- Journal Reading -

Acute kidney injury

in patients hospitalized with COVID-19

DOKTER PEMBIMBING : D R . K AT H A R I N A S E T YAWAT I , S P. P D

DISUSUN OLEH : H U D A N M U T TA Q I N L AT I F - 2 0 1 6 7 3 0 0 4 7

KEPANITERAAN KLINIK DEPARTEMEN ILMU PENYAKIT DALAM

FAKULTAS KEDOKTERAN DAN KESEHATAN
UNIVERSITAS MUHAMMADIYAH JAKARTA
PERIODE 25 JANUARI – 21 MARET 2021
RUMAH SAKIT UMUM DAERAH R. SYAMSUDIN SH KOTA SUKABUMI
2021
 • Since late 2019
when the severe acute respiratory coronavirus 2 (coronavirus disease 2019 [COVID-19]), developed in
Wuhan, China. COVID-19 has become a worldwide pandemic

• In late January 2020

United States had its first COVID-19 case in Washington state, followed by massive growth of infections
in New York

INTRODUCTION
 INTRODUCTION
• As we cared for patients with COVID-19, we noticed an alarming number of
patients who developed acute kidney injury (AKI), at rates higher than had been
reported from China.
• Early reports from China and Italy found the rate of AKI to range widely from 0.5%
to 29%.
• U.S. data has been limited to critically ill patients in the ICU in a Seattle hospital
showing a 19% rate of AKI
RESULTS
Characteristics of Patients

Among the 5449 patients :

 888 (16.3%) died
 3280 (60.2%) were discharged to
home or to a rehabilitation facility
 1281 (23.5%) were still intreatment.

A total of 1190 patients (21.8%) were

treated with mechanical ventilation at
some point during the hospitalization.
Overall, 1993 of 5449 patients (36.6%) developed AKI during their hospitalization.

The peak stages of AKI

were
stage 1 in 927 (46.5%)
stage 2 in 447 (22.4%), and
stage 3 in 619 (31.1%)
37.3% either arriving with AKI or developing it within 24 hours of admission.
• The number of patients requiring dialytic support at some point was 285 (overall 5.2% of all
patients, representing 14.3% of those with AKI).
 Hemodialysis only in 154 patients (54% of all patients requiring RRT)
 Continuous RRT only in 70 (24.6%)
 Requirement of both treatments at some point in 61 (21.4%).

• The median time of initiation of dialytic support from hospital admission was 2.0 hours.
• The median number of hours from AKI diagnosis to initiation of dialysis was 0.0
• Among patients who required mechanical ventilation, 1068
of 1190 (89.7%) developed AKI.

• The majority of severe (stage 3) AKI (518 of 619 [83.6%])

occurred in patients on mechanical ventilation.

• RRT was required in 9 of 4259 nonventilated patients

(0.2%) compared with 276 of 1190 patients on ventilators
(23.2%).
• Patients who required ventilation and
developed AKI, 52.2% had the onset of
AKI within 24 hours of intubation.

• The median time from mechanical

ventilation to initiation of dialytic
therapy was 0.3 (IQR: 41.1, 92.3)
hours.
• The urine sodium concentration was <35 mEq/l in
65.6% of patients.

• The median urine-specific gravity was 1.020 (IQR:

1.010, 1.020).

• By urine dipstick 46.1% had 2+ to 3+ positivity

• Urine protein was positivy 2+ to 3+ in 42.1%.

• Automated microscopy detected significant

leukocyturia or hematuria in 36.5% and 40.9%.
By univariate analysis : increased age, male sex, diabetes
mellitus, hypertension, history of cardiovascular disease,
increased body mass index (BMI), mechanical ventilation,
vasopressor medications, and a history of treatment with
renal-angiotensin-aldosterone–inhibiting medications were
predictors of AKI.
By multivariate analysis : included older age,
black race, diabetes, hypertension, cardiovascular
disease, mechanical ventilation, and use of
vasopressor medications
Among 1993 patients who developed AKI
during the hospitalization :
• 780 (39%) were still hospitalized
• 519 (26%) were discharged, and
• 694 (35%) died. Of those who died :
 34% stage 1
 64% stage 2, and
 91% stage 3

Among the 285 patients who required RRT :

• 157 died
• 9 discharged from the hospital
• 119 were still undergoing treatment in the hospital, with
108 still on RRT (90.8%).
 DISCUSSION

• COVID-19 is primarily a respiratory illness, but other organs including the kidneys are often
affected
• The important relationship between AKI and respiratory failure is indicated by the following
findings :
1) Severe AKI occurred most commonly in close temporal proximity to the time of intubation and
mechanical ventilation.
2) The rate of AKI was 89.7% among patients on ventilators compared with 21.7% among other patients.
3) Severe (stages 2 and 3) AKI occurred in 65.5% of patients on ventilators compared with 6.7% of
nonventilated patients.
4) Almost all of the patients requiring RRT were on ventilator support (276 of 285 [96.8%]).
• AKI is a common complication Among patients hospitalized with COVID-19,
we found that 36.6% developed AKI during their hospitalization.
• This is a higher rate than has been reported previously from China and other areas
 Cheng et al. reported from Wuhan, China, a rate of AKI of only 5.1% of 701 patients.

• In this study, the clearest risk factors for the development of AKI were indicators of
severe COVID-19
 the need for ventilator support, or
 vasopressor drug treatment.
• independent risk factors for AKI : older age, black race, hypertension, DM,
Cardiovascular disease, vasopressor use, need for ventilation.
• The etiology of AKI in COVID-19 cases has not been fully elucidated.

• In this study, a high median urine-specific gravity and a majority of patients with
urinary sodium <35 mEq/l at the time of development of AKI.
• The study has limitations.
1) This is an observational study, we cannot make inferences regarding causal relationships between exposures
and AKI.
2) Although we have adjusted for potential confounders, there may be potential unmeasured confounders.
3) We relied exclusively on electronic health information systems as the source of data, including identification
of AKI
4) we cannot generalize our findings in the outpatient AKI settings because nonhospitalized patients were not
part of the present study.
5) The data we presented may not represent the true rate of AKI as the denominator may be different if we had
included other health system hospitals in the area.

• In conclusion :

AKI was a relatively common finding among patients hospitalized with COVID-19. The development
of AKI in patients hospitalized for COVID-19 conferred a poor prognosis.
 METHODS

Study design and cohort

• This was a retrospective observational cohort study of a large New York health system
• Data for this study was obtained from the 13 hospitals using the enterprise inpatient electronic health
record Sunrise Clinical Manager (Allscripts, Chicago, IL).
• All adult patients (age >18 years) who tested positive by polymerase chain reaction testing of a
nasopharyngeal sample for COVID-19 and were hospitalized from March 1, 2020, to April 5, 2020,
were eligible.
• For patients who had multiple qualifying hospital admissions, we included only the
first hospitalization.
• Patients who were transferred between hospitals within the health system were
treated as 1 hospital encounter.
• Patients were excluded :
1) Patient transferred to hospitals out of the health system
2) Had end-stage kidney disease (ESKD),
3) Had prior kidney transplant, or
4) Had <2 serum creatinine levels during the admission.
Data cleaning and preparation process
To ensure accurate exclusion of ESKD and kidney transplant additional verification was
performed.

Definitions and measurements

AKI was defined according to Kidney Disease: Improving Global Outcomes (KDIGO)
criteria as follows:
• stage 1—increase in serum creatinine by 0.3 mg/dl within 48 hours or a 1.5 to 1.9 times
increase in serum creatinine from baseline within 7 days
• stage 2—2.9 times increase in serum creatinine within 7 days
• stage 3—3 times or more increase in serum creatinine within 7 days or initiation of RRT.
• The baseline creatinine was defined as the median serum creatinine within 8 to 365 days prior to
hospital admission.
• A ratio of >1.5 from peak to median was classified as AKI.

• The estimated glomerular filtration rate was calculated using the Chronic Kidney Disease
Epidemiology Collaboration creatinine equation.
• urine test : urine electrolytes and urinalysis
Outcomes
• Primary outcome : Development of AKI.
• Secondary outcomes : Need for RRT and hospital disposition (i.e., discharge or death).

Covariates
Collected data on patient :
• Demographics
• History of comorbid conditions, and
• Home medications.

Chronic kidney disease was not included as a comorbid condition

• In addition to baseline clinical data, we collected details :
 Hospital admission such as ICU stay
 Mechanical ventilation,
 Extracorporeal membrane oxygenation
 Vasopressor support, and
 Baseline laboratory test results within 48 hours of hospital admission.
• ICU stay was defined as one of the following: need for invasive mechanical ventilation,
need for vasopressor or inotrope support, care from an ICU service, or care in a known ICU
location.
Statistical analysis
• performed descriptive statistics including means, SDs, medians and IQRs.

• compared baseline patient characteristics between patients with or without AKI using Fisher exact tests

for categorical variables and nonparametric Kruskal-Wallis test for continuous variables
• compare the clinical characteristics of patients across different stages of AKI, we performed Kruskal-Wallis
test.
• To identify risk factors associated with the development of AKI, we performed a logistic regression model.

• variables were entered into the models when the a level of risk factor was <0.15.
• P value <0.05 was considered statistically significant.
• Performed sensitivity analysis for missing data.
• The statistical analyses were performed using R (version 3.6.3; R Foundation for
Statistical Computing, Vienna, Austria).
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