ABSTRACT
Background: After the first reported case of COVID-19 in the U.S., New York City quickly became the epicenter of the pandemic. AKI has been reported in patients with severe COVID-19. The Bronx consists of a predominantly minority population with a high burden of comorbidities that may be at increased risk for AKI in the setting of COVID-19. We aimed to characterize risk factors and short term outcomes in patients hospitalized with COVID-19 and severe AKI. Methods: We performed a retrospective study of 113 adults hospitalized with COVID-19 in a large healthcare system in the Bronx who required nephrology consultation for AKI from March 11-March 30, 2020. We extracted data on demographics, comorbidities, admission vital signs and labs, need for mechanical ventilation, renal replacement therapy (RRT), in-hospital death and discharge. AKI was defined by KDIGO criteria. Chi-square analyses and Wilcoxon tests were used. Data was censored on April 12, 2020. All patients had ≥ 14 days of follow up. Results: Mean age was 63 (SD 12) years old;69% were men and 33% were Black and 23% were Hispanic. Forty-five patients (39.8%) had chronic kidney disease, 58(51%) had diabetes mellitus and 87(77%) had hypertension. The majority presented with AKI within 24 hours of admission and 75% had Stage 3 AKI. Ninety-two (81%) patients had proteinuria and 53(47%) had hematuria. Intensive care unit (ICU) was required in 62(55%), 64(57%) required mechanical ventilation, 56(49.5%) required RRT and 18(16%) were not candidates for RRT. In-hospital death occurred in 68(60%) and 22% were discharged. Of those who required RRT, in-hospital death occurred in 35(62.5%) and only 6 patients were discharged, 5 of whom remained RRT dependent. Heavy proteinuria (3-4+ on urinalysis) and initial C-reactive protein (CRP) were higher in those with AKI who died [21.1 (IQR 14.3-29.6) versus 6.6 (3.2-16.3), p<0.001]. Conclusions: Severe AKI in the setting of COVID-19 is associated with increased utilization of ICU, mechanical ventilation, and RRT. Outcomes are poor in those with Stage 3 AKI, underscoring the need for palliative care involvement and early goals of care discussions. Elevated initial CRP and heavy proteinuria may be useful to risk stratify patients with COVID-19 and severe AKI at increased risk for mortality.
ABSTRACT
Background: Studies indicate that 5% of patients with COVID-19 develop critical illness, warranting ICU level of care. Up to 15% of these critically ill patients develop acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). COVID-19 also appears to generate a pro-thrombotic state in some patients and thrombosis during CRRT could prevent life sustaining clearance and fluid removal. Methods: In this single center study, we performed a retrospective chart review of patients admitted to Montefiore Medical Center, with a confirmed diagnosis of COVID19 in an ICU requiring CRRT between 3/10/2020 - 4/28/2020. Subsequently, we categorized the different anticoagulation (AC) types that were used for each CRRT treatment: no AC, heparin, bivalirudin, apixiban. The primary outcome was to determine the percent of achieved versus prescribed CRRT in patients treated without AC, heparin, or bivalirudin (dosing >;0.25 mg/kg/hr, versus < 0.25 mg/kg/hr). The secondary outcome was to determine the percent reduction in BUN and potassium within 10 hours of CRRT. Results: We excluded patients with renal failure requiring renal replacement therapy (RRT) that did not have a confirmed diagnosis of COVID19, as well as patients with a previous history of thrombosis. We were left with 69 patients, whom we analyzed the first three RRT treatments of each patient. The average age was 59.48 years, 81.2% male, 18.8% female. 15% of patients were African American, 5% Caucasian, 31% Hispanic, and 17% identified as other. The average BMI was 30.2. 40% of patients had diabetes mellitus, 49% hypertension, and 14% CKD or ESRD. We analyzed a total of 162 RRT treatments. Of these 162 treatments, 49% of patients received bivalirudin, 27% heparin, and 23.4% did not receive AC. We found that 84.5% of patients receiving bivalirudin completed their CRRT treatment, 77.7% receiving heparin completed treatment, and 59.3% of patients not on AC completed treatment. Conclusions: Patients with a confirmed diagnosis of COVID 19 that are critically ill and receive CRRT are more likely to finish their CRRT treatment, and therefore achieved improved clearance, if they were given some form of AC to prevent clotting.
ABSTRACT
Introduction: There has been increased focus on the microvascular and macrovascular complications of COVID-19. Here we present a case of renal arterial thrombosis in a woman with mild symptoms of COVID-19. Case Description: A 69 year old female with diabetes, hypertension, coronary artery disease, and acute embolic cerebrovascular event post cardiac catheterization in 2016 presented to the emergency department with acute diffuse intermittent abdominal pain and nonbloody emesis. Prior to this, she had been evaluated for cough, shortness of breath and myalgias which were conservatively managed with improvement. Her medications included aspirin, clopidogrel, furosemide, and insulin. Examination was significant for diffuse nonspecific abdominal tenderness without rebound or guarding. Laboratory assessment revealed preserved renal function with creatinine of 1.10 mg/dL and PCR positive for SARS-CoV-2. A computed tomography of the abdomen and pelvis with intravenous contrast revealed a non-occlusive thrombus in the left renal artery with several large wedge-shaped areas of decreased enhancement consistent with multiple left renal infarctions. On interdisciplinary discussion, the patient was managed conservatively with anticoagulation without acute intervention and was discharged home on apixaban. Discussion: To our knowledge, this is the first description of renal artery thrombosis with renal infarction in the setting of COVID-19 infection. Patients who present with a COVID-19 infection, regardless of disease severity, should be evaluated for coagulopathy and development of thrombi as these may potentially contribute to infarction and endorgan damage. Although it requires a high index of suspicion, renal infarction should be considered part of the differential when evaluating a patient with COVID-19 infection presenting with abdominal pain or acute kidney injury. Initiation of anticoagulation should be considered with consideration of risks involved.
ABSTRACT
Background: The relationship of RAAS inhibitors (RAASi) and their purported role in increasing COVID-19 viral attachment and worse outcomes is controversial. In this study we examined the association of RAASi use with Acute Kidney Injury (AKI) and in-hospital death. Methods: We assembled a cohort of all patients admitted to the 3 main Montefiore hospitals and diagnosed with COVID-19. RAASi use was defined by a prescription within 365 days prior to hospitalization. The association of RAASi use with COVID associated AKI incidence and mortality was evaluated using logistic regression models. Propensity score matching was then used to derive the odds ratio (OR) of AKI and death in those using RAASi compared with controls. Results: Of 3345 hospitalized patients, 9.3% were prescribed a RAASi prior to hospitalization. Those prescribed RAASi were older (71.9 vs 63.6 years, p<0.001), more commonly Black or Hispanic (RAASi users 41.3% Black and 41.0% Hispanic vs non- RAASi 35.4% Black and 36.9% Hispanic) and had higher Charlson co-morbidity scores (median 4 (IQR 3-7) for RAASi users vs 2(1-3) for non-RAASi users). In unadjusted analysis, RAASi use was associated with a higher OR for AKI (OR 1.32(95% CI 1.04- 1.68)) and a higher OR for death (OR 1.53 (95% CI 1.18-1.98). Multivariate adjustment for age, demographics, and clinical comorbidity attenuated associations of AKI and death towards the null (AKI: OR 1.00 (95% CI 0.76-1.31);Death: OR 0.92 (95% CI 0.68- 1.24)). Similarly, in propensity score analysis there was no association between RAASi use and either AKI (OR 0.96 (95%CI 0.88-1.04)) or death (OR: 0.96 (95%CI 0.89-1.05). Conclusions: RAASi use prior to hospitalization was not associated with AKI or inhospital mortality in a cohort of patients hospitalized with COVID-19.