MO328: Acute Renal Failure in COVID-19: Aetiology and Renal Evolution. AKI-COVID Registry of the Spanish Society of Nephrology

BACKGROUND AND AIMS

Acute kidney injury (AKI) has been described as a frequent complication in patients with COVID-19. The incidence of AKI is estimated to be around 5%–80% depending on the series; however, data characterizing the type of AKI and the evolution of renal function parameters in the medium-long term are still limited.

METHOD

Based on the initial AKI-COVID Registry, we developed an extended registry where we registered retrospectively new variables that included clinical and demographic characteristics, infection severity parameters and data related to AKI (ethology, KDIGO classification, need of renal replacement therapy, analytic values: baseline creatinine, maximum creatinine during admission, creatinine at discharge or death, creatinine at 1 month after hospitalization and urinary parameters). Recovery of kidney function was defined as difference in at discharge or posthospitalization creatinine < 0.3 mg/dL with respect basal creatinine.

RESULTS

Our analysis included 196 patients: 74% male, mean age 66 + 13 years; 65% hypertensive, 33% diabetic and 22% chronic kidney disease. According to the KDIGO classification: 66% AKI KDIGO3, 17% KDIGO2 and 15% KDIGO1. Creatinine values ​​are summarized in Table 1. We found significant differences in the baseline/high creatinine differential; these differences were lost after hospitalization.

The main types of AKI were prerenal (35%) and acute tubular necrosis secondary to sepsis (ATN) (53%). 89% of patients with ATN presented AKI KDIGO 3, compared with 57% in the prerenal group (P < .001). Patients with prerenal AKI had greater comorbidity. On the other hand, patients with ATN AKI developed more serious COVID-19 infection: higher percentage of severe pneumonia, admission to the intensive care unit and need for orotracheal intubation. The analytical parameters were more extreme in patients with ATN AKI, except for creatinine and urea upon admission, which were higher in the prerenal AKI group.

A total of 89 patients died during the study; 65% of ATN AKI patients versus 31% of prerenal-AKI patients (P < .001). The ATN was a mortality risk factor, whit a hazard ratio 2.74 [95% confidence interval (95% CI )1.29–5.7] (P = .008) compared with the prerenal AKI.

CONCLUSION

AKI in hospitalized patients with COVID19 presented with two different clinical patterns. Prerenal AKI more frequently affected older, more comorbid patients, and with a mild COVID19 infection. The NTA AKI affected younger patients, with criteria of severity of infection and multiplying mortality almost three times. In analytical control 1-month post-hospitalization, most of the patients recovered their kidney function. Although the implications of AKI associated with COVID-19 in the development of chronic kidney disease are still unclear, our data suggest that most patients will recover kidney function in a medium term.

Incidence of severe breakthrough SARS-CoV-2 infections in vaccinated kidney transplant and haemodialysis patients

Introduction

Given the increased COVID-19 observed in kidney transplant recipients (KTRs) and haemodialysis patients, several studies have tried to establish the efficacy of mRNA vaccines in these populations by evaluating their humoral and cellular responses. However, there is currently no information on clinical protection (deaths and hospitalizations), a gap that this study aims to fill.

Methods

Observational prospective study involving 1,336 KTRs and haemodialysis patients from three dialysis units affiliated to Hospital Clínic of Barcelona, Spain, vaccinated with two doses of mRNA-1273 (Moderna) or BNT162b2 (Pfizer-BioNTech) SARS-CoV-2 mRNA vaccines. The outcomes measured were SARS-CoV-2 infection diagnosed by a positive RT-PCR fourteen days after the second vaccine dose, hospital admissions derived from infection, and a severe COVID-19 composite outcome, defined as either ICU admission, invasive and non-invasive mechanical ventilation, or death.

Results

Six per cent (18/302) of patients on haemodialysis were infected, of whom four required hospital admission (1.3%), only one (0.3%) had severe COVID-19, and none of them died. In contrast, 4.3% (44/1034) of KTRs were infected, and presented more hospital admissions (26 patients, 2.5%), severe COVID-19 (11 patients, 1.1%) or death (4 patients, 0.4%). KTRs had a significantly higher risk of hospital admission than HD patients, and this risk increased with age and male sex (HR 3.37 and 4.74, respectively).

Conclusions

The study highlights the need for booster doses in KTRs. In contrast, the haemodialysis population appears to have an adequate clinical response to vaccination, at least up to four months from its administration.

Graphical abstract

Weight gain following pancreas transplantation in type 1 diabetes is associated with a worse glycemic profile: A retrospective cohort study

AIMS

Evaluate the weight trajectories after pancreas transplantation (PT) and their relationships with pancreas graft outcomes in type 1 diabetes (T1D).

METHODS

Retrospective cohort study. T1D individuals who underwent PT were recruited (T1D-PT; n = 194) and divided into three groups according to transplantation date: 1999-2004 (n = 57), 2005-2009 (n = 79), 2010-2015 (n = 58). For weight comparisons, a random sample of T1D without renal impairment was also recruited during 2015 (n = 61; T1D-control).

RESULTS

The median follow-up for the T1D-PT group was 11.1 years. Despite significant weight loss at 6 months (65.7 ± 12.4 vs. 64.1 ± 11.4 Kg; p < 0.001), a stepped increase was seen thereafter (60 months: 68.0 ± 14.0 Kg; p < 0.001). Participants from the 2010-2015 period showed higher weight gain (p < 0.001), outweighing that observed in the T1D-control (60 months: +4.69 ± 8.49 vs. -0.97 ± 4.59 Kg; p = 0.003). Weight gain between 6 and 36 months was directly associated with fasting glucose and HbA1c at 36 months, and with HbA1c at 60 months (p < 0.05). However, in Cox-regression models adjusted for age, sex, and several recipient and PT-related variables, the third tertile of weight gain between 6 and 36 months showed a non-significant increase in the graft failure/dysfunction (HR 2.33 [0.75-7.27]).

CONCLUSIONS

Weight gain post-PT was associated with glucose-related biochemical markers of graft dysfunction, which needs confirmation in further studies.

Kidney Transplantation in Monoclonal Immunoglobulin Deposition Disease: A Report of 6 Cases

Monoclonal immunoglobulin deposition disease (MIDD) usually leads to kidney failure. Treatment of patients with a bortezomib-based regimen followed by autologous stem cell transplantation (SCT) has been increasingly used, with improvements in the response rates and allograft outcomes in kidney transplant recipients. The objective of this report was to analyze the outcomes of 6 patients who underwent kidney transplantation in our institution after treatment of MIDD between 2010 and 2019. Monoclonal immunoglobulin deposition disease was initially treated with bortezomib-based therapy followed by high-dose melphalan and autologous SCT with complete hematologic response, although all patients remained on dialysis. During a median follow-up of 20.5 months from kidney transplant (54 months from SCT), 1 patient experienced hematologic relapse and 2 had hematologic progression (one of them with MIDD relapse in the allograft) requiring treatment. The patient with organ relapse received daratumumab monotherapy, achieving complete hematologic response but with graft failure. The other 5 patients had functional grafts with median serum creatinine 1.68 mg/dL. These results support that, in patients with MIDD and sustained complete hematologic response, a kidney transplant can be considered. The optimal approach to treatment of hematologic relapse or recurrence of MIDD after kidney transplant remains to be determined.

Severe acute kidney injury in critically ill COVID-19 patients

BACKGROUND

Acute kidney injury (AKI) is frequent in Coronavirus Infection Disease 2019 (COVID-19) patients. Factors associated with AKI in COVID-19 intensive care unit (ICU) patients and their outcomes have not been previously explored.

METHODS

Prospective observational study of COVID-19 patients admitted to the ICUs of the Hospital Clínic of Barcelona (Spain), from March 25th to April 21st, 2020, who developed AKI stage 2 or higher (AKIN classification). The primary goal was to describe the characteristics of moderate-severe AKI of COVID-19 patients in an ICU context. As a secondary goal, we aimed to find independent predictors of AKI progression, Renal Replacement Therapy (RRT) requirement and mortality among these patients.

RESULTS

During the study period, 52 out of 237 ICU patients, developed AKIN stage 2 or higher and were included in the study. A Sequential Organ Failure Assessment (SOFA) score at AKI diagnosis of 8 or higher was associated with RRT, OR 5.2, p 0.032. At the time of AKI diagnosis, patients had a worse liver profile and higher inflammation markers than at admission. Fifty per cent of the patients presented AKI progression from AKIN 2 to 3 and 28.85% required RRT. The use of corticosteroids in 69.2% of patients was associated with a reduced requirement of RRT, OR 0.13 (CI 95% 0.02-0.89), p 0.037. AKI was associated with high mortality (50%) and a longer hospital stay, median 35 vs 18 days (p 0.024).

CONCLUSIONS

The prevalence of moderate/severe AKI in COVID-19 patients admitted to the ICU is high and has a strong correlation with mortality and length of hospital stay.

Outcomes of pancreas transplantation in older diabetic patients

OBJECTIVE

Improvement in insulin alternatives is leading to a delayed presentation of microvascular and macrovascular complications of diabetes. The objective of this study was to evaluate the long-term outcomes of older (≥50 years) diabetic patients who receive a pancreas transplantation (PT).

RESEARCH DESIGN AND METHODS

We retrospectively evaluated all 338 PTs performed at our center between 2000 and 2016 (mean follow-up 9.4±4.9 years). Recipient and graft survivals were estimated for up to 10 years after PT. Major adverse cardiovascular events (MACEs) before and after PT were included in the analysis.

RESULTS

Thirty-nine patients (12%) were ≥50 years old (52.7±2.3 years) at the day of PT, of which 29 received a simultaneous pancreas-kidney transplantation (SPK) and 10 a pancreas after kidney transplantation (PAK). SPK recipients were first transplants, whereas in the PAK up to 50% were pancreas re-transplantations. Recipient and pancreas graft survivals at 10 years were similar between the group <50 years old and the older group for both SPK and PAK (log-rank p>0.05). The prevalence of MACE prior to PT was similar between both groups (31% vs 29%). Following PT, older recipients presented inferior post-transplant MACE-free survival. In a multivariate regression model, diabetes vintage (HR 1.054, p=0.03) and pre-transplantation MACE (HR 1.98, p=0.011), but not recipient age (HR 1.45, p=0.339), were associated with post-transplant MACE.

CONCLUSIONS

Long-term survival of older pancreas transplant recipients are similar to younger counterparts. Diabetes vintage, but not age, increased the risk of post-transplantation MACE. These results suggest pancreas transplantation is a valuable treatment alternative to older diabetic patients.