Deaths Sky High in Hospitalized COVID Patients With Kidney Injury

Pam Harrison

September 09, 2020

More evidence indicates that the development of acute kidney injury (AKI) in patients hospitalized with COVID-19 is associated not only with dramatically higher than usual mortality rates but also that a significant proportion of patients with AKI do not recover kidney function by the time they are discharged.

"This...is the first study in the United States to report the persistence of kidney dysfunction (lack of recovery) in survivors of COVID-19–associated AKI [and] this is in marked contrast to other forms of AKI where over 80% of patients recover their renal function by 10 days," Lili Chan, MD, of the Icahn School of Medicine at Mount Sinai, New York City, and colleagues observe.

The research is a retrospective, observational cohort study published online September 3 in the Journal of the American Society of Nephrology

"We may be facing an epidemic of post-COVID-19 kidney disease and that, in turn, could mean much greater numbers of patients who require kidney dialysis and even transplants," said senior author Girish Nadkarni, MD, a nephrologist, in a statement from Mount Sinai.

Nephrologists will need to prepare for a significant uptick in patients with chronic kidney disease as a result of exposure to the SARS-CoV-2 virus that causes COVID-19, the researchers warn. 

"These findings may help centers with resource planning and preparing for the increased load resulting from survivors of COVID-19–associated AKI who do not experience recovery of kidney function," they add.

Analysis of Patients From February to End of May 2020

"AKI among hospitalized patients with COVID-19 in the United States is not well described," they note in their article.

And so they analyzed data from five major hospitals in the Mount Sinai Health System (MSHS) between February 27 and May 30 of this year, during which 3993 patients were hospitalized within the system for COVID-19. The MSHS has a patient population of racially and ethnically diverse citizens from New York.

AKI was defined using Kidney Disease: Improving Global Outcomes (KDIGO) criteria. AKI occurred in 46% of the overall cohort of patients, 19% of whom required dialysis.

However, among those patients who required admission to the intensive care unit (ICU), over three quarters (76%) developed AKI and almost one third of ICU patients required dialysis, the investigators say.

"The median time from hospital admission until AKI diagnoses was 1...day and the median time from AKI diagnosis to dialysis was 3...days," they explain.

The proportion of patients with stages 1, 2, or 3 AKI among those admitted to hospital were 39%, 19%, and 42%, respectively. In patients requiring admission to ICU, 28% had stage 1 AKI, 17% had stage 2, and 56% had stage 3.

And among those who required dialysis for AKI, the median peak serum creatinine was 8.2 mg/dL compared with 2.2 mg/dL for those who did not require dialysis.

Predictors of AKI: Male Sex, Potassium Levels, and Pre-existing CKD

Almost two thirds of patients (65%) had recovered from their kidney injury by the time they left hospital but 35% had acute kidney disease. Of this latter group, on follow-up, 36% had recovered from it, the investigators note.

Conversely, of those patients who had recovered from AKI by hospital discharge, 14% went on to develop acute kidney disease at the time of follow-up.

And 30% of patients who had required dialysis at some point during their hospital care required dialysis again within 72 hours of being discharged, the investigators note.

Predictors of severe AKI included male sex (adjusted odds ratio [aOR], 1.46), potassium levels on admission (aOR, 1.7), and pre-existing chronic kidney disease (CKD) (aOR, 2.8).

Most compellingly, "in-hospital mortality in patients who experienced AKI was 50% [versus] 8% in patients without AKI (P < .001)," Nadkarni and colleagues report.

Among those who required ICU care, 42% of patients with AKI died compared with 7% of those in ICU who did not develop AKI, while in patients cared for outside of ICU, 62% with AKI died compared with only 13% of those who did not develop AKI.  

And after adjusting for demographics, comorbidities, and laboratory values, the aOR for death was 11.4 times higher for ICU patients with AKI compared to ICU patients without AKI, the authors emphasize.

In all patients who developed AKI, the aOR for mortality was 9.2 compared to patients who did not develop AKI, they add.

Perhaps predictably, the risk of death rose with increasing stage of AKI, and patients with stage 3 AKI who required dialysis were at highest risk of death, the authors observe.

Sheer Number of AKI Cases, Need for Dialysis Unprecedented

"The sheer number of AKI cases and the overwhelming need for dialysis that we are seeing in the context of COVID-19 is unprecedented," Nadkarni said.

"These findings bring clinical evidence to the hypothesis of lingering organ dysfunction among patients recovering from COVID-19 and serve as a reminder to hospitals around the country to be very strategic in the allocation of resources to care for patients who experience AKI," he cautioned.

"We are grappling with a great deal of uncertainty as to how the virus will impact the kidneys in the long haul," Nadkarni added. "We may be facing an epidemic of post-COVID-19 kidney disease, and that, in turn, could mean much greater numbers of patients who require kidney dialysis and even transplants."

Nadkarni has reported serving as a consultant and advisory board member for RenalytixAI and owns equity in the company.

JASN. Published online September 3, 2020. Full text

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