麻豆传媒

New data from two health systems in New York City -- where hospitals struggled to keep up with dialysis demands as they were flooded with COVID-19 patients -- detailed a high rate of acute kidney injury among infected patients.

In the first 1,000 patients with COVID-19 at NewYork-Presbyterian/Columbia University Irving Medical Center, 33.9% developed acute kidney injury.

Of the 236 who ended up in the ICU, 78% developed AKI, Ruijun Chen, MD, and colleagues .

A separate analysis of nearly 5,500 patients with COVID-19 treated by April 5 in the 13 hospitals of the Northwell Health system, the AKI rate was a similar 36.6%.

The rate was 89.7% among those on mechanical ventilation, Kenar Jhaveri, MD, of Northwell Health in Great Neck, New York, and colleagues

New York City hospitals had described precarious situations with dialysis supply and machine shortages, with reportedly due to lack of capacity to cope with the surge of acute kidney injury during the peak of COVID-19 cases in the city.

The new data have implications for hospital preparedness as the pandemic continues, commented National Kidney Foundation President-elect Paul Palevsky, MD, of the University of Pittsburgh School of Medicine, who was not involved in the studies.

"What it does tell us is acute kidney injury is an important component of the disease process in patients who have COVID-19, particularly severe COVID-19," he told 麻豆传媒. "Hospitals need to have surge capacity in providing dialysis to provide services. If we see a surge as social distancing is relaxed, as I've seen in reports from Alabama and Texas, they're going to need to be prepared to increase acute dialysis services in hospitals."

The rates were higher than expected from the initial reports from China and Italy, which suggested 0.5% to 29% overall AKI, "with most estimates on the lower end," and the 19% reported initially from a Seattle ICU, Jhaveri's group noted.

The variation in rates may have a number of components.

Age and number of comorbidities of the studied population matter, as does severity of illness, commented Ladan Golestaneh MD, of Montefiore Medical Center in New York City.

"It seems to me as if clinicians caring for these patients will be looking at comorbidity burden and need for ICU stay as strong indicators of AKI development, in which case they may need to prepare for provision of renal replacement therapy," Golestaneh said.

"Our patients had a higher average body mass index, greater prevalence of hypertension, diabetes, and chronic pulmonary disease than those characterized in Italian and Chinese cohorts," noted Chen's group.

How AKI is identified is also a factor, Palevsky noted.

Jhaveri's study of 5,449 patients admitted with COVID-19 used medical chart review with the to define AKI.

While about half of patients only reached stage 1 AKI, stage 2 developed in 22.4% and stage 3 in 31.1%. Of these, 14.3% required renal replacement therapy, and 96.8% of the 285 who did need dialysis were on ventilators.

Prognosis of those who developed AKI was poor as 35% died. It was "bleaker" with requirement for dialysis: 157 of the 285 such patients died and "only 9 were discharged from the hospital at the time of analysis."

Chen's group examined records for the first 1,000 patients with positive PCR tests for SARS-CoV-2 who were seen in the emergency department or hospitalized at their center, although testing criteria shifted during March and April.

In this cohort, 13.8% required inpatient dialysis overall, a rate which rose to 35.2% in the ICU.

The high rate of renal complications might have been in part due to limiting use of IV fluids when treating patients with acute respiratory distress syndrome as a lung protective fluid management strategy, Chen's group noted.

"Alternatively, there might be inherent renal toxicity associated with the pathophysiology of COVID-19," they wrote, "given that the rates of acute kidney injury are high even in patients not receiving intensive care or in those without acute respiratory distress syndrome."

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