Decreasing Incidence of Acute Kidney Injury in Patients with COVID-19 Critical Illness in New York City

Abstract

Introduction Reports from the United States suggest that acute kidney injury (AKI) frequently complicates COVID-19, but understanding of AKI risks and outcomes is incomplete. Additionally, whether kidney outcomes have evolved during the course of the pandemic is unknown. Methods We used electronic records to identify COVID-19 patients with and without AKI admitted to 3 New York Hospitals between March 2 and August 25, 2020. Outcomes included AKI overall and according to admission week, AKI stage, the requirement for new renal replacement therapy (RRT), mortality and recovery of kidney function. Logistic regression was utilized to assess associations of patient characteristics and outcomes. Results Out of 4732 admissions 1386 (29.3%) patients had AKI. Among those with AKI, 717 (51.7%) had Stage 1, 132 (9.5%) Stage 2, 537 (38.7%) stage 3, and 237 (17.1%) required RRT initiation. In March 536/1648 (32.5%) of patients developed AKI compared with 15/87 (17.2%) in August (P<0.001 for monthly trend) whereas RRT initiation was required in 6.9% and 0% of admission, in March and August respectively. Mortality was higher with than without AKI (51.6% vs 8.6%) and was 71.9% in individuals requiring RRT. However, most patients with AKI who survived hospitalization (77%) recovered to within 0.3 mg/dL of baseline creatinine. Among those surviving to discharge, 62% discontinued RRT. Conclusions AKI impacts a high proportion of admitted COVID-19 patients and is associated with high mortality, particularly when RRT is required. AKI incidence appears to be decreasing over time and kidney function frequently recovers in those who survive.

Pathophysiology of COVID-19-associated acute kidney injury

“…Of note, wide geographical disparities in the incidence of AKI among US veteran patients hospitalized with COVID-19 have been reported, ranging from 10% to 56% 23 . This finding, combined with evidence that rates of COVID-19 AKI have declined over time (from 40% in March 2020 to 27% in July 2020) 23 with similar findings reported in a New York study 24 , suggests that changes in patient management have had a positive impact on kidney outcomes and the incidence of AKI among patients with COVID-19.…”

Dapagliflozin in patients with cardiometabolic risk factors hospitalised with COVID-19 (DARE-19): a randomised, double-blind, placebo-controlled, phase 3 trial

“…The rates of organ dysfunction and death were lower than initially anticipated due to improvement in standard of care for treatment of COVID-19. 27,28,38 Consequently, the accrued number of events would not allow detection of statistically significant treatment effects with a HR exceeding 0•72 (which is a possible explanation for the observed lack of statistical significance for the primary endpoint of prevention, given the observed HR of 0•80). Accordingly, we amended the protocol to elevate recovery from a secondary endpoint to be included as a dual primary outcome, as faster and more complete recovery had become an important treatment goal and a frequently used trial endpoint in patients hospitalised with COVID-19.…”

“…After the original protocol was designed, changes in the standard of care for patients hospitalised with COVID-19 resulted in substantially lower event rates than originally projected. 27 , 28 Consequently, faster and more complete recovery became an important treatment goal in addition to the prevention of complications and death, prompting the addition of recovery to the primary objectives on Nov 20, 2020. The primary outcome of prevention was a composite of time to new or worsened respiratory, cardiovascular, or kidney organ dysfunction during the index hospitalisation, or death from any cause at any time during the 30 day treatment period ( appendix 1, pp 7–8 ).…”

Long-term clinical follow-up of patients suffering from moderate-to-severe COVID-19 infection: a monocentric prospective observational cohort study

“…Although COVID-19 was associated with a high prevalence of AKI (10.9 % our cohort), we have few data at follow-up to evaluate the long-term impact and risk of CKD. Large cohort studies have demonstrated at discharge that >70% recovered from AKI ( 42 ). In our cohort, patients having eGFR below 60ml/min/1.73m 2 at 3 months are in majority patients who have eGFR <60 ml/min/1.73m 2 at hospital admission and probably are patients with CKD previous to the admission.…”