Rationale and Objective Coronavirus disease 2019 (COVID-19) may be associated with high rates of AKI and kidney replacement therapy (KRT), potentially overwhelming healthcare resources. Our objective was to determine the pooled prevalence of AKI and KRT among hospitalized patients with COVID-19. Study Design Systematic Review and Meta-analysis Data sources Medline, Embase, the Cochrane Library, and a registry of preprinted studies, published up to 14 Oct 2020. Study Selection Eligible studies reported the prevalence of AKI in hospitalized patients with COVID-19 according to the Kidney Disease Improving Global Outcomes (KDIGO) definition. Data Extraction and Synthesis We extracted data on patient characteristics, the proportion of patients developing AKI and commencing KRT, important clinical outcomes (discharge from hospital, ongoing hospitalization and death), and risk of bias. Outcomes and Measures We calculated the pooled prevalence of AKI and receipt of KRT, along with 95% confidence intervals (CI) using a random effects model. We performed subgroup analysis based on admission to an intensive care unit (ICU). Results Of 2,711 records reviewed, we included 53 published and 1 preprint study in the analysis, which comprised 30,657 hospitalized patients with COVID-19. Data on AKI were available for 30,639 patients (n=54 studies), and the receipt of KRT for 27,525 patients (n=48 studies). The pooled prevalence of AKI was 28% (95% CI 22% to 34%; I 2 =99%), and the pooled prevalence of KRT was 9% (95% CI 7% to 11%; I 2 =97). The pooled prevalence of AKI among patients admitted to the ICU was 46% (95% CI 35% to 57%, I 2 =99%) and 19% of all ICU patients with COVID-19 (95% CI 15% to 22%; I 2 =88%) commenced KRT. Limitations There was significant heterogeneity among the included studies which remained unaccounted for in sub-group analysis. Conclusions AKI complicated the course of nearly 1 in 3 patients hospitalized with COVID-19. The risk of AKI was higher in critically ill patients with a substantial number receiving KRT at rates higher than the general ICU population. Since COVID-19 will be a public health threat for the foreseeable future, these estimates should help guide KRT resource planning.

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IntroductionTechnological adjuncts have been developed to improve the accuracy of fluid removal goals in maintenance dialysis recipients. We aimed to determine whether the introduction of these tools has been shown to impact clinical outcomes.MethodsWe performed a systematic review and meta-analysis of randomized controlled trials that compared fluid management guided by technological adjuncts to standard care in hemodialysis and peritoneal dialysis. The primary outcome was all-cause mortality. Secondary outcomes were cardiovascular events, hospitalizations, intradialytic hypotension, blood pressure, symptoms, antihypertensive medications. and left ventricular mass index.ResultsOf the 2940 citations retrieved, we identified a total of 12 eligible trials comprising 2406 participants. In the 10 studies (n = 2111) with data on mortality, the use of adjunct technologies was not associated with a reduction of mortality (rate ratio [RR]: 0.92; confidence interval [CI]: 0.57–1.51; I2 = 36%). The intervention conferred a reduction in systolic arterial pressure (mean difference: −3.14; CI: −5.89 to −0.38; I2 = 39%) but did not affect other outcomes. In a subgroup analysis, bioimpedance was associated with a reduced risk of hospitalization (RR: 0.68; CI: 0.46–0.99; I2 = 55%). The risk of bias was high or unclear in most studies and the quality of evidence was judged to be low.ConclusionsAmong maintenance dialysis recipients, technological adjuncts for fluid management did not improve survival. Trials mostly investigated the use of bioimpedance, whereas the evidence for use of other technologies remain very scarce. Future adequately powered trials should assess a broader array of promising technologies using meaningful clinical outcomes over a prolonged follow-up duration.

Background: Anticoagulation with either with a vitamin K antagonist or a direct oral anticoagulant (DOAC) may be associated with acute kidney injury (AKI). Our objective was to assess the risk of AKI among elderly individuals with atrial fibrillation (AF) newly prescribed a DOAC (dabigatran, rivaroxaban, or apixaban) versus warfarin. Methods: A population-based cohort study of 20,683 outpatients in Ontario, Canada, ≥66 years, with atrial fibrillation who were prescribed warfarin, dabigatran, rivaroxaban or apixaban between 2009- 2017. Inverse probability of treatment weighting based on derived propensity scores for the treatment with each DOAC was used to balance baseline characteristics among patients receiving each of the three DOACs, compared to warfarin. Cox proportional hazards regression was performed in the weighted population to compare the association between the prescribed anticoagulant and the outcomes of interest. The exposure was an outpatient prescription of warfarin, or one of the DOACs. The primary outcome was a hospital encounter with AKI, defined using KDIGO thresholds. Prespecified subgroup analyses were conducted by estimated glomerular filtration rate (eGFR) category, and by the percentage of international normalized ratio measurements in range, a validated marker of anticoagulation control. Results: : Each DOAC was associated with a significantly lower risk of AKI compared to warfarin (weighted HR 0.65; 95% CI 0.53 to 0.80 for dabigatran, weighted HR 0.85; 95% CI 0.73 to 0.98 for rivaroxaban; and weighted HR 0.81; 95% CI 0.72 to 0.93 for apixaban). In subgroup analysis, the lower risk of AKI associated with each DOAC was consistent across each eGFR strata. The risk of AKI was significantly lower among users of each of the DOACs compared to warfarin users who had a percentage of international normalized ratio measurements ≤56.1%. Conclusions: DOACs were associated with a lower risk of AKI compared to warfarin.