CLINICAL RESEARCH www.jasn.

org

AKI in Hospitalized Patients with COVID-19

Lili Chan,1,2,3,4 Kumardeep Chaudhary,3,4,5 Aparna Saha,3,4 Kinsuk Chauhan ,1 Akhil Vaid,6
Shan Zhao,6,7 Ishan Paranjpe,6 Sulaiman Somani,6 Felix Richter,5,6 Riccardo Miotto,5,6
Anuradha Lala,7,8 Arash Kia,9,10 Prem Timsina,9,10 Li Li ,5,11 Robert Freeman ,9,10
Rong Chen,5,11 Jagat Narula,12,13 Allan C. Just,14 Carol Horowitz,2,9 Zahi Fayad,15,16
Carlos Cordon-Cardo,17 Eric Schadt,5,11 Matthew A. Levin,7 David L. Reich,7
Valentin Fuster,8 Barbara Murphy,1,2 John C. He,1,2 Alexander W. Charney,5,18,19
Erwin P. Böttinger ,6,20 Benjamin S. Glicksberg ,5,6 Steven G. Coca ,1,2 and
Girish N. Nadkarni,1,2,3,4,6 on behalf of the Mount Sinai COVID Informatics Center (MSCIC)*
Due to the number of contributing authors, the affiliations are listed at the end of this article.

ABSTRACT
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.

CLINICAL RESEARCH
Of all patients with AKI, only 30% survived with recovery of kidney function by the time of discharge.

JASN 32: 151–160, 2021. doi: https://doi.org/10.1681/ASN.2020050615

Received May 8, 2020. Accepted August 3, 2020.

Preliminary reports indicate that AKI and kidney ab- L.C. and K. Chaudhary are co-first authors.

normalities seem to be associated with coronavirus A.S. and K. Chauhan are co-second authors.

disease 2019 (COVID-19) severity and outcomes. A B.S.G., S.G.C., and G.N.N. are co-senior authors.

recently published study that utilized autopsy speci-
mens from 26 patients who died of COVID-19 in
China1 demonstrated that there is evidence of the in-
vasion of severe acute respiratory syndrome corona-
virus 2 (SARS-CoV-2) into kidney tissue, along with
significant acute tubular injury and endothelial dam-
age, as well as glomerular and vascular changes indic-
ative of underlying diabetic or hypertensive disease.
*The list of nonauthor contributors is extensive and has been
provided in Supplemental Summary 1.
Published online ahead of print. Publication date available at
www.jasn.org.
Correspondence: Dr. Steven G. Coca or Dr. Girish N. Nadkarni,
Icahn School of Medicine at Mount Sinai, One Gustave L. Levy
Place, Box 1243, New York, NY 10029. Email: steven.coca@
mssm.edu or girish.nadkarni@mountsinai.org
Copyright © 2021 by the American Society of Nephrology

JASN 32: 151–160, 2021 ISSN : 1046-6673/3201-151 151

 CLINICAL RESEARCH www.jasn.org
Small studies from China, Europe, and the United States
thus far have reported a wide range of the incidence of
AKI, ranging between 1% and 42%. The two largest studies
published to date show widely disparate rates of AKI. Guan
et al.2 reported an incidence rate of AKI of only 0.5% in 1099
patients from 552 hospitals in China. In a study out of Ire-
land in patients admitted to the intensive care unit (ICU),
reported incidence of AKI requiring dialysis was 22.2%, with
mortality exceeding 75%.3 In New York, 37% of patients
developed AKI, and 14% of patients with AKI required
dialysis.4
New York City (NYC) has been at the epicenter of the
COVID-19 pandemic in the United States and worldwide
and as such, has had the highest number of hospitalizations.
The burden of severe AKI in the setting of COVID-19 has led
to widespread shortages in NYC of dialysis nurses, machines,
replacement fluids and cartridges for continuous RRT, and
dialysis.4,5 The number of patients with AKI requiring acute
RRT is unprecedented in modern history.
Despite the anecdotal stories regarding the incidence and
severity of AKI, the epidemiology of AKI, especially recovery
from AKI in hospitalized patients in the United States and
particularly NYC, is not well described. Thus, the objective
of this report was to describe the incidence, severity, risk fac-
tors, and outcomes associated with AKI in the setting of hos-
pitalization of COVID-19 in a major NYC health care system.
METHODS
Study Population
The Mount Sinai Health System (MSHS) serves a large racially
and ethnically diverse patient population. In this study, patient
data came from the electronic health records (EHRs) from five
major hospitals that are part of MSHS: Mount Sinai Hospital
located in East Harlem, Manhattan; Mount Sinai Morningside
located in Morningside Heights, Manhattan; Mount Sinai
West located in Midtown and the West Side, Manhattan;
Mount Sinai Brooklyn located in Midwood, Brooklyn; and
Mount Sinai Queens located in Astoria, Queens. Mount Sinai
Beth Israel was not included in this cohort as they used a
different EHR.
Inclusion Criteria
We included patients who were at least 18 years old, had a
laboratory-confirmed SARS-CoV-2 infection, and were ad-
mitted to any of the aforementioned five MSHS hospitals be-
tween February 27 and 12 AM on May 30, 2020, with follow-up
data until June 5, 2020 (time of data freeze). A confirmed case
of COVID-19 was defined by a positive RT-PCR assay of a
specimen collected via nasopharyngeal swab. The Mount Sinai
Institutional Review Board approved this research under a
broad regulatory protocol allowing for analysis of patient-
level data.
152 JASN
Significance Statement
Early reports have indicated that AKI and other kidney abnormali-
ties 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 mor-
tality 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 in-
creased load resulting from survivors of COVID-19–associated AKI
who do not experience recovery of kidney function.
Exclusion Criteria
We excluded patients with known ESKD prior to admission
and patients who were hospitalized for ,48 hours
(Supplemental Figure 1, Supplemental Table 1).
Data Collection
The dataset was obtained from different sources and aggre-
gated by the Mount Sinai COVID Informatics Center
(MSCIC; further description of MSCIC is provided in
Supplemental Material). We obtained demographics, diagno-
sis codes (International Classification of Diseases 9/10 Clinical
Modification [ICD-9/10-CM] codes), and procedures as well
as vital signs and laboratory measurements during hospitali-
zation. Demographics included age, sex, and language as well
as race and ethnicity in the EHR. Racial groups included
White, Black, Asian or Pacific Islander, and other. Ethnic
groups included non-Hispanic/Latino, Hispanic/Latino, or
unknown. Vital signs and laboratory values during the first
48 hours of admissions that were obtained as part of clinical
care were included.
Definitions of Preexisting Conditions
We defined a preexisting condition as the presence of ICD-9/
10-CM codes associated with specific diseases as per the Elix-
hauser Comorbidity Software.6,7
Definitions of Outcomes
AKI, the primary end point, was defined as per Kidney Disease
Improving Global Outcomes (KDIGO) criteria: a change in
the serum creatinine of 0.3 mg/dl over a 48-hour period or
50% increase in baseline creatinine.8 For patients with a pre-
vious serum creatinine in the 7–365 days prior to admission,
the most recent serum creatinine value was considered the
baseline creatinine. For patients without a baseline creatinine
in the 7–365 days prior to admission, the admission creatinine
was imputed on the basis of a Modification of Diet in Renal
Disease (MDRD) eGFR of 75 ml/min per 1.73 m as per the
KDIGO AKI guidelines.8 AKI stages were defined using the
KDIGO AKI stage creatinine definitions: stage 1 as an in-
crease in serum creatinine of $0.3 mg/dl or increase to
$1.5–1.9 times baseline serum creatinine, stage 2 as an
JASN 32: 151–160, 2021

increase to .2–2.9 times from baseline serum creatinine,
and stage 3 as an increase to more than three times baseline
serum creatinine or a peak serum creatinine $4.0 mg/dl or if
the patient received RRT during admission. Proteinuria was
defined as a protein-creatinine ratio of $0.5, 11 proteinuria
or higher on dipstick (trace counted as no proteinuria), or
$30 mg/dl on urinalysis. Leukocyturia was defined as more
than five white blood cells per high-power field. Hematuria
was defined as 11 or higher on dipstick or urinalysis.
We assessed in-hospital mortality defined by survival sta-
tus at discharge. A small proportion of patients (3%) was still
admitted at the time of this manuscript preparation. These
patients were not included in mortality analyses. The need
for acute dialysis was ascertained by procedure codes
and was crossreferenced with nursing flow sheets. For AKI
recovery, we compared the last hospital creatinine and post-
discharge creatinine with the baseline creatinine and grou-
ped them as recovered or with acute kidney disease (AKD)
stage 1, 2, or 3 (Supplemental Table 2).9
Statistical Analyses
Baseline characteristics were reported as medians and
interquartile ranges (IQRs) for continuous variables. Cate-
gorical variables were summarized as counts and percent-
ages. We used Kruskal–Wallis for continuous variables and
chi-squared tests for comparison across groups. For survival
analyses, we generated Kaplan–Meier survival curves, and
comparison was done using the log-rank test. Patients who
were discharged from the hospital were not censored and
were still considered at risk for death. Patients who were
still hospitalized at the time of data freeze were regarded as
having a censored length of stay. Logistic regression models
adjusted for covariates (adjusted for age; sex; race; comor-
bidities including CKD, hypertension, congestive heart fail-
ure, diabetes mellitus, liver disease, and peripheral vascular
disease; laboratory values including white blood cell count,
lymphocyte percentage, hemoglobin, platelets, sodium, po-
tassium, aspartate aminotransferase, alkaline phosphatase,
and albumin; and vitals including temperature, systolic BP,
heart rate, respiratory rate, and oxygen saturation) were
used to estimate the adjusted odds ratio (aOR) for death in
patients with AKI versus without AKI. Covariates were cho-
sen on the basis of univariate testing and physician input. We
used local regression (loess) for smoothening creatinine val-
ues across the interval of 2 weeks posthospital admission to
visualize trajectories by AKD category. All analyses were per-
formed with R version 3.4.3 and SAS 9.4 (SAS Institute Inc.,
Cary, NC).
RESULTS
A consort diagram of included patients and outcomes is de-
picted in Supplemental Figure 1.
JASN 32: 151–160, 2021
www.jasn.org CLINICAL RESEARCH
Demographic and Clinical Characteristics
From February 27 to May 30, 2020, 3993 COVID-19–positive
patients who fulfilled our inclusion and exclusion criteria were
hospitalized at one of five MSHS NYC hospitals. One hundred
twenty-four (3%) of patients were still admitted at the time of
manuscript drafting. Ninety-two percent of patients had a
positive SARS-CoV-2 PCR test on the day of admission. Base-
line creatinine was available prior to admission in 1455 (36%);
for the patients without baseline creatinine, this was imputed
using the MDRD equation as described in Methods. Patient
demographics and preexisting conditions as well as vital signs
and laboratory values stratified by AKI are displayed in Table 1.
Patients who developed incident AKI were older and were
more likely to have hypertension, congestive heart failure, di-
abetes mellitus, and CKD. Patients who developed AKI also
had higher white blood cell count, lower lymphocyte percent-
ages, and higher creatinine values. Other variables were sta-
tistically significant but likely not clinically significant given
small absolute differences.
Incidence and Severity of AKI
AKI occurred in 1835 patients (46%), and 347 (19%) of
those with AKI required dialysis. In the 976 (24%) patients
admitted to intensive care, 745 (76%) experienced AKI. The
median time from hospital admission until AKI diagnoses
was 1 (IQR, 1–4) day, and the median time from AKI di-
agnosis to dialysis need was 3 (IQR, 1–6) days. The propor-
tions of patients with AKI in all patients and in the ICU
varied by the five MSHS locations (Table 1, Supplemental
Table 3). In all admissions, the proportions with stages 1, 2,
and 3 AKI were 39%, 19%, and 42%, respectively. In those
admitted to the ICU, the proportions were 28%, 17%, and
56%, respectively, and 32% required acute RRT (Figure 1).
The median peak serum creatinine was 2.2 (IQR, 1.5–3.6)
mg/dl in those who did not receive dialysis and was 8.2 (IQR,
6.1–11) mg/dl in those who did receive dialysis. The propor-
tions of AKI and of AKI stages were not different when lim-
ited to only those with a prehospital baseline creatinine or
when the nadir hospital creatinine was used as the baseline
(data not shown).
AKI incidence in patients who had a baseline creatinine was
49%, while in patients who had imputed baseline creatinine it
was 45%, P50.02. Urine studies were available for 656 (16%)
patients, of whom 435 (66%) patients had AKI; 639 (97%) of
all patients had any urinary abnormalities. Of the 435 patients
with AKI and urine studies, 84% had proteinuria, 81% had
hematuria, and 60% had leukocyturia. Proteinuria, hematu-
ria, and leukocyturia were significantly more common in pa-
tients with AKI than patients without AKI (Supplemental
Figure 2).
AKI Recovery
Among 1835 patients with AKI, 832 were discharged from the
hospital. At hospital discharge, 541 of 832 (65%) had recovery
of AKI, and 291 (35%) had AKD; the median serum creatinine
AKI in COVID-19 153
 CLINICAL RESEARCH www.jasn.org

Table 1. Patient characteristics of all patients and those with and without AKI
Patient Characteristics All, n53993 AKI, n51835 No AKI, n52158 P Value
Age, yr, median (IQR) 64 (56–78) 71 (61–81) 63 (51–75) ,0.001
Sex, n (%)
Women 1704 (43) 734 (40) 970 (45) 0.002
Race/ethnicity, n (%) 0.002
White 954 (24) 439 (24) 515 (24)
Black 1054 (36) 536 (29) 518 (24)
Hispanic 1038 (26) 439 (24) 599 (28)
Asian 173 (4) 74 (4) 99 (5)
Other or unknown 774 (19) 347 (19) 427 (20)
Comorbidities, n (%)
Hypertension 1527 (38) 820 (45) 707 (33) ,0.001
Congestive heart failure 396 (10) 244 (13) 152 (7) ,0.001
Diabetes mellitus 1019 (26) 568 (31) 451 (21) ,0.001
Liver disease 191 (5) 99 (5) 92 (4) 0.09
Peripheral vascular disease 362 (9) 194 (11) 168 (8) 0.002
CKD 420 (11) 339 (18) 81 (4) ,0.001
Laboratory values, median (IQR)
White blood cell count, 103/ml 7.55 (5.4–10.9) 8.68 (6–12.3) 6.9 (5.1–9.55) ,0.001
Lymphocyte percentage, % 13.1 (8.1–20.6) 10.6 (6–12.3) 15.5 (9.8–23.1) ,0.001
Hemoglobin, g/dl 12.6 (11.1–13.8) 12.3 (10.7–13.8) 12.8 (11.5–13.9) ,0.001
Platelets, 103/L 214 (160–282) 207 (151–272) 221 (165–291) ,0.001
Sodium, mEq/L 139 (136–142) 139 (136–143) 138 (136–141) ,0.001
Potassium, mEq/L 4.2 (3.9–4.6) 4.3 (3.9–4.8) 4.1 (3.8–4.5) ,0.001
Chloride, mEq/L 104 (101–107) 104 (100–109) 103 (101–106) ,0.001
Bicarbonate, mEq/L 23 (20.5–26) 22 (19–25) 24 (21.8–26.1) ,0.001
BUN, mg/dl 18 (12–32) 31 (18–51) 13 (10–19) ,0.001
Serum creatinine, mg/dl 0.94 (0.72–1.41) 1.42 (0.95–2.25) 0.8 (0.67–0.97) ,0.001
AST, U/L 42 (28–68) 48 (30–79) 39 (27–60) ,0.001
ALT, U/L 30 (18–52) 29 (18–53) 30 (19–52) ,0.001
Alkaline phosphatase, U/L 75 (59–100) 76 (60–102) 73 (58–98) 0.005
Albumin, g/dl 2.9 (2.6–3.3) 2.8 (2.5–3.2) 3 (2.7–3.4) ,0.001
Vital signs, median (IQR)
Temperature, °C 36.9 (36.6–37.5) 36.9 (36.5–37.4) 37(36.6–37.5) ,0.001
Systolic BP, mm Hg 124 (111–140) 125 (111–141.5) 124 (112–138) 0.40
Diastolic BP, mm Hg 71 (63–79) 70 (61–80) 72 (64–79) ,0.001
Heart rate, BPM 87 (76–98) 87 (76–99) 87 (76–97) 0.08
Respiratory rate, per min 19 (10–20) 20 (18–21) 18 (18–20) ,0.001
Oxygen saturation, % 96 (94–98) 96 (94–98) 96 (95–98) ,0.001
Discharged, n (%) 3869 (97) 1750 (95) 2119 (98) ,0.001
Hospital facility ,0.001
Mount Sinai Hospital located in East Harlem, Manhattan 1507 (38) 662 (36) 845 (39)
Mount Sinai Morningside located in Morningside Heights, Manhattan 699 (18) 340 (19) 359 (17)
Mount Sinai West located in Midtown and the West Side, Manhattan 480 (12) 167 (9) 313 (15)
Mount Sinai Brooklyn located in Midwood, Brooklyn 641 (16) 345 (19) 296 (14)
Mount Sinai Queens located in Astoria, Queens 666 (17) 321 (18) 345 (16)
AST, aspartate transaminase; ALT, alanine transaminase; BPM, beats per minute.

at discharge was 1.1 (IQR, 0.8–1.6 mg/dl) (Figure 2). Only
30% (541 of 1835) of patients with AKI recovered kidney
function and were discharged alive; 212 of 1835 (12%) pa-
tients who had AKI during their hospitalization had postho-
spitalization follow-up creatinine data at a median of 21 (IQR,
8–38) days after hospital discharge (Figure 2). On follow-up,
of the 77 of 212 (36%) patients with AKD on discharge, 28 of
77 (36%) had recovery of AKD on follow-up. Of the 135 of 212
(64%) patients who had recovery of AKI at discharge, 18 of
135 (14%) had AKD on follow-up (Figure 2). Of the 87 of 832
patients who started on dialysis and were discharged alive, 26
(30%) patients required dialysis within 72 hours of discharge.
At 7 days after AKI diagnoses or at discharge or death if it
occurred before 7 days, 720 of 1835 (39%) had AKI recovery.
The characteristics of patients by recovery and each AKD stage
are presented in Supplemental Table 4. Creatinine trends by
recovery group are presented in Figure 3 for differing subsets
of the population.

154 JASN JASN 32: 151–160, 2021


100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
All (n=1835) ICU admission (n=745)
AKI Stage 1 AKI Stage 2
Figure 1. AKI requiring dialysis was common and varied by need for ICU admimssion. While 19% of patients overall required dialysis,
32% of patients who were admitted to the ICU required dialysis.
Independent Predictors of Severe AKI
Independent predictors of incident stage 3 AKI in patients
(n5731) admitted to the hospital with COVID-19 were men
(aOR, 1.46; 95% confidence interval [95% CI], 1.2 to 1.8),
admission potassium (aOR, 1.7; 95% CI, 1.6 to 2.0), and
CKD (aOR, 2.8; 95% CI, 2.1 to 3.7) (Supplemental Figure 3).
AKI and Outcomes
Patients with AKI were more likely to have ICU admissions, have
mechanical ventilation, and require vasopressors administration
(Supplemental Table 5). In-hospital mortality in patients who
experienced AKI was 50%, and it was 8% in patients without
AKI (P,0.001). In-hospital mortality percentages of patients
with AKI in the ICU (42%), and non-ICU setting (62%) were
markedly higher than those without AKI (ICU, 7% and non-ICU,
13%). The results of Kaplan–Meier survival analysis stratified by
AKI status are presented in Figure 4. Patients with AKI had sig-
nificantly lower survival than patients without AKI (log-rank P
value ,0.001). After adjustment for demographics, comorbidi-
ties, and laboratory values, the aOR for death was 11.4 (95% CI,
7.2 to 18) for ICU with AKI versus no AKI, and the aOR for death
was 9.2 (95% CI, 7.5 to 11.3) for all patients with AKI versus no
AKI (Supplemental Table 6). There was an increasing risk of death
with increasing stages of AKI, with the highest risk seen in patients
with AKI stage 3 requiring dialysis (Supplemental Table 6).
DISCUSSION
In nearly 4000 patients with COVID-19 admitted to MSHS,
AKI occurred in nearly half of patients, and nearly a quarter of
JASN 32: 151–160, 2021
www.jasn.org CLINICAL RESEARCH
No ICU admission (n=1090)
AKI Stage 3 - no dialysis AKI Stage 3 - Dialysis
those patients required acute dialysis. AKI was independently
associated with higher mortality. Many survivors (35%) did
not recover kidney function by hospital discharge, and of all
patients with AKI, only 30% survived and recovered kidney
function.
Although the current COVID-19 pandemic is caused by a
coronavirus like the severe acute respiratory syndrome coro-
navirus 1 outbreak in 2005, the reported incidence of AKI
associated with COVID-19 disease seems to be substantially
higher.10 Additionally, the incidence of AKI associated with
COVID-19 is higher than reported in patients hospitalized
with community-acquired pneumonia (34%) and severe sep-
sis (22%) in the United States.11,12 During the last pandemic in
recent history, the 2009 pandemic influenza A (H1N1), AKI
incidence was found to be high (34%–67%).13–15 Although
the incidence of AKI may be similarly high between the two
pandemics, the spread of COVID-19 far exceeds than that of
the H1N1 pandemic: 2 million people with confirmed
COVID-19 in the United States over the first 6 months com-
pared with 1 million with confirmed H1N1 over a 10-year
period. Reports suggest that rhabdomyolysis may have
been a contributing factor to AKI from H1N1. Although
we do not have creatinine kinase values, the presence of protein-
uria, leukocyturia, and hematuria in patients with COVID-19–
associated AKI suggests a different mechanism of injury.
The incidence of AKI in this study is higher than what has
been reported in China and Italy and similar to the incidence
in another NYC health care system.16 There are several key
differences in the MSHS cohort, including higher proportions
of patients with comorbidities of hypertension, diabetes, and
CKD, which are risk factors for developing AKI.2 In our
AKI in COVID-19 155
 CLINICAL RESEARCH www.jasn.org

Discharge AKI survivors at discharge (N = 832)

6%
6%

Recovered
23% AKD Stage 1
65%
AKD Stage 2
AKD Stage 3

AKI Survivors stratified by recovery status at

discharge (N = 212)
7%
6%

64%
23%

Post-discharge Follow-up

Non-recovered Recovered

Kidney Function at follow-up in those Kidney Function at follow-up in those

non-recovered at discharge that recovered at discharge

18%

36%
13% 86% 10%

2%
2%
33%

AKI survivors at post-

hospitalization follow-up (N = 212)

6% 8%

18%

68%

Figure 2. Approximately a third of patients did not have renal recovery at discharge or post-hospitalization follow up. Proportion of
patients with AKI stratified by recovery versus nonrecovery at discharge and discharge follow-up. Recovery of kidney function was
stratified into recover and AKD defined as (1) recovery: difference in creatinine is #0.3 and creatinine change in percentage is #25%;
(2) stage 1: difference in creatinine is .0.3 and creatinine change in percentage is #25% or creatinine change in percentage is .25%
and #100%; (3) stage 2: creatinine change in percentage is .100% and #200%; and (4) stage 3: creatinine change in percentage is
.200% or requiring dialysis 72 hours prior to discharge.

156 JASN JASN 32: 151–160, 2021


Creatinine 7.5
5.0
2.5
0.0
1 2 3 4 5 6
AKD stage
Recovered
AKD Stage 1
AKD Stage 2
AKD Stage 3
Figure 3. Trajectory of creatinine during the first 14 days of hospitalizations in patients who were discharged by recovery and non-
recovery which demonstrate the severity and prolonged nature of the AKI. We used local regression (loess) for smoothening creatinine
values across the interval of 2 weeks posthospital admission to visualize trajectories by AKD category.
analysis, there was no association between hypertension and
diabetes with severe AKI, but CKD was independently associ-
ated with severe AKI. As others have reported, patients who
were admitted to the ICU had a higher incidence of AKI likely
reflective of more severe disease.
Currently, the exact mechanisms of AKI due to COVID-19
are unclear. A postmortem patient series reported by Su et al.1
found significant acute tubular injury in all patients. A sepa-
rate study found a high frequency of urinalysis abnormalities
(hematuria, proteinuria, and leukocyturia) despite normal
creatine values; which suggest renal pathology is not limited
to acute tubular injury (Zhou H, Zhang Z, Fan H, Li J, Li M,
Dong Y, et al.: Urinalysis, but not blood biochemistry, detects
the early renal-impairment in patients with COVID-19.
https://www.medrxiv.org/content/10.1101/2020.04.03.
20051722v1.full.pdf, 2020). In this study, of patients who had
urine studies sent, nearly all patients had urine abnormalities.
Although urine abnormalities were more frequent in patients
with AKI diagnosis, a large proportion of patients without AKI
by creatinine criteria also had urine abnormalities. These find-
ings are in contrast to studies in critically ill patients and pa-
tients undergoing cardiac surgery that demonstrated that only
JASN 32: 151–160, 2021
www.jasn.org CLINICAL RESEARCH
N=55
N=47
N=189
N=541
7 8 9 10 11 12 13 14
Days
33%–48% of patients had proteinuria and that 65% had hem-
aturia.17–19 Given the high incidence of AKI and lack of full
recovery at and after discharge, identification of potential
mechanisms of COVID-19–related AKI would allow for po-
tential interventions to reduce this devastating complication.
This study is the first study in the United States to report the
persistence of kidney dysfunction (lack of recovery) in survi-
vors of COVID-19–associated AKI. A third of patients with
AKI in the setting of COVID-19 did not recover kidney func-
tion back to baseline. The low recovery rate is expected given
the overall severity of AKI (high peak creatinine, need for di-
alysis), as well as the knowledge that many patients with
COVID-19 have extensive acute tubular injury on tissue ex-
amination, potential microthrombi, and a high prevalence of
proteinuria.1 A study in a Chinese cohort reports similar find-
ings, with less than half of patients fully recovering kidney
function.20 This is in marked contrast to other forms of AKI
where over 80% of patients recover their renal function by 10
days.21 It remains to be seen what the implications for post-
AKI CKD, progression of prior CKD, and ESKD are for
COVID-19–associated AKI.22–27 This will require long-term
follow-up and further investigation.
AKI in COVID-19 157
 CLINICAL RESEARCH www.jasn.org
Survival 0.75
0.5
+ Censored
Log Rank p < .0001
0
0 5 10
Days from Admission
AKI
No AKI 2158 2103 2037
AKI 1835 1643 1344
Figure 4. Survival probability is lower in patients with AKI. Kaplan–Meier survival curves for patients with and without AKI. Red line
indicates patients with AKI, and blue line is for those without AKI. All patients were censored at 30 days. Patients who were discharged
alive before 30 days were treated as still at risk and not censored at discharge.
Our study should be interpreted in light of the following
limitations. Over half of patients did not have a baseline cre-
atinine values. However, we used MDRD imputation as sug-
gested by KDIGO guidelines, and the incidence was compa-
rable for those with known baseline serum creatinine versus
those who we imputed because of missing serum creatinine
prior to admission.8 Although we presented data stratified by
those who did and did not have ICU admissions, we did not
examine the temporal relationship between the development
of AKI and ICU admission. We did not have data regarding
acute respiratory distress syndrome or ICU severity scores
(e.g., Acute PHysiology and Chronic Health Evaluation or Se-
quential Organ Failure Assessment), which are often associ-
ated with AKI and need for dialysis. However, many features
that make up these scores (age, vital signs, and laboratory
values) were features that we included in our multivariable
model. Recovery was assessed at time of discharge, and we
only had postdischarge creatinine values in a subset of pa-
tients. As patients could receive dialysis care outside of the
MSHS, we are unable to determine dialysis dependence at
postdischarge follow-up. As the COVID-19 pandemic is still
evolving, few long term follow-up laboratory test have been
performed. We did not have sufficient data on inflammatory
makers (e.g., IL-6, ferritin, and fibrinogen) in a large propor-
tion of patients because they were not routinely checked early
in the pandemic and a majority of patients did not have these
values (Paranjpe I, Russak A, Freitas JKD, Lala A, Miotto R,
Vaid A, et al.; Mount Sinai Covid Informatics Center
[MSCIC]: Clinical characteristics of hospitalized Covid-19 pa-
tients in New York City. medRxiv:2020.04.19.20062117,
158 JASN
15 20 25 30
NO Yes
2011 2000 1994 1982
1159 1060 986 945
2020). Additionally, urinalysis was also missing in the majority
of patients. Although we provide analysis of the subset of pa-
tients who did have urine studies obtained, this is likely a bias
subset as the urine samples were obtained for a clinical reason.
Lastly, baseline medications of interest, including angiotensin-
converting enzyme inhibitors, angiotensin receptor blockers,
statins, and other nonsteroidal anti-inflammatory drugs, were
not included.
In conclusion, in a diverse cohort of patients hospitalized
with COVID-19 in NYC, we described a very high incidence of
AKI, severe AKI requiring dialysis, and risk of death associated
with AKI. We identified several predictors associated severe
AKI and found that a third of patients did not recover kidney
function at time of discharge. The results of this study may be
useful to other centers for resource planning during the
COVID-19 pandemic, for potential additional waves of
COVID-19, and for preparing for the increased load of pa-
tients with COVID-19 and CKD due to severe AKI and lack of
recovery.
DISCLOSURES
S. Coca, J.C. He, B. Murphy, and G. Nadkarni receive financial compensa-
tion as consultants and advisory board members for RenalytixAI and own
equity in RenalytixAI. Z. Fayad has a patent Trained Therapeutix discovery
patents with royalties paid to Trained Therapeutix Discovery. B. Murphy is a
nonexecutive director of RenalytixAI. B. Murphy reports personal fees from
Renalytix AI, outside the submitted work. All remaining authors have nothing
to disclose.
JASN 32: 151–160, 2021

FUNDING
None.
ACKNOWLEDGMENTS
To all of the nurses, physicians, and providers who contributed to the care of
these patients. To the patients and their family members who were affected by
this pandemic.
Dr. Lili Chan, Dr. Steven Coca, and Dr. Girish Nadkarni conceptualized and
designed the study; Dr. Lili Chan, Dr. Kumardeep Chaudhary, Dr. Steven
Coca, and Dr. Giurish Nadkarni provided acquisition, analysis, or in-
terpretation of data; Dr. Lili Chan, Dr. Kumardeep Chaudhary, Dr. Steven
Coca, Dr. Girish Nadkarni, and members of MSCIC had full access to all of
the data in the study and take responsibility for the integrity of the data and
the accuracy of the data analysis; Dr. Lili Chan, Dr. Steven Coca, and
Dr. Girish Nadkarni drafted the manuscript; Dr. Kumardeep Chaudhary,
Dr. Kinsuk Chauhan, Dr. Aparna Saha, and Dr. Akhil Vaid provided
statistical analysis; members of MSCIC provided administrative, technical,
or material support; Dr. Steven Coca and Dr. Girish Nadkarni provided
supervision; and all authors critically revised the manuscript for important
intellectual content.
Dr. Lili Chan reports grants from the National Institutes of Health and
Renal Research Institute, outside the submitted work. In the past 3 years,
Dr. Steven Coca has received consulting fees from Bayer, Boehringer-Ingelheim,
CHF Solutions, Goldfinch Bio, inRegen, pulseData, Quark, Relypsa, and Takeda
Pharmaceuticals, and National Institutes of Health grants U01DK106962,
R01DK115562, R01HL085757, U01OH011326, R01DK112258, and RRTI UG
2019 outside the submitted work. Dr. Zahi Fayad reports grants from Amgen,
Bristol Myers Squibb, Daiichi Sankyo, and Siemens Healthineers and personal fees
from Alexion, GlaxoSmithKline, and Trained Therapeutix Discovery, outside the
submitted work. Dr. John C. He reports fees from RenalytixAL and grants from
Shangpharma, outside the submitted work. In the past 3 years, Dr. Girish Nadkarni
has received consulting fees from AstraZeneca, BioVie, GLG Consulting, Pensieve
Health, and Reata, grant support from Goldfinch Bio, National Institutes
of Diabetes and Digestive and Kidney Diseases Career Development Award
K23DK107908, and National Institutes of Health grants R01DK108803,
U01HG007278, and U01DK116100, outside the submitted work.
SUPPLEMENTAL MATERIAL
This article contains the following supplemental material online at http://
jasn.asnjournals.org/lookup/suppl/doi:10.1681/ASN.2020050615/-/
DCSupplemental.
Supplemental Figure 1. Study flow diagram.
Supplemental Figure 2. Proportion of patients with hematuria, leukocytu-
ria, and proteinuria by AKI status in a subset of patients with urine studies
(N5656).
Supplemental Figure 3. Patient characteristics that were associated with
severe AKI (stage 3).
Supplemental Summary 1. Supplemental methods: Mount Sinai COVID
Informatics Center data platform and investigators.
Supplemental Table 1. ICD codes used for identification of ESKD cohort;
ESKD was defined as having both an ESKD diagnosis code and an ESKD
procedure code.
Supplemental Table 2. Definitions of acute kidney disease.
Supplemental Table 3. Incidence of AKI in patients admitted to the ICU by
MSHS hospital (P,0.06).
Supplemental Table 4. Patient characteristics by kidney recovery and acute
kidney disease stages excluding patients who were still admitted to the
hospital.
JASN 32: 151–160, 2021
www.jasn.org CLINICAL RESEARCH
Supplemental Table 5. Outcomes in patients with AKI and without AKI and
the full cohort (n53993).
Supplemental Table 6. Adjusted and unadjusted OR of in-hospital mortality
in patients with outcomes data available.
REFERENCES
1. Su H, Yang M, Wan C, Yi LX, Tang F, Zhu HY, et al: Renal histopatho-
logical analysis of 26 postmortem findings of patients with COVID-19 in
China. Kidney Int 98: 219–227, 2020
2. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al; China Medical
Treatment Expert Group for Covid-19: Clinical characteristics of coro-
navirus disease 2019 in China. N Engl J Med 382: 1708–1720, 2020
3. Intensive Care National Audit & Research Centre: ICNARC report on
COVID-19 in critical care, 2020. Available at: https://www.icnarc.org/
DataServices/Attachments/Download/c31dd38d-d77b-ea11-9124-
00505601089b. Accessed April 21, 2020
4. Abelson R, Fink S, Kulish N, Thomas K: An overlooked, possibly fatal
coronavirus crisis: A dire need for kidney dialysis. New York Times,
2020. Available at: https://www.nytimes.com/2020/04/18/health/
kidney-dialysis-coronavirus.html. Accessed April 24, 2020
5. Goldfarb DS, Benstein JA, Zhdanova O, Hammer E, Block CA, Caplin
NJ, et al: Impending shortages of kidney replacement therapy for
COVID-19 patients. Clin J Am Soc Nephrol 15: 880–882, 2020
6. Agency for Healthcare Research and Quality: Elixhauser Comorbidity
Software, Version 3.7. Available at: https://www.hcup-us.ahrq.gov/
toolssoftware/comorbidity/comorbidity.jsp. Accessed April 25, 2020
7. Package comorbidity, 2020. Available at: https://cran.r-project.org/
web/packages/comorbidity/comorbidity.pdf. Accessed April 15, 2020
8. Kidney Disease: Improving Global Outcomes (KDIGO): Acute Kidney
Injury (AKI). Available at: https://kdigo.org/guidelines/acute-kidney-
injury/. Accessed April 10, 2020
9. Duff S, Murray PT: Defining early recovery of acute kidney injury
[published online ahead of print April 1, 2020]. Clin J Am Soc Nephrol
doi:10.2215/CJN.13381019
10. Chu KH, Tsang WK, Tang CS, Lam MF, Lai FM, To KF, et al: Acute renal
impairment in coronavirus-associated severe acute respiratory syn-
drome. Kidney Int 67: 698–705, 2005
11. Murugan R, Karajala-Subramanyam V, Lee M, Yende S, Kong L, Carter
M, et al; Genetic and Inflammatory Markers of Sepsis (GenIMS) Inves-
tigators: Acute kidney injury in non-severe pneumonia is associated
with an increased immune response and lower survival. Kidney Int 77:
527–535, 2010
12. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky
MR: Epidemiology of severe sepsis in the United States: Analysis of
incidence, outcome, and associated costs of care. Crit Care Med 29:
1303–1310, 2001
13. Pettilä V, Webb SA, Bailey M, Howe B, Seppelt IM, Bellomo R: Acute
kidney injury in patients with influenza A (H1N1) 2009. Intensive Care
Med 37: 763–767, 2011
14. Bagshaw SM, Sood MM, Long J, Fowler RA, Adhikari NKJ; Canadian
Critical Care Trials Group H1N1 Collaborative: Acute kidney injury
among critically ill patients with pandemic H1N1 influenza A in Canada:
Cohort study. BMC Nephrol 14: 123, 2013
15. Demirjian SG, Raina R, Bhimraj A, Navaneethan SD, Gordon SM,
Schreiber MJ Jr., et al: 2009 influenza A infection and acute kidney
injury: Incidence, risk factors, and complications. Am J Nephrol 34: 1–8,
2011
16. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T,
Davidson KW, et al; and the Northwell COVID-19 Research Consor-
tium: Presenting characteristics, comorbidities, and outcomes among
5700 patients hospitalized with COVID-19 in the New York City area.
JAMA 323: 2052–2059, 2020
AKI in COVID-19 159
 CLINICAL RESEARCH www.jasn.org

17. Molnar AO, Parikh CR, Sint K, Coca SG, Koyner J, Patel UD, et al:
Association of postoperative proteinuria with AKI after cardiac surgery
among patients at high risk. Clin J Am Soc Nephrol 7: 1749–1760,
2012
18. Han SS, Ahn SY, Ryu J, Baek SH, Chin HJ, Na KY, et al: Proteinuria and
hematuria are associated with acute kidney injury and mortality in
critically ill patients: A retrospective observational study. BMC Nephrol
15: 93, 2014
19. Yeter H, Yõldõrõm T, Eyüpo glu D, Paşayev T, Aslan A, Çetik S, et al:
Mild to moderate proteinuria is a heralding sign for acute kidney injury
and mortality for intensive care unit patients. Turk J Med Sci 49:
543–550, 2019
20. Pei G, Zhang Z, Peng J, Liu L, Zhang C, Yu C, et al: Renal involvement
and early prognosis in patients with COVID-19 pneumonia. J Am Soc
Nephrol 31: 1157–1165, 2020
21. Heung M, Steffick DE, Zivin K, Gillespie BW, Banerjee T, Hsu CY, et al;
Centers for Disease Control and Prevention CKD Surveillance Team:
Acute kidney injury recovery pattern and subsequent risk of CKD: An
analysis of veterans health administration data. Am J Kidney Dis 67:
742–752, 2016
22. Basile DP: Rarefaction of peritubular capillaries following ischemic
acute renal failure: A potential factor predisposing to progressive ne-
phropathy. Curr Opin Nephrol Hypertens 13: 1–7, 2004
23. Basile DP, Fredrich K, Alausa M, Vio CP, Liang M, Rieder MR, et al:
Identification of persistently altered gene expression in the kidney after
functional recovery from ischemic acute renal failure. Am J Physiol
Renal Physiol 288: F953–F963, 2005
24. Spurgeon-Pechman KR, Donohoe DL, Mattson DL, Lund H, James L,
Basile DP: Recovery from acute renal failure predisposes hypertension
and secondary renal disease in response to elevated sodium. Am
J Physiol Renal Physiol 293: F269–F278, 2007
25. Chawla LS, Eggers PW, Star RA, Kimmel PL: Acute kidney injury and
chronic kidney disease as interconnected syndromes. N Engl J Med
371: 58–66, 2014
26. Coca SG, Singanamala S, Parikh CR: Chronic kidney disease after acute
kidney injury: A systematic review and meta-analysis. Kidney Int 81:
442–448, 2012
27. Coca SG, Garg AX, Thiessen-Philbrook H, Koyner JL, Patel UD, Krumholz HM,
et al; for the TRIBE-AKI Consortium: Urinary biomarkers of AKI and mor-
tality 3 years after cardiac surgery. J Am Soc Nephrol 25: 1063–1071, 2014
See related editorial, “COVID-19–Associated Acute Kidney Injury: Learning
from the First Wave,” and article “AKI Treated with Renal Replacement Therapy in
Critically Ill Patients with COVID-19,” on pages 4–6 and 161–176, respectively.

AFFILIATIONS

1
Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
2
Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
3
The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
4
BioMe Phenomics Center, Icahn School of Medicine at Mount Sinai, New York, New York
5
Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
6
The Hasso Plattner Institute for Digital Health at Mount Sinai, New York, New York
7
Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
8
The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
9
Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
10
Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York
11
Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, New York
12
Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York
13
Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
14
Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, New York
15
BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York
16
Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
17
Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
18
The Pamela Sklar Division of Psychiatric Genomics, Icahn School of Medicine at Mount Sinai, New York, New York
19
Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
20
Digital Health Center, Hasso Plattner Institute, University of Potsdam, Potsdam, Germany

160 JASN JASN 32: 151–160, 2021

Title: Acute Kidney Injury in Hospitalized Patients with COVID-19

Supplemental Methods:

Mount Sinai COVID Informatics Center (MSCIC) Data Platform

This dataset of clinical data is the first part of a larger effort that aims to create an
heterogeneous collection of COVID-19 patient data. This effort brings together different
stakeholders from MSHS, including research faculty, data scientists, clinicians, and hospital
administrators, among others. The resulting dataset includes or will include longitudinal
electronic health record (EHR) patient clinical data, multi-omics, such as genomics, imaging,
such as chest CT scans, among others. The data, which are updated on a daily basis, is made
available within a secure computational framework based on internal Microsoft Azure Cloud to
researchers and analysts within the MSHS and the Icahn School of Medicine at Mount Sinai.
This dataset is intended to foster research projects to improve the knowledge of this disease
and augment clinical operations with machine intelligence.
Supplemental Figure 1: Study flow diagram
Supplemental Figure 2: Proportion of patients with hematuria, leukocyturia, and proteinuria by
AKI status in subset of patients with urine studies (N=656)
Supplemental Figure 3: Patient characteristics that were associated with severe AKI (Stage 3)

Supplemental Table 1: ICD codes used for identification of ESKD cohort. ESKD was defined as
having both an ESKD diagnosis code and an ESKD procedure code.
Supplemental Table 2: Definitions of acute kidney disease
Supplemental Table 3: Incidence of AKI in patients admitted to the ICU by MSHS hospital,
P<0.001)
Supplemental Table 4: Patient characteristics by kidney recovery and acute kidney disease
stages.
Supplemental Table 5: Outcomes in patients with AKI and without AKI inthe full cohort
Supplemental Table 6. Adjusted and Unadjusted OR of in-hospital mortality
Supplemental Table 1: ICD codes used for identification of ESKD cohort. ESKD was defined
as having both an ESKD diagnosis code and an ESKD procedure code.

Study Variable ICD9 Description

Diagnosis Code 585.6 End Stage Kidney Disease (need this and any of below)
Dialysis procedures 39.95 Hemodialysis
Dialysis diagnosis V45.11, V45.12, Hemodialysis
V56.0, V56.1
Peritoneal Dialysis 54.98, V56.2, Peritoneal Dialysis, Fitting and adjustment of peritoneal
procedures V56.8, 996.68, dialysis catheter, Encounter for other dialysis, Infection and
V56.32 inflammatory reaction due to peritoneal dialysis catheter,
Encounter for adequacy testing for peritoneal dialysis

Study Variable ICD10 Description

Diagnosis Code N18.6 End Stage Kidney Disease (need this and any of below)
Dialysis procedures 5A1D70Z Hemodialysis
Dialysis diagnosis Z99.2, Z91.15, Hemodialysis, Encounter for fitting and adjustment of
Z49.01, Z49.3, extracorporeal dialysis catheter
Z49.31, Z49.32
Peritoneal Dialysis 3E1M39Z, Z49.02, Irrigation of Peritoneal Cavity using Dialysate,
procedures Z49.32, T85.611x, Percutaneous Approach, Encounter for fitting and
T85.621x, adjustment of peritoneal dialysis catheter, Breakdown
T85.631, (mechanical) of intraperitoneal dialysis catheter,
T85.691x, Displacement of intraperitoneal dialysis catheter, Leakage
T85.71x, Z49.32 of intraperitoneal dialysis catheter, Other mechanical
complication of intraperitoneal dialysis catheter, Infection
and inflammatory reaction due to peritoneal dialysis
catheter, Encounter for adequacy testing for peritoneal
dialysis
Supplemental Table 2: Definitions of acute kidney disease

AKD Stage Definitions

Recovered Difference in Creatinine is <= 0.3 and Creatinine change
in % <= 25%
Stage 1 Difference in Creatinine > 0.3 and Creatinine change in % is
<= 25%
Creatinine change in % is > 25% and <= 100%
Stage 2 Creatinine change in % is > 100% and <= 200%
Stage 3 Creatinine change in % is > 200%
Supplemental Table 3: Incidence of AKI in patients admitted to the ICU by MSHS hospital,
P=0.06)

Hosp. facility AKI (n=745) No AKI (n=231)

Mount Sinai Hospital located in East Harlem, 312 (42) 106 (46)
Manhattan (MSH)
Mount Sinai Morningside located in 147 (20) 48 (21)
Morningside Heights, Manhattan (STLH)
Mount Sinai West located in Midtown and the 73 (10) 32 (14)
West Side, Manhattan (RVTH)

Mount Sinai Brooklyn located in Midwood, 110 (15) 24 (10)

Brooklyn (BIKH)
Mount Sinai Queens located in Astoria, 103 (14) 21 (9)
Queens
Supplemental Table 4: Patient characteristics by kidney recovery and acute kidney disease
stages in those who outcomes.

Recovered AKD Stage 1 AKD Stage 2 AKD Stage 3 p-value

(n= 673) (n= 387) (n= 199) (n= 491)
Age Median (IQR) 69 (58-79) 74 (65-83) 77 (68-85) 70 (61-79) <0.001
Sex, n (%)
Female 292 (43) 185 (48) 72 (36) 155 (32) <0.001
Race/Ethnicity, n (%) 0.03
White 144 (21) 101 (26) 64 (32) 117 (24)
Black 218 (32) 14 (30) 41 (21) 143 (29)
Hispanic 174 (26) 85 (22) 43 (22) 115 (23)
Asian 26 (4) 13 (3) 5 (3) 21 (4)
Other or unknown 111 (17) 74 (19) 46 (23) 95 (19)
Comorbidities, n (%)
Hypertension 316 (47) 189 (49) 93 (47) 196 (40) 0.04
Congestive Heart 96 (14) 71 (18) 27 (14) 39 (8) <0.001
Failure
Diabetes Mellitus 225 (33) 139 (36) 52 (26) 128 (26) 0.003
Liver disease 42 (6) 17 (4) 12 (6) 21 (4) 0.38
Peripheral Vascular 81 (12) 54 (14) 15 (8) 34 (7) 0.002
Disease
CKD 112 (17) 90 (23) 39 (20) 87 (18) 0.06
Lab values, Median (IQR)
White blood cell count 8.4 (5.82-12) 7.8 (5.6-10.9) 9.8 (6.7-14.5) 9.3 (6.6-13.5) <0.001
Lymphocyte 11.3 (7.4- 12.2 (5.6-10.9) 8.8 (5.7-14.4) 9.4 (6-15.3) <0.001
percentage 17.6)
Hemoglobin (g/dL) 12.4 (11- 11.8 (10.2- 12.4 (10.7- 12.5 (10.9- <0.001
13.9) 13.3) 13.8) 13.9)
Platelets (109/L) 210.5 (156- 206 (145-269) 205 (153-283) 200 (150-269) 0.2
275)
Sodium (mEq/L) 139 (135- 140 (136-143) 140 (136-146) 139 (136-143) 0.1
143)
Potassium (mEq/L) 4.3 (3.9-4.7) 4.4 (4-4.8) 4.4 (3.8-4.9) 4.5 (4-4.9) <0.001
Chloride (mEq/L) 104 (100- 105 (101-109) 105 (101-110) 104 (100-109) 0.14
109)
Bicarbonate (mEq/L) 22.7 (19.5- 22 (19-25) 22 (19-25) 22 (18-24.7) 0.001
25.3)
BUN blood urea 28 (16-45) 34 (21-52) 36 (22-60) 33 (18-60) <0.001
nitrogen (mg/dL)
Serum Creatinine 1.3 (0.9-1.9) 1.5 (1.1-2.2) 1.7 (1.1-2.4) 1.7 (0.9-3.4) <0.001
(mg/dL)
AST (U/L) 44 (29-68) 42 (27-70) 47 (30-78) 60 (35-96) <0.001
ALT (U/L) 30 (18-49) 25 (15-45) 27 (18-48) 33 (21-61) <0.001
Alkaline phosphatase 75 (60-100) 2.9 (2.5-3.2) 75 (60-109) 77 (59-103) 0.94
(U/L)
Albumin in (g/dL) 2.9 (2.5-3.2) 2.9 (2.5-3.2) 2.7 (2.4-3.1) 2.8 (2.5-3.2) 0.06
Vital signs, median (IQR)
Temperature (F) 98.5 (97.7- 98.3 (97.7- 98.3 (97.6-99) 98.4 (97.7- 0.04
99.4) 99.1) 99.5)
Systolic BP (mmHg) 123 (110- 125 (112-144) 126 (110-141) 128 (112-146) 0.01
139)
Diastolic BP (mmHg) 70 (62-79) 70 (62-79) 70 (60-81) 70 (61-81) 0.72
Heart rate (BPM) 86 (75-98) 85 (76-98) 84 (74-98) 89 (79-101) 0.002
Respiratory rate (per 19 (18-21) 19 (18-20) 20 (18-22) 20 (18-22) 0.002
min)
Oxygen saturation, % 96 (94-98) 96 (95-98) 96 (93-98) 95 (93-98) <0.001
Hosp. facility <.001
Mount Sinai Hospital 276 (41) 131 (34) 57 (29) 154 (31)
located in East Harlem,
Manhattan (MSH)
Mount Sinai 148 (22) 82 (21) 25 (13) 74 (15)
Morningside located in
Morningside Heights,
Manhattan (STLH)
Mount Sinai West 70 (10) 25 (7) 26 (13) 35 (7)
located in Midtown and
the West Side,
Manhattan (RVTH)
Mount Sinai Brooklyn 77 (11) 89 (23) 39 (20) 130 (26)
located in Midwood,
Brooklyn (BIKH)
Mount Sinai Queens 102 (15) 60 (16) 52 (26) 98 (20)
located in Astoria,
Queens
Supplemental Table 5: Outcomes in patients with AKI and without AKI in the full cohort
(N=3993)

Outcomes, n (%) AKI No AKI p-value

Full cohort N=1835 N=2158
ICU admission 745 (41) 231 (11) <0.001
Mechanical ventilation 803 (44) 126 (6) <0.001
Vasopressor use 783 (43) 210 (10) <0.001
Still admitted at time of manuscript 85 (5) 39 (2) <0.001
Length of stay for those discharged, median(IQR) 10 (6-18) 7 (4-11) <0.001
In-hospital Mortality 918 (50) 167 (8) <0.001
Supplemental Table 6. Adjusted and Unadjusted OR of in-hospital mortality in patients with
outcomes data available

AKI vs no-AKI Unadjusted OR Adjusted ORa

All patients with outcome data 12.9 (10.7-15.5) 9.2 (7.5-11.3)
(n=3869)
All patients with outcome data that had ICU
admissions 13.3 (8.8-20.2) 11.4 (7.2-18)
(n=899)

AKI Stage vs. no-AKI (all patients) Unadjusted OR Adjusted ORa

Stage 1 (n=683) 5.9 (4.7-7.3) 4.5 (3.5-5.6)
Stage 2 (n=336) 10.9 (8.3-14.2) 6.6 (4.9-8.9)
Stage 3 – no dialysis (n=411) 29.7 (22.8-38.8) 20.2 (15-27.3)
Stage 3 – requiring dialysis (n=320) 31.3 (23.4-41.9) 38.7 (27.4-54.6)

AKI Stage vs. no-AKI (ICU patients) Unadjusted OR Adjusted ORa

Stage 1 (n=179) 4.9 (3-8) 4.5 (2.7-7.7)
Stage 2 (n=105) 11.1 (6.3-19.2) 8 (4.4-14.8)
Stage 3 – no dialysis (n=178) 24.7 (14.5-42.1) 19.9 (11.1-35.6)
Stage 3 – requiring dialysis (n=219) 27.9 (15-41.4) 30.2 (16.8-54.4)

a
Adjusted for age, gender, race, comorbidities including chronic kidney disease, hypertension,
congestive heart failure, diabetes mellitus, liver disease, peripheral vascular disease, lab values
including white blood cell count, lymphocyte percentage, hemoglobin, platelets, sodium,
potassium, AST, alkaline phosphatase, albumin, vitals including temperature, systolic BP, heart
rate, respiratory rate, oxygen saturation
Core Investigators
Alex Charney, MD, PhD Laura Huckins, PhD
Assistant Professor Assistant Professor
Genetics and Genomic Sciences Genetic and Genomic Sciences

Allan C. Just, PhD Paul O'Reilly, PhD

Assistant Professor Senior Faculty
Environmental Medicine and Public Health Genetics and Genomic Sciences

Benjamin Glicksberg, PhD Riccardo Miotto, PhD

Assistant Professor Assistant Professor
Hasso Plattner Institute for Digital Health at Hasso Plattner Institute for Digital Health at
Mount Sinai Mount Sinai
Genetics and Genomic Sciences
Zahi Fayad, PhD
Girish Nadkarni, MD, MPH Institute Director
Assistant Professor, Director of Clinical Research BioMedical Engineering & Imaging Institute
Medicine, Nephrology (BMEII)
Hasso Plattner Institute for Digital Health at
Mount Sinai
Data Scientists/Analysts
Adam J. Russak, MD Felix Richter
Resident MD/PhD Student
Internal Medicine Graduate School of Biomedical Sciences

Adeeb Rahman, PhD Georgios Soultanidis, PhD

Associate Professor Postdoctoral fellow
Genetics and Genomic Sciences BioMedical Engineering and Imaging Institute

Akhil Vaid Ishan Paranjpe

Postdoctoral Fellow Medical Student
Genetics and Genomic Sciences Hasso Plattner Institute for Digital Health at
Mount Sinai
Amanda Le Dobbyn, PhD
Research Assistant Professor Ismail Nabeel, MD, MPH
Genetics and Genomic Sciences Associate Professor
Environmental Medicine and Public Health
Andrew Leader
MD/PhD Student Jessica De Freitas
Oncological Sciences PhD Student
Hasso Plattner Institute for Digital Health at
Arden Moscati Mount Sinai
Statistical Geneticist
Charles Bronfman Institute for Personalized Jiayi Xu
Medicine Postdoctoral Fellow
Pamela Sklar Division of Psychiatric Genomics
Arjun Kapoor
Medical Student Johnathan Rush
Hasso Plattner Institute for Digital Health at Biostatistician
Mount Sinai Environmental Medicine and Public Health

Christie Chang Kipp Johnson, PhD

Data Science Analyst I MD/PhD student (completed PhD)
Immunobiology Genetics and Genomic Sciences

Christopher Bellaire Krishna Vemuri, MPH

Medical Student Biostatistician I
Icahn School of Medicine at Mount Sinai Environmental Medicine & Public Health

Daniel Carrion, PhD, MPH Kumardeep Chaudhary, PhD

Postdoctoral Fellow Postdoctoral Fellow
Environmental Medicine and Public Health Charles Bronfman Institute for Personalized
Medicine
Fayzan Chaudhry
Data Analyst Lauren Lepow
Genetics and Genomic Sciences
Neuroscience Graduate Student and PGY-3 Ross O'Hagan
Psychiatry Resident Medical Student
Psychiatry Hasso Plattner Institute for Digital Health at
Mount Sinai
Liam Cotter
Master's Student Shan Zhao
Psychiatric Genomics / Hasso Plattner Institute Resident
for Digital Health at Mount Sinai Anesthesiology, Perioperative & Pain Medicine

Lora Liharska, MS SulaimanSomani

PhD student Medical Student
Genetics and Genomic Sciences Icahn School of Medicine at Mount Sinai

Marco Pereanez Tielman T Van Vleck, PhD

Programmer Analyst Director of Clinical Linguistics and Data Science,
BioMedical Engineering & Imaging Institute BioMe Phenomics Center
(BMEII) Institute for Personalized Medicine

MesudeBicak, PhD TinayeMutetwa

Senior Scientist Research Trainee
Genetics and Genomics Department General Internal Medicine

Nicholas DeFelice, PhD Tingyi Wanyan

Assistant Professor Visiting Research Associate
Environmental Medicine & Public Health Genetics and Genomic Sciences

Nidhi Naik Valentin Fauveau

Masters' student Programmer Analyst II
Icahn School of Medicine at Mount Sinai BioMedical Engineering & Imaging Institute
(BMEII)
Noam Beckmann
Postdoctoral Fellow Yang Yang, PhD
Genetic and Genomic Sciences Assistant Professor
Radiology
Rajiv Nadukuru, MS
Database Analysist III Yonit Lavin
Personalized Medicine Institute Resident
Internal Medicine
Operations/Infrastructure
AlonaLanksy
Clinical Research Coordinator Manbir Singh
Oncological Sciences Associate IT Director
Hasso Plattner Institute for Digital Health at
Ashish Atreja, MD, MPH Mount Sinai
Associate Professor
Gastroenterology Matteo Danieletto, PhD
Pathology, Molecular and Cell Based Medicine Postdoctoral Fellow
Hasso Plattner Institute for Digital Health at
Diane Del Valle Mount Sinai
Project Manager
Immunobiology Melissa A. Nieves, BA
Grants Manager
Dara Meyer, MS, PMP Hasso Plattner Institute for Digital Health at
Senior Project Manager Mount Sinai
Genetics and Genomic Sciences
Micol Zweig, MPH
Eddye Golden, MPH Associate Director
Program Manager Hasso Plattner Institute for Digital Health at
Hasso Plattner Institute for Digital Health at Mount Sinai
Mount Sinai
RenataPyzik, MS, MA
Farah Fasihuddin Project Manager
Clinical Research Coordinator II Radiology / BioMedical Engineering & Imaging
Gastroenterology Institute (BMEII)

Huei Hsun Wen Rima Fayad, MPH

Clinical Research Coordinator Clinical Research Manager
Hasso Plattner Institute for Digital Health at Radiology
Mount Sinai
Patricia Glowe
Jason Rogers Sr. Director, Strategy & Operations
Program Manager Hasso Plattner Institute for Digital Health at
Mount Sinai AppLab Mount Sinai

Jennifer Lilly Gutierrez, MS SharleneCalorossi

Communications Director Program Manager II
Genetics and Genomic Sciences Genetics and Genomic Sciences
Icahn Institute for Data Science and Genomic
Technology Sparshdeep Kaur
Clinical Research Manager
Laura Walker Hasso Plattner Institute for Digital Health at
Clinical Research & Project Manager, Lead of Mount Sinai
CITE-seq team
Human Immune Monitoring Center (HIMC)
Steven Ascolillo YovannaRoa, MSW
Accessioning Specialist Program Manager
Genetics and Genomic Sciences Hasso Plattner Institute for Digital Health at
Mount Sinai
Other Investigators
Anuradha Lala-Trindade, MD Kirk Campbell, MD
Assistant Professor Associate Professor
Medicine, Cardiology Medicine, Nephrology
Population Health Science and Population
Nicholas Chun, MD
Steven G Coca, DO, MS Assistant Professor
Associate Professor Medicine, Nephrology
Medicine, Nephrology
Miriam Chung, MD
Bethany Percha, PhD Associate Professor
Assistant Professor Medicine, Nephrology
Genetics and Genomic Sciences
Priya Deshpande, MD
Keith Sigel, MD, PhD, MPH Assistant Professor
Associate Professor, Physician, Physician Medicine, Nephrology
Scientist
Medicine Samira S. Farouk, MD, MSCR
Assistant Professor
Paz Polak, PhD Medicine, Nephrology
Assistant Professor
Oncological Sciences Lewis Kaufman, MD
Associate Professor
Robert Hirten, MD Medicine, Nephrology
Gastroenterologist, Assistant Professor
Gastroenterology Tonia Kim, MD
Associate Professor
Talia Swartz, MD, PhD Medicine, Nephrology
Assistant Professor
Medicine, Infectious Diseases Holly Koncicki, MD
Associate Professor
Ron Do, PhD Medicine, Nephrology
Assistant Professor
The Charles Bronfman Institute for Personalized Vijay Lapsia, MD
Medicine Associate Professor
Medicine, Nephrology
Ruth J.F. Loos, PhD
Professor Staci Leisman, MD
The Charles Bronfman Institute for Personalized Associate Professor
Medicine Medicine, Nephrology

Mukta Baweja, MD Emily Lu, MD

Assistant Professor Assistant Professor
Medicine, Nephrology Medicine, Nephrology
Kristin Meliambro, MD
Assistant Professor
Medicine, Nephrology

Madhav C. Menon, MD
Associate Professor
Medicine, Nephrology

Joshua L. Rein, DO
Instructor
Medicine, Nephrology

Shuchita Sharma, MD
Assistant Professor
Medicine, Nephrology

Joji Tokita, MD
Associate Professor
Medicine, Nephrology

Jaime Uribarri, MD
Professor
Medicine, Nephrology

Joseph A. Vassalotti, MD
Professor
Medicine, Nephrology

Jonathan Winston, MD
Professor
Medicine, Nephrology

Kusum S. Mathews, MD, MPH, MSCR

Assistant Professor
Medicine, Pulmonary, Critical Care and Sleep
Emergency Medicine
Leadership Oversight
Board
Dennis Charney, MD
Dean, Icahn School of Medicine at Mount Sinai
President for Academic Affairs, Mount Sinai
Health System
Professor, Psychiatry
Professor, Neuroscience
Professor, Pharmacological Sciences
Eric Nestler, MD, PhD
Dean for Academic Science Affairs
Director, Friedman Brain Institute
Professor, Neuroscience
Professor, Pharmacological Sciences
Professor, Psychiatry
Barbara Murphy, MD
Dean, Clinical Integration and Population Health
Chair of the Department of Medicine, Mount
Sinai Health System
Murray M. Rosenberg Professor of Medicine
David Reich, MD
President & Chief Operating Officer
The Mount Sinai Hospital and Mount Sinai
Queens
Erwin Bottinger, MD
Director, Hasso Plattner Institute for Digital
Health at Mount Sinai
Professor, Medicine and Systems Pharmacology
and Therapeutics, Icahn School of Medicine at
Mount Sinai, New York City, U.S.A.
Director, Digital Health Center, Hasso Plattner
Institute,
Professor, Digital Health- Personalized
Medicine, Hasso Plattner Institute and
Universität Potsdam, Germany
Kumar Chatani, MBA
Executive Vice President
Chief Information Officer
Dean for Information Technology
Mount Sinai Health System
Glenn Martin, MD
Senior Associate Dean for Human Subjects
Research
Associate Professor, Psychiatry
The Mount Sinai Hospital
Scientific Advisory
Board
Eric Nestler, MD, PhD
Dean for Academic Science Affairs
Director, Friedman Brain Institute
Professor, Neuroscience
Professor, Pharmacological Sciences
Professor, Psychiatry
Patricia Kovatch, BS
Senior Associate Dean for Scientific Computing
and Data Science
Associate Professor, Genetics and Genomic
Sciences
Associate Professor, Pharmacological Sciences
Joseph Finkelstein, MD, PhD
Chief Research Informatics Officer
Senior Associate Dean, Information Technology
Professor, Population Health and Science
Director, Center for Biomedical and Population
Health informatics
Associate Director, Cancer Information
Technology at The Tisch Cancer Institute
Barbara Murphy, MD
Dean, Clinical Integration and Population Health
Chair of the Department of Medicine, Mount
Sinai Health System
Murray M. Rosenberg Professor of Medicine
Joseph Buxbaum, PhD
Professor, Psychiatry
Professor, Neuroscience
Professor, Genetics and Genomic Sciences
Judy Cho, MD
Dean of Translational Genetics
Director, The Charles Bronfman Institute for
Personalized Medicine
Professor, Genetics and Genomic Sciences
Professor, Medicine, Gastroenterology
Andrew Kasarskis, PhD
Executive Vice President
Chief Data Officer, Mount Sinai Health System
Professor, Genetics and Genomic Sciences
Carol Horowitz, MD, MPH
Dean for Gender Equity in Science and Medicine
Professor, Population Health Science and Policy
Professor, Medicine, General Internal Medicine
Carlos Cordon-Cardo, MD, PhD
Professor and SystemChair, Pathology,
Molecular and Cell Based Medicine
Professor, Oncological Sciences
Professor, Genetics and Genomic Sciences
Monica Sohn
Senior Executive Director of Development
Precision Medicine & Children’s Health
Mount Sinai Health System
Glenn Martin, MD
Senior Associate Dean for Human Subjects
Research
Associate Professor, Psychiatry
The Mount Sinai Hospital
Adolfo Garcia-Sastre, PhD
Director, Global Health and Emerging
Pathogens Institute
Professor, Microbiology
Professor, Medicine, Infectious Diseases
Emilia Bagiella, PhD
Professor, Population Health Science and Policy
Icahn School of Medicine at Mount Sinai
Florian Krammer, PhD
Professor, Microbiology
Icahn School of Medicine at Mount Sinai
Judith Aberg, MD
Professor, Medicine, Infectious Diseases
Icahn School of Medicine at Mount Sinai
Jagat Narula, MD, PhD
Associate Dean for Global Affairs
Professor, Medicine, Cardiology
Professor, Radiology
Robert Wright, MD, MPH
Professor and System Chair, Environmental
Medicine & Public Health
Professor, Pediatrics
Director, Institute for Exposomic Research
Erik Lium, PhD
President, Mount Sinai Innovation Partners
Executive Vice President and Chief Commercial
Innovation Officer
Mount Sinai Health System
Rosalind Wright, MD
Dean for Translational Biomedical Research
Professor, Pediatrics, Pulmonary and Critical
Care
Professor, Environmental Medicine & Public
Health
Professor, Medicine, Pulmonary, Critical Care
and Sleep Medicine
AnnetineGelijns, PhD, JD
Professor and System Chair
Population Health Science and Policy
Valentin Fuster, MD, PhD
Director, Zena and Michael A. Wiener
Cardiovascular Institute
Physician-in-Chief, The Mount Sinai Hospital
Professor, Medicine, Cardiology
Miriam Merad, MD, PhD
Director, Precision Immunology Institute
Professor, Oncological Sciences
Professor, Medicine, Hematology, and Medical
Oncology