ABSTRACT
Background: Recent meta-analyses suggest that Hospital Acquired AKI (HA) has a worse prognosis than Community Acquired AKI (CA). The effect of prior CA on HA in COVID-19 is largely unknown. COVID-19 case series that use lowest hospital creatinine (Cr) rather than outpatient baseline Cr may underestimate CA incidence. Methods: Excluding ESKD and hospital transfers, COVID-19 PCR confirmed cases admitted to 4 hospitals between 3/01/20 & 5/31/20 had data collected through 7/31/20 including readmissions. Baseline Cr was adjudicated by manual review from 6 months prior until 5 months post admission. AKI and renal recovery were scored using KDIGO staging. CA is AKI with the highest Cr on admission, rising Cr from admission, or RRT in 48 hrs of admission. HA is AKIs occurring after >48 hrs. HA with CA (HA+CA) is AKI occurring in CA patients after renal recovery for > 48 hrs. Results: AKI was present in 402 of 706 patients with COVID-19. HA+CA occurred in 63. Patients with HA+CA were older, had more comorbidities, lower eGFR, and lower admission albumin than patients with HA. Laboratory markers of COVID severity were similar in patients with HA or HA+CA and much worse than CA. Outcomes, including stage of AKI, renal recovery, ICU parameters, and mortality were similar in HA and HA+CA and much better in CA. Conclusions: In COVID-19, HA + CA occurs in older patients with more comorbidities than HA but shares similar adverse disease markers and poor outcomes. We hypothesize that among older patients who recover from CA, those with severe disease markers are at risk for HA+CA.
ABSTRACT
Background: The etiology of AKI in COVID-19 correlates strongly with age, comorbidities, and laboratory markers of disease severity. Outpatients with COVID-19 have different exposures that may cause AKI than hospitalized patients;thus, the etiology of AKI occurring before hospitalization [community-acquired AKI (CA)] may differ from those with hospital-acquired AKI (HA). Methods: Excluding ESKD and hospital transfers, all COVID-19 PCR-confirmed cases admitted to 4 hospitals from 3/01/20 to 5/31/20 had data collected electronically through 7/31/20 including readmissions. Baseline C-EPI eGFR was determined by chart review for the period of 6 months prior to 5 months post-admission. AKI and recovery from AKI were scored using KDIGO staging. CA was defined as AKI with the highest level of creatinine (Cr) on admission, rising Cr on admission, or RRT started within 48 hours of admission without a subsequent AKI event after recovery. All AKI occurring > 48 hours was considered HA. To test which laboratory values correlated with CA or HA, we used a model adjusted for demographics, BMI, Elixhauser comorbidity index (ECI), and CKD stage. Results: The table shows patients with HA and CA had similar demographics with only the ECI differing significantly. CA had less severe AKI, improved recovery to baseline, and lower mortality than HA. The lower mortality in CA was directly related to the lower stage of AKI. Within a given stage of AKI, mortality was not different between CA and HA. Recovery of renal function was significantly better in CA stage 1 vs. HA (8% vs. 26%, p = 0.001) but was not different for stage 2 or 3. In an adjusted model, higher maximum dimers, ALT, AST, Bili, BNP, lactic acid, CRP, ferritin, LDH, neutrophils, troponin and lower minimum lymphocyte count were significantly associated with HA compared with CA. In contrast, on admission, only higher BNP, higher CRP, lower CPK and higher total CO2 were associated with HA versus CA. Conclusions: Compared to patients with CA, patients with HA had higher stages of AKI that correlated with higher mortality. They also had worsened recovery from stage 1 AKI and increased markers of COVID severity (except for CPK) in-hospital and on admission. We propose that factors other than COVID-19 disease severity led to CA, with volume and rhabdomyolysis as possible contributors.
ABSTRACT
Background: Emory University affiliated hospitals serve the metro Atlanta area, where a significant number of C19 cases have ocurred. In this report we describe the outcomes of AKI and ESRD patients with confirmed C19 admitted to our health-system. Methods: All patients seen by Emory Nephrology at 2 tertiary referral and one county hospital were categorized as ESRD if they required dialysis prior to C19 infection, or AKI if they developed acute kidney injury as a result of C19 infection. Outcomes of interest included patient survival and discharge from the hospital. Admission to Intensive care unit and use of mechanical ventilation were recorded. Comorbid conditions and outpatient use of medications were analyzed. Results: From 3/1/20 to 5/26/20, 474 consecutive patients were seen in COVID-19 related consultation. 287 patients were considered PUI and eventually tested negative for C19. The remaining 187 patients were C19 positive by nasopharyngeal swab or tracheal aspirate and represent the study population for this report. There were 43 ESRD (23%) and 144 AKI (77%) patients. Age (64 vs 63 years), gender (63 vs 66% males) ethnicity (86 vs 82% African-americans) and comorbid conditions were similar in AKI and ESRD patients. AKI patients were more likely to be admitted to ICU (83 vs 35%) and to require mechanical ventilation (73 vs 20%) compared to ESRD patients (p<0.05). Figure 1 presents the outcomes based on the type of renal disease at presentation. The eGFR of AKI patients at time of admission was 50±34 ml/kg/m2. 84 AKI patients required dialysis during their hospitalization (52.5%). Conclusions: Patients with ESRD C19+ were less likely to require ICU admission or mechanical ventilation. Mortality of ESRD patients was 14% compared with 42% of AKI patients, (p<0.002). ESRD patients with C19 were also more likely to be discharged from the hospital compared to those with AKI. Despite similar demographics and comorbidities, hospitalized C19 AKI patients had worse mortality than those receiving chronic dialysis.