Saturday, September 05, 2020

JASN: Acute Kidney Injury In Hospitalized Patients With COVID-19

 Credit Wikipedia


Very early on in the emergence of COVID-19 it became apparent that the SARS-CoV-2 virus was producing a high morbidity - low mortality pandemic; several times deadlier than than seasonal flu, but not as lethal as MERS-CoV, SARS, or avian H5N1, H5N6, or H7N9. 

Depending upon the availability of modern medical care, the CFR (Case Fatality Rate) of COVID-19 has hovered around 1%.

While reassuring, a 99% recovery rate doesn't tell the whole story.  Somewhere between 10% and 20% of cases are sick enough to be hospitalized, and among them, hospitalizations are often prolonged, and recovery - even after returning home - can be both lengthy and complicated. 

Until recently the media has focused primarily on the grim daily death toll, while paying less attention to long recovery times and long-term health problems and/or disability associated with SARS-CoV-2 infection.

While originally viewed as a primarily a respiratory infection, 8 weeks ago in Nature Med. Review: Extrapulmonary manifestations of COVID-19, we looked at just how broadly SARS-CoV-2 attacks the human body.

Some of the adverse outcomes reported among COVID-19 survivors include:

JAMA: Two Studies Linking SARS-CoV-2 Infection To Cardiac Injury

Over the past few months, we've seen cardiologists and neurologists weigh in on the potential for seeing huge increases in COVID-19 related heart failure and neurological diseases, some that may not become fully apparent for years. 

Clyde W. Yancy, MD, MSc1,2; Gregg C. Fonarow, MD3,4
JAMA Cardiol. Published online July 27, 2020. doi:10.1001/jamacardio.2020.3575

Emily A. Troyer, Jordan N. Kohn, and Suzi Hong

And last July Dr. Anthony Fauci expressed concerns that many COVID patients are suffering from a post-viral syndrome - similar to ME/CFS - which has disabled and traumatized well over a million Americans over the past 3 decades (see NIH About CFS/ME). 

We are literally just scratching at the surface of the damage this pandemic virus has caused, and may cause going forward.

Today we've another report - this time from the Journal of American Society of Nephrology - which examined the kidney function of nearly 4,000 hospitalized COVID-19 patients admitted to Mt. Sinai in NYC last spring, and found nearly half (46%) experienced AKI (Acute Kidney Injury) during the course of their illness. 

Lili Chan, Kumardeep Chaudhary, Aparna Saha, Kinsuk Chauhan, Akhil Vaid, Shan Zhao, Ishan Paranjpe, Sulaiman Somani, Felix Richter, Riccardo Miotto, Anuradha Lala, Arash Kia, Prem Timsina, Li Li, Robert Freeman, Rong Chen, Jagat Narula, Allan C. Just, Carol Horowitz, Zahi Fayad, Carlos Cordon-Cardo, Eric Schadt, Matthew A. Levin, David L. Reich, Valentin Fuster, Barbara Murphy, John C. He, Alexander W. Charney, Erwin P. Böttinger, Benjamin S. Glicksberg, Steven G. Coca, Girish N. Nadkarni, on behalf of the Mount Sinai COVID Informatics Center (MSCIC) and Li Li
JASN September 2020, ASN.2020050615; DOI:  

Significance Statement

Early reports have indicated that AKI and other kidney abnormalities are associated with coronavirus disease 2019 (COVID-19). Of 3993 hospitalized patients with COVID-19 in a New York City health system, AKI occurred in 1835 (46%) patients; among patients with AKI, 19% required dialysis, and half of them died in the hospital. Among patients who were discharged, 35% had not recovered to baseline kidney function at the time of discharge. AKI is common among patients with COVID-19 and is associated with higher mortality than in patients without AKI; among those who survive, only about a third are discharged with renal recovery. 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.


Background Early reports indicate that AKI is common among patients with coronavirus disease 2019 (COVID-19) and associated with worse outcomes. However, AKI among hospitalized patients with COVID-19 in the United States is not well described.

Methods This retrospective, observational study involved a review of data from electronic health records of patients aged ≥18 years with laboratory-confirmed COVID-19 admitted to the Mount Sinai Health System from February 27 to May 30, 2020. We describe the frequency of AKI and dialysis requirement, AKI recovery, and adjusted odds ratios (aORs) with mortality.

Results Of 3993 hospitalized patients with COVID-19, AKI occurred in 1835 (46%) patients; 347 (19%) of the patients with AKI required dialysis. The proportions with stages 1, 2, or 3 AKI were 39%, 19%, and 42%, respectively.
A total of 976 (24%) patients were admitted to intensive care, and 745 (76%) experienced AKI. Of the 435 patients with AKI and urine studies, 84% had proteinuria, 81% had hematuria, and 60% had leukocyturia. Independent predictors of severe AKI were CKD, men, and higher serum potassium at admission. In-hospital mortality was 50% among patients with AKI versus 8% among those without AKI (aOR, 9.2; 95% confidence interval, 7.5 to 11.3).
Of survivors with AKI who were discharged, 35% had not recovered to baseline kidney function by the time of discharge. An additional 28 of 77 (36%) patients who had not recovered kidney function at discharge did so on posthospital follow-up.

Conclusions AKI is common among patients hospitalized with COVID-19 and is associated with high mortality. Of all patients with AKI, only 30% survived with recovery of kidney function by the time of discharge.

While this study has limitations (including more than half of the patients not having a baseline creatinine value), the incidence of AKI among hospitalized COVID-19 cases appears unusually high - and like previous reports of cardiomyopathy - may presage long-term sequelae in some COVID survivors. 

Following the 1918-1919 H1N1 pandemic, there were reports of greatly increased rates of Parkinson's Disease, and a global epidemic of Encephalitis Lethargica (see Nature Comms: Revisiting The Influenza-Parkinson's Link and The Lancet: COVID-19: Can We Learn From Encephalitis Lethargica?- both of which have been linked to viral infections.

Although it may have only scratched the surface, three weeks ago in PAHO Epi Alert: Complications & Sequelae Of COVID-19we looked at a 16-page PAHO (Pan American Health Organization) Epidemiological Alert on Complications and sequelae of COVID-19.

Although a 1% CFR pandemic isn't as bad as it might have been, it may take years before we can fully appreciate COVID-19's impact on individual's long-term health and on our society as a whole.