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1.
Ther Apher Dial ; 26(3): 566-582, 2022 Jun.
Article in English | MEDLINE | ID: covidwho-1816498

ABSTRACT

COVID-19 has challenged the global healthcare system through rapid proliferation and lack of existing treatment resulting in over 180 million cases and 3.8 million deaths since December 2019. Although pediatric patients only comprise 1%-2% of diagnosed cases, their incidence of acute kidney injury ranges from 8.2% to 18.2% compared to 49% in adults. Severe infection, initiated by dysregulated host response, can lead to multiorgan failure. In this review, we focus on the use of various blood filters approved for use in pediatric kidney replacement therapy to mitigate adverse effects of severe illness. Therapeutic effects of these blood filters range from cytokine removal (CytoSorb, HA330, HCO/MCO), endotoxin removal (Toraymyxin, CPFA), both cytokine and endotoxin removal (oXiris), and nonspecific removal of proteins (PMMA) that have already been established and can be used to mitigate the various effects of the cytokine storm syndrome in COVID-19.


Subject(s)
Acute Kidney Injury , COVID-19 , Acute Kidney Injury/epidemiology , Acute Kidney Injury/therapy , Adult , COVID-19/therapy , Child , Cytokines/metabolism , Endotoxins , Female , Humans , Male , Renal Replacement Therapy/methods
2.
Front Immunol ; 13: 821681, 2022.
Article in English | MEDLINE | ID: covidwho-1708117

ABSTRACT

Peritoneal dialysis (PD) is a valuable 'home treatment' option, even more so during the ongoing Coronavirus pandemic. However, the long-term use of PD is limited by unfavourable tissue remodelling in the peritoneal membrane, which is associated with inflammation-induced angiogenesis. This appears to be driven primarily through vascular endothelial growth factor (VEGF), while the involvement of other angiogenic signaling pathways is still poorly understood. Here, we have identified the crucial contribution of mesothelial cell-derived angiogenic CXC chemokine ligand 1 (CXCL1) to peritoneal angiogenesis in PD. CXCL1 expression and peritoneal microvessel density were analysed in biopsies obtained by the International Peritoneal Biobank (NCT01893710 at www.clinicaltrials.gov), comparing 13 children with end-stage kidney disease before initiating PD to 43 children on chronic PD. The angiogenic potential of mesothelial cell-derived CXCL1 was assessed in vitro by measuring endothelial tube formation of human microvascular endothelial cells (HMECs) treated with conditioned medium from human peritoneal mesothelial cells (HPMCs) stimulated to release CXCL1 by treatment with either recombinant IL-17 or PD effluent. We found that the capillary density in the human peritoneum correlated with local CXCL1 expression. Both CXCL1 expression and microvessel density were higher in PD patients than in the age-matched patients prior to initiation of PD. Exposure of HMECs to recombinant CXCL1 or conditioned medium from IL-17-stimulated HPMCs resulted in increased endothelial tube formation, while selective inhibition of mesothelial CXCL1 production by specific antibodies or through silencing of relevant transcription factors abolished the proangiogenic effect of HPMC-conditioned medium. In conclusion, peritoneal mesothelium-derived CXCL1 promotes endothelial tube formation in vitro and associates with peritoneal microvessel density in uremic patients undergoing PD, thus providing novel targets for therapeutic intervention to prolong PD therapy.


Subject(s)
Chemokine CXCL1/metabolism , Neovascularization, Pathologic/pathology , Peritoneal Dialysis/methods , Peritoneum/blood supply , Renal Replacement Therapy/methods , COVID-19/pathology , Cells, Cultured , Child , Child, Preschool , Epithelium/metabolism , Humans , Infant , Interleukin-17/metabolism , Kidney Failure, Chronic/therapy , Peritoneum/pathology , Vascular Endothelial Growth Factor A/metabolism , Vascular Remodeling/physiology
4.
Semin Dial ; 35(4): 325-329, 2022 07.
Article in English | MEDLINE | ID: covidwho-1685435

ABSTRACT

INTRODUCTION: The aim of our study is to compare clotting of CRRT filters in patients with COVID-19-associated AKI versus septic shock-associated AKI. METHODS: Retrospective study of adult ICU patients with COVID-19 compared to those with septic shock admitted to a tertiary hospital April-October 2020. Independent t test and chi-square test used to determine statistical significance of CRRT filter clotting between the two groups. Time-to-event data analyzed with Kaplan-Meier curves. Analyses performed on Microsoft Excel and MedCalc. RESULTS: Twenty-seven ICU patients with AKI requiring CRRT were included, 13 with COVID-19 and 14 non-COVID-19 patients with septic shock. The mean half-life of CRRT hemofilter was similar in COVID-19 patients compared to non-COVID-19 patients (27.4 vs. 27.5 h, p = 0.79). The number of CRRT hemofilter changes per day was similar in both groups (0.6 filter changes per day, p = 0.84). However, significantly more patients with COVID-19 were on systemic heparin (69% vs. 13%, p = 0.02). CONCLUSION: We found that COVID-19 patients with AKI requiring CRRT had similar CRRT hemofilter half-life compared with sepsis-associated AKI patients with use of regional citrate and systemic heparin. Further studies are needed to find which methods of anticoagulation are optimal in patients with COVID-19 infection with AKI requiring CRRT.


Subject(s)
Acute Kidney Injury , COVID-19 , Continuous Renal Replacement Therapy , Shock, Septic , Acute Kidney Injury/chemically induced , Acute Kidney Injury/therapy , Adult , Anticoagulants/therapeutic use , COVID-19/complications , COVID-19/therapy , Citrates , Citric Acid , Half-Life , Heparin/therapeutic use , Humans , Renal Dialysis , Renal Replacement Therapy/methods , Retrospective Studies
5.
Clin Transl Sci ; 15(3): 732-740, 2022 03.
Article in English | MEDLINE | ID: covidwho-1526361

ABSTRACT

Remdesivir, an antiviral agent for the treatment of coronavirus disease 2019 (COVID-19), is metabolized intracellularly, with these metabolites eliminated predominantly in urine. Because of a lack of safety and pharmacokinetic (PK) data, remdesivir is not currently recommended for patients with estimated glomerular filtration rate less than 30 ml/min/1.73 m2 and those on hemodialysis. This study evaluated the PKs of remdesivir and its metabolite, GS-441524, in patients with COVID-19 who were and were not receiving renal replacement therapy (RRT). This study enrolled two patients with normal renal function, two with impaired renal function not receiving RRT, two receiving continuous RRT (CRRT), and three undergoing intermittent hemodialysis (IHD). Patients were administered 200 mg remdesivir on the first day, followed by 100 mg/day for 5-10 days. Serial blood samples were collected for PK analysis, and PK parameters were assessed by a noncompartmental method. Systemic exposure to remdesivir was higher in patients with impaired renal function and those receiving CRRT than in patients with normal renal function, but was similar in patients undergoing IHD and those with normal renal function. By contrast, systemic exposure to GS-441524 was highest in patients undergoing IHD, followed by patients with impaired renal function and those receiving CRRT, and lowest in patients with normal renal function. The PK profiles of remdesivir and GS-441524 varied according to renal function and RRT. The impact of PK changes of remdesivir and its metabolite on safety and efficacy should be considered when administering remdesivir to patients with COVID-19 with renal impairment.


Subject(s)
COVID-19 , Adenosine/analogs & derivatives , Adenosine Monophosphate/analogs & derivatives , Alanine/analogs & derivatives , COVID-19/drug therapy , Humans , Kidney/metabolism , Renal Replacement Therapy/methods
6.
BMC Nephrol ; 22(1): 359, 2021 11 01.
Article in English | MEDLINE | ID: covidwho-1496153

ABSTRACT

BACKGROUND: Acute kidney injury (AKI) is common among patients hospitalised with COVID-19 and associated with worse prognosis. The aim of this study was to investigate the epidemiology, risk factors and outcomes of AKI in patients with COVID-19 in a large UK tertiary centre. METHODS: We analysed data of consecutive adults admitted with a laboratory-confirmed diagnosis of COVID-19 across two sites of a hospital in London, UK, from 1st January to 13th May 2020. RESULTS: Of the 1248 inpatients included, 487 (39%) experienced AKI (51% stage 1, 13% stage 2, and 36% stage 3). The weekly AKI incidence rate gradually increased to peak at week 5 (3.12 cases/100 patient-days), before reducing to its nadir (0.83 cases/100 patient-days) at the end the study period (week 10). Among AKI survivors, 84.0% had recovered renal function to pre-admission levels before discharge and none required on-going renal replacement therapy (RRT). Pre-existing renal impairment [odds ratio (OR) 3.05, 95%CI 2.24-4,18; p <  0.0001], and inpatient diuretic use (OR 1.79, 95%CI 1.27-2.53; p <  0.005) were independently associated with a higher risk for AKI. AKI was a strong predictor of 30-day mortality with an increasing risk across AKI stages [adjusted hazard ratio (HR) 1.59 (95%CI 1.19-2.13) for stage 1; p < 0.005, 2.71(95%CI 1.82-4.05); p < 0.001for stage 2 and 2.99 (95%CI 2.17-4.11); p < 0.001for stage 3]. One third of AKI3 survivors (30.7%), had newly established renal impairment at 3 to 6 months. CONCLUSIONS: This large UK cohort demonstrated a high AKI incidence and was associated with increased mortality even at stage 1. Inpatient diuretic use was linked to a higher AKI risk. One third of survivors with AKI3 exhibited newly established renal impairment already at 3-6 months.


Subject(s)
Acute Kidney Injury , COVID-19 , Renal Replacement Therapy , Acute Kidney Injury/diagnosis , Acute Kidney Injury/etiology , Acute Kidney Injury/mortality , Acute Kidney Injury/therapy , COVID-19/complications , COVID-19/diagnosis , COVID-19/epidemiology , Cohort Studies , Hospital Mortality , Humans , Incidence , Intensive Care Units/statistics & numerical data , Kidney Function Tests/methods , Male , Middle Aged , Outcome and Process Assessment, Health Care , Patient Acuity , Renal Replacement Therapy/methods , Renal Replacement Therapy/statistics & numerical data , Risk Factors , SARS-CoV-2/isolation & purification , Severity of Illness Index , United Kingdom/epidemiology
7.
Blood Purif ; 51(8): 660-667, 2022.
Article in English | MEDLINE | ID: covidwho-1495749

ABSTRACT

BACKGROUND AND OBJECTIVES: Acute kidney injury (AKI) is a common complication among patients with COVID-19 and acute respiratory distress syndrome. Reports suggest that COVID-19 confers a pro-thrombotic state, which presents challenges in maintaining hemofilter patency and delivering continuous renal replacement therapy (CRRT). We present our initial experience with CRRT in critically ill patients with COVID-19, emphasizing circuit patency and the association between fluid balance during CRRT and respiratory parameters. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Retrospective chart review of 32 consecutive patients with COVID-19 and AKI managed with continuous venovenous hemodiafiltration with regional citrate anticoagulation (CVVHDF-RCA) according to the University of Michigan protocol. Primary outcome was mean CRRT circuit life per patient during the first 7 days of CRRT. We used simple linear regression to assess the relationship between patient characteristics and filter life. We also explored the relationship between fluid balance on CRRT and respiratory parameters using repeated measures modeling. RESULTS: Patients' mean age was 54.8 years and majority were Black (75%). Comorbidities included hypertension (90.6%), obesity (70.9%) diabetes (56.2%), and chronic kidney disease (40.6%). Median CRRT circuit life was 53.5 [interquartile range 39.1-77.6] hours. There was no association between circuit life and inflammatory or pro-thrombotic laboratory values (ferritin p = 0.92, C-reactive protein p = 0.29, D-dimer p = 0.24), or with systemic anticoagulation (p = 0.37). Net daily fluid removal during the first 7 days of CRRT was not associated with daily (closest recorded values to 20:00) PaO2/FIO2 ratio (p = 0.21) or positive end-expiratory pressure requirements (p = 0.47). CONCLUSIONS: We achieved adequate CRRT circuit life in COVID-19 patients using an established CVVHDF-RCA protocol. During the first 7 days of CRRT therapy, cumulative fluid balance was not associated with improvements in respiratory parameters, even after accounting for baseline fluid balance.


Subject(s)
Acute Kidney Injury , COVID-19 , Continuous Renal Replacement Therapy , Thrombosis , Acute Kidney Injury/etiology , Anticoagulants , COVID-19/complications , COVID-19/therapy , Critical Illness/therapy , Humans , Middle Aged , Renal Replacement Therapy/methods , Retrospective Studies , Thrombosis/complications
8.
Blood Purif ; 51(7): 584-589, 2022.
Article in English | MEDLINE | ID: covidwho-1455789

ABSTRACT

BACKGROUND: The COVID-19 pandemic led to a rapidly increased demand for intensive care unit (ICU) and renal replacement therapy (RRT) worldwide. RRT delivery was threatened by a lack of specially trained staff and equipment. We investigated how the first wave of COVID-19 affected RRT delivery in Swedish ICUs. METHODS: An Internet-based questionnaire was sent to ICU lead physicians which included quantitative and qualitative questions regarding RRT demand, equipment availability, and use of continuous renal replacement therapy (CRRT), intermittent haemodialysis (IHD), and peritoneal dialysis (PD) during spring 2020. RESULTS: Twenty-five ICUs responded and these treated 64% of COVID-19 ICU patients in Sweden. ICU capacity increased by 292% (IQR 171-347%). Median peak capacity was reached during the 18th week of the year. RRT use increased overall by 133% and in Stockholm by 188%. 36% of units sequestered CRRT machines. IHD was used in 68% and PD in 12% of ICUs. RRT fluid and filter shortages were experienced by 45% and 33% of wards, respectively; consequently, prescription alterations were made by 24% of ICUs. Calcium solution shortages were reported in 12% of units that led to citrate protocol changes. Staffing shortages resulted in RRT sometimes being delivered by non-RRT-trained staff, safety incidents relating to this occurred, although no patient harm was reported. CONCLUSION: During the first wave of the COVID-19 pandemic, RRT demand increased extensively causing staff and equipment shortages, altered CRRT protocols, and increased use of IHD and PD. The impact on patient outcomes should be assessed to effectively plan for further surge capacity RRT demand.


Subject(s)
Acute Kidney Injury , COVID-19 , Acute Kidney Injury/therapy , COVID-19/epidemiology , COVID-19/therapy , Humans , Intensive Care Units , Pandemics , Renal Replacement Therapy/methods , Sweden/epidemiology
9.
Chest ; 160(3): 929-943, 2021 09.
Article in English | MEDLINE | ID: covidwho-1220138

ABSTRACT

BACKGROUND: Subphenotypes have been identified in patients with sepsis and ARDS and are associated with different outcomes and responses to therapies. RESEARCH QUESTION: Can unique subphenotypes be identified among critically ill patients with COVID-19? STUDY DESIGN AND METHODS: Using data from a multicenter cohort study that enrolled critically ill patients with COVID-19 from 67 hospitals across the United States, we randomly divided centers into discovery and replication cohorts. We used latent class analysis independently in each cohort to identify subphenotypes based on clinical and laboratory variables. We then analyzed the associations of subphenotypes with 28-day mortality. RESULTS: Latent class analysis identified four subphenotypes (SP) with consistent characteristics across the discovery (45 centers; n = 2,188) and replication (22 centers; n = 1,112) cohorts. SP1 was characterized by shock, acidemia, and multiorgan dysfunction, including acute kidney injury treated with renal replacement therapy. SP2 was characterized by high C-reactive protein, early need for mechanical ventilation, and the highest rate of ARDS. SP3 showed the highest burden of chronic diseases, whereas SP4 demonstrated limited chronic disease burden and mild physiologic abnormalities. Twenty-eight-day mortality in the discovery cohort ranged from 20.6% (SP4) to 52.9% (SP1). Mortality across subphenotypes remained different after adjustment for demographics, comorbidities, organ dysfunction and illness severity, regional and hospital factors. Compared with SP4, the relative risks were as follows: SP1, 1.67 (95% CI, 1.36-2.03); SP2, 1.39 (95% CI, 1.17-1.65); and SP3, 1.39 (95% CI, 1.15-1.67). Findings were similar in the replication cohort. INTERPRETATION: We identified four subphenotypes of COVID-19 critical illness with distinct patterns of clinical and laboratory characteristics, comorbidity burden, and mortality.


Subject(s)
Acute Kidney Injury/therapy , COVID-19/epidemiology , Critical Illness/epidemiology , Pandemics , Renal Replacement Therapy/methods , Acute Kidney Injury/epidemiology , Aged , COVID-19/therapy , Comorbidity , Female , Humans , Male , Middle Aged , SARS-CoV-2 , United States/epidemiology
10.
Medicine (Baltimore) ; 100(15): e25255, 2021 Apr 16.
Article in English | MEDLINE | ID: covidwho-1180670

ABSTRACT

RATIONALE: Fibrinolysis shutdown associated with severe thrombotic complications is a recently recognized syndrome that was previously seldom investigated in patients with severe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. It presents a unique therapeutic dilemma, as anticoagulation with heparin alone is insufficient to address the imbalance in fibrinolysis. And while the use of fibrinolytic agents could limit the disease severity, it is often associated with bleeding complications. There is a need for biomarkers that will guide the timely stratification of patients into those who may benefit from both anticoagulant and fibrinolytic therapies. PATIENT CONCERNS: All 3 patients presented with shortness of breath along with comorbidities predisposing them to severe SARS-CoV-2 infection. One patient (Patient 3) also suffered from bilateral deep venous thrombosis. DIAGNOSES: All 3 patients tested positive for SARS-CoV-2 RNA by reverse transcription polymerase chain reaction (RT-PCR) and were eventually diagnosed with respiratory failure necessitating intubation. INTERVENTIONS: All 3 patients required mechanical ventilation support, 2 of which also required renal replacement therapy. All 3 patients were also placed on anticoagulation therapy. OUTCOMES: In Patients 1 and 2, the initial D-dimer levels of 0.97 µg/ml fibrinogen equivalent units (FEU) and 0.83 µg/ml FEU were only slightly elevated (normal <0.50 µg/ml FEU). They developed rising D-dimer levels to a peak of 13.21 µg/ml FEU and >20.0 µg/ml FEU, respectively, which dropped to 1.34 µg/ml FEU 8 days later in Patient 1 and to 2.94 µg/ml on hospital day 13 in Patient 2. In Patient 3, the D-dimer level on admission was found to be elevated to >20.00 µg/ml FEU together with imaging evidence of thrombosis. And although he received therapeutic heparin infusion, he still developed pulmonary embolism (PE) and his D-dimer level declined to 5.91 µg/ml FEU. Despite "improvement" in their D-dimer levels, all 3 patients succumbed to multi-system organ failure. On postmortem examination, numerous arterial and venous thromboses of varying ages, many consisting primarily of fibrin, were identified in the lungs of all patients. LESSONS: High D-dimer levels, with subsequent downtrend correlating with clinical deterioration, seems to be an indicator of fibrinolysis suppression. These findings can help form a hypothesis, as larger cohorts are necessary to demonstrate their reproducibility.


Subject(s)
Anticoagulants/therapeutic use , COVID-19 , Fibrin Fibrinogen Degradation Products/analysis , Multiple Organ Failure , Thrombolytic Therapy/methods , Autopsy/methods , COVID-19/blood , COVID-19/complications , COVID-19/physiopathology , COVID-19/therapy , Clinical Deterioration , Female , Fibrinolysis , Humans , Male , Middle Aged , Multiple Organ Failure/blood , Multiple Organ Failure/diagnosis , Multiple Organ Failure/etiology , Predictive Value of Tests , Prognosis , Renal Replacement Therapy/methods , Respiration, Artificial/methods , SARS-CoV-2/isolation & purification , Severity of Illness Index , Venous Thrombosis/blood , Venous Thrombosis/complications , Venous Thrombosis/diagnosis
11.
Biomarkers ; 26(5): 417-424, 2021 Jul.
Article in English | MEDLINE | ID: covidwho-1146879

ABSTRACT

BACKGROUND: About 20% of ICU patients with COVID-19 require renal replacement therapy (RRT). Mid-regional pro-adrenomedullin (MR-proADM) might be used for risk assessment. This study investigates MR-proADM for RRT prediction in ICU patients with COVID-19. METHODS: We analysed data of consecutive patients with COVID-19, requiring ICU admission at a university hospital in Germany between March and September 2020. Clinical characteristics, details on AKI, and RRT were assessed. MR-proADM was measured on admission. RESULTS: 64 patients were included (49 (77%) males). Median age was 62.5y (54-73). 47 (73%) patients were ventilated and 50 (78%) needed vasopressors. 25 (39%) patients had severe ARDS, and 10 patients needed veno-venous extracorporeal membrane oxygenation. 29 (45%) patients required RRT; median time from admission to RRT start was 2 (1-9) days. MR-proADM on admission was higher in the RRT group (2.491 vs. 1.23 nmol/l; p = 0.002) and showed the highest correlation with renalSOFA. ROC curve analysis showed that MR-proADM predicts RRT with an AUC of 0.69 (95% CI: 0.543-0.828; p = 0.019). In multivariable logistic regression MR-proADM was an independent predictor (OR: 3.813, 95% CI 1.110-13.102, p<0.05) for RRT requirement. CONCLUSION: AKI requiring RRT is frequent in ICU patients with COVID-19. MR-proADM on admission was able to predict RRT requirement, which may be of interest for risk stratification and management.


Subject(s)
Acute Kidney Injury/therapy , Adrenomedullin/metabolism , COVID-19/prevention & control , Critical Illness/therapy , Protein Precursors/metabolism , Renal Replacement Therapy/methods , SARS-CoV-2/isolation & purification , Acute Kidney Injury/diagnosis , Aged , Biomarkers/metabolism , COVID-19/virology , Cohort Studies , Female , Germany , Hospitals, University , Humans , Intensive Care Units , Male , Middle Aged , Predictive Value of Tests , ROC Curve , SARS-CoV-2/physiology
13.
J Nephrol ; 34(2): 285-293, 2021 04.
Article in English | MEDLINE | ID: covidwho-1002198

ABSTRACT

BACKGROUND: Acute kidney injury (AKI) is frequent in Coronavirus Infection Disease 2019 (COVID-19) patients. Factors associated with AKI in COVID-19 intensive care unit (ICU) patients and their outcomes have not been previously explored. METHODS: Prospective observational study of COVID-19 patients admitted to the ICUs of the Hospital Clínic of Barcelona (Spain), from March 25th to April 21st, 2020, who developed AKI stage 2 or higher (AKIN classification). The primary goal was to describe the characteristics of moderate-severe AKI of COVID-19 patients in an ICU context. As a secondary goal, we aimed to find independent predictors of AKI progression, Renal Replacement Therapy (RRT) requirement and mortality among these patients. RESULTS: During the study period, 52 out of 237 ICU patients, developed AKIN stage 2 or higher and were included in the study. A Sequential Organ Failure Assessment (SOFA) score at AKI diagnosis of 8 or higher was associated with RRT, OR 5.2, p 0.032. At the time of AKI diagnosis, patients had a worse liver profile and higher inflammation markers than at admission. Fifty per cent of the patients presented AKI progression from AKIN 2 to 3 and 28.85% required RRT. The use of corticosteroids in 69.2% of patients was associated with a reduced requirement of RRT, OR 0.13 (CI 95% 0.02-0.89), p 0.037. AKI was associated with high mortality (50%) and a longer hospital stay, median 35 vs 18 days (p 0.024). CONCLUSIONS: The prevalence of moderate/severe AKI in COVID-19 patients admitted to the ICU is high and has a strong correlation with mortality and length of hospital stay.


Subject(s)
Acute Kidney Injury/etiology , COVID-19/complications , Critical Illness , Renal Replacement Therapy/methods , Acute Kidney Injury/diagnosis , Acute Kidney Injury/epidemiology , Aged , COVID-19/epidemiology , Female , Follow-Up Studies , Hospital Mortality/trends , Hospitalization/trends , Humans , Incidence , Intensive Care Units/statistics & numerical data , Male , Pandemics , Prospective Studies , Risk Factors , SARS-CoV-2 , Spain/epidemiology
14.
PLoS One ; 15(12): e0244131, 2020.
Article in English | MEDLINE | ID: covidwho-999832

ABSTRACT

INTRODUCTION: A large proportion of patients with COVID-19 develop acute kidney injury (AKI). While the most severe of these cases require renal replacement therapy (RRT), little is known about their clinical course. METHODS: We describe the clinical characteristics of COVID-19 patients in the ICU with AKI requiring RRT at an academic medical center in New York City and followed patients for outcomes of death and renal recovery using time-to-event analyses. RESULTS: Our cohort of 115 patients represented 23% of all ICU admissions at our center, with a peak prevalence of 29%. Patients were followed for a median of 29 days (2542 total patient-RRT-days; median 54 days for survivors). Mechanical ventilation and vasopressor use were common (99% and 84%, respectively), and the median Sequential Organ Function Assessment (SOFA) score was 14. By the end of follow-up 51% died, 41% recovered kidney function (84% of survivors), and 8% still needed RRT (survival probability at 60 days: 0.46 [95% CI: 0.36-0.56])). In an adjusted Cox model, coronary artery disease and chronic obstructive pulmonary disease were associated with increased mortality (HRs: 3.99 [95% CI 1.46-10.90] and 3.10 [95% CI 1.25-7.66]) as were angiotensin-converting-enzyme inhibitors (HR 2.33 [95% CI 1.21-4.47]) and a SOFA score >15 (HR 3.46 [95% CI 1.65-7.25). CONCLUSIONS AND RELEVANCE: Our analysis demonstrates the high prevalence of AKI requiring RRT among critically ill patients with COVID-19 and is associated with a high mortality, however, the rate of renal recovery is high among survivors and should inform shared-decision making.


Subject(s)
Acute Kidney Injury/etiology , Acute Kidney Injury/pathology , COVID-19/complications , Kidney/pathology , Acute Kidney Injury/virology , Aged , Critical Illness/mortality , Female , Humans , Intensive Care Units , Kidney/virology , Male , Middle Aged , New York City , Proportional Hazards Models , Renal Replacement Therapy/methods , Retrospective Studies , SARS-CoV-2/pathogenicity , Survivors
15.
J Crit Care ; 62: 190-196, 2021 04.
Article in English | MEDLINE | ID: covidwho-988305

ABSTRACT

PURPOSE: The aim of this study is to describe the incidence of Acute Kidney Injury (AKI) amongst patients admitted to the Intensive Care Unit (ICU) with COVID-19. In addition we aim to detail the range of Renal Replacement Therapy (RRT) modalities offered to these patients (including peritoneal dialysis - PD - and intermittent haemodialysis - IHD) in order to meet demand during pandemic conditions. MATERIALS AND METHODS: Single-centre retrospective case note review of adult patients with confirmed COVID-19 admitted to ICU. RESULTS: Amongst 136 patients without a prior history of End Stage Kidney Disease (ESKD), 108 (79%) developed AKI and 63% of admitted patients received RRT. Due to resource limitations the range of RRT options were expanded from solely Continuous Veno-Venous HaemoDiaFiltration (CVVHDF - our usual standard of care) to include PD (in 35 patients) and IHD (in 15 patients). During the study period the proportion of RRT provided within ICU as CVVHDF fell from 100% to a nadir of 39%. There were no significant complications of either PD or IHD. CONCLUSIONS: During periods of resource limitations PD and IHD can safely be used to reduce dependence on CVVHDF in select patients with AKI secondary to COVID-19.


Subject(s)
Acute Kidney Injury/etiology , Acute Kidney Injury/therapy , COVID-19/complications , Critical Care/methods , Renal Replacement Therapy/methods , Adult , Aged , Continuous Renal Replacement Therapy/methods , Female , Humans , Intensive Care Units , Intermittent Renal Replacement Therapy/methods , Male , Middle Aged , Peritoneal Dialysis/statistics & numerical data , Retrospective Studies , SARS-CoV-2 , Tertiary Care Centers , United Kingdom/epidemiology
16.
CMAJ Open ; 8(4): E788-E795, 2020.
Article in English | MEDLINE | ID: covidwho-970110

ABSTRACT

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is responsible for millions of infections worldwide, and a substantial number of these patients will be admitted to the intensive care unit (ICU). Our objective was to describe the characteristics, outcomes and management of critically ill patients with COVID-19 pneumonia at a single designated pandemic centre in Montréal, Canada. METHODS: A descriptive analysis was performed on consecutive critically ill patients with COVID-19 pneumonia admitted to the ICU at the Jewish General Hospital, a designated pandemic centre in Montréal, between Mar. 5 and May 21, 2020. Complete follow-up data corresponding to death or discharge from hospital health records were included to Aug. 4, 2020. We summarized baseline characteristics, management and outcomes, including mortality. RESULTS: A total of 106 patients were included in this study. Twenty-one patients (19.8%) died during their hospital stay, and the ICU mortality was 17.0% (18/106); all patients were discharged home or died, except for 4 patients (2 awaiting a rehabilitation bed and 2 awaiting long-term care). Twelve of 65 patients (18.5%) requiring mechanical ventilation died. Prone positioning was used in 29 patients (27.4%), including in 10 patients who were spontaneously breathing; no patient was placed on extracorporeal membrane oxygenation. High-flow nasal cannula was used in 51 patients (48.1%). Acute kidney injury was the most common complication, seen in 20 patients (18.9%), and 12 patients (11.3%) required renal replacement therapy. A total of 53 patients (50.0%) received corticosteroids. INTERPRETATION: Our cohort of critically ill patients with COVID-19 had lower mortality than that previously described in other jurisdictions. These findings may help guide critical care decision-making in similar health care systems in further COVID-19 surges.


Subject(s)
COVID-19/diagnosis , Critical Illness/mortality , Intensive Care Units/statistics & numerical data , SARS-CoV-2/genetics , Acute Kidney Injury/epidemiology , Acute Kidney Injury/therapy , Adrenal Cortex Hormones/therapeutic use , Aged , COVID-19/epidemiology , COVID-19/mortality , COVID-19/virology , Canada/epidemiology , Cannula/statistics & numerical data , Cohort Studies , Critical Illness/nursing , Female , Hospitalization/statistics & numerical data , Humans , Length of Stay/statistics & numerical data , Male , Middle Aged , Practice Patterns, Physicians'/trends , Prone Position , Renal Replacement Therapy/methods , Respiration, Artificial/mortality , Respiration, Artificial/statistics & numerical data , Retrospective Studies , Treatment Outcome
17.
Acta Anaesthesiol Scand ; 65(3): 364-372, 2021 03.
Article in English | MEDLINE | ID: covidwho-944614

ABSTRACT

BACKGROUND: Acute kidney injury (AKI) is a syndrome of reduced glomerular filtration rate and/or reduced urine flow associated with mortality in corona virus disease 2019 (COVID-19). AKI is often associated with renal tissue damage, which may lead to chronic kidney disease. Biomarkers of tissue damage may identify patients of particular risk. METHODS: In a prospective observational study of 57 patients admitted to intensive care, AKI incidence and characteristics was evaluated according to KDIGO criteria and related to days after admission. Urinary albumin, Neutrophil Gelatinase-Associated Lipocalin (NGAL), Kidney Injury Molecule 1 (KIM-1) and Plasma Tissue Inhibitor of MetalloProteinase 2 (TIMP-2) were analysed in 52 patients at admission. The majority (n = 51, 89%) of patients developed AKI, and 27 (47%) patients had predominantly oliguric AKI where oliguria was more severe than plasma Creatinine increase. Severe oliguria within first 2 days after admission was common (n = 37, 65%), whereas stage 2 and 3 AKI due to Creatinine occurred later than day 2 in 67% (12/18) of cases. Renal replacement therapy was started in 9 (16%) patients, and 30-day mortality was 28%. Urinary biomarkers were increased in a majority of patients, but did not robustly predict KDIGO stage. Most patients had microalbuminuria, and severe albuminuria (albumin Creatinine ratio > 30 mg/mmol) was found in n = 9 (17%) patients. CONCLUSIONS: A majority of patients with COVID-19 admitted to the ICU develop AKI. The functional deficit is often low urinary volume, and initial levels of biomarkers are generally increased without clear relation to final AKI stage.


Subject(s)
Acute Kidney Injury/etiology , COVID-19/complications , Critical Care/methods , Oliguria/etiology , Acute Kidney Injury/therapy , Acute Kidney Injury/urine , Biomarkers/urine , COVID-19/urine , Female , Humans , Intensive Care Units , Male , Middle Aged , Oliguria/therapy , Oliguria/urine , Prospective Studies , Renal Replacement Therapy/methods , SARS-CoV-2
18.
Ther Apher Dial ; 25(1): 55-65, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-936606

ABSTRACT

HD care may experience great stress with the coronavirus disease 2019 (COVID-19) pandemic. A modified HD modality named bed-sided short-duration renal replacement therapy (BSRRT) was used in noncritical maintenance HD (MHD) patients diagnosed with COVID-19 in Wuhan due to extreme situation. To determine the safety and efficacy as a substitution for intermittent HD (IHD), we conducted this study. We used the data of 88 noncritical COVID-19 MHD patients collected from 65 medical units at the hospitals in Wuhan, China, from January 1 to March 10, 2020. t-test, Wilcoxon rank sum test, and Fisher exact probability method were used to compare the baseline characteristics, treatment, and death. Log-rank test and Cox regression multivariate analysis was used to compare the survival of noncritical patients who were transferred to BSRRT modality versus those who were continued on the IHD. Univariate analysis showed the level of reported fatigue symptom at present, bilateral lung computed tomography infiltration and steroid treatment differed between the two groups. The outcome of death of the two groups did not show significant differences in univariate analysis (P = .0563). Multivariate Cox regression analysis dialysis showed modality of treatment after COVID-19 diagnosis was not a significant predictor of death (P = .1000). These data suggest that for noncritical COVID-19 MHD patients, the transfer from IHD to BSRRT does not have significant difference in the risk of death compared with IHD group. This finding suggests this modified modality could be an option for the substitution for IHD during the COVID-19 pandemic period.


Subject(s)
COVID-19/therapy , Point-of-Care Systems , Renal Replacement Therapy/methods , COVID-19/epidemiology , China/epidemiology , Female , Humans , Male , Middle Aged , Pandemics , Pneumonia, Viral/epidemiology , Pneumonia, Viral/virology , Retrospective Studies , SARS-CoV-2
19.
BMC Nephrol ; 21(1): 486, 2020 11 16.
Article in English | MEDLINE | ID: covidwho-926325

ABSTRACT

BACKGROUND: Critically ill coronavirus disease 2019 (COVID-19) patients have a high risk of acute kidney injury (AKI) that requires renal replacement therapy (RRT). A state of hypercoagulability reduces circuit life spans. To maintain circuit patency and therapeutic efficiency, an optimized anticoagulation strategy is needed. This study investigates whether alternative anticoagulation strategies for RRT during COVID-19 are superior to administration of unfractionated heparin (UFH). METHODS: Retrospective cohort study on 71 critically ill COVID-19 patients (≥18 years), admitted to intensive care units at a tertiary health care facility in the southwestern part of Germany between February 26 and May 21, 2020. We collected data on the disease course, AKI, RRT, and thromboembolic events. Four different anticoagulatory regimens were administered. Anticoagulation during continuous veno-venous hemodialysis (CVVHD) was performed with UFH or citrate. Anticoagulation during sustained low-efficiency daily dialysis (SLEDD) was performed with UFH, argatroban, or low molecular weight heparin (LMWH). Primary outcome is the effect of the anticoagulation regimen on mean treatment times of RRT. RESULTS: In patients receiving CVVHD, mean treatment time in the UFH group was 21.3 h (SEM: ±5.6 h), in the citrate group 45.6 h (SEM: ±2.7 h). Citrate anticoagulation significantly prolonged treatment times by 24.4 h (P = .001). In patients receiving SLEDD, mean treatment time with UFH was 8.1 h (SEM: ±1.3 h), with argatroban 8.0 h (SEM: ±0.9 h), and with LMWH 11.8 h (SEM: ±0.5 h). LMWH significantly prolonged treatment times by 3.7 h (P = .008) and 3.8 h (P = .002), respectively. CONCLUSIONS: UFH fails to prevent early clotting events in the dialysis circuit during COVID-19. For patients, who do not require effective systemic anticoagulation, regional citrate dialysis is the most effective strategy. For patients, who require effective systemic anticoagulation, the usage of LMWH results in the longest circuit life spans. The proposed anticoagulatory strategies are safe, can easily be monitored, and allow an individualized treatment.


Subject(s)
Acute Kidney Injury/therapy , Anticoagulants/administration & dosage , Betacoronavirus , Coronavirus Infections/epidemiology , Pneumonia, Viral/epidemiology , Renal Replacement Therapy/methods , Acute Kidney Injury/blood , Acute Kidney Injury/epidemiology , Adult , Aged , Arginine/analogs & derivatives , Blood Coagulation , COVID-19 , Citric Acid/administration & dosage , Comorbidity , Coronavirus Infections/blood , Critical Care , Critical Illness , Equipment Failure , Female , Germany/epidemiology , Heparin/administration & dosage , Heparin, Low-Molecular-Weight/administration & dosage , Humans , Male , Middle Aged , Pandemics , Pipecolic Acids/administration & dosage , Pneumonia, Viral/blood , Renal Replacement Therapy/instrumentation , Retrospective Studies , SARS-CoV-2 , Sulfonamides , Tertiary Care Centers
20.
Br J Hosp Med (Lond) ; 81(10): 1-8, 2020 Oct 02.
Article in English | MEDLINE | ID: covidwho-903014

ABSTRACT

Despite initial reports, renal involvement, including acute kidney injury, has emerged as a serious complication of COVID-19 disease, particularly in critically ill patients. The reported prevalence varies considerably, which may reflect reporting practices, although differences in pre-existing comorbidities and socioeconomic factors, and differences between ethnic groups, almost certainly contribute. Renal involvement may present as an active urinary sediment or as changes in serum creatinine levels and urine output leading to acute kidney injury. In common with acute kidney injury complicating critical illness, the cause is often multifactorial and often presents as part of a multiorgan dysfunction syndrome. Treatment is, in the main, supportive, with kidney replacement therapy required in nearly 25% of reported cases. Few data currently exist as to the long-term burden of COVID-19-associated acute kidney injury but evidence suggests that only approximately one-third of patients are discharged with recovered renal function.


Subject(s)
Acute Kidney Injury , Coronavirus Infections/complications , Patient Care Management/methods , Pneumonia, Viral/complications , Acute Kidney Injury/epidemiology , Acute Kidney Injury/etiology , Acute Kidney Injury/therapy , Betacoronavirus , COVID-19 , Coronavirus Infections/physiopathology , Coronavirus Infections/therapy , Critical Illness/therapy , Humans , Kidney Function Tests , Pandemics , Pneumonia, Viral/physiopathology , Pneumonia, Viral/therapy , Renal Replacement Therapy/methods , Risk Factors , SARS-CoV-2
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