Recovery from AKI requiring kidney replacement therapy in critically ill patients with COVID-19

Background: Acute kidney injury (AKI) requiring kidney replacement therapy (KRT) occurs in as many as one in five critically ill patients with COVID-19. Expanding on previous work by this group, we examined the association of clinical factors at the time of KRT initiation with the outcome of kidney recovery at hospital discharge, accounting for the competing outcome of death. Methods: We used data from the Study of the Treatment and Outcomes in Critically Ill Patients with COVID-19 (STOP-COVID), a multicenter cohort study that enrolled adults with COVID-19 admitted to ICUs at 68 hospitals across the US from March 4 to June 22, 2020. Among those who acutely required KRT, the outcome of kidney non-recovery (continued dialysis dependence at hospital discharge) was explored with multinomial logistic regression, with kidney recovery (independence from dialysis at discharge) as the reference outcome and death as an alternate outcome. Exposures of interest included demographics, baseline medical status, and markers of illness acuity at the time of KRT initiation. Results: Of 876 patients with AKI-KRT, 588 (67%) died, 95 (11%) survived to discharge and remained dependent on KRT, and 193 (22%) survived to discharge without KRT dependence. Patients with lower baseline eGFR had greater odds of kidney non-recovery, with OR 8.58 (95% CI: 3.03-24.28) among patients with eGFR ≤15 vs >60. Reduced urine output on the day of KRT initiation was also associated with kidney non-recovery, with OR 4.23 (95% CI: 1.61-11.15) for urine output <50 mL/day vs >500 mL/day (Figure). Conclusions: Among critically ill patients with COVID-19 with AKI requiring KRT, lower baseline kidney function and reduced urine output at the time of KRT initiation are associated with kidney non-recovery.

A multicenter observational study of clinical features and outcomes of AKI in critically ill patients with COVID-19

Background: Acute kidney injury (AKI) is emerging as an important sequela of COVID-19 infection. Existing data on the incidence and clinical features of AKI in patients with COVID-19 are mainly limited to single-center studies. Given the high incidence of severe AKI among patients with COVID-19 and its strong association with mortality in other settings, we conducted a multicenter nationally representative cohort study to examine the incidence, clinical features, risk factors, and outcomes of AKI in critically ill patients with COVID-19. Methods: We used data from a multicenter observational study that collected granular, patient-level data from >3,000 critically ill adults with laboratory-confirmed COVID-19 admitted to participating ICUs from 67 centers across the United States. Using multivariable logistic regression, we examined risk factors for the primary composite outcome, AKI requiring renal replacement therapy or death (RRT/death) in the 14 days following ICU admission. Results: Among 3099 patients, 1205 (38.9%) developed the primary outcome of RRT/death (n=637 required RRT, n=792 died within 14 days, and n=224 both required RRT and died within 14 days). Independent risk factors for RRT/death included chronic kidney disease (odds ratio [OR], 5.02;95% CI, 3.55-7.10 for eGFR<30 vs. ≥60;OR 1.90;95% CI, 1.55-2.33 for eGFR 30-59 vs. ≥60), as well as older age, male sex, higher body mass index, and greater severity of hypoxemia on ICU admission (Figure). Patients admitted to hospitals with higher degrees of strain also had a greater risk of RRT/death (OR 1.49;95% CI, 1.06-2.06 for highest versus lowest quintile of hospital strain). Conclusions: This multicenter study identifies several key insights into the risk factors for RRT/death in critically ill patients with COVID-19. (Figure Presented).