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COVID-19 and Acute Kidney Injury.

Acute kidney injury (AKI) has increasingly been observed in a significant number of patients experiencing COVID-19. Two articles are reviewed exploring AKI in patients who are hospitalized.

Article Reviewed

Chan, L., Chaudhary, K., Saha, A., Chauhan, K, Vaid, A., Zhao, S., Paranjpe, I., Somani, S., Richter, F., Miotto, R., Lala, A., Kia, A., Timsina, P., Li, L., Freeman, R. Chen, R., Narula, J., Just, A.C., Horowitz, C., ... Nadkarmi, G.N., on behalf of the Mount Sinai COVID Informatics Center (MSCIC). (2020). AKI in hospitalized patients with COVID-19. JASN: Journal of the American Society of Nephrology, 31(10).

The emergence of COVID-19 has led to the development of associated acute kidney injury (AKI) in an unanticipated and alarming number of patients, often requiring kidney replacement therapy (KRT). Chan and colleagues (2020) described the incidence of AKI, the need for therapeutic intervention, and early outcomes.

The retrospective, observational study examined patients who were admitted to five major hospitals in a hospital system in greater New York City that serves a large, racially and ethnically diverse patient population between February 27 to May 30, 2020, with follow up endingJune 5, 2020. Patients who were at least 18 years old had laboratory confirmation of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Patients known to have end stage kidney disease (ESKD) were excluded. Kidney Disease Improving Global Outcomes (KDIGO) criteria were used to define the end point of AKI.

There were 3993 patients in the study--1835 of whom developed AKI (46%), with 347 of the 1835 (19%) requiring dialysis. Independent predictors of severe AKI included being male, having chronic kidney disease (CKD), and having higher potassium levels at the time of admission. Admission to intensive care units, mechanical ventilation, and the need for vasopressors were more likely in patients with AKI. Of the 976 (24%) patients admitted to intensive care, 76% developed AKI. Patients with AKI had a substantially higher incidence of proteinuria, hematuria, and leukocyturia than patients without AKI. The mortality was 50% in the AKI population versus 8% in those not experiencing AKI. Only 30% of the patients with AKI recovered their kidney function and were discharged alive. Kidney function had not returned to baseline at the time of discharge in 35% of the patients, and 36% of those (28 of 77) recovered kidney function after hospitalization. The status of some patients is reported as unknown because follow up and/or dialysis occurred outside of the reporting health care systems.

Article Reviewed

Fisher, M., Neugarten, J., Bellin, E., Yunes, M., Stahl, L., Johns, T.S., Abramowitz, M.K., Levy, R., Kumar, N., Mokrzycki, M.H., Coco, M., Dominguez, M, Prudhvi, K., & Golestaneh. (2020). AKI in hospitalized patients with and without COVID-19: A comparative study. JASN: Journal of the American Society of Nephrology, 31(9), 2145-2157

Acute kidney injury (AKI) has been associated with patients who have COVID-19; however, prior to this study, the occurrence of AKI had not been compared to hospitalized patients without the viral infection to ascertain if there were unique risks for the patients who had AKI with COVID-19. Fisher and colleagues (2020) conducted a retrospective, observational study to explore the incidence, risk factors, and outcomes of AKI for 3345 adults with COVID-19 and 1265 patients without the illness. The study was conducted in a large New York City health care system from March 11 to April 26, 2020, in which the authors used an historical cohort of 9859 patients hospitalized the previous year over the approximate same time frame for comparison. The Bronx, where the study took place, had the highest number of COVID-19 cases per 100,000 population of the five boroughs of New York City. The Bronx is identified as one of the poorest urban communities in the nation, with excess mortality arising from heart disease, stroke, and diabetes. As such, the population was at increased risk for COVID-19 and its possible complications.

Study Criteria

Study inclusion required patients to be 18 years of age, not have known ESKD, and have a positive test for the viral infection upon admission. Excluded were those with unknown creatinine values and one patient with an unknown sex assignment. Sociodemographic variable data (age, sex, race/ethnicity, and socioeconomic status) were extracted, plus a variable, "crowding," meaning the number of people in a household based upon census tract data of more than 1.5 occupants per room in the dwelling. Comorbidity data included obesity using body mass index, diabetes mellitus, CKD, congestive heart failure, lung disease, HIV/AIDS, malignancy, and rheumatologic disease.

Using a change from baseline creatinine, an increase of 0.3 mg/dL or greater than a 50% increase in serum creatinine to the maximum level during hospitalization met the criteria for AKI. The lowest creatinine during hospitalization was used for the baseline when a pre-hospitalization level was unknown. AKI staging was done using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. When patients required KRT, they were classified as AKI Stage 3. Urine volumes were not included as a parameter because they were not consistently collected.


More than half of the subjects in the COVID-19-positive group were men, and 16.4% of those were nursing home residents. Black and Hispanic males comprised the largest proportion of the cohort; other risk factors included obesity, diabetes mellitus, and being below the state's median socioeconomic status. In contrast, those who were COVID-19-negative were younger, more likely female, had a lower incidence of obesity, and fewer resided in nursing homes. COVID-19-positive patients with AKI had the same risk factors as described above. "Patients with AKI but negative for COVID-19 had similar patterns of association, demonstrating older age, a higher prevalence of comorbidities, and a higher proportion of men compared to those without AKI" (Fisher et al., 2020, p. 2148).

The COVID-19-positive cohort had distinguishing findings upon presentation to the hospital: higher respiratory and pulse rates and lower oxygen saturation. Patients without COVID-19 but with AKI had similar findings as the positive group. Patients with AKI also had heavy proteinuria, regardless of their COVID-19 status. Of the patients who required intensive care admission, 87.2% were COVID-19-positive compared with 65% in the negative cohort. More patients with AKI required mechanical ventilation in both positive and negative groups, although the positive COVID-19 group required KRT more often.

Prognosis for Patients Following AKI Stage 3

Recovery of kidney function was poorer in the COVID-19-positive group when compared to both the negative and historical groups. In-hospital deaths were similar among the three groups. Even though fewer COVID-19-positive patients with AKI requiring KRT remained dependent upon the therapy than the negative group or historical group; this was noted as likely being a reflection of the high rate of mortality in the COVID-19-positive and AKI Stage 3 group.


Patients who were men, Black, and older (especially those over age 50 years), were more likely to experience AKI in both COVID-19 positive and negative groups.

"We were able to demonstrate the effect of COVID-19 on hospital resources including a disproportionate need for ICU, mechanical ventilation, [renal replacement therapy], increased length of stay, and higher mortality compared with those without COVID-19" (Fisher et al., 2020, p. 2154). When compared with the historical cohort, the COVID-19-negative patients had worse outcomes, which was thought to be due--at least in part to false-negative SARS-CoV-2 results and allocation of resources away from those patients testing negative, and patient avoidance of hospitals during that timeframe for fear of contracting the infectious viral disease.

Men were more likely to develop serious infection and subsequent increased risk for AKI in all groups. The authors speculated that the increased risk for the Black race may be a function of racial disparity, with low income individuals having poorer access to medical care and resulting inadequate management of comorbidities, and perhaps increased exposure to nephrotoxic agents.

Key Words:

COVID-19, acute kidney injury.

Karen C. Robbins, MS, RN, CNNe

Karen C. Robbins, MS, RN, CNNe, is the Associate Editor of the Nephrology Nursing Journal, a Past-President of ANNA, and a member of ANNA's Desert Vista Chapter.

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Title Annotation:NNJ Journal Club
Author:Robbins, Karen C.
Publication:Nephrology Nursing Journal
Geographic Code:1USA
Date:Sep 1, 2020
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