ABSTRACT
Background: Although the respiratory tract is the initial site of infection for SARS-CoV-2, coronavirus disease 19 (COVID-19) can affect multiple organ systems with devastating consequences. Acute kidney injury (AKI) has emerged as a leading cause of morbidity, affecting more than a third of adult patients hospitalized with COVID-19. SARS-CoV-2 infection is believed to cause AKI through different mechanisms, including interaction with the angiotensin-converting enzyme 2 (ACE2) receptor, cytokine storm, hemodynamic compromise, and direct viral infection of kidney cells. A major barrier to studying the kidney as a potential site of viral infection and replication is the limited availability of fresh kidney tissue from human subjects. To overcome this limitation, we assessed the presence of SARS-CoV-2 RNA in urine of critically ill COVID-19 patients. Methods: Fifty-two sequential urine and nasal swab specimens were collected from 18 patients (median (IQR) age 57 (50-62) years) hospitalized in the intensive care unit (ICU) with COVID-19. We performed single genome amplification and sequence analysis of the full-length SARS-CoV-2 spike gene to determine the frequency of genetic mutations in urine compared to those amplified from nasal swabs. Results: Forty single genome SARS-CoV-2 spike sequences were amplified in urine samples from four of the ten patients that developed AKI. Analysis of these sequences revealed that deletions and mutations of the SARS-CoV-2 furin-cleavage site (RRAR) were the predominant mutations observed in urine-derived viral RNA (30/40). For 3 of the 4 patients the corresponding nasal swabs were negative for SARS-CoV-2, suggesting that these patients were shedding viral RNA in urine but had cleared the infection in the respiratory tract. None of the 15 nasal swab sequences derived from the fourth patient had deletions or mutations in the furin-cleavage site. Conclusion: Our study identified unique mutations/deletions in the SARS-CoV-2 spike gene amplified from urine samples of critically ill COVID-19 patients. Notably, these mutations/deletions have been infrequently observed in SARS-CoV-2 genome sequences from respiratory tract samples deposited in the publicly available databases but have been reported to occur after passaging the virus in the African green monkey kidney cell line, Vero-E6, raising the possibility of SARS-CoV-2 renal tropism or cell/organ specific selection of viral variants. Our data provide in vivo evidence of a phenomenon previously reported only in vitro.
ABSTRACT
Background: Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is marked by coagulopathy that may relate to disease severity. Aims: We sought to understand the link between coagulopathy and acute respiratory distress syndrome (ARDS) in critically ill patients with Coronavirus Disease 2019 (COVID-19). Methods: We prospectively evaluated coagulation factor-specific biomarkers by ELISA and activity assays, viscoelastic testing by rotational thromboelastometry (ROTEM), and clinical data in 56 critically ill patients with COVID-19. One and two-way analyses of variance were performed to uncover association of factor levels with mortality, ECMO-requirement, major thrombotic events, and ARDS severity by PaO2/FiO2 ratio. Results: Patients averaged 57.2 years in age. Twenty-five percent had a major thromboembolic event, 16% had a major hemorrhage, and 23% died. All patients displayed hypercoagulability on viscoelastic testing, although those requiring veno-venous extracorporeal membrane oxygenation (ECMO) also had signs of consumptive coagulopathy and more frequent hemorrhagic complications than ECMO-naïve patients. In all patients, plasminogen activator inhibitor-1 (PAI-1) levels were increased, and ROTEM-determined clot lysis limited despite increased D-dimer levels, consistent with fibrinolytic suppression. In patients with thromboembolic events, regardless of ECMO status, PAI-1, von Willebrand Factor (vWF), and factor VIII levels were elevated. Increased PAI-1 and vWF and decreased ADAMTS13 levels correlated with ARDS severity and mortality. Conclusions: Our study defines the relationship between COVID-19 associated coagulopathy and the severity of acute lung injury by describing elevation in markers of endotheliopathy in association with low PaO2/FiO2 ratios. We identified increased PAI-1 with ARDS severity and thrombotic events, implicating fibrinolytic suppression in the microcirculatory injury and subsequent micro-and macrovascular thrombosis of severe COVID-19. Further investigation into therapeutic approaches to limit endothelial injury is needed. Other items for consideration: The study was approved by the Duke Institutional Review Board (Pro00101196 and Pro00105315).
ABSTRACT
Introduction: COVID-19 is a coagulopathic disease marked by elevated d-dimers, fibrinogen, and von Willebrand factor (vWF) levels accompanying arterial and venous thrombosis. While the majority of thrombotic events associated with COVID-19 occur in hospitalized patients, a subset of patients with minimal risk factors for CVA but with positive SARS-CoV-2 testing present with stroke as presumed first manifestation of infection. It is unclear if the pro-coagulant milieu present in patients requiring hospitalization for the respiratory complications of COVID-19 is the same as that of patients who present with stroke as first symptom of disease. Methods: Following emergent revascularization, clinical vWF levels were measured in patients presenting with stroke who tested positive for COVID-19. In parallel, plasma vWF levels from 28 patients with COVID-19 requiring ICU-level care and 8 healthy volunteers were measured via ELISA. Results: Three otherwise healthy patients between the ages of 45-55 years with positive test for SARS-CoV-2 presented with large-vessel stroke. By comparison, the average age of non-COVID stroke patients was 66 years. The consistency of the clots extracted through the aspirating catheter was dark, gelatinous throughout, without evidence of calcification, and distal thrombosis was noted minutes after revascularization. The vWF level for one patient was 345%, while the other two patients had vWF levels >400% of normal, exceeding the upper limit of detection of clinical assays. In the ICU cohort, 12 of 28 had thrombotic events during hospitalization. vWF levels were elevatedby a mean of 800% over healthy controls with a range of 230-1670%. Conclusions: vWF levels were markedly elevated in both ICU patients and stroke patients withCOVID-19 with an overlapping range of elevation over healthy controls. This suggests thatwidespread endothelial inflammation accompanies infection with SARS-CoV-2 even in the absenceof respiratory symptoms.