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Ooi SH, Ng KP, Sthaneshwar P, Lim SK, Khor PY, Lim JY, Siow WS, Lim KW, Azlan M. A study of hospitalized COVID-19 patients with AKI in a setting of multiracial developing country. BMC Nephrol 2024; 25:122. [PMID: 38580977 PMCID: PMC10998399 DOI: 10.1186/s12882-024-03498-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 02/12/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND The commonest indication for hospitalization in COVID-19 patients is hypoxemia or severe respiratory symptoms. However, COVID-19 disease may result in extrapulmonary complications including kidney-related pathology. The reported incidence of renal involvement related to COVID infection varies based on geographical location. OBJECTIVE This study aimed to assess the incidence rate of AKI in hospitalized COVID-19 patients and identify risk factors and prognostic predictors. METHOD In this retrospective study, we recruited hospitalized COVID-19 patients from January 2021 until June 2021 at the University Malaya Medical Center. The inclusion criteria were hospitalized for ≥ 48 h with confirmed COVID-19 infection and at least 18 years old. Patient demographic and clinical data were collected from electronic medical records. The staging of AKI was based on criteria as per KDIGO guidelines. RESULTS One thousand five hundred twenty-nine COVID patients fulfilled the inclusion criteria with a male-to-female ratio of 759 (49.6%) to 770 (50.3%). The median age was 55 (IQR: 36-66). 500 patients (32.7%) had diabetes, 621 (40.6%) had hypertension, and 5.6% (n = 85) had pre-existing chronic kidney disease (CKD). The incidence rate of AKI was 21.1% (n = 323). The percentage of COVID patients in different AKI stages of 1,2 and 3 were 16.3%, 2.1%, and 2.7%, respectively. Fifteen hospitalized patients (0.98%) required renal replacement therapy. 58.8% (n = 190) of AKI group had complete recovery of kidney function. Demographic factors included age (p < 0.001), diabetes (p < 0.001), hypertension (p < 0.012), CKD (p < 0.001), and vaccination status (p = 0.042) were associated with an increased risk of developing AKI. We found that the AKI cohort had statistically significant lower platelet counts and higher ferritin levels than the non-AKI cohort. AKI is a risk predictor of prolonged hospitalization (p < 0.001) and higher mortality rates (P < 0.001). CONCLUSION AKI is a common clinical complication among hospitalized COVID-19 patients. The etiology of AKI is multifactorial and may have an adverse impact on patient morbidity and mortality.
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Affiliation(s)
- S H Ooi
- Internal Medicine Department, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - K P Ng
- Internal Medicine Department, University Malaya Medical Center, Kuala Lumpur, Malaysia.
| | | | - S K Lim
- Internal Medicine Department, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - P Y Khor
- Internal Medicine Department, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - J Y Lim
- Internal Medicine Department, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - W S Siow
- Internal Medicine Department, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - K W Lim
- Internal Medicine Department, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Muhummad Azlan
- Internal Medicine Department, University Malaya Medical Center, Kuala Lumpur, Malaysia
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2
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Taneska AC, Rambabova-Bushljetik I, Markovska ZS, Milenkova M, Vasileva AS, Zafirova B, Pushevski V, Severova G, Trajceska L, Spasovski G. Predictive Admission Risk Factors, Clinical Features and Kidney Outcomes in Covid-19 Hospitalised Patients with Acute Kidney Injury. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2023; 44:107-119. [PMID: 38109446 DOI: 10.2478/prilozi-2023-0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
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.
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Affiliation(s)
| | - Irena Rambabova-Bushljetik
- 1University Clinic of Nephrology, Medical Faculty, Ss Cyril and Methodius University, Skopje, RN Macedonia
| | | | - Mimoza Milenkova
- 1University Clinic of Nephrology, Medical Faculty, Ss Cyril and Methodius University, Skopje, RN Macedonia
| | | | - Biljana Zafirova
- 2Institute of Anatomy, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, RN Macedonia
| | - Vladimir Pushevski
- 1University Clinic of Nephrology, Medical Faculty, Ss Cyril and Methodius University, Skopje, RN Macedonia
| | - Galina Severova
- 1University Clinic of Nephrology, Medical Faculty, Ss Cyril and Methodius University, Skopje, RN Macedonia
| | - Lada Trajceska
- 1University Clinic of Nephrology, Medical Faculty, Ss Cyril and Methodius University, Skopje, RN Macedonia
| | - Goce Spasovski
- 1University Clinic of Nephrology, Medical Faculty, Ss Cyril and Methodius University, Skopje, RN Macedonia
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3
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Alkhalifa H, Alsalman Z, Alfaraj A, Algaraash M, Alsalman M. Thrombocytopenia and clinical outcomes among patients with COVID-19 disease: A cohort study. Health Sci Rep 2023; 6:e1111. [PMID: 36794125 PMCID: PMC9923718 DOI: 10.1002/hsr2.1111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/14/2023] [Accepted: 01/31/2023] [Indexed: 02/16/2023] Open
Abstract
Background and Aims Thrombocytopenia is increasingly recognized among patients with critical illness and plays a role in several diseases affecting different organ systems. Therefore, we studied the prevalence of thrombocytopenia among hospitalized COVID-19 patients and its correlation with disease severity and clinical outcomes. Methods This was an observational retrospective cohort study conducted on 256 hospitalized COVID-19 patients. Thrombocytopenia is defined as a platelet count below 150,000/μL. Disease severity was classified based on the five-point CXR scoring tool. Results Thrombocytopenia was found in 66 (25.78%) patients. In outcomes, 41 (16%) patients were admitted to intensive care unit, 51 (19.9%) died, and 50 (19.5%) had acute kidney injury (AKI). Of the total patients with thrombocytopenia, 58 (87.9%) had early thrombocytopenia, while 8 (12.1%) had late thrombocytopenia. Notably, mean survival time was markedly decreased in late-onset thrombocytopenia cases (p < 0.0001). Patients with thrombocytopenia showed a significant increase in creatinine compared to those with normal platelet counts (p < 0.05). Moreover, thrombocytopenia was more prevalent in patients with chronic kidney disease compared to other comorbidities (p < 0.05). In addition, hemoglobin was significantly lower in the thrombocytopenia group (p < 0.05). Conclusion Thrombocytopenia is a common finding among COVID-19 patients, with a predilection toward a specific group of patients, though the exact reasons are unclear. It predicts poor clinical outcomes and is closely linked to mortality, AKI, and the need for mechanical ventilation. These findings suggest that more research is required to study the mechanism of thrombocytopenia and the possibility of thrombotic microangiopathy in COVID-19 patients.
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Affiliation(s)
- Hussain Alkhalifa
- Department of Medicine, College of MedicineKing Faisal UniversitySaudi Arabia
| | - Zaenb Alsalman
- Department of Family and Community Medicine, College of MedicineKing Faisal UniversitySaudi Arabia
| | - Aman Alfaraj
- Department of MedicineKing Fahad Specialist HospitalDammamSaudi Arabia
| | | | - Mortadah Alsalman
- Department of Medicine, College of MedicineKing Faisal UniversitySaudi Arabia
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4
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Shen L, Chen L, Chi H, Luo L, Ruan J, Zhao X, Jiang Y, Tung TH, Zhu H, Zhou K, Shen B, Xu J. Parameters and Morphological Changes of Erythrocytes and Platelets of COVID-19 Subjects: A Longitudinal Cohort Study. Infect Drug Resist 2023; 16:1657-1668. [PMID: 36992967 PMCID: PMC10041993 DOI: 10.2147/idr.s400735] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/25/2023] [Indexed: 03/31/2023] Open
Abstract
Purpose Information about dynamic changes occurring in the parameters and morphology of erythrocytes and platelets during the coronavirus disease 2019 (COVID-19) infection and convalescence is scarce. To explore potential associations between dynamic erythrocyte and platelet parameters, morphological changes, and the course or severity of the disease is essential. Patients and Methods From January 17th, 2020, to February 20th, 2022, we followed up on 35 patients with non-severe and 11 patients with severe COVID-19 following their discharge. We collected clinical features, dynamic complete blood count (CBC), and peripheral blood smears (PBS) and analyzed parameter and morphological changes of erythrocytes and platelets depending on the course or severity of the disease. The course of the disease included four periods, namely onset (T1), discharge (T2), 1-year follow-up (T3), and 2-year follow-up (T4). Results Red blood cell (RBC) counts and hemoglobin were the lowest in T2, followed by T1, and lower in T1 and T2 than in T3 and T4. Inversely, the red blood cell distribution width (RDW) was the highest in T2, followed by T1, and higher than in T3 and T4. Compared to non-severe patients, the platelet of severe patients was lower in T1 and T2. In contrast, the mean platelet volume (MPV) and platelet distribution width (PDW) tended to be higher in severe patients. Similarly, anisocytosis was more common in peripheral blood smears at early stages and in severe patients. Finally, large platelets were more common in severe patients. Conclusion Anisocytosis of erythrocytes and large platelets are found in patients with severe COVID-19, these changes may help primary hospitals to identify patients with a high risk of severe COVID-19 at an early stage.
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Affiliation(s)
- Liping Shen
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Linping Chen
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Hongbo Chi
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Lifei Luo
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Jinsu Ruan
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Xinzhuan Zhao
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Yi Jiang
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Tao-Hsin Tung
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Hongguo Zhu
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Kai Zhou
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Bo Shen
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
| | - Jiaqin Xu
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China
- Correspondence: Jiaqin Xu; Bo Shen, Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People’s Republic of China, Tel +86-13968607148; +86 13586121278, Email ;
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5
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Shan C, Yu F, Deng X, Ni L, Luo X, Li J, Cai S, Huang M, Wang X. Biogenesis aberration: One of the mechanisms of thrombocytopenia in COVID-19. Front Physiol 2023; 14:1100997. [PMID: 37020458 PMCID: PMC10067878 DOI: 10.3389/fphys.2023.1100997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/02/2023] [Indexed: 04/07/2023] Open
Abstract
Background: The pathogenesis of COVID-19, including thrombocytopenia, has not been fully clarified. The lungs are a major organ of platelet production and thrombocytopenia induced by severe COVID-19 was proposed. Methods: the change of platelet level was analysed with clinical parameters in 95 hospitalized COVID-19 patients in Wuhan Third Hospital. The production of platelets in the lungs was explored in an ARDS rat model. Results: The level of platelets was negatively correlated with disease severity and was recovered with disease improvement. The non-survivors were accompanied by lower levels of platelet. The odds ratio (OR) of the valley level of the platelet count (PLTlow) was greater than 1, suggesting that PLTlow could be a death exposure factor. The platelet/lymphocyte ratio (PLR) was positively associated with severity of COVID-19, and the platelet/lymphocyte ratio threshold of 248.5 was best correlated with death risk (sensitivity 0.641 and specificity 0.815). To demonstrate the possible biogenesis aberration of platelet in lungs, an LPS-induced ARDS rat model was applied. Lower level of platelet in peripheral and less production of platelet from lungs in ARDS were demonstrated. Though megakaryocyte (MK) number in ARDS lungs is higher than controls, the immature platelet fraction (IPF) in postpulmonary blood is still at the same level as prepulmonary in ARDS rat, indicating that ARDS rats generated fewer platelets in lungs. Conclusion: Our data suggested that COVID-19-induced severe lung inflammation may impair platelet production in the lung. Thrombocytopenia may be mainly caused by platelet consumption for multiorgan thrombosis; however, biogenesis aberration of platelet in the lung induced by diffuse interstitial pulmonary damage cannot be ruled out.
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Affiliation(s)
- Cuiting Shan
- Department of Respiratory Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Feng Yu
- Shanghai Putuo District People’s Hospital, Shanghai, China
| | - Xuemei Deng
- Department of Neurology, Wuhan Third Hospital, China and Tongren Hospital of Wuhan University, Wuhan, Hubei, China
| | - Li Ni
- Shanghai Putuo District People’s Hospital, Shanghai, China
| | - Xuming Luo
- Department of Respiratory Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jialin Li
- Department of Respiratory Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Si Cai
- Department of Respiratory Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Mian Huang
- Department of Neurology, Wuhan Third Hospital, China and Tongren Hospital of Wuhan University, Wuhan, Hubei, China
- *Correspondence: Xiongbiao Wang, ; Mian Huang,
| | - Xiongbiao Wang
- Department of Respiratory Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- *Correspondence: Xiongbiao Wang, ; Mian Huang,
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6
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Silva AVBDA, Campanati JDEAG, Barcelos IDES, Santos ACL, Deus UPDE, Soares TDEJ, Amaral LSDEB. COVID-19 and Acute Kidney Injury - Direct and Indirect Pathophysiological Mechanisms Underlying Lesion Development. AN ACAD BRAS CIENC 2022; 94:e20211501. [PMID: 36477239 DOI: 10.1590/0001-3765202220211501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/08/2022] [Indexed: 11/29/2022] Open
Abstract
COVID-19 is a pandemic disease caused by the SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) responsible for millions of deaths worldwide. Although the respiratory system is the main target of COVID-19, the disease can affect other organs, including the kidneys. Acute Kidney Injury (AKI), commonly seen in patients infected with COVID-19, has a multifactorial cause. Several studies associate this injury with the direct involvement of the virus in renal cells and the indirect damage stimulated by the infection. The direct cytopathic effects of SARS-CoV-2 are due to the entry and replication of the virus in renal cells, changing several regulatory pathways, especially the renin-angiotensin-aldosterone system (RAAS), with repercussions on the kallikrein-kinin system (KKS). Furthermore, the virus can deregulate the immune system, leading to an exaggerated response of inflammatory cells, characterizing the state of hypercytokinemia. The such exaggerated inflammatory response is commonly associated with hemodynamic changes, reduced renal perfusion, tissue hypoxia, generation of reactive oxygen species (ROS), endothelial damage, and coagulopathies, which can result in severe damage to the renal parenchyma. Thereby, understanding the molecular mechanisms and pathophysiology of kidney injuries induced by SARS-COV-2 is of fundamental importance to obtaining new therapeutic insights for the prevention and management of AKI.
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Affiliation(s)
- Antônio V B DA Silva
- Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde, 45029-094 Vitória da Conquista, BA, Brazil
| | - João DE A G Campanati
- Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde, 45029-094 Vitória da Conquista, BA, Brazil
| | - Isadora DE S Barcelos
- Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde, 45029-094 Vitória da Conquista, BA, Brazil
| | - Alberto C L Santos
- Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde, 45029-094 Vitória da Conquista, BA, Brazil
| | - Uildson P DE Deus
- Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde, 45029-094 Vitória da Conquista, BA, Brazil
| | - Telma DE J Soares
- Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde, 45029-094 Vitória da Conquista, BA, Brazil
| | - Liliany S DE B Amaral
- Universidade Federal da Bahia, Instituto Multidisciplinar em Saúde, 45029-094 Vitória da Conquista, BA, Brazil
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7
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Uzun G, Althaus K, Hammer S, Bakchoul T. Assessment and Monitoring of Coagulation in Patients with COVID-19: A Review of Current Literature. Hamostaseologie 2022; 42:409-419. [PMID: 35477118 DOI: 10.1055/a-1755-8676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Coagulation abnormalities are common in patients with COVID-19 and associated with high morbidity and mortality. It became a daily challenge to navigate through these abnormal laboratory findings and deliver the best possible treatment to the patients. The unique character of COVID-19-induced coagulopathy necessitates not only a dynamic follow-up of the patients in terms of hemostatic findings but also the introduction of new diagnostic methods to determine the overall function of the coagulation system in real time. After the recognition of the high risk of thromboembolism in COVID-19, several professional societies published their recommendations regarding anticoagulation in patients with COVID-19. This review summarizes common hemostatic findings in COVID-19 patients and presents the societal recommendations regarding the use of coagulation laboratory findings in clinical decision-making. Although several studies have investigated coagulation parameters in patients with COVID-19, the methodological shortcomings of published studies as well as the differences in employed anticoagulation regimens that have changed over time, depending on national and international guidelines, limit the applicability of these findings in other clinical settings. Accordingly, evidence-based recommendations for diagnostics during acute COVID-19 infection are still lacking. Future studies should verify the role of coagulation parameters as well as viscoelastic methods in the management of patients with COVID-19.
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Affiliation(s)
- Günalp Uzun
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Karina Althaus
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany.,Medical Faculty of Tuebingen, Institute for Clinical and Experimental Transfusion Medicine, Tuebingen, Germany
| | - Stefanie Hammer
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Tamam Bakchoul
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany.,Medical Faculty of Tuebingen, Institute for Clinical and Experimental Transfusion Medicine, Tuebingen, Germany
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8
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Schrottmaier WC, Schmuckenschlager A, Pirabe A, Assinger A. Platelets in Viral Infections - Brave Soldiers or Trojan Horses. Front Immunol 2022; 13:856713. [PMID: 35419008 PMCID: PMC9001014 DOI: 10.3389/fimmu.2022.856713] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/03/2022] [Indexed: 11/13/2022] Open
Abstract
Viral infections are often associated with platelet activation and haemostatic complications. In line, low platelet counts represent a hallmark for poor prognosis in many infectious diseases. The underlying cause of platelet dysfunction in viral infections is multifaceted and complex. While some viruses directly interact with platelets and/or megakaryocytes to modulate their function, also immune and inflammatory responses directly and indirectly favour platelet activation. Platelet activation results in increased platelet consumption and degradation, which contributes to thrombocytopenia in these patients. The role of platelets is often bi-phasic. Initial platelet hyper-activation is followed by a state of platelet exhaustion and/or hypo-responsiveness, which together with low platelet counts promotes bleeding events. Thereby infectious diseases not only increase the thrombotic but also the bleeding risk or both, which represents a most dreaded clinical complication. Treatment options in these patients are limited and new therapeutic strategies are urgently needed to prevent adverse outcome. This review summarizes the current literature on platelet-virus interactions and their impact on viral pathologies and discusses potential intervention strategies. As pandemics and concomitant haemostatic dysregulations will remain a recurrent threat, understanding the role of platelets in viral infections represents a timely and pivotal challenge.
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Affiliation(s)
- Waltraud C Schrottmaier
- Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Anna Schmuckenschlager
- Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Anita Pirabe
- Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Alice Assinger
- Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
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9
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Kidney Injury in COVID-19: Epidemiology, Molecular Mechanisms, and Potential Therapeutic Targets. Int J Mol Sci 2022; 23:ijms23042242. [PMID: 35216358 PMCID: PMC8877127 DOI: 10.3390/ijms23042242] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 01/08/2023] Open
Abstract
As of December 2021, SARS-CoV-2 had caused over 250 million infections and 5 million deaths worldwide. Furthermore, despite the development of highly effective vaccines, novel variants of SARS-CoV-2 continue to sustain the pandemic, and the search for effective therapies for COVID-19 remains as urgent as ever. Though the primary manifestation of COVID-19 is pneumonia, the disease can affect multiple organs, including the kidneys, with acute kidney injury (AKI) being among the most common extrapulmonary manifestations of severe COVID-19. In this article, we start by reflecting on the epidemiology of kidney disease in COVID-19, which overwhelmingly demonstrates that AKI is common in COVID-19 and is strongly associated with poor outcomes. We also present emerging data showing that COVID-19 may result in long-term renal impairment and delve into the ongoing debate about whether AKI in COVID-19 is mediated by direct viral injury. Next, we focus on the molecular pathogenesis of SARS-CoV-2 infection by both reviewing previously published data and presenting some novel data on the mechanisms of cellular viral entry. Finally, we relate these molecular mechanisms to a series of therapies currently under investigation and propose additional novel therapeutic targets for COVID-19.
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10
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Zhang Y, Cai X, Ge W, Wang D, Zhu G, Qian L, Xiang N, Yue L, Liang S, Zhang F, Wang J, Zhou K, Zheng Y, Lin M, Sun T, Lu R, Zhang C, Xu L, Sun Y, Zhou X, Yu J, Lyu M, Shen B, Zhu H, Xu J, Zhu Y, Guo T. Potential Use of Serum Proteomics for Monitoring COVID-19 Progression to Complement RT-PCR Detection. J Proteome Res 2022; 21:90-100. [PMID: 34783559 PMCID: PMC8610005 DOI: 10.1021/acs.jproteome.1c00525] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Indexed: 12/18/2022]
Abstract
RT-PCR is the primary method to diagnose COVID-19 and is also used to monitor the disease course. This approach, however, suffers from false negatives due to RNA instability and poses a high risk to medical practitioners. Here, we investigated the potential of using serum proteomics to predict viral nucleic acid positivity during COVID-19. We analyzed the proteome of 275 inactivated serum samples from 54 out of 144 COVID-19 patients and shortlisted 42 regulated proteins in the severe group and 12 in the non-severe group. Using these regulated proteins and several key clinical indexes, including days after symptoms onset, platelet counts, and magnesium, we developed two machine learning models to predict nucleic acid positivity, with an AUC of 0.94 in severe cases and 0.89 in non-severe cases, respectively. Our data suggest the potential of using a serum protein-based machine learning model to monitor COVID-19 progression, thus complementing swab RT-PCR tests. More efforts are required to promote this approach into clinical practice since mass spectrometry-based protein measurement is not currently widely accessible in clinic.
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Affiliation(s)
- Ying Zhang
- Taizhou Hospital of Zhejiang Province
Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000,
China
| | - Xue Cai
- Key Laboratory of Structural Biology of Zhejiang
Province, School of Life Sciences, Westlake University, Xihu
District, Hangzhou, Zhejiang 310000, China
- Center for Infectious Disease Research,
Westlake Laboratory of Life Sciences and Biomedicine, Xihu
District, Hangzhou, Zhejiang 310000, China
- Institute of Basic Medical Sciences,
Westlake Institute for Advanced Study, Xihu District,
Hangzhou, Zhejiang 310000, China
| | - Weigang Ge
- Key Laboratory of Structural Biology of Zhejiang
Province, School of Life Sciences, Westlake University, Xihu
District, Hangzhou, Zhejiang 310000, China
- Center for Infectious Disease Research,
Westlake Laboratory of Life Sciences and Biomedicine, Xihu
District, Hangzhou, Zhejiang 310000, China
- Institute of Basic Medical Sciences,
Westlake Institute for Advanced Study, Xihu District,
Hangzhou, Zhejiang 310000, China
- Westlake Omics (Hangzhou) Biotechnology
Co., Ltd., No.1, Yunmeng Road, Cloud Town, Xihu District, Hangzhou,
Zhejiang 310000, China
| | - Donglian Wang
- Taizhou Hospital of Zhejiang Province
Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000,
China
| | - Guangjun Zhu
- Taizhou Hospital of Zhejiang Province
Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000,
China
| | - Liujia Qian
- Key Laboratory of Structural Biology of Zhejiang
Province, School of Life Sciences, Westlake University, Xihu
District, Hangzhou, Zhejiang 310000, China
- Center for Infectious Disease Research,
Westlake Laboratory of Life Sciences and Biomedicine, Xihu
District, Hangzhou, Zhejiang 310000, China
- Institute of Basic Medical Sciences,
Westlake Institute for Advanced Study, Xihu District,
Hangzhou, Zhejiang 310000, China
| | - Nan Xiang
- Key Laboratory of Structural Biology of Zhejiang
Province, School of Life Sciences, Westlake University, Xihu
District, Hangzhou, Zhejiang 310000, China
- Center for Infectious Disease Research,
Westlake Laboratory of Life Sciences and Biomedicine, Xihu
District, Hangzhou, Zhejiang 310000, China
- Institute of Basic Medical Sciences,
Westlake Institute for Advanced Study, Xihu District,
Hangzhou, Zhejiang 310000, China
- Westlake Omics (Hangzhou) Biotechnology
Co., Ltd., No.1, Yunmeng Road, Cloud Town, Xihu District, Hangzhou,
Zhejiang 310000, China
| | - Liang Yue
- Key Laboratory of Structural Biology of Zhejiang
Province, School of Life Sciences, Westlake University, Xihu
District, Hangzhou, Zhejiang 310000, China
- Center for Infectious Disease Research,
Westlake Laboratory of Life Sciences and Biomedicine, Xihu
District, Hangzhou, Zhejiang 310000, China
- Institute of Basic Medical Sciences,
Westlake Institute for Advanced Study, Xihu District,
Hangzhou, Zhejiang 310000, China
| | - Shuang Liang
- Key Laboratory of Structural Biology of Zhejiang
Province, School of Life Sciences, Westlake University, Xihu
District, Hangzhou, Zhejiang 310000, China
- Center for Infectious Disease Research,
Westlake Laboratory of Life Sciences and Biomedicine, Xihu
District, Hangzhou, Zhejiang 310000, China
- Institute of Basic Medical Sciences,
Westlake Institute for Advanced Study, Xihu District,
Hangzhou, Zhejiang 310000, China
| | - Fangfei Zhang
- Key Laboratory of Structural Biology of Zhejiang
Province, School of Life Sciences, Westlake University, Xihu
District, Hangzhou, Zhejiang 310000, China
- Center for Infectious Disease Research,
Westlake Laboratory of Life Sciences and Biomedicine, Xihu
District, Hangzhou, Zhejiang 310000, China
- Institute of Basic Medical Sciences,
Westlake Institute for Advanced Study, Xihu District,
Hangzhou, Zhejiang 310000, China
| | - Jing Wang
- Taizhou Hospital of Zhejiang Province
Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000,
China
| | - Kai Zhou
- Taizhou Hospital of Zhejiang Province
Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000,
China
| | - Yufen Zheng
- Taizhou Hospital of Zhejiang Province
Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000,
China
| | - Minjie Lin
- Taizhou Hospital of Zhejiang Province
Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000,
China
| | - Tong Sun
- Taizhou Hospital of Zhejiang Province
Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000,
China
| | - Ruyue Lu
- Taizhou Hospital of Zhejiang Province
Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000,
China
| | - Chao Zhang
- Taizhou Hospital of Zhejiang Province
Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000,
China
| | - Luang Xu
- Key Laboratory of Structural Biology of Zhejiang
Province, School of Life Sciences, Westlake University, Xihu
District, Hangzhou, Zhejiang 310000, China
- Center for Infectious Disease Research,
Westlake Laboratory of Life Sciences and Biomedicine, Xihu
District, Hangzhou, Zhejiang 310000, China
- Institute of Basic Medical Sciences,
Westlake Institute for Advanced Study, Xihu District,
Hangzhou, Zhejiang 310000, China
| | - Yaoting Sun
- Key Laboratory of Structural Biology of Zhejiang
Province, School of Life Sciences, Westlake University, Xihu
District, Hangzhou, Zhejiang 310000, China
- Center for Infectious Disease Research,
Westlake Laboratory of Life Sciences and Biomedicine, Xihu
District, Hangzhou, Zhejiang 310000, China
- Institute of Basic Medical Sciences,
Westlake Institute for Advanced Study, Xihu District,
Hangzhou, Zhejiang 310000, China
| | - Xiaoxu Zhou
- Key Laboratory of Structural Biology of Zhejiang
Province, School of Life Sciences, Westlake University, Xihu
District, Hangzhou, Zhejiang 310000, China
- Institute of Basic Medical Sciences,
Westlake Institute for Advanced Study, Xihu District,
Hangzhou, Zhejiang 310000, China
| | - Jing Yu
- Key Laboratory of Structural Biology of Zhejiang
Province, School of Life Sciences, Westlake University, Xihu
District, Hangzhou, Zhejiang 310000, China
- Center for Infectious Disease Research,
Westlake Laboratory of Life Sciences and Biomedicine, Xihu
District, Hangzhou, Zhejiang 310000, China
- Institute of Basic Medical Sciences,
Westlake Institute for Advanced Study, Xihu District,
Hangzhou, Zhejiang 310000, China
| | - Mengge Lyu
- Key Laboratory of Structural Biology of Zhejiang
Province, School of Life Sciences, Westlake University, Xihu
District, Hangzhou, Zhejiang 310000, China
- Center for Infectious Disease Research,
Westlake Laboratory of Life Sciences and Biomedicine, Xihu
District, Hangzhou, Zhejiang 310000, China
- Institute of Basic Medical Sciences,
Westlake Institute for Advanced Study, Xihu District,
Hangzhou, Zhejiang 310000, China
| | - Bo Shen
- Taizhou Hospital of Zhejiang Province
Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000,
China
| | - Hongguo Zhu
- Taizhou Hospital of Zhejiang Province
Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000,
China
| | - Jiaqin Xu
- Taizhou Hospital of Zhejiang Province
Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000,
China
| | - Yi Zhu
- Key Laboratory of Structural Biology of Zhejiang
Province, School of Life Sciences, Westlake University, Xihu
District, Hangzhou, Zhejiang 310000, China
- Center for Infectious Disease Research,
Westlake Laboratory of Life Sciences and Biomedicine, Xihu
District, Hangzhou, Zhejiang 310000, China
- Institute of Basic Medical Sciences,
Westlake Institute for Advanced Study, Xihu District,
Hangzhou, Zhejiang 310000, China
| | - Tiannan Guo
- Key Laboratory of Structural Biology of Zhejiang
Province, School of Life Sciences, Westlake University, Xihu
District, Hangzhou, Zhejiang 310000, China
- Center for Infectious Disease Research,
Westlake Laboratory of Life Sciences and Biomedicine, Xihu
District, Hangzhou, Zhejiang 310000, China
- Institute of Basic Medical Sciences,
Westlake Institute for Advanced Study, Xihu District,
Hangzhou, Zhejiang 310000, China
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11
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Legrand M, Bell S, Forni L, Joannidis M, Koyner JL, Liu K, Cantaluppi V. Pathophysiology of COVID-19-associated acute kidney injury. Nat Rev Nephrol 2021; 17:751-764. [PMID: 34226718 PMCID: PMC8256398 DOI: 10.1038/s41581-021-00452-0] [Citation(s) in RCA: 241] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 02/06/2023]
Abstract
Although respiratory failure and hypoxaemia are the main manifestations of COVID-19, kidney involvement is also common. Available evidence supports a number of potential pathophysiological pathways through which acute kidney injury (AKI) can develop in the context of SARS-CoV-2 infection. Histopathological findings have highlighted both similarities and differences between AKI in patients with COVID-19 and in those with AKI in non-COVID-related sepsis. Acute tubular injury is common, although it is often mild, despite markedly reduced kidney function. Systemic haemodynamic instability very likely contributes to tubular injury. Despite descriptions of COVID-19 as a cytokine storm syndrome, levels of circulating cytokines are often lower in patients with COVID-19 than in patients with acute respiratory distress syndrome with causes other than COVID-19. Tissue inflammation and local immune cell infiltration have been repeatedly observed and might have a critical role in kidney injury, as might endothelial injury and microvascular thrombi. Findings of high viral load in patients who have died with AKI suggest a contribution of viral invasion in the kidneys, although the issue of renal tropism remains controversial. An impaired type I interferon response has also been reported in patients with severe COVID-19. In light of these observations, the potential pathophysiological mechanisms of COVID-19-associated AKI may provide insights into therapeutic strategies.
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Affiliation(s)
- Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco, CA, USA.
- Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists network, Nancy, France.
| | - Samira Bell
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Lui Forni
- Intensive Care Unit, Royal Surrey Hospital NHS Foundation Trust, Surrey, UK
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Surrey, UK
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Jay L Koyner
- Divisions of Nephrology, Departments of Medicine, University of Chicago, Chicago, IL, USA
| | - Kathleen Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of San Francisco, San Francisco, CA, USA
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
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12
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Delshad M, Safaroghli-Azar A, Pourbagheri-Sigaroodi A, Poopak B, Shokouhi S, Bashash D. Platelets in the perspective of COVID-19; pathophysiology of thrombocytopenia and its implication as prognostic and therapeutic opportunity. Int Immunopharmacol 2021; 99:107995. [PMID: 34304001 PMCID: PMC8295197 DOI: 10.1016/j.intimp.2021.107995] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/09/2021] [Accepted: 07/15/2021] [Indexed: 02/07/2023]
Abstract
Despite endorsed and exponential research to improve diagnostic and therapeutic strategies, efforts have not yet converted into a better prospect for patients infected with the novel coronavirus (2019nCoV), and still, the name of SARS-CoV-2 is coupled with numerous unanswered questions. One of these questions is concerning how this respiratory virus reduces the number of platelets (PLTs)? The results of laboratory examinations showed that about a quarter of COVID-19 cases experience thrombocytopenia, and more remarkably, about half of these patients succumb to the infection due to coagulopathy. These findings have positioned PLTs as a pillar in the management as well as stratifying COVID-19 patients; however, not all the physicians came into a consensus about the prognostic value of these cells. The current review aims to unravel the contributory role of PLTs s in COVID-19; and also to summarize the original data obtained from international research laboratories on the association between COVID-19 and PLT production, activation, and clearance. In addition, we provide a special focus on the prognostic value of PLTs and their related parameters in COVID-19. Questions on how SARS-CoV-2 induces thrombocytopenia are also responded to. The last section provides a general overview of the most recent PLT- or thrombocytopenia-related therapeutic approaches. In conclusion, since SARS-CoV-2 reduces the number of PLTs by eliciting different mechanisms, treatment of thrombocytopenia in COVID-19 patients is not as simple as it appears and serious cautions should be considered to deal with the problem through scrutiny awareness of the causal mechanisms.
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Affiliation(s)
- Mahda Delshad
- Department of Laboratory Sciences, School of Allied Medical Sciences, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Ava Safaroghli-Azar
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atieh Pourbagheri-Sigaroodi
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Behzad Poopak
- Department of Hematology, Faculty of Paramedical Sciences, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Shervin Shokouhi
- Department of Infectious Diseases and Tropical Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Davood Bashash
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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13
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Lippi G, Henry BM, Favaloro EJ. Mean Platelet Volume Predicts Severe COVID-19 Illness. Semin Thromb Hemost 2021; 47:456-459. [PMID: 33893630 DOI: 10.1055/s-0041-1727283] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Brandon M Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
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14
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Chen J, Wang W, Tang Y, Huang XR, Yu X, Lan HY. Inflammatory stress in SARS-COV-2 associated Acute Kidney Injury. Int J Biol Sci 2021; 17:1497-1506. [PMID: 33907513 PMCID: PMC8071761 DOI: 10.7150/ijbs.58791] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/01/2021] [Indexed: 01/08/2023] Open
Abstract
Increasing clinical evidence shows that acute kidney injury (AKI) is a common and severe complication in critically ill COVID-19 patients. The older age, the severity of COVID-19 infection, the ethnicity, and the history of smoking, diabetes, hypertension, and cardiovascular disease are the risk factor for AKI in COVID-19 patients. Of them, inflammation may be a key player in the pathogenesis of AKI in patients with COVID-19. It is highly possible that SARS-COV-2 infection may trigger the activation of multiple inflammatory pathways including angiotensin II, cytokine storm such as interleukin-6 (IL-6), C-reactive protein (CRP), TGF-β signaling, complement activation, and lung-kidney crosstalk to cause AKI. Thus, treatments by targeting these inflammatory molecules and pathways with a monoclonal antibody against IL-6 (Tocilizumab), C3 inhibitor AMY-101, anti-C5 antibody, anti-TGF-β OT-101, and the use of CRRT in critically ill patients may represent as novel and specific therapies for AKI in COVID-19 patients.
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Affiliation(s)
- Junzhe Chen
- Departments of Medicine & Therapeutics, Li Ka Shing Institute of Health Sciences, and Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong, China
- Department of Nephrology, The Third Affiliated hospital, Southern Medical university, Guangzhou, China
| | - Wenbiao Wang
- Departments of Medicine & Therapeutics, Li Ka Shing Institute of Health Sciences, and Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong, China
- Guangdong Key Laboratory of Virology, Institute of Medical Microbiology, Jinan University, Guangzhou, China
| | - Ying Tang
- Department of Nephrology, The Third Affiliated hospital, Southern Medical university, Guangzhou, China
| | - Xiao-ru Huang
- Departments of Medicine & Therapeutics, Li Ka Shing Institute of Health Sciences, and Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong, China
- Guangdong-Hong Kong Joint Laboratory for Immunity and Genetics of Chronic Kidney Disease, Guangdong Academy of Medical Science, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Xueqing Yu
- Guangdong-Hong Kong Joint Laboratory for Immunity and Genetics of Chronic Kidney Disease, Guangdong Academy of Medical Science, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Hui-Yao Lan
- Departments of Medicine & Therapeutics, Li Ka Shing Institute of Health Sciences, and Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong, China
- Guangdong-Hong Kong Joint Laboratory for Immunity and Genetics of Chronic Kidney Disease, The Chinese University of Hong Kong, Hong Kong, China
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