IntroductionElderly patients with COVID-19 are at a higher risk of severity and death as not only several comorbidities but also aging itself has been considered a relevant risk factor. Acute kidney injury (AKI), one of the worst complications of SARS-CoV-2 infection, is associated with worse outcomes. Studies on AKI with COVID-19 in Latin-American patients of older age remain scarce.ObjectivesTo determine AKI incidence and the risk factors associated with its development, as well as to compare outcome of elderly patients with or without AKI associated with SARS-CoV-2 infectionMethodsThis retrospective cohort study evaluated patients with SARS-CoV2 infection admitted to a Public Tertiary Referral Hospital from 03/01/2020 to 12/31/2020, from admission to resolution (hospital discharge or death). Demographic, clinical, and laboratory data were collected from patients during hospitalization. Daily kidney function assessment was performed by measuring serum creatinine and urine output. AKI was diagnosed according to KDIGO 2012 criteria.ResultsOf the 347 patients with COVID-19 admitted to our hospital during the study period, 52.16% were elderly, with a median age of 72 years (65- 80 years). In this age group, most patients were males (56.91%), hypertensive (73.48%), and required ICU care (55.25%). AKI overall incidence in the elderly was 56.9%, with higher frequency in ICU patients (p < 0.001). There was a predominance of KDIGO 3 (50.48%), and acute kidney replacement therapy (AKRT) was required by 47.57% of the patients. The risk factors associated with AKI development were higher baseline creatinine level (OR 10.54, CI 1.22 -90.61, p = 0.032) and need for mechanical ventilation (OR 9.26, CI 1.08-79.26, p = 0.042). Mortality was also more frequent among patients with AKI (46.41%vs24.7%, p < 0.0001), with death being associated with CPK level (OR 1.009, CI 1.001-1.017, p = 0.042), need for mechanical ventilation (OR 17.71, CI 1.13-277.62, p = 0.002) and KDIGO 3 (OR 2.017 CI 1.039 -3.917, p = 0.038).ConclusionAKI was frequent among the elderly hospitalized with COVID-19 and its risk factors were higher baseline creatinine and need for mechanical ventilation. AKI was independently associated with a higher risk of death.
Background and Aims In the different waves of the pandemic caused by the SARS-CoV-2 virus, the elderly continued to be affected with more severe cases of the disease and possible progression to death. The objective of this study was to compare the incidence of acute kidney injury (AKI) in the elderly during the first and second waves of the pandemic in Brazil; the risk factors associated with its development and death. Method Retrospective cohort study that evaluated patients over 60 years of age admitted to a Public, Tertiary, and Reference Hospital for COVID-19 with a diagnosis of SARS-CoV-2 infection, from March to December/2020 (first wave), and from January to May/2021 (second wave), from admission to hospital outcome (discharge or death). Results Throughout the entire period, 434 elderly patients diagnosed with COVID-19 were admitted, 173 in the first wave and 261 patients in the second wave. These two groups of patients were similar in terms of age (71±8.41 vs 70±8.03, p = 0.3239), need for intensive care unit admission (56.1% vs 58.2%, p = 0.655), vasoactive drug use (43.9% vs 52.9%, p = 0.068), need for mechanical ventilation (43.4% vs 52.5%, p = 0.062), higher APACHE values (19±7.53 vs 17 ±5.64, p = 0.312), SOFA (9±4.07 vs 7±3.56, p = 0.332), CPK (96.5±705.74 vs 150±4830.47, p = 0.0886), the incidence of AKI (56.6% vs 58.6%, p = 0.684) and mortality (46.8% vs 55.2%, p = 0.088). However, they differed in terms of white race (77.5% vs 86.8%, p = 0.011), use of corticosteroids (56.6 vs 93.9%, p < 0.001), presence of proteinuria (44.8% vs 58.2%, p = 0.031), higher values of ATN-ISS (0.76±0.23 vs 0.86±0.21, p = 0.004) and D Dimer (5098±5995.04 vs 2436.5±8398.38, p = 0.0147). The two waves were similar regarding the following factors associated with the development of AKI: higher baseline creatinine, CPK, and D-Dimer values during hospitalization, higher APACHE values, need for mechanical ventilation, use of vasoactive drugs, presence of proteinuria and hematuria in the urine 1 on hospital admission. There was a difference between the waves regarding males (47.40% vs 64.08%, p = 0.037), a relevant factor in the development of AKI in the first wave; while the presence of SAH (63.9% vs 77.8%, p = 0.0202), the use of ACEI/ARB (42.6% vs 56.2%, p 0.0412) and the filtration rate basal glomerular (91±29.61 vs 80.5±26.79, p = 0.0021) were observed as factors associated with AKI only in the second wave. In the logistic regression of both waves, mechanical ventilation remained a risk factor for the development of AKI. In the first wave, the highest baseline creatinine value was also maintained as a risk factor (OR 10.54, CI 1.22-90.61, p = 0.032); while in the second, SAH (OR 1.646, CI 1.150-1.839, p = 0.018), hematuria (OR 1.681, CI 1.124-1.822, p = 0.018) and higher value of D Dimer (OR 1.977, CI 2.000-2.003, p = 0.023) remained as relevant factors for the development of AKI. As factors associated with mortality in the first wave, the highest value of CPK (OR 1.009, CI 1.001-1.017, p = 0.042) and the need for mechanical ventilation (OR 17.71, CI 1.13-277.62, p = 0.002). In the second wave, the factors associated with death were the presence of DM (OR 4.875 CI 2.602-7.094, p = 0.001), ARF (OR 1.858, CI 1.070-1.287, p < 0.001), need for dialysis (OR 1.813, CI 1.086-1.407, p < 0.001), proteinuria (OR 1.968, CI 1.142-1.913, p = 0.032) and higher ATN-ISS value (OR 5865.316, CI 1.325-25967740, p = 0.043). Conclusion The incidence of AKI was similar between the two waves of the pandemic; however, its severity was greater in the second wave, in which it was identified as a factor associated with death. Despite the greater severity of AKI, evidenced by the higher ATN-ISS, there was no higher patient mortality during the second wave of the pandemic.
Background and Aims Although diffuse alveolar damage and acute respiratory failure are the main features of COVID-19 disease in its severe form, renal involvement is frequent (4-37%). To assess the incidence of acute kidney injury (AKI) in Brazilian patients hospitalized with COVID-19 and to identify both the risk factors associated with its onset and those associated with its prognosis. Method This is a prospective cohort study of patients hospitalized with COVID-19 at a public and tertiary university hospital in São Paulo from March 2020 to May 2021, encompassing the first and second waves of the pandemic. Patients were followed up until the clinical outcome (discharge or death). The evaluation of renal function was performed by measuring serum creatinine and urinary output and the diagnosis of AKI was performed according to the KDIGO 2012 criteria. The occurrence of AKI was established as the dependent variable, using the Chi-Square Test for the comparison of categorical variables and the t Test for continuous variables. Afterwards, a multivariate analysis was performed using the logistic regression model, with calculations of the Odds Ratio (OR), including in the model all the variables that showed association with the outcome (p≤0.20). A similar procedure was performed after establishing death as the dependent variable. Results 887 patients with COVID-19 were analyzed, 54.6% were admitted to the intensive care unit (ICU) and 45.4% were admitted to the ward. The overall incidence of AKI was 48.1%, more frequent in the ICU (83.8 vs 17.1%, p<0.0001). Upon hospital admission, 487 patients were submitted to urine test I, of which 58.5% had hematuria and 51.5% had proteinuria. The overall mortality was 38.9%. The average time for the diagnosis of AKI was 6 days and AKI KDIGO 3 was the most frequent (60.2%). Acute renal support was indicated in 58.8% of patients. According to logistic regression, the risk factors for AKI were the use of diuretics (OR 2.2, CI 1.2-4.1, p<0.05), mechanical ventilation (OR 12.9, CI 4.3-38.2, p<0.05), VAD (OR 2.7, CI 0.9-7.7, p = 0.06), dyslipidemia (OR 0.54, CI 0.3-1.05, p = 0.07), proteinuria (OR 2, CI 1.1-3.4, p<0.05), hematuria (OR 2, CI 1.1-3.5, p<0.05), CKD (OR 2.6, CI 1.2-5.5, p<0.05), older age (OR 1.03, CI 1-1.07, p<0.05), CPK (OR 1.02, CI 1-1.07, p<0.05) and D-dimer (OR 1.02, CI 1.01-1.09, p<0.05). The risk factors for death were arterial hypertension (OR 1.7, CI 1-3, p = 0.05), use of mechanical ventilation (OR 12.9, CI 4.3-38.2, p<0.05), presence of proteinuria (OR 1.6, CI 0.9-2.7, p = 0.07), presence of AKI (OR 6, CI 2.9-12.2, p<0.05), mainly KDIGO 3 (OR 0.6, CI 0.2-1.3, p = 0.2), high D-dimer (OR 1, CI 1, p = 0.05), SOFA score (1.35, CI 1.1-1.6, p<0.05) and ATN-ISS score (OR 996.4, CI 4.8-203271, p<0.05). Finally, the variables that showed the difference in the profile of patients between the two waves of the pandemic were identified, being less frequent in the second wave male gender (OR 0.51, CI 0.35-0.74, p<0.05) and Caucasian ethnicity (OR 0.47, CI 0.2-0.8, p<0.05), and more frequent in the second wave the use of mechanical ventilation (OR 1.57, CI 1-2.3, p<0.05), proteinuria (OR 1.44, CI 1-2.1, p<0.05), higher D-dimer values (OR 1.09, CI 1-1.1, p<0.05) and ATN-ISS score (OR 40.9, CI 1.7-948.1, p<0.05). Conclusion AKI associated with severe COVID-19 in Brazil was more frequent than in the Chinese, European, and North American cohorts, and the risk factors associated with its development are the use of diuretics, mechanical ventilation, VAD, dyslipidemia, proteinuria, hematuria, CKD, older age, elevated CPK and D-dimer. Mortality was high and higher in patients with arterial hypertension, on mechanical ventilation, with proteinuria, with AKI, mainly KDIGO 3, high D-dimer, and higher SOFA and ATN-ISS. In the second wave, AKI severity was greater, but mortality was similar to that of the first wave, which may reflect both the effectiveness of vaccines against SARS-CoV-2, as well as the constant learning that frontline professionals have built throughout the pandemic, to provide greater support to its patients.
Background and Aims The Coronavirus Disease-19, COVID-19 caused by the Sars-Cov-2 virus has been associated with either asymptomatic and mild conditions or severe acute respiratory syndrome with generalized organ dysfunction and death. One of the most important is Acute Kidney Injury (AKI). It is acknowledged that AKI is multifactorial, as the most relevant factors for its development are the cytokine storm, metabolic stress, medication use, rhabdomyolysis, renal viral tropism, and multiple organ dysfunction. However, little is known about the impact of AKI's pathophysiology on its clinical outcome. Method Retrospective cohort study that evaluated the medical records of patients diagnosed with COVID-19 admitted to a Tertiary Public Hospital, from 06/01/2020 to 07/31/2021 from their admission until the outcome. The evaluation of renal function occurred through the variation of urinary output and serum creatinine measurement, and the diagnosis of AKI followed the 2012 KDIGO criteria. The occurrence of AKI was an inclusion criterion in the study. The nephrotoxic drug usage and the leak of clinical and laboratory data were exclusion criteria in the study. In addition to urine output and serum creatinine, the creatine phosphokinase, type 1 urine test concerning proteinuria and haematuria, cardiocirculatory and ventilatory parameters, and vasoactive, diuretic, antihypertensive and corticoid drugs usage were analysed. Univariate analysis was performed to identify whether the pathophysiological mechanisms of AKI (ischemic, cytokine storm- CS, rhabdomyolysis, renal viral tropism, or multiple organ failure- MOF) are associated with death. Results Until now, we have included 283 patients. There was a predominance of males (55.5%), Caucasian ethnicity (80.6%); median age was 64 years. Most patients were admitted to the ICU (85.1%). The predominant AKI was KDIGO 3 (56.9%). Regarding the different etiologies of AKI, Renal Viral Tropism was the most frequent (21.5%), followed by MOF (19.1%), Septic (16.6%), Mixed Renal Viral Tropism (16.2%), Ischemic (15.5%) and CS (10,9%). Regarding the CS, patients were more often admitted to the ICU (100%; p<0.001) made the least use of corticosteroids (51.6%; p>0.001) and diuretics (12.9%; p = 0.016), they made the most use of mechanical ventilation (100%), vasoactive drugs (100%) and dialysis (74.2%; p<0.001). Paradoxically, they were the most obese (67.74% p = 0.011), but had less hypertension (48.4%; p = 0.025), less previous cardiovascular disease (6.45% p = 0.01), and less dyslipidemia (9.68%; p = 0.012). In general, the mixed etiology markedly comes closest to the CS etiology, followed by the MOF. Patients who least needed dialysis were those with septic etiology (18.18%; p<0.001). Preliminary tests show an impressive mortality of 69.61%, which is associated with the AKI pathophysiological mechanisms (p<0.0001). CS (87.1%), MOF (87.0%), and Mixed Etiologies (89.1%) are the pathophysiological mechanisms associated with poor prognosis; and Viral Renal Tropism (54.3%), Sepsis (48.3%), and Ischemic Injury (34.1%) are the pathophysiological mechanisms related to the best outcomes. Conclusion AKI related to COVID-19 patients are mostly elderly, admitted to ICU, classified as KDIGO 3 and their mortality is notable. Nevertheless, the mortality and the need for dialysis depends on the pathophysiological mechanism their AKI, as CS, MOF, and Mixed Etiologies are the pathophysiological mechanisms associated with poorest prognosis; and Viral Renal Tropism, Sepsis, and Ischemic Injury are related to the best outcomes.
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