Clinical Characteristics and Outcomes of Community- and Hospital-Acquired Acute Kidney Injury with COVID-19 in a US Inner City Hospital System

Acute Kidney Injury in the Context of COVID-19: An Analysis in Hospitalized Mexican Patients

During the COVID-19 pandemic, a considerable proportion of patients developed a severe condition that included respiratory failure, shock, or multiple organ dysfunction. Acute Kidney Injury (AKI) has been recognized as a possible cause of severe COVID-19 development. Given this, this study investigates the occurrence and consequences of AKI in Mexican patients to contribute to better knowledge and management of this problem. Methods: Using a retrospective observational cohort methodology, we investigated 313 cases from a cohort of 1019 patients diagnosed with COVID-19 at the IMSS Zacatecas General Hospital of Zone No. 1 in 2020. The prevalence of AKI was determined using the AKIN criteria based on serum creatinine levels and a detailed review of demographic characteristics, medical history, comorbidities, and clinical development. Results: The data showed a 25.30% prevalence of AKI among patients infected with severe COVID-19. Remarkably, these patients with AKI exhibited an advanced age (>65 years), arterial hypertension, a higher number of white blood cells during admission and the hospital stay, and elevated levels of C-reactive protein, serum creatinine, and blood urea nitrogen (BUN). Clinically, patients with AKI had signs of prostration, pneumonia, and the requirement for ventilatory assistance when compared to those without AKI. Finally, those diagnosed with AKI and COVID-19 had a 74% death rate. Relative risk analyses indicated that age (>65 years), arterial hypertension, high creatinine levels, endotracheal intubation, and pneumonia are associated with the development of AKI. On the other hand, among the protective factors against AKI, high hemoglobin levels and the consumption of statins during COVID-19 were found. Conclusions: The findings of this study underscore the significance of promptly identifying and effectively managing AKI to potentially alleviate the negative consequences of this complication within the Mexican population during COVID-19.

Associated Factors and Outcomes of Acute Kidney Injury in COVID-19 Patients in Kenya

Background

Corona Virus Disease 2019 (COVID-19), an infection caused by the SARS-CoV-2 virus, has been the largest global pandemic since the turn of the 21st century. With emerging research on this novel virus, studies from the African continent have been few. Corona Virus Disease 2019 has been shown to affect various organs including the lungs, gut, nervous system, and the kidneys. Acute kidney injury (AKI) is an independent risk factor for mortality and increases the health care burden for patients with persistent kidney dysfunction and maintenance dialysis. Sub-Saharan Africa has a high number of poorly controlled chronic illnesses, economic inequalities, and health system strains that may contribute to higher cases of kidney injury in patients with COVID-19 disease.

Objectives

The objective of this study was to determine the incidence, associated factors, and outcomes of AKI in patients hospitalized with COVID-19 in Kenya.

Methods

This retrospective cohort study included 1366 patients with confirmed COVID-19 illness hospitalized at the Aga Khan University Hospital in Nairobi, Kenya, between April 1, 2020 and October 31, 2021. Data were collected on age, sex, the severity of COVID-19 illness, existing pregnancy and comorbid conditions including human immunodeficiency virus (HIV), diabetes mellitus, hypertension, and functioning kidney transplant patients. Univariate analysis was carried out to determine the association of clinical and demographic factors with AKI. To determine independent associations with AKI incidence, a logistic regression model was used and the relationship was reported as odds ratios (ORs) with a 95% confidence interval (CI). The outcomes of AKI including the in-hospital mortality rate, renal recovery rate at hospital discharge, and the duration of hospital stay were reported and stratified based on the stage of AKI.

Results

The median age of study patients was 56 years (interquartile range [IQR] = 45-68 years), with 67% of them being male (914 of 1366). The AKI incidence rate was 21.6% (n = 295). Patients with AKI were older (median age = 64 years vs 54 years; P < .001), majority male (79% of men with AKI vs 63.6% without AKI; P < .001), and likely to have a critical COVID-19 (OR = 8.03, 95% CI = 5.56-11.60; P < .001). Diabetes and hypertension, with an adjusted OR of 1.75 (95% CI = 1.34-2.30; P < .001) and 1.68 (95% CI = 1.27-2.23; P < .001), respectively, were associated with AKI occurrence in COVID-19. Human immunodeficiency virus, pregnancy, and a history of renal transplant were not significantly associated with increased AKI risk in this study. Patients with AKI had significantly higher odds of mortality, and this effect was proportional to the stage of AKI (OR = 11.35, 95% CI = 7.56-17.03; P < .001). 95% of patients with stage 1 AKI had complete renal recovery vs 33% of patients with stage 3 AKI. Of the patients with stage 3 AKI (n = 64), 10 underwent hemodialysis, with 1 recovery in renal function and 3 patients requiring ongoing dialysis after discharge.

Conclusions

This study was conducted at a single private tertiary-level health care facility in Kenya and only up to the time of hospital discharge. It is one of the first large studies from sub-Saharan Africa looking at the associated factors and outcomes of AKI in COVID-19 and forms a foundation for further analysis on the long-term consequences of COVID-19 on the kidneys. A major limitation of the study is the lack of baseline pre-admission creatinine values for most patients; thus, the impact of chronic kidney disease/baseline creatinine values on the incidence of AKI could not be established.

Epidemiology, patterns of care and prognosis of acute kidney injury in critically ill patients: A multicenter study in Argentina (The EPIRA study)

BACKGROUND

Acute kidney injury (AKI) is associated with high morbidity and mortality rates in the intensive care unit (ICU). In low- and middle-income countries (LMICs), epidemiological information about this condition is still scarce. Our main objective was to characterize its epidemiology, prognosis, and its treatment.

METHODS

This multicenter prospective cohort study included 1466 patients from 35 ICUs during 6 months in Argentina in 2018. Risk factors and outcomes in patients with and without AKI, and between AKI on admission (AKIadm) and that developed during hospitalization (AKIhosp) were analyzed.

RESULTS

AKI occurred in 61.3% of patients (900/1466); 72.6% were AKIadm and 27.3% AKIhosp. Risk factors were age, BMI, arterial hypertension, cardiovascular diseases, diabetes, SOFA, APACHE II, dehydration, sepsis, vasopressor use, radiocontrast, diuresis/h and mechanical ventilation. Independent predictors for AKI were sepsis, diabetes, dehydration, vasopressors on admission, APACHE II and radiocontrast use. Renal replacement therapies (RRT) requirement in AKI patients was 14.8%. Hospital mortality in AKI vs. non-AKI was 38.7% and 23.3% (p < 0.001); and in AKIadm vs. AKIhosp, 41.2% and 37.8% (p = 0.53).

CONCLUSIONS

ICU-acquired AKI has high incidence, complications and mortality. Risk factors for AKI and RRT utilization were similar to those described in other epidemiological studies. AKIadm was more frequent than AKIhosp, but had equal prognosis.

Long-term outcomes of COVID-19 survivors with hospital AKI: association with time to recovery from AKI

BACKGROUND

Although coronavirus disease 2019 (COVID-19) patients who develop in-hospital acute kidney injury (AKI) have worse short-term outcomes, their long-term outcomes have not been fully characterized. We investigated 90-day and 1-year outcomes after hospital AKI grouped by time to recovery from AKI.

METHODS

This study consisted of 3296 COVID-19 patients with hospital AKI stratified by early recovery (<48 hours), delayed recovery (2-7 days) and prolonged recovery (>7-90 days). Demographics, comorbidities and laboratory values were obtained at admission and up to the 1-year follow-up. The incidence of major adverse cardiovascular events (MACE) and major adverse kidney events (MAKE), rehospitalization, recurrent AKI and new-onset chronic kidney disease (CKD) were obtained 90-days after COVID-19 discharge.

RESULTS

The incidence of hospital AKI was 28.6%. Of the COVID-19 patients with AKI, 58.0% experienced early recovery, 14.8% delayed recovery and 27.1% prolonged recovery. Patients with a longer AKI recovery time had a higher prevalence of CKD (P < .05) and were more likely to need invasive mechanical ventilation (P < .001) and to die (P < .001). Many COVID-19 patients developed MAKE, recurrent AKI and new-onset CKD within 90 days, and these incidences were higher in the prolonged recovery group (P < .05). The incidence of MACE peaked 20-40 days postdischarge, whereas MAKE peaked 80-90 days postdischarge. Logistic regression models predicted 90-day MACE and MAKE with 82.4 ± 1.6% and 79.6 ± 2.3% accuracy, respectively.

CONCLUSION

COVID-19 survivors who developed hospital AKI are at high risk for adverse cardiovascular and kidney outcomes, especially those with longer AKI recovery times and those with a history of CKD. These patients may require long-term follow-up for cardiac and kidney complications.

Risk Factors and Clinical Characteristics of Acute Kidney Injury in Patients with COVID-19: A Systematic Review and Meta-Analysis

Acute kidney injury (AKI) is associated with a worse prognosis in coronavirus disease 2019 (COVID-19) patients. Identification of AKI, particularly in COVID-19 patients, is important for improving patients' management. The study aims to assess risk factors and comorbidities of AKI in COVID-19 patients. We systematically searched PubMed and DOAJ databases for relevant studies involving confirmed COVID-19 patients with data on risk factors and comorbidities of AKI. The risk factors and comorbidities were compared between AKI and non-AKI patients. A total of 30 studies involving 22385 confirmed COVID-19 patients were included. Male (OR: 1.74 (1.47, 2.05)), diabetes (OR: 1.65 (1.54, 1.76)), hypertension (OR: 1.82 (1.12, 2.95)), ischemic cardiac disease (OR: 1.70 (1.48, 1.95)), heart failure (OR: 2.29 (2.01, 2.59)), chronic kidney disease (CKD) (OR: 3.24 (2.20, 4.79)), chronic obstructive pulmonary disease (COPD) (OR: 1.86 (1.35, 2.57)), peripheral vascular disease (OR: 2.34 (1.20, 4.56)), and history of nonsteroidal anti-inflammatory drugs (NSAID) (OR: 1.59 (1.29, 1.98)) were independent risk factors associated with COVID-19 patients with AKI. Patients with AKI presented with proteinuria (OR: 3.31 (2.59, 4.23)), hematuria (OR: 3.25 (2.59, 4.08)), and invasive mechanical ventilation (OR: 13.88 (8.23, 23.40)). For COVID-19 patients, male gender, diabetes, hypertension, ischemic cardiac disease, heart failure, CKD, COPD, peripheral vascular disease, and history of use of NSAIDs are associated with a higher risk of AKI.

Characteristics of COVID-19 patients with multiorgan injury across the pandemic in a large academic health system in the Bronx, New York

Purpose

To investigate the evolution of COVID-19 patient characteristics and multiorgan injury across the pandemic.

Methods

This retrospective cohort study consisted of 40,387 individuals tested positive for SARS-CoV-2 in the Montefiore Health System in Bronx, NY, between March 2020 and February 2022, of which 11,306 were hospitalized. Creatinine, troponin, and alanine aminotransferase were used to define acute kidney injury (AKI), acute cardiac injury (ACI) and acute liver injury, respectively. Demographics, comorbidities, emergency department visits, hospitalization, intensive care utilization, and mortality were analyzed across the pandemic.

Results

COVID-19 positive cases, emergency department visits, hospitalization and mortality rate showed four distinct waves with a large first wave in April 2020, two small (Alpha and Delta) waves, and a large Omicron wave in December 2021. Omicron was more infectious but less lethal (p = 0.05). Among hospitalized COVID-19 patients, age decreased (p = 0.014), female percentage increased (p = 0.023), Hispanic (p = 0.028) and non-Hispanic Black (p = 0.05) percentages decreased, and patients with pre-existing diabetes (p = 0.002) and hypertension (p = 0.04) decreased across the pandemic. More than half (53.1%) of hospitalized patients had major organ injury. Patients with AKI, ACI and its combinations were older, more likely males, had more comorbidities, and consisted more of non-Hispanic Black and Hispanic patients (p = 0.005). Patients with AKI and its combinations had 4-9 times higher adjusted risk of mortality than those without.

Conclusions

There were shifts in demographics toward younger age and proportionally more females with COVID-19 across the pandemic. While the overall trend showed improved clinical outcomes, a substantial number of COVID-19 patients developed multi-organ injuries over time. These findings could bring awareness to at-risk patients for long-term organ injuries and help to better inform public policy and outreach initiatives.

Urinary albumin-to-creatinine ratio and serum albumin are predictors of acute kidney injury in non-ventilated COVID-19 patients: a single-center prospective cohort study

PURPOSE

Acute kidney injury (AKI) is a frequent complication among COVID-19 patients in the intensive care unit, but it is less frequently investigated in general internal medicine wards. We aimed to examine the incidence, the predictors of AKI, and AKI-associated mortality in a prospective cohort of non-ventilated COVID-19 patients. We aimed to describe the natural history of AKI by describing trajectories of urinary markers of hemodynamic, glomerular, and tubular injury.

METHODS

141 COVID-19 patients were enrolled to the study. AKI was defined according to KDIGO guidelines. Urine and renal function parameters were followed twice a week. Multivariate logistic regression was used to determine the predictors of AKI and mortality. Trajectories of urinary markers were described by unadjusted linear mixed models.

RESULTS

19.7% patients developed AKI. According to multiple logistic regression, higher urinary albumin-to-creatinine ratio (OR 1.48, 95% CI 1.04-2.12/1 mg/mmol) and lower serum albumin (OR 0.86, 95% CI 0.77-0.94/1 g/L) were independent predictors of AKI. Mortality was 42.8% in the AKI and 8.8% in the group free from AKI (p < 0.0001). According to multiple logistic regression, older age, lower albumin, and AKI (OR 3.9, 95% CI 1.24-12.21) remained independent predictors of mortality. Urinary protein-to-creatinine trajectories were diverging with decreasing values in those without incident AKI.

CONCLUSION

We found high incidence of AKI and mortality among moderately severe, non-ventilated COVID-19 patients. Its development is predicted by higher albuminuria suggesting that the originally damaged renal structure may be more susceptible for virus-associated effects. No clear relationship was found with a prerenal mechanism, and the higher proteinuria during follow-up may point toward tubular damage.

Outcomes, Healthcare Resource Utilization, and Costs of Overall, Community-Acquired, and Hospital-Acquired Acute Kidney Injury in COVID-19 Patients

Background: In hospitalized patients with COVID-19, acute kidney injury (AKI) is associated with higher mortality, but data are lacking on healthcare resource utilization (HRU) and costs related to AKI, community-acquired AKI (CA-AKI), and hospital-acquired AKI (HA-AKI). Objectives: To quantify the burden of AKI, CA-AKI, and HA-AKI among inpatients with COVID-19. Methods: This retrospective cohort study included inpatients with COVID-19 discharged from US hospitals in the Premier PINC AI™ Healthcare Database April 1-October 31, 2020, categorized as AKI, CA-AKI, HA-AKI, or no AKI by ICD-10-CM diagnosis codes. Outcomes were assessed during index (initial) hospitalization and 30 days postdischarge. Results: Among 208 583 COVID-19 inpatients, 30%, 25%, and 5% had AKI, CA-AKI, and HA-AKI, of whom 10%, 7%, and 23% received dialysis, respectively. Excess mortality, HRU, and costs were greater for HA-AKI than CA-AKI. In adjusted models, for patients with AKI vs no AKI and HA-AKI vs CA-AKI, odds ratios (ORs) (95% CI) were 3.70 (3.61-3.79) and 4.11 (3.92-4.31) for intensive care unit use and 3.52 (3.41-3.63) and 2.64 (2.52-2.78) for in-hospital mortality; mean length of stay (LOS) differences and LOS ratios (95% CI) were 1.8 days and 1.24 (1.23-1.25) and 5.1 days and 1.57 (1.54-1.59); and mean cost differences and cost ratios were $7163 and 1.35 (1.34-1.36) and $19 127 and 1.78 (1.75-1.81) (all P < .001). During the 30 days postdischarge, readmission LOS was ≥6% longer for AKI vs no AKI and HA-AKI vs CA-AKI; outpatient costs were ≥41% higher for HA-AKI vs CA-AKI or no AKI. Only 30-day new dialysis (among patients without index hospitalization dialysis) had similar odds for HA-AKI vs CA-AKI (2.37-2.8 times higher for AKI, HA-AKI, or CA-AKI vs no AKI). Discussion: Among inpatients with COVID-19, HA-AKI had higher excess mortality, HRU, and costs than CA-AKI. Other studies suggest that interventions to prevent HA-AKI could decrease excess morbidity, HRU, and costs among inpatients with COVID-19. Conclusions: In adjusted models among COVID-19 inpatients, AKI, especially HA-AKI, was associated with significantly higher mortality, HRU, and costs during index admission, and higher dialysis and longer readmission LOS during the 30 days postdischarge. These findings support implementation of interventions to prevent HA-AKI in COVID-19 patients.

COVID-19-associated AKI

PURPOSE OF REVIEW

While it is now widely established acute kidney injury (AKI) is a common and important complication of coronavirus disease (COVID-19) disease, there is marked variability in its reported incidence and outcomes. This narrative review provides a mid-2022 summary of the latest epidemiological evidence on AKI in COVID-19.

RECENT FINDINGS

Large observational studies and meta-analyses report an AKI incidence of 28-34% in all inpatients and 46-77% in intensive care unit (ICU). The incidence of more severe AKI requiring renal replacement therapy (RRT) in ICU appears to have declined over time, in data from England and Wales RRT use declined from 26% at the start of the pandemic to 14% in 2022. The majority of survivors apparently recover their kidney function by hospital discharge; however, these individuals appear to remain at increased risk of future AKI, estimated glomerular filtration rate (eGFR) decline and chronic kidney disease. Importantly even in the absence of overt AKI a significant proportion of survivors of COVID-19 hospitalisation had reduced eGFR on follow-up.

SUMMARY

This review summarises the epidemiology, risk factors, outcomes and treatment of COVID-19-associated AKI across the global pandemic. In particular the long-term impact of COVID-19 disease on kidney health is uncertain and requires further characterisation.

Clinical Outcome and Risk Assessment in Hospitalized COVID-19 Patients with Elevated Transaminases and Acute Kidney Injury: A Single Center Study

OBJECTIVES

Initial reports indicate a high incidence of abnormal aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels in patients with COVID-19 and possible association with acute kidney injury (AKI). We aimed to investigate clinical features of elevated transaminases on admission, its association with AKI, and outcomes in patients with COVID-19.

METHODS

A retrospective analysis of the registered data of hospitalized patients with laboratory-confirmed COVID-19 and assessment of the AST and ALT was performed. Multinomial logistic regression was used to determine factors associated with community-acquired AKI (CA-AKI) and hospital-acquired AKI (HA-AKI).

RESULTS

The subjects comprised 828 patients (mean age = 65.0±16.0 years; 51.4% male). Hypertension was present in 70.3% of patients, diabetes mellitus in 26.0%, and chronic kidney disease in 8.5%. In-hospital mortality was 21.0%. At admission, only 41.5% of patients had hypertransaminasemia. Patients with elevated transaminases at admission were younger, had higher levels of inflammatory markers and D-dimer, and poorer outcomes. The AKI incidence in the study population was 27.1%. Patients with hypertransaminasemia were more likely to develop AKI (33.5% vs. 23.3%, p = 0.003). Patients with predominantly elevated AST (compared to elevated ALT) were more likely to have adverse outcomes. Multinomial logistic regression found that hypertension, chronic kidney disease, elevated AST, and hematuria were associated with CA-AKI. Meanwhile, age > 65 years, hypertension, malignancy, elevated AST, and hematuria were predictors of HA-AKI.

CONCLUSIONS

Elevated transaminases on admission were associated with AKI and poor outcomes. Patients with elevated AST were more likely to have adverse outcomes. Elevated AST on admission was associated with CA-AKI and was a predictor of HA-AKI.

Long-short-term memory machine learning of longitudinal clinical data accurately predicts acute kidney injury onset in COVID-19: a two-center study

OBJECTIVES

This study used the long-short-term memory (LSTM) artificial intelligence method to model multiple time points of clinical laboratory data, along with demographics and comorbidities, to predict hospital-acquired acute kidney injury (AKI) onset in patients with COVID-19.

METHODS

Montefiore Health System data consisted of 1982 AKI and 2857 non-AKI (NAKI) hospitalized patients with COVID-19, and Stony Brook Hospital validation data consisted of 308 AKI and 721 NAKI hospitalized patients with COVID-19. Demographic, comorbidities, and longitudinal (3 days before AKI onset) laboratory tests were analyzed. LSTM was used to predict AKI with fivefold cross-validation (80%/20% for training/validation).

RESULTS

The top predictors of AKI onset were glomerular filtration rate, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, and C-reactive protein. Longitudinal data yielded marked improvement in prediction accuracy over individual time points. The inclusion of comorbidities and demographics further improves prediction accuracy. The best model yielded an area under the curve, accuracy, sensitivity, and specificity to be 0.965 ± 0.003, 89.57 ± 1.64%, 0.95 ± 0.03, and 0.84 ± 0.05, respectively, for the Montefiore validation dataset, and 0.86 ± 0.01, 83.66 ± 2.53%, 0.66 ± 0.10, 0.89 ± 0.03, respectively, for the Stony Brook Hospital validation dataset.

CONCLUSION

LSTM model of longitudinal clinical data accurately predicted AKI onset in patients with COVID-19. This approach could help heighten awareness of AKI complications and identify patients for early interventions to prevent long-term renal complications.

Sex differences in sequelae from COVID-19 infection and in long COVID syndrome: a review

OBJECTIVE

We conducted literature reviews to uncover differential effects of sex on sequelae from coronavirus disease 2019 (COVID-19) and on long COVID syndrome.

METHODS

Two authors independently searched OvidSP in Embase, Medline, Biosis, and Derwent Drug File. Publications reporting original, sex-disaggregated data for sequelae of COVID-19 (published before August 2020) and long COVID syndrome (published before June 2021) were included in the reviews. The association between COVID-19 sequelae (i.e. lasting <4 weeks after symptom onset) and sex, and between long COVID syndrome (i.e. lasting >4 weeks after symptom onset) and sex, was determined by odds ratio (OR) and 95% confidence interval (CI) (statistical significance defined by 95% CI not including 1).

RESULTS

Of 4346 publications identified, 23 and 12 met eligibility criteria for COVID-19 sequelae and long COVID syndrome, respectively. COVID-19 sequelae in the categories of psychiatric/mood (OR = 1.80; 95% CI: 1.35-2.41), ENT (OR = 1.42; 95% CI: 1.39-1.46), musculoskeletal (OR = 1.15; 95% CI: 1.14-1.16), and respiratory (OR = 1.09; 95% CI: 1.08-1.11) were significantly more likely among females (vs. males), whereas renal sequelae (OR = 0.83; 95% CI: 0.75-0.93) were significantly more likely among males. The likelihood of having long COVID syndrome was significantly greater among females (OR = 1.22; 95% CI: 1.13-1.32), with the odds of ENT (OR = 2.28; 95% CI: 1.94-2.67), GI (OR = 1.60; 95% CI: 1.04-2.44), psychiatric/mood (OR = 1.58; 95% CI: 1.37-1.82), neurological (OR = 1.30; 95% CI: 1.03-1.63), dermatological (OR = 1.29; 95% CI: 1.05-1.58), and other (OR = 1.36; 95% CI: 1.25-1.49) disorders significantly higher among females and the odds of endocrine (OR = 0.75; 95% CI: 0.69-0.81) and renal disorders (OR = 0.74; 95% CI: 0.64-0.86) significantly higher among males.

CONCLUSIONS

Sex-disaggregated differences for COVID-19 sequelae and long COVID syndrome were observed. Few COVID-19 studies report sex-disaggregated data, underscoring the need for further sex-based research/reporting of COVID-19 disease.

Clinical characteristics and factors associated with acute kidney injury among patients hospitalized with coronavirus disease: an observational retrospective study

BACKGROUND

Coronavirus disease 19 (COVID-19) is a multisystemic disease with high incidence of acute kidney injury (AKI).

OBJECTIVE

To describe the clinical characteristics and factors associated with AKI among patients hospitalized with COVID-19.

DESIGN AND SETTING

Retrospective cohort conducted at Hospital Civil de Culiacan, Mexico.

METHODS

We included 307 patients hospitalized due to COVID-19. AKI was defined and staged based on serum creatinine levels in accordance with the criteria of the Acute Kidney Injury Network (AKIN). Multivariate logistic regression analysis was used to determine factors associated with AKI.

RESULTS

The patients' age was 56 ± 15 years (64.5% male). The incidence of AKI was 33.6% (n = 103). Overall, 53.4% of patients had community-acquired AKI, and 46.6% had hospital-acquired AKI. Additionally, 15.5% of them presented AKIN stage 1; 34% had AKIN stage 2; and 50.5% had AKIN stage 3. Hemodialysis was required for 10.7% of the patients. The factors associated with AKI were chronic kidney disease (odds ratio, OR: 10.8; P = 0.04), use of norepinephrine (OR: 7.3; P = 0.002), diabetes mellitus (OR: 2.9; P = 0.03), C-reactive protein level (OR: 1.005; P = 0.01) and COVID-19 severity index based on chest tomography (OR: 1.09; statistical trend, P = 0.07). Hospital stay (11 ± 7 days; P < 0.001) and mortality (83.5 versus 31.4%; P < 0.05) were greater among patients with AKI.

CONCLUSION

AKI was a frequent and serious complication in our cohort of patients hospitalized with COVID-19, which was associated with high mortality and long hospital stay.

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.

Provider Perspectives and Clinical Outcomes with Inpatient Telenephrology

BACKGROUND AND OBJECTIVES

Despite the dramatic increase in the provision of virtual nephrology care, only anecdotal reports of outcomes without comparators to usual care exist in the literature. This study aimed to provide objective determination of clinical noninferiority of hybrid (telenephrology plus face-to-face) versus standard (face-to-face) inpatient nephrology care.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This retrospective study compares objective outcomes in patients who received inpatient hybrid care versus standard nephrology care at two Mayo Clinic Health System community hospitals. Outcomes were then additionally compared with those patients receiving care at another Mayo Clinic Health System site where only standard care is available. Hospitalized adults who had nephrology consults from March 1, 2020 to February 28, 2021 were considered. Regression was used to assess 30-day mortality, length of hospitalization, readmissions, odds of being prescribed dialysis, and hospital transfers. Sensitivity analysis was performed using patients who had ≥50% of their care encounters via telenephrology. Structured surveys were used to understand the perspectives of non-nephrology hospital providers and telenephrologists.

RESULTS

In total, 850 patients were included. Measured outcomes that included the number of hospital transfers (odds ratio, 1.19; 95% confidence interval, 0.37 to 3.82) and 30-day readmissions (odds ratio, 0.97; 95% confidence interval, 0.84 to 1.06), among others, did not differ significantly between controls and patients in the general cohort. Telenephrologists (n=11) preferred video consults (82%) to phone for communication. More than half (64%) of telenephrologists spent less time on telenephrology compared with standard care. Non-nephrology hospital providers (n=21) were very satisfied (48%) and satisfied (29%) with telenephrology response time and felt telenephrology was as safe as standard care (67%), while providing them enough information to make patient care decisions (76%).

CONCLUSIONS

Outcomes for in-hospital nephrology consults were not significantly different comparing hybrid care versus standard care. Non-nephrology hospital providers and telenephrologists had favorable opinions of telenephrology and most perceived it is as safe and effective as standard care.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_04_11_CJN13441021.mp3.

Outcomes of Hospitalized Patients With COVID-19 With Acute Kidney Injury and Acute Cardiac Injury

Purpose

This study investigated the incidence, disease course, risk factors, and mortality in COVID-19 patients who developed both acute kidney injury (AKI) and acute cardiac injury (ACI), and compared to those with AKI only, ACI only, and no injury (NI).

Methods

This retrospective study consisted of hospitalized COVID-19 patients at Montefiore Health System in Bronx, New York between March 11, 2020 and January 29, 2021. Demographics, comorbidities, vitals, and laboratory tests were collected during hospitalization. Predictive models were used to predict AKI, ACI, and AKI-ACI onset. Longitudinal laboratory tests were analyzed with time-lock to discharge alive or death.

Results

Of the 5,896 hospitalized COVID-19 patients, 44, 19, 9, and 28% had NI, AKI, ACI, and AKI-ACI, respectively. Most ACI presented very early (within a day or two) during hospitalization in contrast to AKI (p < 0.05). Patients with combined AKI-ACI were significantly older, more often men and had more comorbidities, and higher levels of cardiac, kidney, liver, inflammatory, and immunological markers compared to those of the AKI, ACI, and NI groups. The adjusted hospital-mortality odds ratios were 17.1 [95% CI = 13.6–21.7, p < 0.001], 7.2 [95% CI = 5.4–9.6, p < 0.001], and 4.7 [95% CI = 3.7–6.1, p < 0.001] for AKI-ACI, ACI, and AKI, respectively, relative to NI. A predictive model of AKI-ACI onset using top predictors yielded 97% accuracy. Longitudinal laboratory data predicted mortality of AKI-ACI patients up to 5 days prior to outcome, with an area-under-the-curve, ranging from 0.68 to 0.89.

Conclusions

COVID-19 patients with AKI-ACI had markedly worse outcomes compared to those only AKI, ACI and NI. Common laboratory variables accurately predicted AKI-ACI. The ability to identify patients at risk for AKI-ACI could lead to earlier intervention and improvement in clinical outcomes.

Kidney Injury in COVID-19: Epidemiology, Molecular Mechanisms, and Potential Therapeutic Targets

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.

Clinical predictors of acute cardiac injury and normalization of troponin after hospital discharge from COVID-19

Background

Although acute cardiac injury (ACI) is a known COVID-19 complication, whether ACI acquired during COVID-19 recovers is unknown. This study investigated the incidence of persistent ACI and identified clinical predictors of ACI recovery in hospitalized patients with COVID-19 2.5 months post-discharge.

Methods

This retrospective study consisted of 10,696 hospitalized COVID-19 patients from March 11, 2020 to June 3, 2021. Demographics, comorbidities, and laboratory tests were collected at ACI onset, hospital discharge, and 2.5 months post-discharge. ACI was defined as serum troponin-T (TNT) level >99th-percentile upper reference limit (0.014ng/mL) during hospitalization, and recovery was defined as TNT below this threshold 2.5 months post-discharge. Four models were used to predict ACI recovery status.

Results

There were 4,248 (39.7%) COVID-19 patients with ACI, with most (93%) developed ACI on or within a day after admission. In-hospital mortality odds ratio of ACI patients was 4.45 [95%CI: 3.92, 5.05, p<0.001] compared to non-ACI patients. Of the 2,880 ACI survivors, 1,114 (38.7%) returned to our hospitals 2.5 months on average post-discharge, of which only 302 (44.9%) out of 673 patients recovered from ACI. There were no significant differences in demographics, race, ethnicity, major commodities, and length of hospital stay between groups. Prediction of ACI recovery post-discharge using the top predictors (troponin, creatinine, lymphocyte, sodium, lactate dehydrogenase, lymphocytes and hematocrit) at discharge yielded 63.73%-75.73% accuracy.

Interpretation

Persistent cardiac injury is common among COVID-19 survivors. Readily available patient data accurately predict ACI recovery post-discharge. Early identification of at-risk patients could help prevent long-term cardiovascular complications.

Funding

None

Longitudinal prediction of hospital-acquired acute kidney injury in COVID-19: a two-center study

BACKGROUND

To investigate the temporal characteristics of clinical variables of hospital-acquired acute kidney injury (AKI) in COVID-19 patients and to longitudinally predict AKI onset.

METHODS

There were 308 hospital-acquired AKI and 721 non-AKI (NAKI) COVID-19 patients from Stony Brook Hospital (New York, USA) data, and 72 hospital-acquired AKI and 303 NAKI COVID-19 patients from Tongji Hospital (Wuhan, China). Demographic, comorbidities, and longitudinal (3 days before and 3 days after AKI onset) clinical variables were used to compute odds ratios for and longitudinally predict hospital-acquired AKI onset.

RESULTS

COVID-19 patients with AKI were more likely to die than NAKI patients (31.5% vs 6.9%, adjusted p < 0.001, OR = 4.67 [95% CI 3.1, 7.0], Stony Brook data). AKI developed on average 3.3 days after hospitalization. Procalcitonin was elevated prior to AKI onset (p < 0.05), peaked, and remained elevated (p < 0.05). Alanine aminotransferase, aspartate transaminase, ferritin, and lactate dehydrogenase peaked the same time as creatinine, whereas D-dimer and brain natriuretic peptide peaked a day later. C-reactive protein, white blood cell and lymphocyte showed group differences - 2 days prior (p < 0.05). Top predictors were creatinine, procalcitonin, white blood cells, lactate dehydrogenase, and lymphocytes. They predicted AKI onset with areas under curves (AUCs) of 0.78, 0.66, and 0.56 at 0, - 1, and - 2 days prior, respectively. When tested on the Tongji Hospital data, the AUCs were 0.80, 0.79, and 0.77, respectively.

CONCLUSIONS

Time-locked longitudinal data provide insight into AKI progression. Commonly clinical variables reasonably predict AKI onset a few days prior. This work may lead to earlier recognition of AKI and treatment to improve clinical outcomes.

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.

Risk Factors for Acute Kidney Injury in Adult Patients With COVID-19: A Systematic Review and Meta-Analysis

Background and Objective: Since December 2019, coronavirus disease 2019 (COVID-19) has spread rapidly around the world. Studies found that the incidence of acute kidney injury (AKI) in COVID-19 patients was more than double the incidence of AKI in non-COVID-19 patients. Some findings confirmed that AKI is a strong independent risk factor for mortality in patients with COVID-19 and is associated with a three-fold increase in the odds of in-hospital mortality. However, little information is available about AKI in COVID-19 patients. This study aimed to analyse the risk factors for AKI in adult patients with COVID-19.

Methods: A systematic literature search was conducted in PubMed, EMBASE, Web of Science, the Cochrane Library, CNKI, VIP and WanFang Data from 1 December 2019 to 30 January 2021. We extracted data from eligible studies to compare the effects of age, sex, chronic diseases and potential risk factors for AKI on the prognosis of adult patients with COVID-19.

Results: In total, 38 studies with 42,779 patients were included in this analysis. The meta-analysis showed that male sex (OR = 1.37), older age (MD = 5.63), smoking (OR = 1.23), obesity (OR = 1.12), hypertension (OR=1.85), diabetes (OR=1.71), pneumopathy (OR = 1.36), cardiovascular disease (OR = 1.98), cancer (OR = 1.26), chronic kidney disease (CKD) (OR = 4.56), mechanical ventilation (OR = 8.61) and the use of vasopressors (OR = 8.33) were significant risk factors for AKI (P < 0.05).

Conclusions: AKI is a common and serious complication of COVID-19. Overall, male sex, age, smoking, obesity, hypertension, diabetes, pneumopathy, cardiovascular disease, cancer, CKD, mechanical ventilation and the use of vasopressors were independent risk factors for AKI in adult patients with COVID-19. Clinicians need to be aware of these risk factors to reduce the incidence of AKI.

System Review Registration: PROSPERO, identifier [CRD42021282233].

Racial differences in cardiopulmonary outcomes of hospitalized COVID-19 patients with acute kidney injury

In-hospital acute kidney injury (IH-AKI) has been reported in a significant proportion of patients with COVID-19 and is associated with increased disease burden and poor outcomes. However, the mechanisms of injury are not fully understood. We sought to determine the significance of race on cardiopulmonary outcomes and in-hospital mortality of hospitalized COVID-19 patients with AKI. We conducted a retrospective cohort study of consecutive patients hospitalized in Grady Health System in Atlanta, Georgia between February and July 2020, who tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) on qualitative polymerase-chain-reaction assay. We evaluated the primary composite outcome of in-hospital cardiac events, and mortality in blacks with AKI versus non-blacks with AKI. In a subgroup analysis, we evaluated the impact of AKI in all blacks and in all non-blacks. Of 293 patients, effective sample size was 267 after all exclusion criteria were applied. The mean age was 61.4 ± 16.7, 39% were female, and 75 (28.1%) had IH-AKI. In multivariable analyses, blacks with IH-AKI were not more likely to have in-hospital cardiac events (aOR 0.3, 95% Confidence interval (CI) 0.04-1.86, p = 0.18), require ICU stay (aOR 0.80, 95% CI 0.20-3.25, p = 0.75), acute respiratory distress syndrome (aOR 0.77, 95% CI 0.16-3.65, p = 0.74), require mechanical ventilation (aOR 0.51, 95% CI 0.12-2.10, p = 0.35), and in-hospital mortality (aOR 1.40, 95% CI 0.26-7.50, p = 0.70) when compared to non-blacks with IH-AKI. Regardless of race, the presence of AKI was associated with worse outcomes. Black race is not associated with higher risk of in-hospital cardiac events and mortality in hospitalized COVID-19 patients who develop AKI. However, blacks with IH-AKI are more likely to have ARDS or die from any cause when compared to blacks without IH-AKI.

Mechanisms of COVID-19-induced kidney injury and current pharmacotherapies

The COVID-19 pandemic created a worldwide debilitating health crisis with the entire humanity suffering from the deleterious effects associated with the high infectivity and mortality rates. While significant evidence is currently available online and targets various aspects of the disease, both inflammatory and noninflammatory kidney manifestations secondary to COVID-19 infection are still largely underrepresented. In this review, we summarized current knowledge about COVID-19-related kidney manifestations, their pathologic mechanisms as well as various pharmacotherapies used to treat patients with COVID-19. We also shed light on the effect of these medications on kidney functions that can further enhance renal damage secondary to the illness.

Mortality and evolution between community and hospital-acquired COVID-AKI

Background

Acute kidney injury (AKI) is associated with poor outcomes in COVID patients. Differences between hospital-acquired (HA-AKI) and community-acquired AKI (CA-AKI) are not well established.

Methods

Prospective, observational cohort study. We included 877 patients hospitalized with COVID diagnosis at two third-level hospitals in Mexico. Primary outcome was all-cause mortality at 28 days compared between COVID patients with CA-AKI and HA-AKI. Secondary outcomes included the need for KRT, and risk factors associated with the development of CA-AKI and HA-AKI.

Results

A total of 377 patients (33.7%) developed AKI. CA-AKI occurred in 202 patients (59.9%) and HA-AKI occurred in 135 (40.1%). Patients with CA-AKI had more significant comorbidities, including diabetes (52.4% vs 38.5%), hypertension (58.4% vs 39.2%), CKD (30.1% vs 14.8%), and COPD (5.9% vs 1.4%), than those with HA-AKI. Patients’ survival without AKI was 87.1%, with CA-AKI it was 75.4%, and with HA-AKI it was 69.6%, log-rank test p < 0.001. Only age > 60 years (OR 1.12, 95% CI 1.06–1.18, p <0.001), COVID severity (OR 1.09, 95% CI 1.03–1.16, p = 0.002), the need in mechanical lung ventilation (OR 1.67, 95% CI 1.56–1.78, p <0.001), and HA-AKI stage 3 (OR 1.16, 95% CI 1.05–1.29, p = 0.003) had a significant increase in mortality. The presence of CKD (OR 1.48, 95% CI 1.391.56, p < 0.001), serum lymphocytes < 1000 μL (OR 1.03, 95% CI 1.00–1.07, p = 0.03), the need in mechanical lung ventilation (OR 1.06, 95% CI 1.02–1.11, p = 0.003), and CA-AKI stage 3 (OR 1.37, 95% CI 1.29–1.46, p < 0.001) were the only variables associated with a KRT start.

Conclusions

We found that COVID patients who are complicated by CA-AKI have more comorbidities and worse biochemical parameters at the time of hospitalization than HA-AKI patients, but despite these differences, their probability of dying is similar.

Acute tubulointerstitial nephritis and COVID-19

Coronavirus disease 2019 (COVID-19) is an ongoing pandemic that to date has spread to >100 countries. Acute kidney injury is not uncommon with this disease. The most common kidney biopsy finding is acute tubular injury. Glomerular diseases such as collapsing glomerulopathy and vasculitis, and thrombotic microangiopathy have been reported. Viral inclusion particles with distinctive spikes in the tubular epithelium and podocytes, and endothelial cells of the glomerular capillary loops, have been visualized by electron microscopy by some but disputed by others as non-viral structures. Interstitial infiltrates have not commonly been described in the published kidney biopsy series from patients with COVID-19. Medications used to treat COVID-19 can lead to interstitial nephritis, but very few have been reported. In summary, interstitial kidney disease is a rare finding in COVID-19.

High SARS-CoV-2 Viral Load in Urine Sediment Correlates with Acute Kidney Injury and Poor COVID-19 Outcome

BACKGROUND

AKI is a complication of coronavirus disease 2019 (COVID-19) that is associated with high mortality. Despite documented kidney tropism of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), there are no consistent reports of viral detection in urine or correlation with AKI or COVID-19 severity. Here, we hypothesize that quantification of the viral load of SARS-CoV-2 in urine sediment from patients with COVID-19 correlates with occurrence of AKI and mortality.

METHODS

The viral load of SARS-CoV-2 in urine sediments (U-viral load) was quantified by qRT-PCR in 52 patients with PCR-confirmed COVID-19 diagnosis, who were hospitalized between March 15 and June 8, 2020. Immunolabeling of SARS-CoV-2 proteins Spike and Nucleocapsid was performed in two COVID-19 kidney biopsy specimens and urine sediments. Viral infectivity assays were performed from 32 urine sediments.

RESULTS

A total of 20 patients with COVID-19 (39%) had detectable SARS-CoV-2 U-viral load, of which 17 (85%) developed AKI with an average U-viral load four-times higher than patients with COVID-19 who did not have AKI. U-viral load was highest (7.7-fold) within 2 weeks after AKI diagnosis. A higher U-viral load correlated with mortality but not with albuminuria or AKI stage. SARS-CoV-2 proteins partially colocalized with the viral receptor ACE2 in kidney biopsy specimens in tubules and parietal cells, and in urine sediment cells. Infective SARS-CoV-2 was not detected in urine sediments.

CONCLUSION

Our results further support SARS-CoV-2 kidney tropism. A higher SARS-CoV-2 viral load in urine sediments from patients with COVID-19 correlated with increased incidence of AKI and mortality. Urinary viral detection could inform the medical care of patients with COVID-19 and kidney injury to improve prognosis.

SARS-CoV-2 Infection and the Kidneys: An Evolving Picture

Since December 2019, a novel coronavirus known as Severe Acute Respiratory Virus 2 (SARS-CoV-2) has caused an outbreak of a respiratory illness worldwide. Even though SARS-CoV-2 primarily affects the respiratory system, other organs such as the heart and kidneys are implicated. The pathophysiology of Acute Kidney Injury (AKI) in coronavirus 2019 (COVID-19) patients is not clearly defined. Direct kidney injury results from virus entry through angiotensin-converting enzyme-2 (ACE2) receptors which are highly expressed by the podocytes and proximal convoluted tubules, as suggested by "viral-like" particles on electron microscopy. However, the link between the presence of viral particles in kidney tissue and kidney injury has not been fully explained. Furthermore, it is also hypothesized that collapsing focal segmental glomerulosclerosis (FSGS), myoglobin toxicity, sepsis-linked, and glomeruli fibrin thrombi is part of the mechanism for AKI. Reported cases link FSGS and high-risk apolipoprotein 1 (APOL1) alleles in patients of African ancestry. Typically, these patients present with AKI and nephrotic-range proteinuria. The rate of AKI in hospitalized patients is high and associated with a higher mortality rate in older patients with comorbidities. Even higher mortality is now being reported in patients with chronic kidney disease and kidney transplant recipients due to immune system dysfunction. Herein, we review the current literature on kidney disease and pathogenesis in COVID-19 patients.

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.

Increased risk of acute kidney injury in coronavirus disease patients with renin-angiotensin-aldosterone-system blockade use: a systematic review and meta-analysis

Acute kidney injury (AKI) is a severe complication of coronavirus disease (COVID-19) that negatively affects its outcome. Concern had been raised about the potential effect of renin-angiotensin-aldosterone system (RAAS) blockades on renal outcomes in COVID-19 patients. However, the association between RAAS blockade use and incident AKI in COVID-19 patients has not been fully understood. We investigated the association between RAAS blockade exposure and COVID-19-related AKI in hospitalized patients through meta-analysis. Electronic databases were searched up to 24th December 2020. Summary estimates of pooled odds ratio (OR) of COVID-19-related AKI depending on RAAS blockade exposure were obtained through random-effects model. The random-effect meta-analysis on fourteen studies (17,876 patients) showed that RAAS blockade use was significantly associated with increased risk of incident AKI in hospitalized COVID-19 patients (OR 1.68; 95% confidence interval 1.19-2.36). Additional analysis showed that the association of RAAS blockade use on COVID-19-related AKI remains significant even after stratification by drug class and AKI severity. RAAS blockade use is significantly associated with the incident AKI in hospitalized COVID-19 patients. Therefore, careful monitoring of renal complications is recommended for COVID-19 patients with recent RAAS blockade use due to the potential risk of AKI.

Pathophysiology and Clinical Manifestations of COVID-19-Related Acute Kidney Injury-The Current State of Knowledge and Future Perspectives

The continually evolving severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has resulted in a vast number of either acute or chronic medical impairments of a pathophysiology that is not yet fully understood. SARS-CoV-2 tropism for the organs is associated with bilateral organ cross-talks as well as targeted dysfunctions, among which acute kidney injury (AKI) seems to be highly prevalent in infected patients. The need for efficient management of COVID-related AKI patients is an aspect that is still being investigated by nephrologists; however, another reason for concern is a disturbingly high proportion of various types of kidney dysfunctions in patients who have recovered from COVID-19. Even though the clinical picture of AKI and COVID-related AKI seems to be quite similar, it must be considered that regarding the latter, little is known about both the optimal management and long-term consequences. These discrepancies raise an urgent need for further research aimed at evaluating the molecular mechanisms associated with SARS-CoV-2-induced kidney damage as well as standardized management of COVID-related AKI patients. The following review presents a comprehensive and most-recent insight into the pathophysiology, clinical manifestations, recommended patient management, treatment strategies, and post-mortem findings in patients with COVID-related AKI.

Broadening COVID-19 Interventions to Drug Innovation: Neprilysin Pathway as a Friend, Foe, or Promising Molecular Target?

The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus is anticipated to transition to an endemic state as vaccines are providing relief in some, but not all, countries. Drug discovery for COVID-19 can offer another tool in the fight against the pandemic. Additionally, COVID-19 impacts multiple organs that call for a systems medicine approach to planetary health and therapeutics innovation. In this context, innovation for drugs that prevent and treat COVID-19 is timely and much needed. As the virus variants emerge under different ecological conditions and contexts in the long haul, a broad array of vaccine and drug options will be necessary. This expert review article argues for a need to expand the COVID-19 interventions, including and beyond vaccines, to stimulate discovery and development of novel medicines against SARS-CoV-2 infection. The Renin-Angiotensin-Aldosterone System (RAAS) is known to play a major role in SARS-CoV-2 infection. Neprilysin (NEP) and angiotensin-converting enzyme (ACE) have emerged as the pharmaceutical targets of interest in the search for therapeutic interventions against COVID-19. While the NEP/ACE inhibitors offer promise for repurposing against COVID-19, they may display a multitude of effects in different organ systems, some beneficial, and others adverse, in modulating the inflammation responses in the course of COVID-19. This expert review offers an analysis and discussion to deepen our present understanding of the pathophysiological function of neprilysin in multiple organs, and the possible effects of NEP inhibitor-induced inflammatory responses in COVID-19-infected patients.

COVID-19 in Solid Organ Transplant Recipients: a Review of the Current Literature

Purpose of review

The approach to ongoing organ transplantation and management of COVID-19 in solid organ transplant recipients (SOTR) has evolved tremendously since the pandemic’s beginning. We summarize the current literature surrounding the virology of SARS-CoV-2, epidemiology of COVID-19 in transplant recipients, review the clinical features and complications of COVID-19 in SOTR, and discuss the safety and efficacy of current therapies and candidate vaccines in this population.

Recent findings

Despite initial suspensions in organ transplantation during early 2020, routine donor testing and de-crowding of hospitals have allowed transplant activity to resume at pre-pandemic rates. COVID-19-associated mortality in SOTR is similar to that of the general population, and lower than that of patients with end-organ disease awaiting transplant. The optimal approach to immunosuppression in SOTR with COVID-19 is unknown and disease severity may influence management decisions. Many vaccines in development are likely to be safe for immunocompromised hosts, though post-marketing investigations will be required to determine the efficacy in the SOTR.

Summary

Though there are multiple unique considerations in the care of SOTR with COVID-19, immunosuppression does not appear to have a detrimental impact on overall outcome. Organ transplantation remains a lifesaving intervention and can be safely performed despite a global pandemic.

Deleterious Effects of SARS-CoV-2 Infection on Human Pancreatic Cells

COVID-19 pandemic has infected more than 154 million people worldwide and caused more than 3.2 million deaths. It is transmitted by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and affects the respiratory tract as well as extra-pulmonary systems, including the pancreas, that express the virus entry receptor, Angiotensin-Converting Enzyme 2 (ACE2) receptor. Importantly, the endocrine and exocrine pancreas, the latter composed of ductal and acinar cells, express high levels of ACE2, which correlates to impaired functionality characterized as acute pancreatitis observed in some cases presenting with COVID-19. Since acute pancreatitis is already one of the most frequent gastrointestinal causes of hospitalization in the U.S. and the majority of studies investigating the effects of SARS-CoV-2 on the pancreas are clinical and observational, we utilized human iPSC technology to investigate the potential deleterious effects of SARS-CoV-2 infection on iPSC-derived pancreatic cultures containing endocrine and exocrine cells. Interestingly, iPSC-derived pancreatic cultures allow SARS-CoV-2 entry and establish infection, thus perturbing their normal molecular and cellular phenotypes. The infection increased a key cytokine, CXCL12, known to be involved in inflammatory responses in the pancreas. Transcriptome analysis of infected pancreatic cultures confirmed that SARS-CoV-2 hijacks the ribosomal machinery in these cells. Notably, the SARS-CoV-2 infectivity of the pancreas was confirmed in post-mortem tissues from COVID-19 patients, which showed co-localization of SARS-CoV-2 in pancreatic endocrine and exocrine cells and increased the expression of some pancreatic ductal stress response genes. Thus, we demonstrate that SARS-CoV-2 can directly infect human iPSC-derived pancreatic cells with strong supporting evidence of presence of the virus in post-mortem pancreatic tissue of confirmed COVID-19 human cases. This novel model of iPSC-derived pancreatic cultures will open new avenues for the comprehension of the SARS-CoV-2 infection and potentially establish a platform for endocrine and exocrine pancreas-specific antiviral drug screening.

Incidence and Outcomes of Acute Kidney Injury in COVID-19: A Systematic Review

BACKGROUND AND OBJECTIVES

The recent worldwide pandemic of COVID-19 has been a serious, multidimensional problem that has left a detrimental worldwide impact on individuals of all ages and several organ systems. The typical manifestation of kidney involvement is acute kidney injury (AKI); however, there is a lack of consensus data regarding AKI epidemiology in COVID-19. This systematic literature review aims to bridge this knowledge gap.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

MEDLINE and Cochrane library were systematically searched for the literature related to AKI in COVID-19 patients of all ages. MedRxIV was searched for relevant unpublished manuscripts. Two reviewers independently assessed the literature on the incidence of AKI and mortality, extracting the need for kidney replacement therapy (KRT).

RESULTS

Sixty studies (n = 43,871 patients) were included in this review. The pooled incidence of AKI among COVID-19 patients was 19.45% (95% confidence intervals [95% CI]: 14.63-24.77%), while the pooled incidence of AKI COVID-19 patients requiring KRT was 39.04% (16.38-64.57%). The pooled proportion of COVID+ patients was significantly lower at 8.83% (5.64% to 12/66%). The overall mortality of COVID-19 patients was calculated to be 17.71% (95% CI: 11.49-24.93%), while the mortality among patients with AKI was higher at 54.24% (95% CI: 44.70-63.63%).

CONCLUSION

This comprehensive systematic review summarizes the available literature pertaining to AKI epidemiology in COVID-19 patients and highlights the incidence, associated mortality, and the need for KRT in this susceptible population.

A review of Covid-19 and acute kidney injury: from pathophysiology to clinical results

Acute kidney injury (AKI) in hospitalized patients with COVID-19 is associated with higher mortality and a worse prognosis. Nevertheless, most patients with COVID-19 have mild symptoms, and about 5% can develop more severe symptoms and involve hypovolemia and multiple organ dysfunction syndrome. In a pathophysiological perspective, severe SARS-CoV-2 infection is characterized by numerous dependent pathways triggered by hypercytokinemia, especially IL-6 and TNF-alpha, leading to systemic inflammation, hypercoagulability, and multiple organ dysfunction. Systemic endotheliitis and direct viral tropism to proximal renal tubular cells and podocytes are important pathophysiological mechanisms leading to kidney injury in patients with more critical infection, with a clinical presentation ranging from proteinuria and/or glomerular hematuria to fulminant AKI requiring renal replacement therapies. Glomerulonephritis, rhabdomyolysis, and nephrotoxic drugs are also associated with kidney damage in patients with COVID-19. Thus, AKI and proteinuria are independent risk factors for mortality in patients with SARS-CoV-2 infection. We provide a comprehensive review of the literature emphasizing the impact of acute kidney involvement in the evolutive prognosis and mortality of patients with COVID-19.

Longitudinal Clinical Profiles of Hospital vs. Community-Acquired Acute Kidney Injury in COVID-19

Acute kidney injury (AKI) is associated with high mortality in coronavirus disease 2019 (COVID-19). However, it is unclear whether patients with COVID-19 with hospital-acquired AKI (HA-AKI) and community-acquired AKI (CA-AKI) differ in disease course and outcomes. This study investigated the clinical profiles of HA-AKI, CA-AKI, and no AKI in patients with COVID-19 at a large tertiary care hospital in the New York City area. The incidence of HA-AKI was 23.26%, and CA-AKI was 22.28%. Patients who developed HA-AKI were older and had more comorbidities compared to those with CA-AKI and those with no AKI (p < 0.05). A higher prevalence of coronary artery disease, heart failure, and chronic kidney disease was observed in those with HA-AKI compared to those with CA-AKI (p < 0.05). Patients with CA-AKI received more invasive and non-invasive mechanical ventilation, anticoagulants, and steroids compared to those with HA-AKI (p < 0.05), but patients with HA-AKI had significantly higher mortality compared to those with CA-AKI after adjusting for demographics and clinical comorbidities (adjusted odds ratio = 1.61, 95% confidence interval = 1.1-2.35, p < 0.014). In addition, those with HA-AKI had higher markers of inflammation and more liver injury (p < 0.05) compared to those with CA-AKI. These results suggest that HA-AKI is likely part of systemic multiorgan damage and that kidney injury contributes to worse outcomes. These findings provide insights that could lead to better management of COVID-19 patients in time-sensitive and potentially resource-constrained environments.

Urine biomarkers for the prediction of mortality in COVID-19 hospitalized patients

Risk factors associated with severity and mortality attributable to COVID-19 have been reported in different cohorts, highlighting the occurrence of acute kidney injury (AKI) in 25% of them. Among other, SARS-CoV-2 targets renal tubular cells and can cause acute renal damage. The aim of the present study was to evaluate the usefulness of urinary parameters in predicting intensive care unit (ICU) admission, mortality and development of AKI in hospitalized patients with COVID-19. Retrospective observational study, in a tertiary care hospital, between March 1st and April 19th, 2020. We recruited adult patients admitted consecutively and positive for SARS-CoV-2. Urinary and serum biomarkers were correlated with clinical outcomes (AKI, ICU admission, hospital discharge and in-hospital mortality) and evaluated using a logistic regression model and ROC curves. A total of 199 COVID-19 hospitalized patients were included. In AKI, the logistic regression model with a highest area under the curve (AUC) was reached by the combination of urine blood and previous chronic kidney disease, with an AUC of 0.676 (95%CI 0.512-0.840; p = 0.023); urine specific weight, sodium and albumin in serum, with an AUC of 0.837 (95% CI 0.766-0.909; p < 0.001) for ICU admission; and age, urine blood and lactate dehydrogenase levels in serum, with an AUC of 0.923 (95%CI 0.866-0.979; p < 0.001) for mortality prediction. For hospitalized patients with COVID-19, renal involvement and early alterations of urinary and serum parameters are useful as prognostic factors of AKI, the need for ICU admission and death.

Prevalence and risk factors of thrombotic events on patients with COVID-19: a systematic review and meta-analysis

BACKGROUND

Coagulation abnormalities in COVID-19 patients accompanied with poor prognosis. This study aimed to determine the prevalence and risk factors of thrombotic events on COVID-19 patients.

METHODS

We systematically reviewed all the studies about thrombotic events on COVID-19 patients in PubMed, Embase, Web of Science, MedRxiv, bioRxiv, from Dec 1, 2019 to July 5, 2020. The weighted mean difference (MD) or odds ratio (OR) or relative risk (RR) with 95 % confidence intervals (CI) for clinical data in COVID-19 patients with or without thrombotic events was calculated.

RESULTS

12 articles contained 1083 patients were included for meta-analysis. The prevalence of thrombosis was 22 % (95 % CI 0.08-0.40) in COVID-19 patients and increased to 43 % (95 % CI 0.29-0.65) after admission to the intensive care unit (ICU). Compared with non-thrombotic patients, thrombotic patients had higher levels of D-dimer (MD = 2.79 μg/ml, 95 % CI 2.27-3.31 μg/ml), lactate dehydrogenase (LDH) (MD = 112.71 U/L, 95 % CI 62.40-163.02 U/L), and white blood cells (WBC) (MD = 1.14 *109/L, 95 % CI 0.47-1.81*109/L) while decreased lymphocytes (MD= -0.20*109/L, 95 % CI -0.38 - -0.02*109/L). Age, platelet counts, and male sex tended to be risks while diabetes tended to be a protection for thrombosis for COVID-19 patients, although no statistical difference was achieved. Finally, patients with thrombosis were at a higher risk of death (OR = 2.39, 95 % CI 1.36-4.20).

CONCLUSIONS

Prevalence of thrombosis in COVID-19 patients was high, especially in ICU, though pharmacologic thromboembolism prophylaxis was applied. Therefore, higher levels of D-dimer, LDH, WBC, and decreased lymphocytes needed to be paid close attention to in patients with COVID-19.

AKI in Hospitalized Patients with COVID-19 and Seasonal Influenza: A Comparative Analysis

Background

Coronavirus disease 2019 (COVID-19) is often compared with seasonal influenza and the two diseases have similarities, including the risk of systemic manifestations such as AKI. The aim of this study was to perform a comparative analysis of the prevalence, risk factors, and outcomes of AKI in patients who were hospitalized with COVID-19 and influenza.

Methods

Retrospective cohort study of patients who were hospitalized with COVID-19 (n=325) or seasonal influenza (n=433). AKI was defined by Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Baseline characteristics and hospitalization data were collected, and multivariable analysis was performed to determine the independent predictors for AKI.

Results

AKI occurred in 33% of COVID-19 hospitalizations (COV-AKI) and 33% of influenza hospitalizations (FLU-AKI). After adjusting for age, sex, and comorbidity count, the risk of stage 3 AKI was significantly higher in COV-AKI (OR, 3.46; 95% CI, 1.63 to 7.37). Pre-existing CKD was associated with a six- to seven-fold increased likelihood for FLU-AKI and COV-AKI. Mechanical ventilation was associated with a higher likelihood of developing AKI in the COVID-19 cohort (OR, 5.85; 95% CI, 2.30 to 15.63). Black race, after adjustment for comorbidities, was an independent risk for COV-AKI.

Conclusions

Pre-existing CKD was a major risk factor for AKI in both cohorts. Black race (independent of comorbidities) and mechanical ventilation were associated with a higher risk of developing COV-AKI, which is characterized by a higher burden of stage 3 AKI and overall poorer prognosis.

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

RATIONALE & OBJECTIVE

Although coronavirus disease 2019 (COVID-19) has been associated with acute kidney injury (AKI), it is unclear whether this association is independent of traditional risk factors such as hypotension, nephrotoxin exposure, and inflammation. We tested the independent association of COVID-19 with AKI.

STUDY DESIGN

Multicenter, observational, cohort study.

SETTING & PARTICIPANTS

Patients admitted to 1 of 6 hospitals within the Yale New Haven Health System between March 10, 2020, and August 31, 2020, with results for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing via polymerase chain reaction of a nasopharyngeal sample.

EXPOSURE

Positive test for SARS-CoV-2.

OUTCOME

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

ANALYTICAL APPROACH

Evaluated the association of COVID-19 with AKI after controlling for time-invariant factors at admission (eg, demographic characteristics, comorbidities) and time-varying factors updated continuously during hospitalization (eg, vital signs, medications, laboratory results, respiratory failure) using time-updated Cox proportional hazard models.

RESULTS

Of the 22,122 patients hospitalized, 2,600 tested positive and 19,522 tested negative for SARS-CoV-2. Compared with patients who tested negative, patients with COVID-19 had more AKI (30.6% vs 18.2%; absolute risk difference, 12.5% [95% CI, 10.6%-14.3%]) and dialysis-requiring AKI (8.5% vs 3.6%) and lower rates of recovery from AKI (58% vs 69.8%). Compared with patients without COVID-19, patients with COVID-19 had higher inflammatory marker levels (C-reactive protein, ferritin) and greater use of vasopressors and diuretic agents. Compared with patients without COVID-19, patients with COVID-19 had a higher rate of AKI in univariable analysis (hazard ratio, 1.84 [95% CI, 1.73-1.95]). In a fully adjusted model controlling for demographic variables, comorbidities, vital signs, medications, and laboratory results, COVID-19 remained associated with a high rate of AKI (adjusted hazard ratio, 1.40 [95% CI, 1.29-1.53]).

LIMITATIONS

Possibility of residual confounding.

CONCLUSIONS

COVID-19 is associated with high rates of AKI not fully explained by adjustment for known risk factors. This suggests the presence of mechanisms of AKI not accounted for in this analysis, which may include a direct effect of COVID-19 on the kidney or other unmeasured mediators. Future studies should evaluate the possible unique pathways by which COVID-19 may cause AKI.

Community- and Hospital-Acquired Acute Kidney Injury in COVID-19: Different Phenotypes and Dismal Prognosis

INTRODUCTION

Acute kidney injury (AKI) is common in coronavirus disease 2019 (COVID-19). It is unknown if hospital-acquired AKI (HA-AKI) and community-acquired AKI (CA-AKI) convey a distinct prognosis.

METHODS

The study aim was to evaluate the incidence and risk factors associated with both CA-AKI and HA-AKI. Consecutive patients hospitalized at a reference center for COVID-19 were included in this prospective cohort study.

RESULTS

We registered 349 (30%) AKI episodes in 1,170 hospitalized patients, 224 (19%) corresponded to CA-AKI, and 125 (11%) to HA-AKI. Compared to patients with HA-AKI, subjects with CA-AKI were older (61 years [IQR 49-70] vs. 50 years [IQR 43-61]), had more comorbidities (hypertension [44 vs. 26%], CKD [10 vs. 3%]), higher Charlson Comorbidity Index (2 points [IQR 1-4] vs. 1 point [IQR 0-2]), and presented to the emergency department with more severe disease. Mortality rates were not different between CA-AKI and HA-AKI (119 [53%] vs. 63 [50%], p = 0.66). In multivariate analysis, CA-AKI was strongly associated to a history of CKD (OR 4.17, 95% CI 1.53-11.3), hypertension (OR 1.55, 95% CI 1.01-2.36), Charlson Comorbidity Index (OR 1.16, 95% CI 1.02-1.32), and SOFA score (OR 2.19, 95% CI 1.87-2.57). HA-AKI was associated with the requirement for mechanical ventilation (OR 68.2, 95% CI 37.1-126), elevated troponin I (OR 1.95, 95% CI 1.01-3.83), and glucose levels at admission (OR 1.05, 95% CI 1.02-1.08).

DISCUSSION/CONCLUSIONS

CA-AKI and HA-AKI portend an adverse prognosis in CO-VID-19. Nevertheless, CA-AKI was associated with a higher comorbidity burden (including CKD and hypertension), while HA-AKI occurred in younger patients by the time severe multiorgan disease developed.

Evaluation of the Current Therapeutic Approaches for COVID-19: A Systematic Review and a Meta-analysis

Background: Limited data on the efficacy and safety of currently applied COVID-19 therapeutics and their impact on COVID-19 outcomes have raised additional concern. Objective and Methods: To estimate the efficacy and safety of COVID-19 therapeutics, we performed meta-analyses of the studies reporting clinical features and treatments of COVID-19 published from January 21 to September 6, 2020. Results: We included 136 studies that involved 102,345 COVID-19 patients. The most prevalent treatments were antibiotics (proportion: 0.59, 95% CI: [0.51, 0.67]) and antivirals (proportion: 0.52, 95% CI: [0.44, 0.60]). The combination of lopinavir/ritonavir and Arbidol was the most effective in treating COVID-19 (standardized mean difference (SMD) = 0.68, 95% CI: [0.15, 1.21]). The use of corticosteroids was associated with a small clinical improvement (SMD = -0.40, 95% CI: [-0.85, -0.23]), but with a higher risk of disease progression and death (mortality: RR = 9.26, 95% CI: [4.81, 17.80]; hospitalization length: RR = 1.54, 95% CI: [1.39, 1.72]; severe adverse events: RR = 2.65, 95% CI: [2.09, 3.37]). The use of hydroxychloroquine was associated with a higher risk of death (RR = 1.68, 95% CI: [1.18, 2.38]). The combination of lopinavir/ritonavir, ribavirin, and interferon-β (RR = 0.34, 95% CI: [0.22, 0.54]); hydroxychloroquine (RR = 0.58, 95% CI: [0.39, 0.58]); and lopinavir/ritonavir (RR = 0.72, 95% CI: [0.56, 0.91]) was associated with reduced hospitalization length. Hydrocortisone (RR = 0.05, 95% CI: [0.03, 0.10]) and remdesivir (RR = 0.74, 95% CI: [0.62, 0.90]) were associated with lower incidence of severe adverse events. Dexamethasone was not significant in reducing disease progression (RR = 0.45, 95% CI: [0.16, 1.25]) and mortality (RR = 0.90, 95% CI: [0.70, 1.16]). The estimated combination of corticosteroids with antivirals was associated with a better clinical improvement than antivirals alone (SMD = -1.09, 95% CI: [-1.64, -0.53]). Conclusion: Antivirals are safe and effective in COVID-19 treatment. Remdesivir cannot significantly reduce COVID-19 mortality and hospitalization length, while it is associated with a lower incidence of severe adverse events. Corticosteroids could increase COVID-19 severity, but it could be beneficial when combined with antivirals. Our data are potentially valuable for the clinical treatment and management of COVID-19 patients.

Characteristics of COVID-19 patients with preexisting CKD history

Purpose

This paper was intended to describe the characteristics of coronavirus disease 2019 (COVID-19) patients with known chronic kidney disease (CKD) history.

Methods

Clinical information of 20 COVID-19 pneumonia patients with CKD history diagnosed between January 20th and March 1st, 2020 were collected in Tongji Hospital, Wuhan. We listed the clinical baseline data, laboratory findings, chest computed tomography (CT) changes and processed a short period of follow-up of these 20 patients.

Results

Based on the estimated glomerular filtration rate (eGFR) on admission, 6 patients were classified as stage 2 of CKD, 5 were as 3a, 2 were as 3b, 3 were as 4 and 4 were as 5, respectively. COVID-19 patients with CKD history were elder and hypertension was the most common comorbidity. Cough and fever accounted for more than 80% of the infectious cases. Lymphopenia, increased d-dimer and elevated infectious indications such as hypersensitive C response protein (hsCRP), interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α) were also common among these patients. Ground-glass opacity (GGO) and consolidation were the major manifestations in CT scans. 4 patients died and 7 patients underwent acute kidney injury (AKI) during observation. Among 16 discharged patients, 12 were with stable renal function and 4 had deteriorating renal function compared with that of admission.

Conclusion

Compared to general population infected with SARS-CoV-2, COVID-19 patients with CKD history had a preference to develop to severity with higher fatality rate.

COVID-19 and Renal Diseases: An Update

BACKGROUND

It becomes increasingly evident that the SARS-CoV-2 infection is not limited to the respiratory system. In addition to being a target of the virus, the kidney also seems to have a substantial influence on the outcomes of the disease.

METHODS

Data was obtained by a comprehensive and non-systematic search in the PubMed, Cochrane, Scopus and SciELO databases, using mainly the terms "SARS-CoV-2", "COVID-19", "chronic kidney disease", "renal transplantation", acute kidney injury" and "renal dysfunction" Discussion: The membrane-bound angiotensin-converting enzyme 2 is the receptor for SARS-CoV- -2, and this interaction may lead to an imbalance of the Renin-Angiotensin System (RAS), associated with worse clinical presentations of COVID-19, including acute pulmonary injury, hyperinflammatory state and hematological alterations. In the framework of renal diseases, the development of acute kidney injury is associated mostly with immune alterations and direct cytopathic lesions by the virus, leading to higher mortality. As for chronic kidney disease, the patients at a non-terminal stage have a worse prognosis, while the hemodialysis patients appear to have mild courses of COVID-19, probably due to lower chances of being affected by the cytokine storm. Furthermore, the current scenario is unfavorable to kidney donation and transplantation. The relationship between COVID-19 and immunosuppression in kidney transplantation recipients has been greatly discussed to determine whether it increases mortality and how it interacts with immunosuppressive medications.

CONCLUSION

The kidney and the RAS exert fundamental roles in the SARS-CoV-2 infection, and more research is required to have a complete understanding of the repercussions caused by COVID-19 in renal diseases.

Decreasing Incidence of Acute Kidney Injury in Patients with COVID-19 Critical Illness in New York City

Introduction

Reports from the United States suggest that acute kidney injury (AKI) frequently complicates coronavirus disease 2019 (COVID-19), but understanding of AKI risks and outcomes is incomplete. In addition, whether kidney outcomes have evolved during the course of the pandemic is unknown.

Methods

We used electronic medical records to identify patients with COVID-19 with and without AKI admitted to 3 New York Hospitals between March 2 and August 25, 2020. Outcomes included AKI overall and according to admission week, AKI stage, the requirement for new renal replacement therapy (RRT), mortality, and recovery of kidney function. Logistic regression was used to assess associations of patient characteristics and outcomes.

Results

Of 4732 admissions, 1386 (29.3%) patients had AKI. Among those with AKI, 717 (51.7%) had stage 1 disease, 132 (9.5%) had stage 2 disease, 537 (38.7%) had stage 3 disease, and 237 (17.1%) required RRT initiation. In March, 536 of 1648 (32.5%) patients developed AKI compared with 15 of 87 (17.2%) in August (P < 0.001 for monthly trend), whereas RRT initiation was required in 6.9% and 0% of admissions in March and August, respectively. Mortality was higher with than without AKI (51.6% vs. 8.6%) and was 71.9% in individuals requiring RRT. However, most patients with AKI who survived hospitalization (77%) recovered to within 0.3 mg/dl of baseline creatinine. Among those surviving to discharge, 62% discontinued RRT.

Conclusions

AKI impacts a high proportion of admitted patients with COVID-19 and is associated with high mortality, particularly when RRT is required. AKI incidence appears to be decreasing over time and kidney function frequently recovers in those who survive.

Kidney Complications of COVID-19: A Systematic Review and Meta-Analysis

Background: Some patients with coronavirus disease 2019 (COVID-19) have been reported to have developed mild to severe kidney injuries. The current systematic review and meta-analysis was carried out to estimate the prevalence and incidence of acute kidney injury (AKI) among COVID-19 patients.

Study design: A systematic review and meta-analysis

Methods: PubMed, Embase, Scopus, Web of Science, and MedRxiv databases were searched from December 1, 2019, up to July 27, 2020. Two independent co-authors completed the screening process, data extraction, and quality assessment of the retrieved records. Random-effects meta-analyses were used to determine the pooled prevalence and 95% confidence interval (CI) of AKI among COVID-19 patients.

Results: Out of 2,332 unique identified records, 51 studies were included in the review. Overall, the studies were carried out on 25,600 patients. A total of 6,505 patients (in 18 cross-sectional studies) were included to estimate the pooled prevalence of AKI, and 18,934 patients (in 27 cohort studies) were included to determine the pooled incidence of AKI. The pooled prevalence of AKI was estimated as 10.08% (95% CI: 4.59, 17.32; I ²=98.56%; P<0.001). Furthermore, the pooled incidence of AKI was 12.78% (95% CI: 7.38, 19.36; I ²=99.27%; P<0.001). The mean (95% CI) values of serum creatinine (SCr), blood urea nitrogen (BUN), potassium, and sodium were 76.10 (69.36, 82.84), 4.60 (4.04, 5.30), 3.94 (3.78, 4.11), and 139.30 (138.26, 140.36) mmol/L, respectively.

Conclusions: The AKI is a considerable complication among COVID-19 patients and should be screened for on clinical examinations. The BUN, SCr, potassium, and sodium levels were within the normal ranges.

Granulomatous interstitial nephritis in a patient with SARS-CoV-2 infection

Background

Acute kidney injury (AKI) associated with severe coronavirus disease 19 (COVID-19) is common and is a significant predictor of morbidity and mortality, especially when dialysis is required. Case reports and autopsy series have revealed that most patients with COVID-19 – associated acute kidney injury have evidence of acute tubular injury and necrosis - not unexpected in critically ill patients. Others have been found to have collapsing glomerulopathy, thrombotic microangiopathy and diverse underlying kidney diseases. A primary kidney pathology related to COVID-19 has not yet emerged. Thus far direct infection of the kidney, or its impact on clinical disease remains controversial. The management of AKI is currently supportive.

Case Presentation

The patient presented here was positive for SARS-CoV-2, had severe acute respiratory distress syndrome and multi-organ failure. Within days of admission to the intensive care unit he developed oliguric acute kidney failure requiring dialysis. Acute kidney injury developed in the setting of hemodynamic instability, sepsis and a maculopapular rash. Over the ensuing days the patient also developed transfusion-requiring severe hemolysis which was Coombs negative. Schistocytes were present on the peripheral smear. Given the broad differential diagnoses for acute kidney injury, a kidney biopsy was performed and revealed granulomatous tubulo-interstitial nephritis with some acute tubular injury. Based on the biopsy findings, a decision was taken to adjust medications and initiate corticosteroids for presumed medication-induced interstitial nephritis, hemolysis and maculo-papular rash. The kidney function and hemolysis improved over the subsequent days and the patient was discharged to a rehabilitation facility, no-longer required dialysis.

Conclusions

Acute kidney injury in patients with severe COVID-19 may have multiple causes. We present the first case of granulomatous interstitial nephritis in a patient with COVID-19. Drug-reactions may be more frequent than currently recognized in COVID-19 and are potentially reversible. The kidney biopsy findings in this case led to a change in therapy, which was associated with subsequent patient improvement. Kidney biopsy may therefore have significant value in pulling together a clinical diagnosis, and may impact outcome if a treatable cause is identified.

SMOTE-NC and gradient boosting imputation based random forest classifier for predicting severity level of covid-19 patients with blood samples

An increase in the number of patients and death rates make Covid-19 a serious pandemic situation. This problem has effects on health security, economical security, social life, and many others. The long and unreliable diagnosis process of the Covid-19 makes the disease spread even faster. Therefore, fast and efficient diagnosis is significant for dealing with this pandemic. Computer-aided medical diagnosis systems are very common applications and due to the importance of the problem, providing accurate predictions is required. In this study, blood samples of patients from Einstein Hospital in Brazil has collected and used for prediction on the severity level of Covid-19 with machine learning algorithms. The study was constructed in two stages; in stage-one, no preprocessing method has applied while in stage-two preprocessing has emphasized for achieving better prediction results. At the end of the study, 0.98 accuracy was obtained with the tuned Random Forest algorithm and several preprocessing methods.

The Prevalence of Acute Kidney Injury in Patients Hospitalized With COVID-19 Infection: A Systematic Review and Meta-analysis

RATIONALE & OBJECTIVE

Coronavirus disease 2019 (COVID-19) may be associated with high rates of acute kidney injury (AKI) and kidney replacement therapy (KRT), potentially overwhelming health care resources. Our objective was to determine the pooled prevalence of AKI and KRT among hospitalized patients with COVID-19.

STUDY DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase, the Cochrane Library, and a registry of preprinted studies, published up to October 14, 2020.

STUDY SELECTION

Eligible studies reported the prevalence of AKI in hospitalized patients with COVID-19 according to the Kidney Disease: Improving Global Outcomes (KDIGO) definition.

DATA EXTRACTION & SYNTHESIS

We extracted data on patient characteristics, the proportion of patients developing AKI and commencing KRT, important clinical outcomes (discharge from hospital, ongoing hospitalization, and death), and risk of bias.

OUTCOMES & MEASURES

We calculated the pooled prevalence of AKI and receipt of KRT along with 95% CIs using a random-effects model. We performed subgroup analysis based on admission to an intensive care unit (ICU).

RESULTS

Of 2,711 records reviewed, we included 53 published and 1 preprint study in the analysis, which comprised 30,657 hospitalized patients with COVID-19. Data for AKI were available for 30,639 patients (n = 54 studies), and receipt of KRT, for 27,525 patients (n = 48 studies). The pooled prevalence of AKI was 28% (95% CI, 22%-34%; I 2 = 99%), and the pooled prevalence of KRT was 9% (95% CI, 7%-11%; I 2 = 97%). The pooled prevalence of AKI among patients admitted to the ICU was 46% (95% CI, 35%-57%; I 2 = 99%), and 19% of all ICU patients with COVID-19 (95% CI, 15%-22%; I 2 = 88%) commenced KRT.

LIMITATIONS

There was significant heterogeneity among the included studies, which remained unaccounted for in subgroup analysis.

CONCLUSIONS

AKI complicated the course of nearly 1 in 3 patients hospitalized with COVID-19. The risk for AKI was higher in critically ill patients, with a substantial number receiving KRT at rates higher than the general ICU population. Because COVID-19 will be a public health threat for the foreseeable future, these estimates should help guide KRT resource planning.