi AS, Iqbal MS, Alqahtani A, Alghamdi S, Alahmari AK. Clinical Characteristics and Outcomes Among COVID-19 Hospitalized Patients with Chronic Conditions: A Retrospective Single-Center Study. J Multidiscip Healthc 2020; 13:1089-1097. [PMID: 33116555 PMCID: PMC7547771 DOI: 10.2147/jmdh.s273918] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/22/2020] [Indexed: 01/08/2023] Open
Abstract
Purpose Evidence to date suggests that having chronic conditions increases the probability of severe illness from severe coronavirus disease 2019 (COVID-19). Thus, it is essential to identify the features of those patients. The purpose of this research was to identify the clinical characteristics and outcomes of COVID-19 patients with chronic conditions. Patients and Methods A retrospective cross-sectional single-center study was conducted using electronic medical records of hospitalized COVID-19 patients between March 1, 2020, and May 20, 2020. Patients’ basic information, laboratory test, clinical data, medications, and outcome data have been extracted and compared among three groups: patients without chronic conditions, patients with one chronic condition, and patients with two or more chronic conditions. Chi-square, Fisher’s exact test, Student’s t-test, and the Mann–Whitney U-test were used. Results The study population was 458 patients, with an average age of 38.8 years (standard deviation (SD) 12.8). There were 398 (86.9%) males in the study population, most of them with one chronic condition. There were 14 (14.3%) smokers, and the majority of them were among patients with two or more chronic conditions. Longer hospital stay and time in the intensive care unit (ICU), a higher probability of ICU admission, and the need for mechanical ventilation were identified among patients with two or more chronic conditions. Dyspnea, an increased level of platelet counts, and a reduction in hemoglobin levels were discovered among patients with two or more chronic conditions. Conclusion Patients with more chronic conditions were at higher risk of yielding poor clinical outcomes. Prevention and treatment of infections in these patients merit more attention.
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Affiliation(s)
- Ziyad Saeed Almalki
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Mohd Faiyaz Khan
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Saja Almazrou
- Clinical Pharmacy Department, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah Salah Alanazi
- Clinical Pharmacy Department, College of Pharmacy, Jouf University, Sakaka, Aljouf, Saudi Arabia
| | - Mohammed Shahid Iqbal
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Abdulhadi Alqahtani
- Clinical Research Department, Research Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Saleh Alghamdi
- Clinical Research Department, Research Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdullah K Alahmari
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
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53
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Shang L, Shao M, Guo Q, Shi J, Zhao Y, Xiaokereti J, Tang B. Diabetes Mellitus is Associated with Severe Infection and Mortality in Patients with COVID-19: A Systematic Review and Meta-analysis. Arch Med Res 2020; 51:700-709. [PMID: 32811670 PMCID: PMC7413048 DOI: 10.1016/j.arcmed.2020.07.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/20/2020] [Accepted: 07/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Currently, the number of patients with coronavirus disease 2019 (COVID-19) infection is increasing rapidly worldwide. In this study, we aimed to assess whether diabetes mellitus (DM) would increase the risk of severe infection and death in patients with COVID-19. METHODS We systematically searched the PubMed, Web of Science, MedRxiv and COVID-19 academic research communication platform for studies reporting clinical severity and/or overall mortality data on DM in patients with COVID-19 published up to July 10, 2020. The primary outcome was to compare the severe infection rate and mortality rate in COVID-19 patients with and without DM, and to calculate the odds ratio (OR) and 95% confidence interval (CI). RESULTS A total of 76 studies involving 31,067 patients with COVID-19 were included in our meta-analysis. COVID-19 patients with DM had higher severe infection and case-mortality rates compared with those without DM (21.4 vs. 10.6% and 28.5 vs. 13.3%, respectively, all p <0.01). COVID-19 patients with DM were at significantly elevated risk of severe infection (OR = 2.38, 95% CI: 2.05-2.78, p <0.001) and mortality (OR = 2.21, 95% CI: 1.83-2.66, p <0.001). CONCLUSION DM is associated with increased risk of severe infection and higher mortality in patients with COVID-19. Our study suggests that clinicians should pay more attention to the monitoring and treatment of COVID-19 patients with DM.
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Affiliation(s)
- Luxiang Shang
- Department of Cardiology, The First Affiliated Hospital of Shandong First Medical University, Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Mengjiao Shao
- Department of Cardiology, Xinjiang Key Laboratory of Cardiovascular Disease Research, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Qilong Guo
- Department of Pacing and Electrophysiology, Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Jia Shi
- Department of Pacing and Electrophysiology, Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yang Zhao
- Department of Pacing and Electrophysiology, Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China; Hospital of Shenzhen General Station of Exit and Entry Frontier Inspection, Shenzhen, China
| | - Jiasuoer Xiaokereti
- Department of Pacing and Electrophysiology, Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Baopeng Tang
- Department of Pacing and Electrophysiology, Xinjiang Key Laboratory of Cardiac Electrophysiology and Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.
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Ad’hiah AH, Allami RH, Mohsin RH, Abdullah MH, AL-Sa’ady AJR, Alsudani MY. Evaluating of the association between ABO blood groups and coronavirus disease 2019 (COVID-19) in Iraqi patients. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2020; 21:50. [PMID: 38624532 PMCID: PMC7483066 DOI: 10.1186/s43042-020-00097-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 09/04/2020] [Indexed: 02/10/2023] Open
Abstract
Background Susceptibility to the pandemic coronavirus disease 2019 (COVID-19) has recently been associated with ABO blood groups in patients of different ethnicities. This study sought to understand the genetic association of this polymorphic system with risk of disease in Iraqi patients. Two outcomes of COVID-19, recovery and death, were also explored. ABO blood groups were determined in 300 hospitalized COVID-19 Iraqi patients (159 under therapy, 104 recovered, and 37 deceased) and 595 healthy blood donors. The detection kit for 2019 novel coronavirus (2019-nCoV) RNA (PCR-Fluorescence Probing) was used in the diagnosis of disease. Results Mean age was significantly increased in patients compared to controls (49.8 ± 11.7 vs. 28.9 ± 6.6 years; p < 0.001). A similar observation was made in recovered (42.1 ± 10.4 vs. 28.9 ± 6.6 years; p < 0.001) and deceased (53.6 ± 9.7 vs. 28.9 ± 6.6 years; p < 0.001) cases. The mean age was also significantly increased in deceased cases compared to recovered cases (53.6 ± 9.7 vs. 42.1 ± 10.4 years; p < 0.001). There were gender-dependent differences in COVID-19 prevalence. The percentage of COVID-19 was higher in males than in females (all cases: 59.7 vs. 40.3%; recovered cases: 55.8 vs. 44.2%). Such male-gender preponderance was more pronounced in deceased cases (67.6 vs. 32.4%). Logistic regression analysis revealed that groups AB and B + AB were significantly associated with increased risk to develop COVID-19 (OR = 3.10; 95% CI 1.59-6.05; pc = 0.007 and OR = 2.16; 95% CI 1.28-3.63; pc = 0.028, respectively). No ABO-associated risk was observed in recovered cases. On the contrary, groups A (OR = 14.60; 95% CI 2.85-74.88; pc = 0.007), AB (OR = 12.92; 95% CI 2.11-79.29; pc = 0.042), A + AB (OR = 14.67; 95% CI 2.98-72.33; pc = 0.007), and A + B + AB (OR = 9.67; 95% CI 2.02-46.24; pc = 0.035) were associated with increased risk of death in deceased cases. Conclusions The findings of this study suggest that group AB may be a susceptibility biomarker for COVID-19, while group A may be associated with increased risk of death.
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Affiliation(s)
- Ali H. Ad’hiah
- Tropical-Biological Research Unit, College of Science, University of Baghdad, Baghdad, Iraq
| | | | | | | | - Ali J. R. AL-Sa’ady
- Biotechnology Department, College of Science, University of Baghdad, Baghdad, Iraq
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55
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Zeng F, Su J, Peng C, Liao M, Zhao S, Guo Y, Chen X, Deng G. Prognostic Implications of Metabolism Related Gene Signature in Cutaneous Melanoma. Front Oncol 2020; 10:1710. [PMID: 33014847 PMCID: PMC7509113 DOI: 10.3389/fonc.2020.01710] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 07/31/2020] [Indexed: 12/15/2022] Open
Abstract
Metabolic reprogramming is closely related to melanoma. However, the prognostic role of metabolism-related genes (MRGs) remains to be elucidated. We aimed to establish a nomogram by combining MRGs signature and clinicopathological factors to predict melanoma prognosis. Eighteen prognostic MRGs between melanoma and normal samples were identified using The Cancer Genome Atlas (TCGA) and GSE15605. WARS (HR = 0.881, 95% CI = 0.788–0.984, P = 0.025) and MGST1 (HR = 1.124, 95% CI = 1.007–1.255, P = 0.037) were ultimately identified as independent prognostic MRGs with LASSO regression and multivariate Cox regression. The MRGs signature was established according to these two genes and externally validated in the Gene Expression Omnibus (GEO) dataset. Kaplan-Meier survival analysis indicated that patients in the high-risk group had significantly poorer overall survival (OS) than those in the low-risk group. Furthermore, the MRGs signature was identified as an independent prognostic factor for melanoma survival. An MRGs nomogram based on the MRGs signature and clinicopathological factors was developed in TCGA cohort and validated in the GEO dataset. Calibration plots showed good consistency between the prediction of nomogram and actual observation. The receiver operating characteristic curve and decision curve analysis indicated that MRGs nomogram had better OS prediction and clinical net benefit than the stage system. To our knowledge, we are the first to develop a prognostic nomogram based on MRGs signature with better predictive power than the current staging system, which could assist individualized prognosis prediction and improve treatment.
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Affiliation(s)
- Furong Zeng
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Department of Dermatology, Hunan Engineering Research Center of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Juan Su
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Department of Dermatology, Hunan Engineering Research Center of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Cong Peng
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Department of Dermatology, Hunan Engineering Research Center of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Mengting Liao
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Department of Dermatology, Hunan Engineering Research Center of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Shuang Zhao
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Department of Dermatology, Hunan Engineering Research Center of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Ying Guo
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Department of Dermatology, Hunan Engineering Research Center of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Xiang Chen
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Department of Dermatology, Hunan Engineering Research Center of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Guangtong Deng
- Hunan Key Laboratory of Skin Cancer and Psoriasis, Department of Dermatology, Hunan Engineering Research Center of Skin Health and Disease, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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56
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Jialal I, Devaraj S. Defining the Cytokine Storm Syndrome of COVID-19: Role of the Clinical Laboratory. ANNALS OF CLINICAL AND LABORATORY SCIENCE 2020; 50:703-705. [PMID: 33067221 PMCID: PMC8547873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Ishwarlal Jialal
- Department of Pathology, Section of Clinical Chemistry, VA Medical Center, Sacramento, Mather, CA
| | - Sridevi Devaraj
- Department of Pathology and Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
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57
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Abstract
Coronavirus disease 2019 (COVID-19) is spreading rapidly worldwide. Here, we review recently published studies on COVID-19-associated acute kidney injury (AKI) in China. The pooled incidence of AKI in all reported COVID-19 patients was 6.5%, with a much higher rate in patients from the intensive care unit (32.5%). AKI is associated with the severity of COVID-19 and mortality rates, which is similar to other kidney abnormalities including proteinuria and hematuria. The renal tubule is the main site of injury in COVID-19 patients, and the etiology of renal impairment in COVID-19 patients likely is diverse and multifactorial. Apart from direct viral attack via angiotensin-converting enzyme 2 and transmembrane serine proteases 2, hypoxia and hypercoagulability also may contribute to the occurrence of renal injury. To date, there is only randomized controlled trial evidence to support the use of dexamethasone in patients requiring oxygen therapy and remdesivir for shortening the time to recovery, with no specific treatment for COVID-19-associated AKI. Studies researching kidney pathologies or reporting renal outcome and prognosis are in urgent need. Further studies are urgently warranted to identify risk factors, to predict prognosis and renal outcome, to explore the exact mechanisms of renal injury, and to suggest targeted interventions.
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Affiliation(s)
- Xizi Zheng
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China; Peking University Institute of Nephrology, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Youlu Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China; Peking University Institute of Nephrology, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
| | - Li Yang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China; Peking University Institute of Nephrology, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.
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58
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Fu EL, Janse RJ, de Jong Y, van der Endt VHW, Milders J, van der Willik EM, de Rooij ENM, Dekkers OM, Rotmans JI, van Diepen M. Acute kidney injury and kidney replacement therapy in COVID-19: a systematic review and meta-analysis. Clin Kidney J 2020; 13:550-563. [PMID: 32897278 PMCID: PMC7467593 DOI: 10.1093/ckj/sfaa160] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) can affect hospitalized patients with coronavirus disease 2019 (COVID-19), with estimates ranging between 0.5% and 40%. We performed a systematic review and meta-analysis of studies reporting incidence, mortality and risk factors for AKI in hospitalized COVID-19 patients. METHODS We systematically searched 11 electronic databases until 29 May 2020 for studies in English reporting original data on AKI and kidney replacement therapy (KRT) in hospitalized COVID-19 patients. Incidences of AKI and KRT and risk ratios for mortality associated with AKI were pooled using generalized linear mixed and random-effects models. Potential risk factors for AKI were assessed using meta-regression. Incidences were stratified by geographic location and disease severity. RESULTS A total of 3042 articles were identified, of which 142 studies were included, with 49 048 hospitalized COVID-19 patients including 5152 AKI events. The risk of bias of included studies was generally low. The pooled incidence of AKI was 28.6% [95% confidence interval (CI) 19.8-39.5] among hospitalized COVID-19 patients from the USA and Europe (20 studies) and 5.5% (95% CI 4.1-7.4) among patients from China (62 studies), whereas the pooled incidence of KRT was 7.7% (95% CI 5.1-11.4; 18 studies) and 2.2% (95% CI 1.5-3.3; 52 studies), respectively. Among patients admitted to the intensive care unit, the incidence of KRT was 20.6% (95% CI 15.7-26.7; 38 studies). Meta-regression analyses showed that age, male sex, cardiovascular disease, diabetes mellitus, hypertension and chronic kidney disease were associated with the occurrence of AKI; in itself, AKI was associated with an increased risk of mortality, with a pooled risk ratio of 4.6 (95% CI 3.3-6.5). CONCLUSIONS AKI and KRT are common events in hospitalized COVID-19 patients, with estimates varying across geographic locations. Additional studies are needed to better understand the underlying mechanisms and optimal treatment of AKI in these patients.
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Affiliation(s)
- Edouard L Fu
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Roemer J Janse
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ype de Jong
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Vera H W van der Endt
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jet Milders
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Esmee M van der Willik
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther N M de Rooij
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Joris I Rotmans
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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