The Association of COVID-19 With Acute Kidney Injury Independent of Severity of Illness: A Multicenter Cohort Study

SARS-CoV-2 PCR cycle threshold value at admission might not be a good predictor of in-hospital COVID-19-associated AKI

Background

Acute kidney injury (AKI) is a prevalent complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and a predictor of disease severity and mortality; furthermore, a prompt diagnosis and treatment of this complication may enhance COVID-19 prognosis. Therefore, we aim to investigate potential risk factors for SARS-CoV-2-associated AKI, including SARS-CoV-2 PCR cycle threshold value (CT value), which correlation with AKI is conflicting.

Methods

This case-control study included 110 hospitalized patients with SARS-CoV-2-associated AKI as cases and 110 random SARS-CoV-2 hospitalized patients as controls. Reverse transcription real-time PCR of admission nasopharyngeal swabs evaluated E gene cycle thresholds. Additional clinical and paraclinical information extracted from medical records. The patient's status at discharge, and 14 and 30 days after discharge. Therefore, after adjusting for age and gender, the correlation between variables was assessed.

Results

SARS-CoV-2 AKI is significantly associated with age above 60, hypertension, diabetes mellitus, ischemic heart disease, and underlying kidney diseases. Abnormal admission hemoglobin or alkaline phosphatase, proteinuria or hematuria in urine sediment, and abnormal creatinine during hospitalization were the paraclinical features correlated to SARS-CoV-2 AKI. AKI group demonstrated greater in-hospital, 14- and 30-day mortality. Nevertheless, this study did not evidence a correlation between the admission CT value and mortality or AKI.

Conclusion

Admission CT values provide limited information regarding the dynamic viral load and varying hospitalization time points; thus, they may not be reliable for predicting the prognosis and complications of COVID-19 in all populations. Further studies with serial CT measurements or symptom onset time adjustment are recommended.

New insights into kidney disease after COVID-19 infection and vaccination: histopathological and clinical findings

In addition to its pulmonary effects, coronavirus disease 2019 (COVID-19) has also been found to cause acute kidney injury (AKI), which has been linked to high mortality rates. In this review, we collected data from 20 clinical studies on post-COVID-19-related AKI and 97 cases of AKI associated with COVID-19 vaccination. Acute tubular injury was by far the most common finding in the kidneys of patients with COVID-19-related AKI. Among patients hospitalized for COVID-19, 34.0% developed AKI, of which 59.0%, 19.1% and 21.9% were Stages 1, 2 and 3, respectively. Though kidney disease and other adverse effects after COVID-19 vaccination overall appear rare, case reports have accumulated suggesting that COVID-19 vaccination may be associated with a risk of subsequent kidney disease. Among the patients with post-vaccination AKI, the most common pathologic findings include crescentic glomerulonephritis (29.9%), acute tubular injury (23.7%), IgA nephropathy (18.6%), antineutrophil cytoplasmic autoantibody-associated vasculitis (17.5%), minimal change disease (17.5%) and thrombotic microangiopathy (10.3%). It is important to note that crescentic glomerulonephritis appears to be more prevalent in patients who have newly diagnosed renal involvement. The proportions of patients with AKI Stages 1, 2 and 3 after COVID-19 vaccination in case reports were 30.9%, 22.7% and 46.4%, respectively. In general, clinical cases of new-onset and recurrent nephropathy with AKI after COVID-19 vaccination have a positive prognosis. In this article, we also explore the underlying pathophysiological mechanisms of AKI associated with COVID-19 infection and its vaccination by describing key renal morphological and clinical features and prognostic findings.

The dynamics and outcomes of AKI progression during the COVID-19 pandemic

PURPOSE

Acute kidney injury (AKI) associated with COVID-19 is associated with poor prognosis. This study assessed the hitherto uninvestigated impact of COVID-19 on the progression and clinical outcomes of patients with AKI.

METHODS

Data from 576 patients with AKI admitted between 13/3/20 and 13/5/20 were studied. Increasingly complex analyses, from logistic regressions to competing-risk and multi-state models, have revealed insights into AKI progression dynamics associated with PCR-confirmed COVID-19 acquisition and death. Meta-analyses of case fatality ratios among patients with AKI were also conducted.

RESULTS

The overall case-fatality ratio was 0.33 [95% CI (0.20-0.36)]; higher in COVID-19 positive (COVID+) patients 0.52 [95% CI (0.46-0.58)] than in their negative (COVID-) counterparts 0.16 [95% CI (0.12-0.20)]. In AKI Stage-3 patients, that was 0.71 [95% CI (0.64-0.79)] among COVID+ patients with 45% dead within 14 days and 0.35 [95% CI (0.25-0.44)] in the COVID- group and 28% died within 14 days. Among patients diagnosed with AKI Stage-1 within 24 h, the probability of progression to AKI Stage-3 on day 7 post admission was 0.22 [95% CI (0.17-0.27)] among COVID+ patients, and 0.06 [95% CI (0.03, 0.09)] among those who tested negative. The probability of discharge by day 7 was 0.71 [95% CI (0.66, 0.75)] in COVID- patients, and 0.27 [95% CI (0.21, 0.32)] in COVID+ patients. By day 14, in AKI Stage-3 COVID+ patients, that was 0.35 [95% CI (0.25, 0.44)] with little change by day 10, that is, 0.38 [95% CI (0.29, 0.47)].

CONCLUSION

These results are consistent with either a rapid progression in severity, prolonged hospital care, or high case fatality ratio among AKI Stage-3 patients, significantly exacerbated by COVID-19 infection.

An unprecedented global challenge, emerging trends and innovations in the fight against COVID-19: A comprehensive review

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a highly contagious and dangerous virus that caused the global COVID-19 pandemic in early 2020. It primarily affects the respiratory system, leading to severe illness and high rates of mortality worldwide. The virus enters the body by binding to a receptor called ACE2, which is present in specific cells of the lungs known as type 2 alveolar epithelial cells. Numerous studies have investigated the consequences of SARS-CoV-2 infection, revealing various impacts on the body. This review provides an overview of SARS-CoV-2, including its structure and how it infects cells. It also examines the different variants of concern, such as Alpha, Beta, Gamma, Delta, and the more recent Omicron variant, discussing their characteristics and the level of damage they cause. The usage of drugs to treat COVID-19 is another aspect that has been covered and compares the effectiveness and use of antiviral drugs in the treatment and its potential benefits in COVID-19 treatment. Furthermore, this review explores the consequences and abnormalities associated with SARS-CoV-2 infection, including its impact on various organs and systems in the body. And also discussing the different COVID-19 vaccines available and their effectiveness in preventing infection and reducing the severity of illness. The current review ensures the recent update of the COVID research with expert's knowledge, collection of numerous data from reliable sources and methodologies as well as update of findings based on reviews. This review also provided clear contextual explanations to aid the interpretation and application of the results. The main motto and limitation of this manuscript are to address the computational methods of drug discovery against the rapidly evolving SARS-CoV-2 virus, which has been discussed. Additionally, current computational approaches which are cost effective and can able to predict the therapeutic agents for the treatment against the virus have also been discussed.

Specific and Non-specific Aspects and Future Challenges of ICU Care Among COVID-19 Patients with Obesity: A Narrative Review

PURPOSE OF REVIEW

Since the end of 2019, the coronavirus disease 2019 (COVID-19) pandemic has infected nearly 800 million people and caused almost seven million deaths. Obesity was quickly identified as a risk factor for severe COVID-19, ICU admission, acute respiratory distress syndrome, organ support including mechanical ventilation and prolonged length of stay. The relationship among obesity; COVID-19; and respiratory, thrombotic, and renal complications upon admission to the ICU is unclear.

RECENT FINDINGS

The predominant effect of a hyperinflammatory status or a cytokine storm has been suggested in patients with obesity, but more recent studies have challenged this hypothesis. Numerous studies have also shown increased mortality among critically ill patients with obesity and COVID-19, casting doubt on the obesity paradox, with survival advantages with overweight and mild obesity being reported in other ICU syndromes. Finally, it is now clear that the increase in the global prevalence of overweight and obesity is a major public health issue that must be accompanied by a transformation of our ICUs, both in terms of equipment and human resources. Research must also focus more on these patients to improve their care. In this review, we focused on the central role of obesity in critically ill patients during this pandemic, highlighting its specificities during their stay in the ICU, identifying the lessons we have learned, and identifying areas for future research as well as the future challenges for ICU activity.

Nucleocapsid protein accumulates in renal tubular epithelium of a post-COVID-19 patient

IMPORTANCE

Even though the coronavirus disease 2019 (COVID-19) pandemic is slowly developing into a conventional infectious disease, the long-term effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus infection are still not well understood. One of the problems is that many COVID-19 cases develop acute kidney injuries. Still, it is heavily debated whether SARS-CoV-2 virus enters and actively replicates in kidney tissue and if SARS-CoV-2 virus particles can be detected in kidney during or post-infection. Here, we demonstrated that nucleocapsid N protein was detected in kidney tubular epithelium of patients that already recovered form COVID-19. The presence of the abundantly produced N protein without signs of viral replication could have implications for the recurrence of kidney disease and have a continuing effect on the immune system.

Predictive Admission Risk Factors, Clinical Features and Kidney Outcomes in Covid-19 Hospitalised Patients with Acute Kidney Injury

Introduction: In COVID-19 patients, acute kidney injury (AKI) is recognized as a cause of high mortality. The aim of our study was to assess the rate and the predictors of AKI as well as survival among COVID-19 patients. Methods: We analyzed clinical and laboratory admission data, predictors of AKI and outcomes including the need for renal replacement therapy (RRT) and mortality at 30 days. Results: Out of 115 patients, 62 (53.9%) presented with AKI: 21 (33.9%) at stage 1, 7(11.3%) at stage 2, and 34 (54.8%) at stage 3. RRT was required in 22.6% of patients and was resolved in 76%. Pre-existing CKD was associated with a 13-fold risk of AKI (p= 0.0001). Low albumin (p = 0.017), thrombocytopenia (p = 0.022) and increase of creatine kinase over 350UI (p = 0.024) were independently associated with a higher risk for AKI. Mortality rates were significantly higher among patients who developed AKI compared to those without (59.6% vs 30.2%, p= 0.003). Low oxygen blood saturation at admission and albumin were found as powerful independent predictors of mortality (OR 0.937; 95%CI: 0.917 - 0.958, p = 0.000; OR 0.987; 95%CI: 0.885-0.991, p= 0.024, respectively). Longer survival was observed in patients without AKI compared to patients with AKI (22.01± 1.703 vs 16.69 ± 1.54, log rank p= 0.009). Conclusion: Renal impairment is significant in hospitalized COVID-19 patients. The severity of the disease itself is emphasized as main contributing mechanism in the occurrence of AKI, and lower blood saturation at admission is the strongest mortality predictor, surpassing the significance of the AKI itself.

Assessing the cardiovascular events and clinical outcomes of COVID-19 on patients with primary aldosteronism

BACKGROUND

Primary Aldosteronism (PA) is a common subtype of hypertension that increases the risk of adverse cardiovascular and kidney events. The impact of COVID-19 on patients with PA is not well understood. This study aimed to investigate the impact of COVID-19 on patients with PA and compare their outcomes with hypertensive patients with essential hypertension.

METHODS

A cohort study was conducted using data from the Trinetx platform, including 9,817,307 participants enrolled between January 1, 2020, and July 31, 2022. The study group consisted of participants who tested positive for PCR SARS-CoV-2. The primary outcome was critical care and all-cause mortality, while the secondary outcomes were major adverse cardiac events (MACE) or major adverse kidney events (MAKE). The study included 4814 patients with PA and 4814 hypertensive controls.

RESULTS

Patients with PA had a higher risk of critical outcomes than the hypertensive control group (adjusted hazard ratio [aHR] 1.14, p = 0.001). Moreover, they had higher risks of MACE (aHR 1.32, p < 0.001) and MAKE (aHR 1.36, p < 0.001) for up to 180 days after COVID-19. The analysis of the aHR as a horizon plot after discharge showed that patients with pre-existing PA and COVID-19 had the highest risk of critical outcomes at 7 months (aHR = 1.21), MACE (aHR = 1.35) at 9 months, and MAKE (aHR = 1.47) at 10 months compared to those with EH.

CONCLUSIONS

This study provides a comprehensive analysis of the cardiovascular impact of the COVID-19 pandemic on individuals with PA. The findings underscore the increased risk of mortality, critical care, MACE, and MAKE among patients with PA and COVID-19. The study highlights the need for continued optimization of strategies for follow-up care for patients with PA after SARS-CoV-2 infections.

The heterophilicic epitopes in conserved HA regions of human and avian influenza viruses can produce antibodies that bound to kidney tissue

Influenza virus infection can cause kidney damage. However, the link between influenza infection and disease is still unclear. The purpose of this study was to analyze the relationship between heterophilic epitopes on H5N1 hemagglutinin (HA) and disease. The monoclonal antibody (mAb) against H5N1 was prepared, mAbs binding to human kidney tissue were screened, and the reactivities of mAbs with five different subtypes of influenza virus were detected. Design and synthesize the peptides according to the common amino acid sequence of these antigens, and analyze the distribution of the epitope on the crystal structure of HA. Immunological methods were used to detect whether the heterophilic epitopes could induce the production of antibodies that cross-react with kidney tissue. The results showed that H5-30 mA b binding to human kidney tissue recognized the heterophilic epitope 191-LVLWGIHHP-199 on the head of HA. The key amino acid were V192, L193, W194 and I196, which were highly conserved in human and avian influenza virus HA. The heterophilic epitope could induce mice to produce different mAbs binding to kidney tissue. Such heterophilic antibodies were also detected in the serum of the patients. It can provide materials for the mechanism of renal diseases caused by influenza virus infection.

Long-term effect of COVID-19 infection on kidney function among COVID-19 patients followed in post-COVID-19 recovery clinics in British Columbia, Canada

BACKGROUND

We investigated the effect of Post-Acute COVID Syndrome or "long-COVID" on kidney function among patients followed in post-COVID recovery clinics (PCRC) in British Columbia, Canada.

METHODS

Long-COVID patients referred to PCRC between July 2020 to April 2022, aged ≥18 years who had an estimated glomerular filtration rate (eGFR) value recorded at 3 months from the coronavirus disease 2019 (COVID-19) diagnosis (index) date were included. Those requiring renal replacement therapy prior to index date were excluded. Primary outcome was change in eGFR and urine albumin-creatinine ratio (UACR) after COVID-19 infection. The proportion of patients in each of the six eGFR categories (<30, 30-44, 45-59, 60-89, 90-120 and >120 mL/min/1.73 m2) and three UACR categories (<3, 3-30 and >30 mg/mmol) in all of the study time points were calculated. Linear mixed model was used to investigate change in eGFR over time.

RESULTS

The study sample included 2212 long-COVID patients. Median age was 56 years, 51% were male. Half (∼47%-50%) of the study sample had normal eGFR (≥90 mL/min/1.73 m2) from COVID-19 diagnosis to 12 months post-COVID and <5% of patients had an eGFR <30 mL/min/1.73 m2. There was an estimated 2.96 mL/min/1.73 m2 decrease in eGFR within 1 year after COVID-19 infection that was equivalent to 3.39% reduction from the baseline. Decline in eGFR was highest in patients hospitalized for COVID-19 (6.72%) followed by diabetic patients (6.15%). More than 40% of patients were at risk of CKD.

CONCLUSIONS

People with long-COVID experienced a substantial decline in eGFR within 1 year from the infection date. The prevalence of proteinuria appeared to be high. Close monitoring of kidney function is prudent among patients with persistent COVID-19 symptoms.

The interface between SARS-CoV-2 and non-communicable diseases (NCDs) in a high HIV/TB burden district level hospital setting, Cape Town, South Africa

BACKGROUND

COVID-19 experiences on noncommunicable diseases (NCDs) from district-level hospital settings during waves I and II are scarcely documented. The aim of this study is to investigate the NCDs associated with COVID-19 severity and mortality in a district-level hospital with a high HIV/TB burden.

METHODS

This was a retrospective observational study that compared COVID-19 waves I and II at Khayelitsha District Hospital in Cape Town, South Africa. COVID-19 adult patients with a confirmed SARS-CoV-2 polymerase chain reaction (PCR) or positive antigen test were included. In order to compare the inter wave period, clinical and laboratory parameters on hospital admission of noncommunicable diseases, the Student t-test or Mann-Whitney U for continuous data and the X2 test or Fishers' Exact test for categorical data were used. The role of the NCD subpopulation on COVID-19 mortality was determined using latent class analysis (LCA).

FINDINGS

Among 560 patients admitted with COVID-19, patients admitted during wave II were significantly older than those admitted during wave I. The most prevalent comorbidity patterns were hypertension (87%), diabetes mellitus (65%), HIV/AIDS (30%), obesity (19%), Chronic Kidney Disease (CKD) (13%), Congestive Cardiac Failure (CCF) (8.8%), Chronic Obstructive Pulmonary Disease (COPD) (3%), cerebrovascular accidents (CVA)/stroke (3%), with similar prevalence in both waves except HIV status [(23% vs 34% waves II and I, respectively), p = 0.022], obesity [(52% vs 2.5%, waves II and I, respectively), p <0.001], previous stroke [(1% vs 4.1%, waves II and I, respectively), p = 0.046]. In terms of clinical and laboratory findings, our study found that wave I patients had higher haemoglobin and HIV viral loads. Wave II, on the other hand, had statistically significant higher chest radiography abnormalities, fraction of inspired oxygen (FiO2), and uraemia. The adjusted odds ratio for death vs discharge between waves I and II was similar (0.94, 95%CI: 0.84-1.05). Wave I had a longer average survival time (8.0 vs 6.1 days) and a shorter average length of stay among patients discharged alive (9.2 vs 10.7 days). LCA revealed that the cardiovascular phenotype had the highest mortality, followed by diabetes and CKD phenotypes. Only Diabetes and hypertension phenotypes had the lowest mortality.

CONCLUSION

Even though clinical and laboratory characteristics differed significantly between the two waves, mortality remained constant. According to LCA, the cardiovascular, diabetes, and CKD phenotypes had the highest death probability.

[Severe post-COVID-19 dialysis dependence and inpatient acute kidney injury]

Background

COVID-19 challenged our health system, within the broad clinical spectrum acute kidney injury was presented as a catastrophic event, acute kidney injury and the risk of dependency after dialysis constitute a clinical problem with high repercussions in the funcionality.

Objective

To identify risk factors for dialysis dependence after acute kidney injury from COVID-19.

Material and methods

A retrospective observational cohort study was carried out at the Hospital de Especialidades del Centro Médico Nacional Siglo XXI, of the Mexican Institute of Social Security, from March 2020 to March 2021. 317 patients were included, we performed descriptive statistics, we compared differences between the stages of acute kidney injury, finding a difference in obesity with a frequency of 2.2% in stage 1, 20.82% stage 2 and 14.51% stage 3, with p value = 0.018.

Results

We found dialysis dependence one year after hospital-acquired acute kidney injury induced by COVID-19 in 58 patients (18.9%), we analyzed by KDIGO stage, in those patients who had AKI KDIGO 1 (2.83%) it depended on dialysis at one year, in the KDIGO stage 2 (3.78%), in the KDIGO stage 3 (11.67%).

Conclusions

Our study allowed us to identify that the risk factors associated with dialysis dependence are: male gender, type 2 diabetes mellitus, obesity, cardiovascular disease.

The diagnostic accuracy of perfusion-only scan in the diagnosis of pulmonary embolism in the era of COVID-19: A single-center study of 434 patients

INTRODUCTION

There is a paucity of data in the literature regarding the diagnostic accuracy of perfusion (Q)-only studies in the absence of ventilation images. This study aims to assess the diagnostic accuracy of Q-only imaging in the pandemic era.

METHODS

Patients who underwent Q-only imaging for pulmonary embolism between March 2020 and February 2021 were analyzed. Patients who underwent lung quantification analysis were excluded. Q-only test results were reported as per modified PIOPED II criteria and single positron emission tomography/computed tomography (SPECT/CT) imaging was performed as needed. Patients were considered concordant or discordant by correlating the Q-only results with CT angiogram (CTA) or clinical diagnosis made through chart review. The diagnostic accuracy was calculated after excluding intermediate probability and nondiagnostic studies.

RESULTS

Four hundred and thirty-four patients were identified. One hundred and twenty-eight patients (29.4%) underwent ultrasound Doppler, 37 patients (8.5%) underwent CTA, and 16 patients (3.6%) underwent both. After excluding patients with intermediate probability or nondiagnostic studies and who did not have follow-up (a total of 87 patients [20%]), 347 patients were enrolled in the final analysis. The combined planar and SPECT/CT sensitivity and specificity were 85.4% (72.2%-93.9% confidence interval [CI]) and 98.7% (96.9%-98.6% CI), respectively. The positive predictive value (PPV) of the Q-only imaging was 89.1% (77.3%-95.1% CI) and the negative predictive value (NPV) was 98.2% (96.4%-99% CI). The sensitivity with SPECT/CT reached 100% (CI: 71.5%-100%) with a specificity of 92.3% (CI: 64%-99.8%). The PPV was 85.7% (CI: 62.1%-95.6%) and the NPV was 100%.

CONCLUSION

Q-only imaging provides clinically acceptable results. The sensitivity of the Q-only scan is increased when coupled with SPECT/CT.

Evaluation of Plasma Biomarkers to Predict Major Adverse Kidney Events in Hospitalized Patients With COVID-19

RATIONALE & OBJECTIVE

Patients hospitalized with COVID-19 are at increased risk for major adverse kidney events (MAKE). We sought to identify plasma biomarkers predictive of MAKE in patients hospitalized with COVID-19.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

A total of 576 patients hospitalized with COVID-19 between March 2020 and January 2021 across 3 academic medical centers.

EXPOSURE

Twenty-six plasma biomarkers of injury, inflammation, and repair from first available blood samples collected during hospitalization.

OUTCOME

MAKE, defined as KDIGO stage 3 acute kidney injury (AKI), dialysis-requiring AKI, or mortality up to 60 days.

ANALYTICAL APPROACH

Cox proportional hazards regression to associate biomarker level with MAKE. We additionally applied the least absolute shrinkage and selection operator (LASSO) and random forest regression for prediction modeling and estimated model discrimination with time-varying C index.

RESULTS

The median length of stay for COVID-19 hospitalization was 9 (IQR, 5-16) days. In total, 95 patients (16%) experienced MAKE. Each 1 SD increase in soluble tumor necrosis factor receptor 1 (sTNFR1) and sTNFR2 was significantly associated with an increased risk of MAKE (adjusted HR [AHR], 2.30 [95% CI, 1.86-2.85], and AHR, 2.26 [95% CI, 1.73-2.95], respectively). The C index of sTNFR1 alone was 0.80 (95% CI, 0.78-0.84), and the C index of sTNFR2 was 0.81 (95% CI, 0.77-0.84). LASSO and random forest regression modeling using all biomarkers yielded C indexes of 0.86 (95% CI, 0.83-0.89) and 0.84 (95% CI, 0.78-0.91), respectively.

LIMITATIONS

No control group of hospitalized patients without COVID-19.

CONCLUSIONS

We found that sTNFR1 and sTNFR2 are independently associated with MAKE in patients hospitalized with COVID-19 and can both also serve as predictors for adverse kidney outcomes.

PLAIN-LANGUAGE SUMMARY

Patients hospitalized with COVID-19 are at increased risk for long-term adverse health outcomes, but not all patients suffer long-term kidney dysfunction. Identification of patients with COVID-19 who are at high risk for adverse kidney events may have important implications in terms of nephrology follow-up and patient counseling. In this study, we found that the plasma biomarkers soluble tumor necrosis factor receptor 1 (sTNFR1) and sTNFR2 measured in hospitalized patients with COVID-19 were associated with a greater risk of adverse kidney outcomes. Along with clinical variables previously shown to predict adverse kidney events in patients with COVID-19, both sTNFR1 and sTNFR2 are also strong predictors of adverse kidney outcomes.

Kidney outcome after mild to moderate COVID-19

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has a remarkable kidney tropism. While kidney effects are common in severe coronavirus disease 2019 (COVID-19), data on non-severe courses are limited. Here we provide a multilevel analysis of kidney outcomes after non-severe COVID-19 to test for eventual kidney sequela.

METHODS

This cross-sectional study investigates individuals after COVID-19 and matched controls recruited from the Hamburg City Health Study (HCHS) and its COVID-19 program. The HCHS is a prospective population-based cohort study within the city of Hamburg, Germany. During the COVID-19 pandemic the study additionally recruited subjects after polymerase chain reaction-confirmed SARS-CoV-2 infections. Matching was performed by age, sex and education. Main outcomes were estimated glomerular filtration rate (eGFR), albuminuria, Dickkopf3, haematuria and pyuria.

RESULTS

A total of 443 subjects in a median of 9 months after non-severe COVID-19 were compared with 1328 non-COVID-19 subjects. The mean eGFR was mildly lower in post-COVID-19 than non-COVID-19 subjects, even after adjusting for known risk factors {β = -1.84 [95% confidence interval (CI) -3.16 to -0.52]}. However, chronic kidney disease [odds ratio (OR) 0.90 (95% CI 0.48-1.66)] or severely increased albuminuria [OR 0.76 (95% CI 0.49-1.09)] equally occurred in post-COVID-19 and non-COVID-19 subjects. Haematuria, pyuria and proteinuria were also similar between the two cohorts, suggesting no ongoing kidney injury after non-severe COVID-19. Further, Dickkopf3 was not increased in the post-COVID-19 cohort, indicating no systematic risk for ongoing GFR decline [β = -72.19 (95% CI -130.0 to -14.4)].

CONCLUSION

While mean eGFR was slightly lower in subjects after non-severe COVID-19, there was no evidence for ongoing or progressive kidney sequela.

Our Experience with SARS-CoV-2 Infection and Acute Kidney Injury: Results from a Single-Center Retrospective Observational Study

BACKGROUND

Renal failure in COVID-19 patients is reportedly related to multiple factors such as a direct SARS-CoV-2 cytopathic effect, cytokine storm, the association of pulmonary and/or cardiovascular lesions, the presence of thrombotic microangiopathy, endothelial damage, or the use of potentially nephrotoxic medications.

METHODS

We retrospectively analyzed 466 cases of SARS-CoV-2 infection, comparing 233 patients with acute kidney injury (AKI) with 233 patients without AKI in terms of their demographic characteristics, comorbidities, clinical background, laboratory investigations, time of AKI onset, therapy, and outcomes after using univariate analysis and a CART decision-tree approach. The latter was constructed in a reverse manner, starting from the top with the root and branching out until the splitting ceased, interconnecting all the predictors to predict the overall outcome (AKI vs. non-AKI).

RESULTS

There was a statistically significant difference between the clinical form distribution in the two groups, with fewer mild (2 vs. 5) and moderate (54 vs. 133) cases in the AKI group than in the non-AKI group and more severe and critical patients in the AKI cohort (116 vs. 92 and 60 vs. 3). There were four deaths (1.71%) in the non-AKI group and 120 deaths in the AKI group (51.5%) (p-value < 0.001). We noted statistically significant differences between the two study groups in relation to different tissue lesions (LDH), particularly at the pulmonary (CT severity score), hepatic (AST, ALT), and muscular levels (Creatine kinase). In addition, an exacerbated procoagulant and inflammatory profile in the study group was observed. The CART algorithm approach yielded decision paths that helped sort the risk of AKI progression into three categories: the low-risk category (0-40%), the medium-risk category (40-80%), and the high-risk category (>80%). It recognized specific inflammatory and renal biomarker profiles with particular cut-off points for procalcitonin, ferritin, LDH, creatinine, initial urea, and creatinine levels as important predictive factors of AKI outcomes (93.3% overall performance).

CONCLUSIONS

Our study revealed the association between particular risk factors and AKI progression in COVID-19 patients. Diabetes, dyspnea on admission, the need for supplemental oxygen, and admission to the intensive care unit all had a crucial role in producing unfavorable outcomes, with a death rate of more than 50%. Necessary imaging studies (CT scan severity score) and changes in specific biomarker levels (ferritin and C-reactive protein levels) were also noted. These factors should be further investigated in conjunction with the pathophysiological mechanisms of AKI progression in COVID-19 patients.

Validation of a predictive model for hospital-acquired acute kidney injury with emergence of SARS-CoV-2 variants

We previously developed and validated a model to predict acute kidney injury (AKI) in hospitalized coronavirus disease 2019 (COVID-19) patients and found that the variables with the highest importance included a history of chronic kidney disease and markers of inflammation. Here, we assessed model performance during periods when COVID-19 cases were attributable almost exclusively to individual variants. Electronic Health Record data were obtained from patients admitted to 19 hospitals. The outcome was hospital-acquired AKI. The model, previously built in an Inception Cohort, was evaluated in Delta and Omicron cohorts using model discrimination and calibration methods. A total of 9104 patients were included, with 5676 in the Inception Cohort, 2461 in the Delta cohort, and 967 in the Omicron cohort. The Delta Cohort was younger with fewer comorbidities, while Omicron patients had lower rates of intensive care compared with the other cohorts. AKI occurred in 13.7% of the Inception Cohort, compared with 13.8% of Delta and 14.4% of Omicron (Omnibus p = 0.84). Compared with the Inception Cohort (area under the curve (AUC): 0.78, 95% confidence interval (CI): 0.76-0.80), the model showed stable discrimination in the Delta (AUC: 0.78, 95% CI: 0.75-0.80, p = 0.89) and Omicron (AUC: 0.74, 95% CI: 0.70-0.79, p = 0.37) cohorts. Estimated calibration index values were 0.02 (95% CI: 0.01-0.07) for Inception, 0.08 (95% CI: 0.05-0.17) for Delta, and 0.12 (95% CI: 0.04-0.47) for Omicron cohorts, p = 0.10 for both Delta and Omicron vs Inception. Our model for predicting hospital-acquired AKI remained accurate in different COVID-19 variants, suggesting that risk factors for AKI have not substantially evolved across variants.

Risk factors, clinical characteristics and prognostic value of acute kidney injury in COVID-19 compared with influenza virus and respiratory syncytial virus

BACKGROUND

Acute Kidney Injury (AKI) complicates a substantial part of patients with COVID-19. Direct viral penetration of renal cells through the Angiotensin Converting Enzyme 2 receptor, and indirect damage by the aberrant inflammatory response characteristic of COVID-19 are likely mechanisms. Nevertheless, other common respiratory viruses such as Influenza and Respiratory Syncytial Virus (RSV) are also associated with AKI.

METHODS

We retrospectively compared the incidence, risk factors and outcomes of AKI among patients who were admitted to a tertiary hospital because of infection with COVID-19, influenza (A + B) or RSV.

RESULTS

We collected data of 2593 patients hospitalized with COVID-19, 2041 patients with influenza and 429 with RSV. Patients affected by RSV were older, had more comorbidities and presented with higher rates of AKI at admission and within 7 days (11.7% vs. 13.3% vs. 18% for COVID-19, influenza and RSV, respectively p = 0.001). Nevertheless, patients hospitalized with COVID-19 had higher mortality (18% with COVID-19 vs. 8.6% and 13.5% for influenza and RSV, respectively P < 0.001) and higher need of mechanical ventilation (12.4% vs. 6.5% vs.8.2% for COVID-19, influenza and RSV, respectively, P = 0.002). High ferritin levels and low oxygen saturation were independent risk factors for severe AKI only in the COVID-19 group. AKI in the first 48 h of admission and in the first 7 days of hospitalization were strong independent risk factors for adverse outcome in all groups.

CONCLUSION

Despite many reports of direct kidney injury by SARS-COV-2, AKI was less in patients with COVID-19 compared to influenza and RSV patients. AKI was a prognostic marker for adverse outcome across all viruses.

COVID-19 and Clostridioides difficile Coinfection Outcomes among Hospitalized Patients in the United States: An Insight from National Inpatient Database

The incidence of Clostridioides difficile infection (CDI) has been increasing compared to pre-COVID-19 pandemic levels. The COVID-19 infection and CDI relationship can be affected by gut dysbiosis and poor antibiotic stewardship. As the COVID-19 pandemic transitions into an endemic stage, it has become increasingly important to further characterize how concurrent infection with both conditions can impact patient outcomes. We performed a retrospective cohort study utilizing the 2020 NIS Healthcare Cost Utilization Project (HCUP) database with a total of 1,659,040 patients, with 10,710 (0.6%) of those patients with concurrent CDI. We found that patients with concurrent COVID-19 and CDI had worse outcomes compared to patients without CDI including higher in-hospital mortality (23% vs. 13.4%, aOR: 1.3, 95% CI: 1.12-1.5, p = 0.01), rates of in-hospital complications such as ileus (2.7% vs. 0.8%, p < 0.001), septic shock (21.0% vs. 7.2%, aOR: 2.3, 95% CI: 2.1-2.6, p < 0.001), length of stay (15.1 days vs. 8 days, p < 0.001) and overall cost of hospitalization (USD 196,012 vs. USD 91,162, p < 0.001). Patients with concurrent COVID-19 and CDI had increased morbidity and mortality, and added significant preventable burden on the healthcare system. Optimizing hand hygiene and antibiotic stewardship during in-hospital admissions can help to reduce worse outcomes in this population, and more efforts should be directly made to reduce CDI in hospitalized patients with COVID-19 infection.

Palliative Care in a Pandemic: A Multicenter Cohort of Critically Ill Patients with Coronavirus Disease 2019

Background: Trends in mortality, palliative care, and end-of-life care among critically ill patients with coronavirus disease 2019 (COVID-19) remain underreported. We hypothesized that use of palliative care and end-of-life care would increase over time, because improved understanding of the disease course and prognosis would potentially lead to more frequent use of these services. Patients and Methods: Adult patients with severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2) during pandemic wave one (W1: March 2020 to September 2020) or wave two (W2: October 2020 to June 2021) admitted to an intensive care unit (ICU) in one of six northeastern U.S. hospitals were identified and clinical characteristics obtained. Vaccination data were unavailable. Outcomes of interest included mortality, palliative care consultation, and any end-of-life care (including hospice and comfort care). Results: There were 1,904 critically ill patients with COVID-19: 817 (42.9%) in W1 and 1,087 (57.1%) in W2. Patients received mechanical ventilation more often during W1 than W2 (52.9% vs. 46.3%; p = 0.004), with no difference in ICU or hospital length of stay between waves. Mortality between W1 and W2 was similar (31.2% vs. 30.9%; p = 0.888). There was no difference in use of palliative care or any end-of-life care between waves. Patients who died during W2 versus W1 were more likely to have received both mechanical ventilation (77.1% vs. 67.1%; p = 0.007) and palliative care services (52.1% vs. 41.2%; p = 0.009). However, logistic regression adjusted for demographics, baseline comorbid disease, and clinical characteristics showed no difference in mortality (odds ratio [OR], 1.15; 95% confidence interval [CI], 0.89-1.48), palliative care (OR, 1.08; 95% CI, 0.84-1.40), or any end-of-life care (OR, 1.05; 95% CI, 0.82-1.34) in W2 versus W1. Conclusions: Mortality among critically ill patients with COVID-19 has remained constant across two pandemic waves with no change in use of palliative or end-of-life care.

SARS-CoV-2 versus other minor viral infection on kidney injury in asymptomatic and mildly symptomatic patients

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has become a global pandemic since December 2019. Most of the patients are mild or asymptomatic and recovered well as those suffered from other respiratory viruses. SARS-CoV-2 infection is supposed to demonstrate more sequelae. Acute kidney injury (AKI) is common among COVID-19 patients and is associated with disease severity and outcomes. Only a few studies focused on a detailed analysis of kidney damage in asymptomatic or mildly symptomatic COVID-19 patients. Whether any minor viral infection is likely to exhibit similar minor effect on renal function as COVID-19 is still unclear, and the definite pathophysiology of viral invasion is not fully understood. Currently, the proposed mechanisms of AKI include direct effects of virus on kidney, dysregulated immune response, or as a result of multi-organs failure have been proposed. This study will discuss the difference between COVID-19 and other viruses, focusing on proposed mechanisms, biomarkers and whether it matters with clinical significance.

Multistate Modeling of Clinical Trajectories and Outcomes in the ICU: A Proof-of-Concept Evaluation of Acute Kidney Injury Among Critically Ill Patients With COVID-19

Multistate models yield high-fidelity analyses of the dynamic state transition and temporal dimensions of a clinical condition's natural history, offering superiority over aggregate modeling techniques for addressing these types of problems.

OBJECTIVES

To demonstrate the utility of these models in critical care, we examined acute kidney injury (AKI) development, progression, and outcomes in COVID-19 critical illness through multistate analyses.

DESIGN SETTING AND PARTICIPANTS

Retrospective cohort study at an urban tertiary-care academic hospital in the United States. All patients greater than or equal to 18 years in an ICU with COVID-19 in 2020, excluding patients with preexisting end-stage renal disease.

MAIN OUTCOMES AND MEASURES

Using electronic health record data, we determined AKI presence/stage in discrete 12-hour time windows and fit multistate models to determine longitudinal transitions and outcomes.

RESULTS

Of 367 encounters, 241 (66%) experienced AKI (maximal stages: 88 stage-1, 49 stage-2, 104 stage-3 AKI [51 received renal replacement therapy (RRT), 53 did not]). Patients receiving RRT overwhelmingly received invasive mechanical ventilation (IMV) (n = 60, 95%) compared with the AKI-without-RRT (n = 98, 53%) and no-AKI groups (n = 39, 32%; p < 0.001), with similar mortality patterns (RRT: n = 36, 57%; AKI: n = 74, 40%; non-AKI: n = 23, 19%; p < 0.001). After 24 hours in the ICU, almost half the cohort had AKI (44.9%; 95% CI, 41.6-48.2%). At 7 days after stage-1 AKI, 74.0% (63.6-84.4) were AKI-free or discharged. By contrast, fewer patients experiencing stage-3 AKI were recovered (30.0% [24.1-35.8%]) or discharged (7.9% [5.2-10.7%]) after 7 days. Early AKI occurred with similar frequency in patients receiving and not receiving IMV: after 24 hours in the ICU, 20.9% of patients (18.3-23.6%) had AKI and IMV, while 23.4% (20.6-26.2%) had AKI without IMV.

CONCLUSIONS AND RELEVANCE

In a multistate analysis of critically ill patients with COVID-19, AKI occurred early and heterogeneously in the course of critical illness. Multistate methods are useful and underused in ICU care delivery science as tools for understanding trajectories, prognoses, and resource needs.

Acute kidney injury outcomes in covid-19 patients: systematic review and meta-analysis

BACKGROUND

Acute kidney injury (AKI) is a frequent complication of coronavirus-19 disease (COVID-19). Therefore, we decided to perform a systematic review and meta-analysis with data from the literature to relate the development of COVID-19 associated-AKI with comorbidities, medications, and the impact of mechanical ventilation.

METHODS

We performed a systematic review using the Newcastle-Ottawa scale and a meta-analysis using the R program. Relevant studies were searched in the PubMed, Medline, and SciELO electronic databases. Search filters were used to include reports after 2020 and cohort studies.

RESULTS

In total, 1166 articles were identified and 55 English-written articles were included based on the risk of bias. Of all COVID-19-hospitalized patients presenting with AKI (n = 18029) classified as Kidney Disease Improving Global Outcomes stage 1 to 3, approximately 18% required mechanical ventilation and 39.2 % died. Around 11.3% of the patients required kidney replacement therapy (KRT) and of these, 1093 died and 321 required continuous KRT. Death is more frequent in individuals with AKI [OR 6.03, 95%CI: 5.73-6.74; p<0.01]. Finally, mechanical ventilation is an aggravating factor in the clinical conditions studied [OR 11.01, 95%CI: 10.29-11.77; p<0.01].

CONCLUSION

Current literature indicates AKI as an important complication in COVID-19. In this context, we observed that comorbidities, such as chronic kidney disease and heart failure, were more related to the development of AKI. In addition, mechanical ventilation was seen as an aggravating factor in this scenario.

Acute Kidney Injury in COVID-19 Patients: Pathogenesis, Clinical Characteristics, Therapy, and Mortality

Coronavirus disease 2019 (COVID-19) is a disease caused by infection with the SARS-CoV-2 virus and has represented one of the greatest challenges humanity has faced in recent years. The virus can infect a large number of organs, including the lungs and upper respiratory tract, brain, liver, kidneys, and intestines, among many others. Although the greatest damage occurs in the lungs, the kidneys are not exempt, and acute kidney injury (AKI) can occur in patients with COVID-19. Indeed, AKI is one of the most frequent and serious organic complications of COVID-19. The incidence of COVID-19 AKI varies widely, and the exact mechanisms of how the virus damages the kidney are still unknown. For this reason, the purpose of this review was to assess current findings on the pathogenesis, clinical features, therapy, and mortality of COVID-19 AKI.

Alterations in the molecular composition of COVID-19 patient urine, detected using Raman spectroscopic/computational analysis

We developed and tested a method to detect COVID-19 disease, using urine specimens. The technology is based on Raman spectroscopy and computational analysis. It does not detect SARS-CoV-2 virus or viral components, but rather a urine ‘molecular fingerprint’, representing systemic metabolic, inflammatory, and immunologic reactions to infection. We analyzed voided urine specimens from 46 symptomatic COVID-19 patients with positive real time-polymerase chain reaction (RT-PCR) tests for infection or household contact with test-positive patients. We compared their urine Raman spectra with urine Raman spectra from healthy individuals (n = 185), peritoneal dialysis patients (n = 20), and patients with active bladder cancer (n = 17), collected between 2016–2018 (i.e., pre-COVID-19). We also compared all urine Raman spectra with urine specimens collected from healthy, fully vaccinated volunteers (n = 19) from July to September 2021. Disease severity (primarily respiratory) ranged among mild (n = 25), moderate (n = 14), and severe (n = 7). Seventy percent of patients sought evaluation within 14 days of onset. One severely affected patient was hospitalized, the remainder being managed with home/ambulatory care. Twenty patients had clinical pathology profiling. Seven of 20 patients had mildly elevated serum creatinine values (>0.9 mg/dl; range 0.9–1.34 mg/dl) and 6/7 of these patients also had estimated glomerular filtration rates (eGFR) <90 mL/min/1.73m² (range 59–84 mL/min/1.73m²). We could not determine if any of these patients had antecedent clinical pathology abnormalities. Our technology (Raman Chemometric Urinalysis—Rametrix^®) had an overall prediction accuracy of 97.6% for detecting complex, multimolecular fingerprints in urine associated with COVID-19 disease. The sensitivity of this model for detecting COVID-19 was 90.9%. The specificity was 98.8%, the positive predictive value was 93.0%, and the negative predictive value was 98.4%. In assessing severity, the method showed to be accurate in identifying symptoms as mild, moderate, or severe (random chance = 33%) based on the urine multimolecular fingerprint. Finally, a fingerprint of ‘Long COVID-19’ symptoms (defined as lasting longer than 30 days) was located in urine. Our methods were able to locate the presence of this fingerprint with 70.0% sensitivity and 98.7% specificity in leave-one-out cross-validation analysis. Further validation testing will include sampling more patients, examining correlations of disease severity and/or duration, and employing metabolomic analysis (Gas Chromatography–Mass Spectrometry [GC-MS], High Performance Liquid Chromatography [HPLC]) to identify individual components contributing to COVID-19 molecular fingerprints.

Desfechos de lesão renal aguda em pacientes com covid-19: revisão sistemática e metanálise

Resumo Antecedentes: Lesão renal aguda (LRA) é uma complicação frequente da doença do coronavírus-19 (COVID-19). Desta forma, decidimos realizar uma revisão sistemática e uma metanálise com dados da literatura para relacionar o desenvolvimento de LRA associada à COVID-19 com comorbidades, medicamentos e o impacto da ventilação mecânica. Métodos: Realizamos uma revisão sistemática usando a escala de Newcastle-Ottawa e uma metanálise utilizando o programa R. Estudos relevantes foram pesquisados nos bancos de dados eletrônicos PubMed, Medline e SciELO. Foram utilizados filtros de pesquisa para incluir relatos após 2020 e estudos de coorte. Resultados: No total, foram identificados 1166 artigos, e foram incluídos 55 artigos escritos em língua inglesa com base no risco de viés. De todos os pacientes hospitalizados por COVID-19 apresentando LRA (n = 18029) classificados como Kidney Disease Improving Global Outcomes estágios 1 a 3, aproximadamente 18% necessitaram de ventilação mecânica e 39,2% foram a óbito. Cerca de 11,3% dos pacientes necessitaram de terapia renal substitutiva (TRS) e destes, 1093 foram a óbito e 321 necessitaram de TRS contínua. O óbito é mais frequente em indivíduos com LRA [OR 6,03; IC95%: 5,73-6,74; p<0,01]. Por fim, a ventilação mecânica é um fator agravante nas condições clínicas estudadas [OR 11,01; IC95%: 10,29-11,77; p<0,01]. Conclusão: A literatura atual indica a LRA como uma complicação importante na COVID-19. Neste contexto, observamos que comorbidades, como doença renal crônica e insuficiência cardíaca, estiveram mais relacionadas ao desenvolvimento de LRA. Além disso, a ventilação mecânica foi vista como um fator agravante neste cenário.

High mortality and residual kidney damage with Coronavirus disease-19-associated acute kidney injury in northern India

BACKGROUND

Acute kidney injury (AKI) is associated with morbidity and mortality in COVID-19 patients. The incidence of AKI and its outcomes vary in different parts of the world. We aimed to analyze the AKI incidence, predictors of AKI, mortality, and renal function outcomes on follow-up in hospitalized patients with COVID-19.

MATERIALS AND METHODS

The study was designed as a retrospective, observational study of electronically captured data on the hospital information system of laboratory-confirmed COVID-19 patients, with and without AKI, between March 2020 to June 2021. The predictor of AKI and mortality and residual damage in recovered AKI patients were analyzed.

RESULTS

Of the 3395 patients, 3010 COVID-19 patients were eligible. AKI occurred in 951 (31.5%); with stages 1, 2, and 3 in 605 (63.7%), 138 (14.5%), and 208 (21.8%) patients, respectively. AKI severity increased with COVID-19 severity. Of 951 AKI patients, 403 died, and 548 were discharged. AKI group had higher mortality (42.3%) than the non-AKI (6.6%). At discharge, complete recovery was noticed in 370(67.5%), while 178 (32.5%) had residual damage. At three months of follow-up, 108 (69.6%) of 155 patients showed complete recovery. Residual damage was observed in 47 (30.3%). In 14 (9%) patients, serum creatinine remained elevated above the baseline. Thirty-three (21.2%) patients showed proteinuria (n = 24) and microscopic hematuria (n = 9).

CONCLUSIONS

AKI is common among patients hospitalized with COVID-19 and is associated with high mortality. Residual kidney damage post-COVID-19 in recovered AKI patients may increase the CKD burden.

Risk Prediction for Acute Kidney Injury in Patients Hospitalized With COVID-19

Rationale & Objective

Acute kidney injury (AKI) is common in patients hospitalized with COVID-19, but validated, predictive models for AKI are lacking. We aimed to develop the best predictive model for AKI in hospitalized patients with coronavirus disease 2019 and assess its performance over time with the emergence of vaccines and the Delta variant.

Study Design

Longitudinal cohort study.

Setting & Participants

Hospitalized patients with a positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction result between March 1, 2020, and August 20, 2021 at 19 hospitals in Texas.

Exposures

Comorbid conditions, baseline laboratory data, inflammatory biomarkers.

Outcomes

AKI defined by KDIGO (Kidney Disease: Improving Global Outcomes) creatinine criteria.

Analytical Approach

Three nested models for AKI were built in a development cohort and validated in 2 out-of-time cohorts. Model discrimination and calibration measures were compared among cohorts to assess performance over time.

Results

Of 10,034 patients, 5,676, 2,917, and 1,441 were in the development, validation 1, and validation 2 cohorts, respectively, of whom 776 (13.7%), 368 (12.6%), and 179 (12.4%) developed AKI, respectively (P = 0.26). Patients in the validation cohort 2 had fewer comorbid conditions and were younger than those in the development cohort or validation cohort 1 (mean age, 54 ± 16.8 years vs 61.4 ± 17.5 and 61.7 ± 17.3 years, respectively, P < 0.001). The validation cohort 2 had higher median high-sensitivity C-reactive protein level (81.7 mg/L) versus the development cohort (74.5 mg/L; P < 0.01) and higher median ferritin level (696 ng/mL) versus both the development cohort (444 ng/mL) and validation cohort 1 (496 ng/mL; P < 0.001). The final model, which added high-sensitivity C-reactive protein, ferritin, and D-dimer levels, had an area under the curve of 0.781 (95% CI, 0.763-0.799). Compared with the development cohort, discrimination by area under the curve (validation 1: 0.785 [0.760-0.810], P = 0.79, and validation 2: 0.754 [0.716-0.795], P = 0.53) and calibration by estimated calibration index (validation 1: 0.116 [0.041-0.281], P = 0.11, and validation 2: 0.081 [0.045-0.295], P = 0.11) showed stable performance over time.

Limitations

Potential billing and coding bias.

Conclusions

We developed and externally validated a model to accurately predict AKI in patients with coronavirus disease 2019. The performance of the model withstood changes in practice patterns and virus variants.

The role of kidney dysfunction in COVID-19 and the influence of age

COVID-19 is strongly influenced by age and comorbidities. Acute kidney injury (AKI) is a frequent finding in COVID-19 patients and seems to be associated to mortality and severity. On the other hand, the role of kidney dysfunction in COVID-19 is still debated. We performed a retrospective study in a cohort of 174 hospitalized COVID-19 patients in Italy from March 3rd to May 21st 2020, to investigate the role of kidney dysfunction on COVID-19 severity and mortality. Moreover, we examined in depth the relationship between kidney function, age, and progression of COVID-19, also using different equations to estimate the glomerular filtration rate (GFR). We performed logistic regressions, while a predictive analysis was made through a machine learning approach. AKI and death occurred respectively in 10.2% and 19.5%, in our population. The major risk factors for mortality in our cohort were age [adjusted HR, 6.2; 95% confidence interval (CI) 1.8-21.4] and AKI [3.36 (1.44-7.87)], while, in these relationships, GFR at baseline mitigated the role of age. The occurrence of AKI was influenced by baseline kidney function, D-dimer, procalcitonin and hypertension. Our predictive analysis for AKI and mortality reached an accuracy of ≥ 94% and ≥ 91%, respectively. Our study scales down the role of kidney function impairment on hospital admission , especially in elderly patients. BIS-1 formula demonstrated a worse performance to predict the outcomes in COVID-19 patients when compared with MDRD and CKD-EPI.

COVID-19 and the Kidney: Recent Advances and Controversies

Kidney involvement is common in coronavirus disease-2019 (COVID-19), and our understanding of the effects of COVID-19 on short- and long-term kidney outcomes has evolved over the course of the pandemic. Initial key questions centered on the spectrum and degree of acute kidney injury (AKI) in patients hospitalized with severe COVID-19. Investigators worldwide have explored the association between COVID-19-associated AKI and short-term outcomes, including inpatient mortality and disease severity. Even as treatments evolved, vaccinations were developed, and newer viral variants arose, subsets of patients were identified as at continued high risk for major adverse kidney outcomes. In this review, we explore key topics of continued relevance including the following: (1) a comparison of COVID-19-associated AKI with AKI developing in other clinical settings; (2) the ongoing controversy over kidney tropism in the setting of COVID-19 and the potential for competitive binding of the severe acute respiratory syndrome coronavirus 2 virus with angiotensin converting enzyme-2 to prevent viral cell entry; and (3) the identification of high-risk patients for adverse outcomes to inform long-term outpatient management. Patients at particularly high risk for adverse kidney outcomes include those with APOL1 high-risk genotype status. Biomarkers of injury, inflammation, tubular health, and repair measured in both the blood and urine may hold prognostic significance.

Acute Kidney Injury among Hospital-Admitted COVID-19 Patients: A Study from Jordan

Objective

During the COVID-19 pandemic, many patients have been admitted to hospitals with severe respiratory disease and suffered complications. Acute kidney injury (AKI) is among the more dangerous complications contributing to morbidity and mortality among patients.

Methods

This retrospective study focused on all hospital-admitted COVID-19 patients between September and December 2020. A total of 1,044 patients were enrolled. Patient demographics, medical records, and laboratory data were gathered. Patients were split into two groups: AKI and non-AKI. Comparisons comprised demographics, labs, ICU transfer, need for ventilation and oxygen therapy, medications, hospital stay, and deaths.

Results

AKI incidence in the cohort was 25.3%, and a majority were stage 1 (53.3%). Among these, hemodialysis was started in 1.8%. Higher age (P<0.001), diabetes mellitus (P=0.001), hypertension (P=0.001), ACEI/ARB use (P=0.008), erythrocyte-sedimentation rate (P=0.002), CRP (P<0.0001), and ferritin (P=0.01) were predictors of AKI. Among all admitted COVID-19 patients, 30.2% died in hospital. Among those with AKI, 75.9% died in comparison to 24.1% of non-AKI patients (P<0.001). Among COVID-19 patients admitted to the ICU, 80.5% died: 70.5% were from the AKI group and 29.5% from the non-AKI group (P<0.001).

Conclusion

High mortality and morbidity is associated with COVID-19 infection, and AKI is contributing significantly to the outcomes of hospitalized patients with the infection. Early recognition of and treatment for AKI will decrease mortality and hospitalization in patients with COVID-19.

Mortality after acute kidney injury and acute interstitial nephritis in patients prescribed immune checkpoint inhibitor therapy

BACKGROUND

In patients receiving immune checkpoint inhibitor (ICI) therapy, acute kidney injury (AKI) is common, and can occur either from kidney injury unrelated to ICI use or from immune activation resulting in acute interstitial nephritis (AIN). In this study, we test the hypothesis that occurrence of AIN indicates a favorable treatment response to ICI therapy and therefore among patients who develop AKI while on ICI therapy, those with AIN will demonstrate greater survival compared with others with AKI.

METHODS

In this observational cohort study, we included participants initiated on ICI therapy between 2013 and 2019. We tested the independent association of AKI and estimated AIN (eAIN) with mortality up to 1 year after therapy initiation as compared with those without AKI using time-varying Cox proportional hazard models controlling for demographics, comorbidities, cancer type, stage, and therapy, and baseline laboratory values. We defined eAIN as those with a predicted probability of AIN >90th percentile derived from a recently validated diagnostic model.

RESULTS

Of 2207 patients initiated on ICIs, 617 (28%) died at 1 year and 549 (25%) developed AKI. AKI was independently associated with higher mortality (adjusted HR, 2.28 (95% CI 1.90 to 2.72)). Those AKI patients with eAIN had more severe AKI as reflected by a higher peak serum creatinine (3.3 (IQR 2.1-6.1) vs 1.4 (1.2-1.9) mg/dL, p<0.001) but exhibited lower mortality than those without eAIN in univariable analysis (HR 0.43 (95% CI 0.21 to 0.89)) and after adjusting for demographics, comorbidities, and cancer type and severity (adjusted HR 0.44 (95% CI 0.21 to 0.93)).

CONCLUSION

In patients treated with ICI, mortality was higher in those with AKI unrelated to ICI but lower in those where the underlying etiology was AIN. Future studies could evaluate the association of biopsy-proven or biomarker-proven AIN with mortality in those receiving ICI therapy.

SARS-CoV-2 infection increases risk of acute kidney injury in a bimodal age distribution

BACKGROUND

Hospitalized patients with SARS-CoV2 develop acute kidney injury (AKI) frequently, yet gaps remain in understanding why adults seem to have higher rates compared to children. Our objectives were to evaluate the epidemiology of SARS-CoV2-related AKI across the age spectrum and determine if known risk factors such as illness severity contribute to its pattern.

METHODS

Secondary analysis of ongoing prospective international cohort registry. AKI was defined by KDIGO-creatinine only criteria. Log-linear, logistic and generalized estimating equations assessed odds ratios (OR), risk differences (RD), and 95% confidence intervals (CIs) for AKI and mortality adjusting for sex, pre-existing comorbidities, race/ethnicity, illness severity, and clustering within centers. Sensitivity analyses assessed different baseline creatinine estimators.

RESULTS

Overall, among 6874 hospitalized patients, 39.6% (n = 2719) developed AKI. There was a bimodal distribution of AKI by age with peaks in older age (≥60 years) and middle childhood (5-15 years), which persisted despite controlling for illness severity, pre-existing comorbidities, or different baseline creatinine estimators. For example, the adjusted OR of developing AKI among hospitalized patients with SARS-CoV2 was 2.74 (95% CI 1.66-4.56) for 10-15-year-olds compared to 30-35-year-olds and similarly was 2.31 (95% CI 1.71-3.12) for 70-75-year-olds, while adjusted OR dropped to 1.39 (95% CI 0.97-2.00) for 40-45-year-olds compared to 30-35-year-olds.

CONCLUSIONS

SARS-CoV2-related AKI is common with a bimodal age distribution that is not fully explained by known risk factors or confounders. As the pandemic turns to disproportionately impacting younger individuals, this deserves further investigation as the presence of AKI and SARS-CoV2 infection increases hospital mortality risk.

Association of acute kidney injury with 1-year outcome of kidney function in hospital survivors with COVID-19: A cohort study

Background

Kidney damage in COVID-19 patients has been of special concern. The association of acute kidney injury (AKI) with post-acute kidney function among COVID-19 survivors was not sufficiently elucidated.

Methods

An ambidirectional cohort study was conducted with enrollment of COVID-19 survivors discharged from hospital between Jan 7, and May 29, 2020. Study participants were invited to follow-up visits at 6 and 12 months after symptom onset. The primary outcome was percentage of estimated glomerular filtration rate (eGFR) decreased from acute phase (between symptom onset and hospital discharge) to follow-up, and secondary outcome was reduced renal function at follow-up.

Findings

In total, 1,734 study participants were included in this study. Median follow-up duration was 342.0 days (IQR, 223.0-358.0) after symptom onset. After multivariable adjustment, percentage of eGFR decreased from acute phase to follow-up was 8.30% (95% CI, 5.99-10.61) higher among AKI participants than those without AKI at acute phase. Participants with AKI had an odds ratio (OR) of 4.60 (95% CI, 2.10-10.08) for reduced renal function at follow-up. The percentage of eGFR decreased for participants with AKI stage 1, stage 2, and stage 3 was 6.02% (95% CI, 3.48-8.57), 15.99% (95% CI, 10.77-21.22), and 17.79% (95% CI, 9.14-26.43) higher compared with those without AKI, respectively.

Interpretation

AKI at acute phase of COVID-19 was closely related to the longitudinal decline and post-acute status of kidney function at nearly one-year after symptom onset. Earlier and more intense follow-up strategies on kidney function management could be beneficial to COVID-19 survivors.

Funding

Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (CIFMS 2020-I2M-CoV19-005, 2018-I2M-1-003, and 2020-I2M-2-013); National Natural Science Foundation of China (82041011); National Key Research and Development Program of China (2018YFC1200102); Major Projects of National Science and Technology on New Drug Creation and Development of Pulmonary Tuberculosis (2020ZX09201001).

Prognostic Significance of Urinary Biomarkers in Patients Hospitalized With COVID-19

RATIONALE & OBJECTIVE

Acute kidney injury (AKI) is common in patients with coronavirus disease 2019 (COVID-19) and associated with poor outcomes. Urinary biomarkers have been associated with adverse kidney outcomes in other settings and may provide additional prognostic information in patients with COVID-19. We investigated the association between urinary biomarkers and adverse kidney outcomes among patients hospitalized with COVID-19.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

Patients hospitalized with COVID-19 (n=153) at 2 academic medical centers between April and June 2020.

EXPOSURE

19 urinary biomarkers of injury, inflammation, and repair.

OUTCOME

Composite of KDIGO (Kidney Disease: Improving Global Outcomes) stage 3 AKI, requirement for dialysis, or death within 60 days of hospital admission. We also compared various kidney biomarker levels in the setting of COVID-19 versus other common AKI settings.

ANALYTICAL APPROACH

Time-varying Cox proportional hazards regression to associate biomarker level with composite outcome.

RESULTS

Out of 153 patients, 24 (15.7%) experienced the primary outcome. Twofold higher levels of neutrophil gelatinase-associated lipocalin (NGAL) (HR, 1.34 [95% CI, 1.14-1.57]), monocyte chemoattractant protein (MCP-1) (HR, 1.42 [95% CI, 1.09-1.84]), and kidney injury molecule 1 (KIM-1) (HR, 2.03 [95% CI, 1.38-2.99]) were associated with highest risk of sustaining primary composite outcome. Higher epidermal growth factor (EGF) levels were associated with a lower risk of the primary outcome (HR, 0.61 [95% CI, 0.47-0.79]). Individual biomarkers provided moderate discrimination and biomarker combinations improved discrimination for the primary outcome. The degree of kidney injury by biomarker level in COVID-19 was comparable to other settings of clinical AKI. There was evidence of subclinical AKI in COVID-19 patients based on elevated injury biomarker level in patients without clinical AKI defined by serum creatinine.

LIMITATIONS

Small sample size with low number of composite outcome events.

CONCLUSIONS

Urinary biomarkers are associated with adverse kidney outcomes in patients hospitalized with COVID-19 and may provide valuable information to monitor kidney disease progression and recovery.

Acute kidney injury in moderate and severe COVID-19 patients: Report of two university hospitals

Acute kidney injury (AKI) is one of the most severe complications of SARS-CoV-2 infection. In a retrospective study, we aimed to describe the influence of COVID-19-related factors on the severity, outcome and timing of AKI in 268 patients admitted in two large COVID-19-designated university hospitals over a period of 6 months. In the univariate analysis, there was a significant relationship between KDIGO stage and the extension of COVID-19 pneumonia on computed tomography (CT), need for oxygen supplementation, serum levels of ferritin, interleukin-6, and procalcitonin, but none of these variables had a value for predicting KDIGO stage in multinomial regression. The odds of recovery of renal function were significantly diminished by d-dimer values. Lack of immunomodulatory treatment was found to be correlated with increased need for renal replacement therapy (RRT). Compared with AKI at admission, hospital-acquired AKI was predicted by the severity of lung damage on CT, evolved more frequently with incomplete recovery of renal function, and was significantly associated with antiviral therapy.

Kidney implications of SARS-CoV2 infection in children

Research indicates that severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection can impact every organ, and the effects can range from asymptomatic to severe disease. Since it was first discovered in December 2019, our understanding has grown about its impact on kidney disease. In general, children have less severe disease than adults, and this tendency appears to extend to special pediatric kidney populations (e.g., chronic kidney disease and immunosuppressed patients with solid organ transplants or nephrotic syndrome). However, in a fraction of infected children, SARS-CoV2 causes an array of kidney manifestations, ranging from acute kidney injury to thrombotic microangiopathy, with potential implications for increased risk of morbidity and mortality. Additional considerations surround the propensity for clotting extracorporeal circuits in children with SARS-CoV2 infection that are receiving kidney replacement therapy. This review provides an update on our current understanding of SARS-CoV2 for pediatric nephrologists and highlights knowledge gaps to be addressed by future research during this ongoing pandemic, particularly the social disparities magnified during this period.

Procalcitonin and High APACHE (Acute Physiological and Chronic Health Evaluation) Level Are Associated with the Course of Acute Kidney Injury in Patients with SARS-CoV-2

BACKGROUND

Acute kidney injury (AKI) is associated with poor outcomes in patients infected with SARS-CoV-2. Sepsis, direct injury to kidney cells by the virus, and severe systemic inflammation are mechanisms implicated in its development. We investigated the association between inflammatory markers (C-reactive protein, procalcitonin, D-dimer, lactate dehydrogenase, and ferritin) in patients infected with SARS-CoV-2 and the development of AKI.

METHODS

A prospective cohort study performed at the Civil Hospital (Dr. Juan I. Menchaca) Guadalajara, Mexico, included patients aged >18 years with a diagnosis of SARS-CoV-2 pneumonia confirmed by RT-PCR and who did or did not present with AKI (KDIGO) while hospitalized. Biomarkers of inflammation were recorded, and kidney function was estimated using the CKD-EPI formula.

RESULTS

291 patients were included (68% males; average age, 57 years). The incidence of AKI was 40.5% (118 patients); 21% developed stage 1 AKI, 6% developed stage 2 AKI, and 14% developed stage 3 AKI. The development of AKI was associated with higher phosphate (p = 0.002) (RR 1.39, CI 95% 1.13-1.72), high procalcitonin levels at hospital admission (p = 0.005) (RR 2.09, CI 95% 1.26-3.50), and high APACHE scores (p = 0.011) (RR 2.0, CI 95% 1.17-3.40). The survival analysis free of AKI according to procalcitonin levels and APACHE scores demonstrated a lower survival in patients with procalcitonin >0.5 ng/ml (p = 0.001) and APACHE >15 points (p = 0.004).

CONCLUSIONS

Phosphate, high procalcitonin levels, and APACHE levels >15 were predictors of AKI development in patients hospitalized with COVID-19.

Kidney Recovery and Death in Critically Ill Patients With COVID-19-Associated Acute Kidney Injury Treated With Dialysis: The STOP-COVID Cohort Study

Rationale & Objective

Acute kidney injury treated with kidney replacement therapy (AKI-KRT) occurs frequently in critically ill patients with coronavirus disease 2019 (COVID-19). We examined the clinical factors that determine kidney recovery in this population.

Study Design

Multicenter cohort study.

Setting & Participants

4,221 adults not receiving KRT who were admitted to intensive care units at 68 US hospitals with COVID-19 from March 1 to June 22, 2020 (the “ICU cohort”). Among these, 876 developed AKI-KRT after admission to the ICU (the “AKI-KRT subcohort”).

Exposure

The ICU cohort was analyzed using AKI severity as the exposure. For the AKI-KRT subcohort, exposures included demographics, comorbidities, initial mode of KRT, and markers of illness severity at the time of KRT initiation.

Outcome

The outcome for the ICU cohort was estimated glomerular filtration rate (eGFR) at hospital discharge. A 3-level outcome (death, kidney nonrecovery, and kidney recovery at discharge) was analyzed for the AKI-KRT subcohort.

Analytical Approach

The ICU cohort was characterized using descriptive analyses. The AKI-KRT subcohort was characterized with both descriptive analyses and multinomial logistic regression to assess factors associated with kidney nonrecovery while accounting for death.

Results

Among a total of 4,221 patients in the ICU cohort, 2,361 (56%) developed AKI, including 876 (21%) who received KRT. More severe AKI was associated with higher mortality. Among survivors, more severe AKI was associated with an increased rate of kidney nonrecovery and lower kidney function at discharge. Among the 876 patients with AKI-KRT, 588 (67%) died, 95 (11%) had kidney nonrecovery, and 193 (22%) had kidney recovery by the time of discharge. The odds of kidney nonrecovery was greater for lower baseline eGFR, with ORs of 2.09 (95% CI, 1.09-4.04), 4.27 (95% CI, 1.99-9.17), and 8.69 (95% CI, 3.07-24.55) for baseline eGFR 31-60, 16-30, ≤15 mL/min/1.73 m², respectively, compared with eGFR > 60 mL/min/1.73 m². Oliguria at the time of KRT initiation was also associated with nonrecovery (ORs of 2.10 [95% CI, 1.14-3.88] and 4.02 [95% CI, 1.72-9.39] for patients with 50-499 and <50 mL/d of urine, respectively, compared to ≥500 mL/d of urine).

Limitations

Later recovery events may not have been captured due to lack of postdischarge follow-up.

Conclusions

Lower baseline eGFR and reduced urine output at the time of KRT initiation are each strongly and independently associated with kidney nonrecovery among critically ill patients with COVID-19.

Urinary SARS-CoV-2 RNA Is an Indicator for the Progression and Prognosis of COVID-19

Background: We aimed to analyze clinical characteristics and find potential factors to predict poor prognosis in patients with coronavirus disease 2019 (COVID-19). Methods: We analyzed the clinical characteristics and laboratory tests of COVID-19 patients and detected SARS-CoV-2 RNA in urine sediments collected from 53 COVID-19 patients enrolled in Renmin Hospital of Wuhan University from 31 January 2020 to 18 February 2020 with qRT-PCR analysis. Then, we classified those patients based on clinical conditions (severe or non-severe syndrome) and urinary SARS-CoV-2 RNA (U_RNA⁻ or U_RNA⁺). Results: We found that COVID-19 patients with severe syndrome (severe patients) showed significantly higher positive rate (11 of 23, 47.8%) of urinary SARS-CoV-2 RNA than non-severe patients (4 of 30, 13.3%, p = 0.006). U_RNA⁺ patients or severe U_RNA⁺ subgroup exhibited higher prevalence of inflammation and immune discord, cardiovascular diseases, liver damage and renal dysfunction, and higher risk of death than U_RNA⁻ patients. To understand the potential mechanisms underlying the viral urine shedding, we performed renal histopathological analysis on postmortems of patients with COVID-19 and found severe renal vascular endothelium lesion characterized by an increase of the expression of thrombomodulin and von Willebrand factor, markers to assess the endothelium dysfunction. We proposed a theoretical and mathematic model to depict the potential factors that determine the urine shedding of SARS-CoV-2. Conclusions: This study indicated that urinary SARS-CoV-2 RNA detected in urine specimens can be used to predict the progression and prognosis of COVID-19 severity.

Evidence For and Against Direct Kidney Infection by SARS-CoV-2 in Patients with COVID-19

Despite evidence of multiorgan tropism of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in patients with coronavirus disease 2019 (COVID-19), direct viral kidney invasion has been difficult to demonstrate. The question of whether SARS-CoV2 can directly infect the kidney is relevant to the understanding of pathogenesis of AKI and collapsing glomerulopathy in patients with COVID-19. Methodologies to document SARS-CoV-2 infection that have been used include immunohistochemistry, immunofluorescence, RT-PCR, in situ hybridization, and electron microscopy. In our review of studies to date, we found that SARS-CoV-2 in the kidneys of patients with COVID-19 was detected in 18 of 94 (19%) by immunohistochemistry, 71 of 144 (49%) by RT-PCR, and 11 of 84 (13%) by in situ hybridization. In a smaller number of patients with COVID-19 examined by immunofluorescence, SARS-CoV-2 was detected in 10 of 13 (77%). In total, in kidneys from 102 of 235 patients (43%), the presence of SARS-CoV-2 was suggested by at least one of the methods used. Despite these positive findings, caution is needed because many other studies have been negative for SARS-CoV-2 and it should be noted that when detected, it was only in kidneys obtained at autopsy. There is a clear need for studies from kidney biopsies, including those performed at early stages of the COVID-19-associated kidney disease. Development of tests to detect kidney viral infection in urine samples would be more practical as a noninvasive way to evaluate SARS-CoV-2 infection during the evolution of COVID-19-associated kidney disease.

Acute Kidney Injury and Renal Replacement Therapy in COVID-19 Versus Other Respiratory Viruses: A Systematic Review and Meta-Analysis

BACKGROUND

Acute kidney injury (AKI) is a potentially fatal complication of Coronavirus Disease-2019 (COVID-19). Binding of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19, to its viral receptor, angiotensin converting enzyme 2 (ACE2), results in viral entry and may cause AKI.

OBJECTIVES

We performed a systematic review and meta-analysis of the frequencies of AKI and renal replacement therapy (RRT) in critically ill COVID-19 patients and compared those frequencies with patients who were infected by respiratory viruses that bind or downregulate ACE2 (ACE2-associated viruses) and viruses that do not bind nor downregulate ACE2 (non-ACE2-associated viruses).

DESIGN

Systematic review and meta-analysis.

SETTING

Observational studies on COVID-19 and other respiratory viral infections reporting AKI and RRT were included. The exclusion criteria were non-English articles, non-peer-reviewed articles, review articles, studies that included patients under the age of 18, studies including fewer than 10 patients, and studies not reporting AKI and RRT rates.

PATIENTS

Adult COVID-19, Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and influenza patients.

MEASUREMENTS

We extracted the following data from the included studies: author, year, study location, age, sex, race, diabetes mellitus, hypertension, chronic kidney disease, shock, vasopressor use, mortality, intensive care unit (ICU) admission, ICU mortality, AKI, and RRT.

METHODS

We systematically searched PubMed and EMBASE for articles reporting AKI or RRT. AKI was defined by authors of included studies. Critical illness was defined by ICU admission. We performed a random effects meta-analysis to calculate pooled estimates for the AKI and RRT rate within each virus group using a random intercept logistic regression model.

RESULTS

Of 23 655 hospitalized, critically ill COVID-19 patients, AKI frequencies were not significantly different between COVID-19 patients (51%, 95% confidence interval [CI]: 44%-57%) and critically ill patients infected with ACE2-associated (56%, 95% CI: 37%-74%, P = .610) or non-ACE2-associated viruses (63%, 95% CI: 43%-79%, P = .255). Pooled RRT rates were also not significantly different between critically ill, hospitalized patients with COVID-19 (20%, 95% CI: 16%-24%) and ACE2-associated viruses (18%, 95% CI: 8%-33%, P = .747). RRT rates for both COVID-19 and ACE2-associated viruses were significantly different (P < .001 for both) from non-ACE2-associated viruses (49%, 95% CI: 44%-54%). After adjusting for shock or vasopressor use, AKI and RRT rates were not significantly different between groups.

LIMITATIONS

Limitations of this study include the heterogeneity of definitions of AKI that were used across different virus studies. We could not match severity of infection or do propensity matching across studies. Most of the included studies were conducted in retrospective fashion. Last, we did not include non-English publications.

CONCLUSIONS

Our findings suggest that viral ACE2 association does not significantly alter the rates of AKI and RRT among critically ill patients admitted to the ICU. However, the rate of RRT is lower in patients with COVID-19 or ACE2-associated viruses when compared with patients infected with non-ACE2-binding viruses, which might partly be due to the lower frequencies of shock and use of vasopressors in these two virus groups. Prospective studies are necessary to demonstrate whether modulation of the ACE2 axis with Renin-Angiotensin System inhibitors impacts the rates of AKI and whether they are beneficial or harmful in COVID-19 patients.

Acute Kidney Disease and Mortality in Acute Kidney Injury Patients with COVID-19

Background: The incidence of AKI in coronavirus disease 2019 (COVID-19) patients is variable and has been associated with worse prognosis. A significant number of patients develop persistent kidney damage defined as Acute Kidney Disease (AKD). There is a lack of evidence on the real impact of AKD on COVID-19 patients. We aim to identify risk factors for the development of AKD and its impact on mortality in COVID-19 patients. Methods: Retrospective analysis of COVID-19 patients with AKI admitted at the Centro Hospitalar Universitário Lisboa Norte between March and August of 2020. The Kidney Disease Improving Global Outcomes (KDIGO) classification was used to define AKI. AKD was defined by presenting at least KDIGO Stage 1 criteria for >7 days after an AKI initiating event. Results: In 339 COVID-19 patients with AKI, 25.7% patients developed AKD (n = 87). The mean age was 71.7 ± 17.0 years, baseline SCr was 1.03 ± 0.44 mg/dL, and the majority of patients were classified as KDIGO stage 3 AKI (54.3%). The in-hospital mortality was 18.0% (n = 61). Presence of hypertension (p = 0.006), CKD (p < 0.001), lower hemoglobin (p = 0.034) and lower CRP (p = 0.004) at the hospital admission and nephrotoxin exposure (p < 0.001) were independent risk factors for the development of AKD. Older age (p = 0.003), higher serum ferritin at admission (p = 0.008) and development of AKD (p = 0.029) were independent predictors of in-hospital mortality in COVID-19-AKI patients. Conclusions: AKD was significantly associated with in-hospital mortality in this population of COVID-19-AKI patients. Considering the significant risk of mortality in AKI patients, it is of paramount importance to identify the subset of higher risk patients.

Overview of acute kidney manifestations and management of patients with COVID-19

Since the start of the COVID-19 pandemic, several manifestations of kidney involvement associated with infection of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus have been described, including proteinuria, hematuria, and acute kidney injury. A growing body of literature has explored the risk factors and pathogenesis of COVID-19-associated acute kidney injury (AKI), including direct and indirect mechanisms, as well as early postdischarge outcomes that may result from various manifestations of kidney involvement. In this review, we explore the current state of knowledge of the epidemiology of COVID-19-associated AKI, potential mechanisms and pathogenesis of AKI, and various management strategies for patients in the acute setting. We highlight how kidney replacement therapy for patients with COVID-19-associated AKI has been affected by the increasing demand for dialysis and how the postacute management of patients, including outpatient follow-up, is vitally important. We also review what is presently known about long-term kidney outcomes after the initial recovery from COVID-19. We provide some guidance as to the management of patients hospitalized with COVID-19 who are at risk for AKI as well as for future clinical research in the setting of COVID-19 and the significance of early identification of patients at highest risk for adverse kidney outcomes.

The role of exercise in rehabilitation of discharged COVID-19 patients

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mainly caused pneumonia and pulmonary fibrosis through upper respiratory tract infection, which resulted in acute respiratory distress syndrome (ARDS) and multiorgan damage of cardiovascular, nervous, digestive, and genitourinary systems. Although the virus test turned negative after the patient recovered, the damage to multiorgan caused by SARS-CoV-2 may irreversible. Therefore, the health status of the recovered patients has gradually become the focus of people's attention. Whether coronavirus disease 2019 (COVID-19) patients can receive exercise rehabilitation training after discharge? and what's the basis? We try to analyze and answer these questions, will provide some ideas about the patients to develop a reasonable and effective exercise rehabilitation program.

Atrial Fibrillation and Clinical Outcomes in a Cohort of Hospitalized Patients with Sars-Cov-2 Infection and Chronic Kidney Disease

The aim of the study was to investigate the role of chronic kidney disease (CKD) on in-hospital mortality and on incident atrial fibrillation (AF) in patients infected with SARS-CoV-2. The incidence of acute kidney injury (AKI) was also investigated. Multivariable regression models were used to assess the association between renal function groups (estimated Glomerular Filtration Rate, eGFR, >60 mL/min, 30-59 mL/min, <30 mL/min) and in-hospital all-cause mortality and incident AF and AKI. A cohort of 2816 patients admitted in one year for COVID-19 disease in two large hospitals was analyzed. The independent predictors of mortality were severe CKD [HR 1.732 (95%CI 1.264-2.373)], older age [HR 1.054 (95%CI 1.044-1.065)], cerebrovascular disease [HR 1.335 (95%CI (1.016-1.754)], lower platelet count [HR 0.997 (95%CI 0.996-0.999)], higher C-reactive protein [HR 1.047 (95%CI 1.035-1.058)], and higher plasma potassium value 1.374 (95%CI 1.139-1.658). When incident AKI was added to the final survival model, it was associated with higher mortality [HR 2.202 (1.728-2.807)]. Incident AF was more frequent in patients with CKD, but in the multivariable model only older age was significantly related with a higher incidence of AF [OR 1.036 (95%CI 1.022-1.050)]. Incident AF was strongly associated with the onset of AKI [HR 2.619 (95%CI 1.711-4.009)]. In this large population of COVID-19 patients, the presence of severe CKD was an independent predictor of in-hospital mortality. In addition, patients who underwent AKI during hospitalization had a doubled risk of death. Incident AF became more frequent as eGFR decreased and it was significantly associated with the onset of AKI.

A validation study of UCSD-Mayo risk score in predicting hospital-acquired acute kidney injury in COVID-19 patients

Introduction

Acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19) patients is associated with poor prognosis. Early prediction and intervention of AKI are vital for improving clinical outcome of COVID-19 patients. As lack of tools for early AKI detection in COVID-19 patients, this study aimed to validate the USCD-Mayo risk score in predicting hospital-acquired AKI in an extended multi-center COVID-19 cohort.

Methods

Five hundred seventy-two COVID-19 patients from Wuhan Tongji Hospital Guanggu Branch, Wuhan Leishenshan Hospital, and Wuhan No. Ninth Hospital was enrolled for this study. Patients who developed AKI or reached an outcome of recovery or death during the study period were included. Predictors were evaluated according to data extracted from medical records.

Results

Of all patients, a total of 44 (8%) developed AKI. The UCSD-Mayo risk score achieved excellent discrimination in predicting AKI with the C-statistic of 0.88 (95%CI: 0.84–0.91). Next, we determined the UCSD-Mayo risk score had good overall performance (Nagelkerke R² = 0.32) and calibration in our cohort. Further analysis showed that the UCSD-Mayo risk score performed well in subgroups defined by gender, age, and several chronic comorbidities. However, the discrimination of the UCSD-Mayo risk score in ICU patients and patients with mechanical ventilation was not good which might be resulted from different risk factors of these patients.

Conclusions

We validated the performance of UCSD-Mayo risk score in predicting hospital-acquired AKI in COVID-19 patients was excellent except for patients from ICU or patients with mechanical ventilation.

Incidence and Outcomes of Acute Kidney Injury in Patients Admitted to Hospital With COVID-19: A Retrospective Cohort Study

BACKGROUND

The incidence of acute kidney injury (AKI) in patients with COVID-19 and its association with mortality and disease severity is understudied in the Canadian population.

OBJECTIVE

To determine the incidence of AKI in a cohort of patients with COVID-19 admitted to medicine and intensive care unit (ICU) wards, its association with in-hospital mortality, and disease severity. Our aim was to stratify these outcomes by out-of-hospital AKI and in-hospital AKI.

DESIGN

Retrospective cohort study from a registry of patients with COVID-19.

SETTING

Three community and 3 academic hospitals.

PATIENTS

A total of 815 patients admitted to hospital with COVID-19 between March 4, 2020, and April 23, 2021.

MEASUREMENTS

Stage of AKI, ICU admission, mechanical ventilation, and in-hospital mortality.

METHODS

We classified AKI by comparing highest to lowest recorded serum creatinine in hospital and staged AKI based on the Kidney Disease: Improving Global Outcomes (KDIGO) system. We calculated the unadjusted and adjusted odds ratio for the stage of AKI and the outcomes of ICU admission, mechanical ventilation, and in-hospital mortality.

RESULTS

Of the 815 patients registered, 439 (53.9%) developed AKI, 253 (57.6%) presented with AKI, and 186 (42.4%) developed AKI in-hospital. The odds of ICU admission, mechanical ventilation, and death increased as the AKI stage worsened. Stage 3 AKI that occurred during hospitalization increased the odds of death (odds ratio [OR] = 7.87 [4.35, 14.23]). Stage 3 AKI that occurred prior to hospitalization carried an increased odds of death (OR = 5.28 [2.60, 10.73]).

LIMITATIONS

Observational study with small sample size limits precision of estimates. Lack of nonhospitalized patients with COVID-19 and hospitalized patients without COVID-19 as controls limits causal inferences.

CONCLUSIONS

Acute kidney injury, whether it occurs prior to or after hospitalization, is associated with a high risk of poor outcomes in patients with COVID-19. Routine assessment of kidney function in patients with COVID-19 may improve risk stratification.

TRIAL REGISTRATION

The study was not registered on a publicly accessible registry because it did not involve any health care intervention on human participants.

Coronavirus disease 2019 and kidney injury

PURPOSE OF REVIEW

In this paper, we seek to review coronavirus disease 2019 (COVID-19) associated kidney injury with a focus on what is known about pathophysiology.

RECENT FINDINGS

Kidney injury is a common complication of SARS-CoV-2 infection and is associated with increased morbidity and mortality. Acute tubular necrosis and glomerular injury are two common findings. Direct viral effect, endothelial dysfunction, and podocyte and tubular epithelial injury have been described. COVID-19-related glomerular injury may also be associated with high-risk APOL1 genotype.

SUMMARY

Data on COVID-19 renal involvement have suggested novel mechanisms of kidney injury that need to be further elucidated. More data are needed on renal involvement in milder disease, renal-specific therapeutic interventions, and long-term sequelae.