COVID-19 Nephrologic Complications: Difference between revisions

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==Overview==
==Overview==
Early reports from china revealed that COVID-19 rarely involves the kidneys, as [[Acute Renal Failure]] was not seen among COVID-19 hospitalized patients and  mild [[BUN]] or creatinine rise [10.8%] and mild proteinuria [7.2%] occurred. However, recent study found 75.4% of hospitalized patients with COVID-19 pneumonia developed [[hematuria]], [[proteinuria]], and [[AKI]]. But, these findings are not significantly different from other critical diseases.[[COVID-19]] can involve many organs leading to organ failure, one of which is kidneys that manifest with mild [[proteinuria]] to advanced [[acute kidney injury]] ([[AKI]])
[[COVID-19]] can involve many organs leading to organ failure, one of which is kidneys that manifest with mild [[proteinuria]] to advanced [[acute kidney injury]] ([[AKI]]).


==Complications==
==Complications==
===[[Acute Kidney Injury]]===
===[[Acute Kidney Injury]]===
*Early reports from china revealed that COVID-19 rarely involves the kidneys, as [[Acute Renal Failure]] was not seen among COVID-19 hospitalized patients and  mild [[BUN]] or creatinine rise [10.8%] and mild proteinuria [7.2%] occurred. <ref name="WangLi2020">{{cite journal|last1=Wang|first1=Luwen|last2=Li|first2=Xun|last3=Chen|first3=Hui|last4=Yan|first4=Shaonan|last5=Li|first5=Dong|last6=Li|first6=Yan|last7=Gong|first7=Zuojiong|title=Coronavirus Disease 19 Infection Does Not Result in Acute Kidney Injury: An Analysis of 116 Hospitalized Patients from Wuhan, China|journal=American Journal of Nephrology|volume=51|issue=5|year=2020|pages=343–348|issn=0250-8095|doi=10.1159/000507471}}</ref>
*[[COVID-19]] can involve many organs leading to organ failure, one of which is kidneys that manifest with mild [[proteinuria]] to advanced [[acute kidney injury]] ([[AKI]]).<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume=  | issue=  | pages=  | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769  }} </ref>
*Early reports from China revealed that COVID-19 rarely involves the kidneys, as [[Acute Renal Failure]] was not seen among COVID-19 hospitalized patients and  mild [[BUN]] or creatinine rise [10.8%] and mild proteinuria [7.2%] occurred. <ref name="WangLi2020">{{cite journal|last1=Wang|first1=Luwen|last2=Li|first2=Xun|last3=Chen|first3=Hui|last4=Yan|first4=Shaonan|last5=Li|first5=Dong|last6=Li|first6=Yan|last7=Gong|first7=Zuojiong|title=Coronavirus Disease 19 Infection Does Not Result in Acute Kidney Injury: An Analysis of 116 Hospitalized Patients from Wuhan, China|journal=American Journal of Nephrology|volume=51|issue=5|year=2020|pages=343–348|issn=0250-8095|doi=10.1159/000507471}}</ref>


* However, recent study found 75.4% of hospitalized patients with COVID-19 pneumonia developed [[hematuria]], [[proteinuria]], and [[AKI]]. But, these findings are not significantly different from other critical diseases.<ref name="PeiZhang2020">{{cite journal|last1=Pei|first1=Guangchang|last2=Zhang|first2=Zhiguo|last3=Peng|first3=Jing|last4=Liu|first4=Liu|last5=Zhang|first5=Chunxiu|last6=Yu|first6=Chong|last7=Ma|first7=Zufu|last8=Huang|first8=Yi|last9=Liu|first9=Wei|last10=Yao|first10=Ying|last11=Zeng|first11=Rui|last12=Xu|first12=Gang|title=Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia|journal=Journal of the American Society of Nephrology|volume=31|issue=6|year=2020|pages=1157–1165|issn=1046-6673|doi=10.1681/ASN.2020030276}}</ref>
* However, recent study found 75.4% of hospitalized patients with COVID-19 pneumonia developed [[hematuria]], [[proteinuria]], and [[AKI]]. But, these findings are not significantly different from other critical diseases.<ref name="PeiZhang2020">{{cite journal|last1=Pei|first1=Guangchang|last2=Zhang|first2=Zhiguo|last3=Peng|first3=Jing|last4=Liu|first4=Liu|last5=Zhang|first5=Chunxiu|last6=Yu|first6=Chong|last7=Ma|first7=Zufu|last8=Huang|first8=Yi|last9=Liu|first9=Wei|last10=Yao|first10=Ying|last11=Zeng|first11=Rui|last12=Xu|first12=Gang|title=Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia|journal=Journal of the American Society of Nephrology|volume=31|issue=6|year=2020|pages=1157–1165|issn=1046-6673|doi=10.1681/ASN.2020030276}}</ref>
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*[[AKI]] is frequently seen among patients with [[COVID-19]] hospitalized in [[ICU]], with prevalence of 0.6-29% in China {{cite web |url=https://www.esicm.org/blog/?p=2789 |title=Acute Kidney Injury in COVID-19 Patients &#124; COVID-19 |format= |work= |accessdate=}} and 22.2% in the USA.<ref name="pmid32320003">{{cite journal| author=Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW | display-authors=etal| title=Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=32320003 | doi=10.1001/jama.2020.6775 | pmc=7177629 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32320003  }} </ref>
*[[AKI]] is frequently seen among patients with [[COVID-19]] hospitalized in [[ICU]], with prevalence of 0.6-29% in China {{cite web |url=https://www.esicm.org/blog/?p=2789 |title=Acute Kidney Injury in COVID-19 Patients &#124; COVID-19 |format= |work= |accessdate=}} and 22.2% in the USA.<ref name="pmid32320003">{{cite journal| author=Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW | display-authors=etal| title=Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=32320003 | doi=10.1001/jama.2020.6775 | pmc=7177629 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32320003  }} </ref>
*While, the real incidence of [[AKI]] in critcally ill patients with [[COVID-19]] is estimated between 27-85%. {{cite web |url=https://www.esicm.org/blog/?p=2789 |title=Acute Kidney Injury in COVID-19 Patients &#124; COVID-19 |format= |work= |accessdate=}}
*While, the real incidence of [[AKI]] in critcally ill patients with [[COVID-19]] is estimated between 27-85%. {{cite web |url=https://www.esicm.org/blog/?p=2789 |title=Acute Kidney Injury in COVID-19 Patients &#124; COVID-19 |format= |work= |accessdate=}}
*[[COVID-19]] can involve many organs leading to organ failure, one of which is kidneys that manifest with mild [[proteinuria]] to advanced [[acute kidney injury]] ([[AKI]]).<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume=  | issue=  | pages=  | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769  }} </ref>
 


====Pathophysiology====
====Pathophysiology====
*Angiotensin-converting enzyme 2 ([[ACE2]]), which is a primary receptor for [[SARS-CoV-2]] entry into cells, mostly presents in renal tubular epithelial cells as well as lungs and heart.<ref name="MalhaMueller2020">{{cite journal|last1=Malha|first1=Line|last2=Mueller|first2=Franco B.|last3=Pecker|first3=Mark S.|last4=Mann|first4=Samuel J.|last5=August|first5=Phyllis|last6=Feig|first6=Peter U.|title=COVID-19 and the Renin-Angiotensin System|journal=Kidney International Reports|volume=5|issue=5|year=2020|pages=563–565|issn=24680249|doi=10.1016/j.ekir.2020.03.024}}</ref>
*Angiotensin-converting enzyme 2 ([[ACE2]]), which is a primary receptor for [[SARS-CoV-2]] entry into cells, mostly presents in renal tubular epithelial cells as well as lungs and heart.<ref name="MalhaMueller2020">{{cite journal|last1=Malha|first1=Line|last2=Mueller|first2=Franco B.|last3=Pecker|first3=Mark S.|last4=Mann|first4=Samuel J.|last5=August|first5=Phyllis|last6=Feig|first6=Peter U.|title=COVID-19 and the Renin-Angiotensin System|journal=Kidney International Reports|volume=5|issue=5|year=2020|pages=563–565|issn=24680249|doi=10.1016/j.ekir.2020.03.024}}</ref>
*Despite kidney injury following [[COVID-19]] infection is less frequent than severe lung injury, [[ACE2]]: [[ACE]] ratio is higher in the kidneys compared to the respiratory system. (1:1 in the kidneys VS 1:20 in the respiratory system)<ref name="MalhaMueller2020">{{cite journal|last1=Malha|first1=Line|last2=Mueller|first2=Franco B.|last3=Pecker|first3=Mark S.|last4=Mann|first4=Samuel J.|last5=August|first5=Phyllis|last6=Feig|first6=Peter U.|title=COVID-19 and the Renin-Angiotensin System|journal=Kidney International Reports|volume=5|issue=5|year=2020|pages=563–565|issn=24680249|doi=10.1016/j.ekir.2020.03.024}}</ref>
*Despite kidney injury following [[COVID-19]] infection is less frequent than severe lung injury, [[ACE2]]: [[ACE]] ratio is higher in the kidneys compared to the respiratory system. (1:1 in the kidneys VS 1:20 in the respiratory system)<ref name="MalhaMueller2020">{{cite journal|last1=Malha|first1=Line|last2=Mueller|first2=Franco B.|last3=Pecker|first3=Mark S.|last4=Mann|first4=Samuel J.|last5=August|first5=Phyllis|last6=Feig|first6=Peter U.|title=COVID-19 and the Renin-Angiotensin System|journal=Kidney International Reports|volume=5|issue=5|year=2020|pages=563–565|issn=24680249|doi=10.1016/j.ekir.2020.03.024}}</ref>
* After [[SARS-CoV-2]] enters through the nasal cavity, it may travel to the kidneys and enters the bloodstream leading to severe inflammatory response activation and cytokine storm.
* After [[SARS-CoV-2]] enters through the nasal cavity, it may travel to the kidneys and enters the bloodstream leading to severe inflammatory response activation and [[cytokine]] storm.
*It is thought that [[AKI]] following COVID-19 is the result of: <ref name="MalhaMueller2020">{{cite journal|last1=Malha|first1=Line|last2=Mueller|first2=Franco B.|last3=Pecker|first3=Mark S.|last4=Mann|first4=Samuel J.|last5=August|first5=Phyllis|last6=Feig|first6=Peter U.|title=COVID-19 and the Renin-Angiotensin System|journal=Kidney International Reports|volume=5|issue=5|year=2020|pages=563–565|issn=24680249|doi=10.1016/j.ekir.2020.03.024}}</ref>
*It is thought that [[AKI]] following COVID-19 is the result of: <ref name="MalhaMueller2020">{{cite journal|last1=Malha|first1=Line|last2=Mueller|first2=Franco B.|last3=Pecker|first3=Mark S.|last4=Mann|first4=Samuel J.|last5=August|first5=Phyllis|last6=Feig|first6=Peter U.|title=COVID-19 and the Renin-Angiotensin System|journal=Kidney International Reports|volume=5|issue=5|year=2020|pages=563–565|issn=24680249|doi=10.1016/j.ekir.2020.03.024}}</ref>
**[[Sepsis]]
**[[Sepsis]]
**[[Hypovolemia]] and Hypotension
**[[Hypovolemia]] and [[Hypotension]]
**Hypoxemia
**[[Hypoxemia]]
**Blood clots formation, leading to impaired blood flow in the renal arterioles.
**Blood clots formation, leading to impaired blood flow in the renal arterioles.
*[[AKI]] often occurs at later stages in critically ill patients with [[COVID-19]] following multiple organ failure.
 
 
[[File:AKI physiopathology COVID.PNG|600px|center]]
[[File:AKI physiopathology COVID.PNG|600px|center]]
====[[AKI Natural history|Natural history]]====
====[[AKI Natural history|Natural history]]====
*Severe [[COVID-19]] pneumonia and [[severe acute respiratory distress syndrome]] are associated with developing [[AKI]].<ref name="PeiZhang2020">{{cite journal|last1=Pei|first1=Guangchang|last2=Zhang|first2=Zhiguo|last3=Peng|first3=Jing|last4=Liu|first4=Liu|last5=Zhang|first5=Chunxiu|last6=Yu|first6=Chong|last7=Ma|first7=Zufu|last8=Huang|first8=Yi|last9=Liu|first9=Wei|last10=Yao|first10=Ying|last11=Zeng|first11=Rui|last12=Xu|first12=Gang|title=Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia|journal=Journal of the American Society of Nephrology|volume=31|issue=6|year=2020|pages=1157–1165|issn=1046-6673|doi=10.1681/ASN.2020030276}}</ref>
*[[AKI]] is more likely to develop in the late stages of [[COVID-19]] in critically ill patients.<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume=  | issue=  | pages=  | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769  }} </ref>
*Approximately half of the new AKI cases following COVID-19 is mild with good short-term prognosis.
*Severe [[COVID-19]] pneumonia and severe [[acute respiratory distress syndrome]] are associated with developing [[AKI]].<ref name="PeiZhang2020">{{cite journal|last1=Pei|first1=Guangchang|last2=Zhang|first2=Zhiguo|last3=Peng|first3=Jing|last4=Liu|first4=Liu|last5=Zhang|first5=Chunxiu|last6=Yu|first6=Chong|last7=Ma|first7=Zufu|last8=Huang|first8=Yi|last9=Liu|first9=Wei|last10=Yao|first10=Ying|last11=Zeng|first11=Rui|last12=Xu|first12=Gang|title=Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia|journal=Journal of the American Society of Nephrology|volume=31|issue=6|year=2020|pages=1157–1165|issn=1046-6673|doi=10.1681/ASN.2020030276}}</ref>
*Approximately half of the new [[AKI]] cases following [[COVID-19]] is mild with good short-term prognosis.
*If no improvement occurs during follow-up, it is contributed to higher mortality.<ref name="PeiZhang2020">{{cite journal|last1=Pei|first1=Guangchang|last2=Zhang|first2=Zhiguo|last3=Peng|first3=Jing|last4=Liu|first4=Liu|last5=Zhang|first5=Chunxiu|last6=Yu|first6=Chong|last7=Ma|first7=Zufu|last8=Huang|first8=Yi|last9=Liu|first9=Wei|last10=Yao|first10=Ying|last11=Zeng|first11=Rui|last12=Xu|first12=Gang|title=Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia|journal=Journal of the American Society of Nephrology|volume=31|issue=6|year=2020|pages=1157–1165|issn=1046-6673|doi=10.1681/ASN.2020030276}}</ref>
*If no improvement occurs during follow-up, it is contributed to higher mortality.<ref name="PeiZhang2020">{{cite journal|last1=Pei|first1=Guangchang|last2=Zhang|first2=Zhiguo|last3=Peng|first3=Jing|last4=Liu|first4=Liu|last5=Zhang|first5=Chunxiu|last6=Yu|first6=Chong|last7=Ma|first7=Zufu|last8=Huang|first8=Yi|last9=Liu|first9=Wei|last10=Yao|first10=Ying|last11=Zeng|first11=Rui|last12=Xu|first12=Gang|title=Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia|journal=Journal of the American Society of Nephrology|volume=31|issue=6|year=2020|pages=1157–1165|issn=1046-6673|doi=10.1681/ASN.2020030276}}</ref>


====History and symptoms of AKI by SARS-CoV-2====
====History and symptoms of AKI by SARS-CoV-2====
*Patients in the early stages of kidney failure may be asymptomatic. If left untreated, patients may progress to develop [[Azotemia]] and [[Uremia]], which occur due to the buildup of waste materials in the blood.
*Patients in the early stages of [[kidney failure]] may be asymptomatic. If left untreated, patients may progress to develop [[Azotemia]] and [[Uremia]], which occur due to the buildup of waste materials in the blood.
*Symptoms of kidney injury include:<ref name="Skorecki">{{cite book |vauthors=Skorecki K, Green J, Brenner BM |veditors=Kasper DL, Braunwald E, Fauci AS |title=Harrison's Principles of Internal Medicine|url=https://archive.org/details/harrisonsprincip00kasp |url-access=limited |edition=16th |year=2005 |publisher=McGraw-Hill |location=New York, NY |isbn=978-0-07-139140-5 |pages=[https://archive.org/details/harrisonsprincip00kasp/page/n1681 1653]–63 |chapter=Chronic renal failure|display-editors=etal}}</ref>  
*Symptoms of kidney injury include:<ref name="Skorecki">{{cite book |vauthors=Skorecki K, Green J, Brenner BM |veditors=Kasper DL, Braunwald E, Fauci AS |title=Harrison's Principles of Internal Medicine|url=https://archive.org/details/harrisonsprincip00kasp |url-access=limited |edition=16th |year=2005 |publisher=McGraw-Hill |location=New York, NY |isbn=978-0-07-139140-5 |pages=[https://archive.org/details/harrisonsprincip00kasp/page/n1681 1653]–63 |chapter=Chronic renal failure|display-editors=etal}}</ref>  
**Nausea and Vomiting
**Nausea and Vomiting
**Weakness
**Weakness
**Fatigue
**Fatigue
**Confusion
**[[Confusion]]
**Weight loss
**Weight loss
**Loss of appetite
**Loss of appetite
**[[Oliguria]] or [[Anuria]]
**[[Oliguria]] or [[Anuria]]
**Fluid retention, leading [[edema]] and swelling of face, extremities
**Fluid retention, leading [[edema]] and swelling of face and extremities
**Electrolyte imbalance; High level of [[Potassium]] which leads to [[cardiac arrhythmia]]
**Electrolyte imbalance; High level of [[Potassium]] which leads to [[cardiac arrhythmia]]
====Diagnosis====
====Diagnosis====


'''Laboratory Findings'''
'''Laboratory Findings'''
*Laboratory findings consistent with the diagnosis of [[AKI]] include:
**Elevated [[BUN]] level
**Elevated [[BUN]] level
**Based on KDIGO definition for the diagnosis of AKI:<ref name="pmid22890468">{{cite journal| author=Khwaja A| title=KDIGO clinical practice guidelines for acute kidney injury. | journal=Nephron Clin Pract | year= 2012 | volume= 120 | issue= 4 | pages= c179-84 | pmid=22890468 | doi=10.1159/000339789 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22890468  }} </ref>  
***Plasma BUN-creatinine ratio> 20 in prerenal [[AKI]]
***Plasma BUN-creatinine ratio< 15 in renal [[AKI]] or [[Acute Tubular Necrosis]]
**Based on KDIGO definition for the diagnosis of [[AKI]]<ref name="pmid22890468">{{cite journal| author=Khwaja A| title=KDIGO clinical practice guidelines for acute kidney injury. | journal=Nephron Clin Pract | year= 2012 | volume= 120 | issue= 4 | pages= c179-84 | pmid=22890468 | doi=10.1159/000339789 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22890468  }} </ref>:
***Elevated serum Creatinine by ≥0.3 mg/dl (≥26.5 μmol/l) within 48 hours; or
***Elevated serum Creatinine by ≥0.3 mg/dl (≥26.5 μmol/l) within 48 hours; or
***Elevated serum Creatinine to ≥1.5 times baseline within the previous 7 days; or
***Elevated serum Creatinine to ≥1.5 times baseline within the previous 7 days; or
***Urine volume < 0.5 ml/kg/h for >6 hours
***Urine volume < 0.5 ml/kg/h for >6 hours
**Fractional excretion of sodium ([[FENa]])
***([[FENa]])< 1% in prerenal [[AKI]]
***([[FENa]])> 2% in renal [[AKI]] or [[Acute Tubular Necrosis]]
**Urinary sediment
***Hyaline casts in prerenal [[AKI]]
***Granular or Muddy brown casts in renal [[AKI]] or [[Acute Tubular Necrosis]]
'''Electrocardiogram'''
'''Electrocardiogram'''
*There are no specific ECG findings associated with AKI. However, electrolyte disturbances such as hyperkalemia might lead to various ECG findings.
*There are no specific [[ECG]] findings associated with AKI. However, [[electrolyte]] disturbances such as [[hyperkalemia]] might lead to various [[ECG]] abnormalities.
====Treatment====
====Treatment====
*Management of [[AKI]] following [[COVID-19]] includes treatment of infection, identifying electrolyte disorders, and [[intravenous fluid]] administration.
*Management of [[AKI]] following [[COVID-19]] includes treatment of infection, identifying [[electrolyte]] disorders, and [[intravenous fluid]] administration.
**Early diagnosis and treatment of [[AKI]] in patients with [[COVID-19]] can avoid the progression of [[AKI]] into [[ERDS]] and reduce mortality.<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume=  | issue=  | pages=  | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769  }} </ref>
**Early diagnosis and treatment of [[AKI]] in patients with [[COVID-19]] can avoid the progression of [[AKI]] into [[ESRD]] and reduce mortality.<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume=  | issue=  | pages=  | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769  }} </ref>
*Treatment of [[AKI]] following [[COVID-19]] includes:<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume=  | issue=  | pages=  | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769  }} </ref>
*Treatment of [[AKI]] following [[COVID-19]] includes:<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume=  | issue=  | pages=  | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769  }} </ref>
**Correction of hypovolemia and hypotension by the administration of adequate [[intravenous fluid]]
**Correction of hypovolemia and hypotension by the administration of adequate [[intravenous fluid]]
Line 68: Line 81:
***If AKI is unresponsive to conservative therapy
***If AKI is unresponsive to conservative therapy
***In volume overload conditions
***In volume overload conditions
***Modality of choice in unstable hemodynamic status
***Modality of choice in unstable hemodynamic status and [[ESRD]]
**Anticoagulants in hypercoagulable conditions
**[[Anticoagulants]] in hypercoagulable conditions
**Sequential extracorporeal therapy
**Sequential extracorporeal therapy


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sogand Goudarzi, MD [2] Nasrin Nikravangolsefid, MD-MPH [3]


Synonyms and keywords: Acute Kidney Injury, Nephrologic Disorders and COVID-19,Acute Renal Failure, AKI, ARF

Overview

COVID-19 can involve many organs leading to organ failure, one of which is kidneys that manifest with mild proteinuria to advanced acute kidney injury (AKI).

Complications

Acute Kidney Injury

  • COVID-19 can involve many organs leading to organ failure, one of which is kidneys that manifest with mild proteinuria to advanced acute kidney injury (AKI).[1]
  • Early reports from China revealed that COVID-19 rarely involves the kidneys, as Acute Renal Failure was not seen among COVID-19 hospitalized patients and mild BUN or creatinine rise [10.8%] and mild proteinuria [7.2%] occurred. [2]
  • However, recent study found 75.4% of hospitalized patients with COVID-19 pneumonia developed hematuria, proteinuria, and AKI. But, these findings are not significantly different from other critical diseases.[3]
  • AKI is frequently seen among patients with COVID-19 hospitalized in ICU, with prevalence of 0.6-29% in China "Acute Kidney Injury in COVID-19 Patients | COVID-19". and 22.2% in the USA.[4]
  • While, the real incidence of AKI in critcally ill patients with COVID-19 is estimated between 27-85%. "Acute Kidney Injury in COVID-19 Patients | COVID-19".


Pathophysiology

  • Angiotensin-converting enzyme 2 (ACE2), which is a primary receptor for SARS-CoV-2 entry into cells, mostly presents in renal tubular epithelial cells as well as lungs and heart.[5]
  • Despite kidney injury following COVID-19 infection is less frequent than severe lung injury, ACE2: ACE ratio is higher in the kidneys compared to the respiratory system. (1:1 in the kidneys VS 1:20 in the respiratory system)[5]
  • After SARS-CoV-2 enters through the nasal cavity, it may travel to the kidneys and enters the bloodstream leading to severe inflammatory response activation and cytokine storm.
  • It is thought that AKI following COVID-19 is the result of: [5]



Natural history

  • AKI is more likely to develop in the late stages of COVID-19 in critically ill patients.[1]
  • Severe COVID-19 pneumonia and severe acute respiratory distress syndrome are associated with developing AKI.[3]
  • Approximately half of the new AKI cases following COVID-19 is mild with good short-term prognosis.
  • If no improvement occurs during follow-up, it is contributed to higher mortality.[3]

History and symptoms of AKI by SARS-CoV-2

  • Patients in the early stages of kidney failure may be asymptomatic. If left untreated, patients may progress to develop Azotemia and Uremia, which occur due to the buildup of waste materials in the blood.
  • Symptoms of kidney injury include:[6]

Diagnosis

Laboratory Findings

    • Elevated BUN level
    • Based on KDIGO definition for the diagnosis of AKI[7]:
      • Elevated serum Creatinine by ≥0.3 mg/dl (≥26.5 μmol/l) within 48 hours; or
      • Elevated serum Creatinine to ≥1.5 times baseline within the previous 7 days; or
      • Urine volume < 0.5 ml/kg/h for >6 hours
    • Fractional excretion of sodium (FENa)
    • Urinary sediment

Electrocardiogram

  • There are no specific ECG findings associated with AKI. However, electrolyte disturbances such as hyperkalemia might lead to various ECG abnormalities.

Treatment

  • Management of AKI following COVID-19 includes treatment of infection, identifying electrolyte disorders, and intravenous fluid administration.
    • Early diagnosis and treatment of AKI in patients with COVID-19 can avoid the progression of AKI into ESRD and reduce mortality.[1]
  • Treatment of AKI following COVID-19 includes:[1]
    • Correction of hypovolemia and hypotension by the administration of adequate intravenous fluid
    • Correction of electrolyte disturbances
    • Renal Replacement Therapy
      • If AKI is unresponsive to conservative therapy
      • In volume overload conditions
      • Modality of choice in unstable hemodynamic status and ESRD
    • Anticoagulants in hypercoagulable conditions
    • Sequential extracorporeal therapy

References

  1. ↑ 1.0 1.1 1.2 1.3 Ronco C, Reis T, Husain-Syed F (2020). "Management of acute kidney injury in patients with COVID-19". Lancet Respir Med. doi:10.1016/S2213-2600(20)30229-0. PMC 7255232 Check |pmc= value (help). PMID 32416769 Check |pmid= value (help).
  2. ↑ Wang, Luwen; Li, Xun; Chen, Hui; Yan, Shaonan; Li, Dong; Li, Yan; Gong, Zuojiong (2020). "Coronavirus Disease 19 Infection Does Not Result in Acute Kidney Injury: An Analysis of 116 Hospitalized Patients from Wuhan, China". American Journal of Nephrology. 51 (5): 343–348. doi:10.1159/000507471. ISSN 0250-8095.
  3. ↑ 3.0 3.1 3.2 Pei, Guangchang; Zhang, Zhiguo; Peng, Jing; Liu, Liu; Zhang, Chunxiu; Yu, Chong; Ma, Zufu; Huang, Yi; Liu, Wei; Yao, Ying; Zeng, Rui; Xu, Gang (2020). "Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia". Journal of the American Society of Nephrology. 31 (6): 1157–1165. doi:10.1681/ASN.2020030276. ISSN 1046-6673.
  4. ↑ Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW; et al. (2020). "Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area". JAMA. doi:10.1001/jama.2020.6775. PMC 7177629 Check |pmc= value (help). PMID 32320003 Check |pmid= value (help).
  5. ↑ 5.0 5.1 5.2 Malha, Line; Mueller, Franco B.; Pecker, Mark S.; Mann, Samuel J.; August, Phyllis; Feig, Peter U. (2020). "COVID-19 and the Renin-Angiotensin System". Kidney International Reports. 5 (5): 563–565. doi:10.1016/j.ekir.2020.03.024. ISSN 2468-0249.
  6. ↑ Skorecki K, Green J, Brenner BM (2005). "Chronic renal failure". In Kasper DL, Braunwald E, Fauci AS, et al. Harrison's Principles of Internal Medicine (16th ed.). New York, NY: McGraw-Hill. pp. 1653–63. ISBN 978-0-07-139140-5.
  7. ↑ Khwaja A (2012). "KDIGO clinical practice guidelines for acute kidney injury". Nephron Clin Pract. 120 (4): c179–84. doi:10.1159/000339789. PMID 22890468.
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