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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 19
| Issue : 4 | Page : 589-594 |
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Incidence of acute kidney injury in hospitalized COVID-19 patients
Yasamine Abdul Hussein Abdul Waheed1, Haider Mehdi Mueen Al-Shireefy2
1 Department of Family and Community Medicine, College of Medicine, University of Babylon, Hilla, Babil, Iraq
2 Department of Medicine, College of Medicine, University of Babylon, Hilla, Babil, Iraq
| Date of Submission | 31-Jul-2022 |
| Date of Acceptance | 23-Aug-2022 |
| Date of Web Publication | 09-Jan-2023 |
Correspondence Address:
Yasamine Abdul Hussein Abdul Waheed
Department of Family and Community Medicine, College of Medicine, University of Babylon, Hilla, Babil
Iraq
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/MJBL.MJBL_143_22
Background: Acute kidney injury (AKI) is common among patients hospitalized with COVID-19 and associated with worse prognosis. Objective: We aim to assess the incidence of AKI in hospitalized COVID-19 patients. Materials and Methods: This is a retrospective cross-sectional study conducted at Merjan Teaching Hospital from May 1 to October 1, 2021. It involved a review of data of 174 hospitalized polymerase chain reaction–confirmed COVID-19 patients from hospital health records. Results: In our hospitalized COVID-19 patients, AKI was found in 14 patients forming 8.05% of the total hospitalized patients. The age of participants with AKI was 62.64 ± 19.08 years; male patients formed the larger proportion (53.45%). More than one-third of the patients (36.21%) had a history of hypertension, and more than one-fifth of the patients had a history of diabetes mellitus (22.99%). History of ischemic heart disease was present in 4.60%, heart failure in 0.57%, asthma in 3.45%, chronic obstructive pulmonary disease in 1.15%, cerebrovascular accidents in 1.75%, and lung fibrosis in 1.15%. Patients with AKI had a significantly higher level of blood urea (22.44 ± 11.74); the level of serum creatinine was also significantly higher among patients with AKI (267.57 ± 87.27); significant relationship was observed between the outcome of the patient and the incidence of AKI. Conclusions: The current study showed a higher risk of mortality and morbidity in COVID-19 patients with AKI. Identifying high-risk groups and earlier diagnosis of AKI in COVID-19 patients can improve results in patients and decrease mortality. Keywords: AKI, COVID-19, urea
How to cite this article:
Abdul Waheed YA, Al-Shireefy HM. Incidence of acute kidney injury in hospitalized COVID-19 patients. Med J Babylon 2022;19:589-94 |
| Introduction | |  |
In December 2019, a new type of coronavirus was identified called novel coronavirus (2019-nCoV, or COVID-19) in Wuhan, China. After that, a rapid spread of this virus was recorded in all parts of China and the world. In March 2020, the WHO announced COVID-19 as a pandemic. Coronaviruses are a group of single-stranded RNA viruses belongs to the Coronaviridae family, Nidovirales order.[1]
COVID-19 generally causes a fever and cough, which may appear after exposure to the virus in some patients between 2 and 14 days, particularly the elderly and others with other chronic health conditions; other reported symptoms are weakness, malaise, respiratory distress, muscle pain, sore throat, loss of taste and/or smell, confusion, and diarrhea in some patients.[2],[3]
These symptoms may develop into pneumonia, which manifests as chest discomfort, shortness of breath, and tightness, which necessitates hospitalization and treatment. Severe pneumonia, acute respiratory distress syndrome, sepsis, and septic shock may all occur in more extreme instances, putting the patient’s life at risk.[4]
There are several ways to diagnose the disease early such as PCR method, computed tomography (CT scan), blood test for serum antibodies, and artificial intelligence. Chest CT finding of COVID-19 infection is typical to be multiple bilateral ground-glass opacities (GGOs) with a predominantly peripheral distribution. The general finding of COVID-19 disease can be with a variety of CT findings, the most common findings in general are GGO, crazy-paving pattern, and consolidation, respectively, pleural thickening, and rarely pleural effusion.[5],[6]
About therapies, there is no specific therapy although variable antiviral agents are tried, including remdesivir, ribavirin, favipiravir, chloroquine, hydroxychloroquine, oseltamivir; immunomodulatory agents (tocilizumab, interferons); and adjunctive agents (O2, plasma transfusion, antibiotics, corticosteroids), among other miscellaneous agents.[7]
The prevention includes home quarantine and avoiding any close contact with any healthy (possible asymptomatic patients) or infected person, the use of face mask, good hygiene, and avoiding travel as possible; many vaccines developed are based upon inactivated or live attenuated viruses, protein subunit, virus-like particles, viral vector, DNA, RNA, and nanoparticles.[8]
Among admitted patients with COVID-19, acute renal failure is the most common renal manifestation. According to KDIGO (Kidney Disease Improving Global Outcomes), acute kidney injury (AKI) is defined as any of the following:
- A serum creatinine (SCr) elevation by ≥0.3 mg/dL within 2 days
- A SCr elevation ≥1.5 times the baseline within the prior 7 days
- Urine volume <0.5 mL/kg/h for 6 h.
Regarding the KDIGO staging:
- Stage 1: SCr elevation to 1.5–1.9 times baseline or by ≥0.3 mg/dL
- Stage 2: SCr elevation to 2.0–2.9 times baseline
- Stage 3: SCr elevation to 3.0 times baseline or to ≥4.0 mg/dL or the initiation of renal replacement therapy.[9]
Additionally, patients who are severely ill are considerably more likely to develop AKI, which is linked to a worse prognosis and a greater mortality rate. As a result, knowledge of the underlying pathophysiology of kidney injury during COVID-19 is essential for early detection and proper management.[10]
| Materials and Methods | | |
This is a retrospective cross-sectional study conducted at Merjan Teaching Hospital from May 1 to October 1, 2021. It involved a review of data of 174 hospitalized PCR-confirmed COVID-19 patients from hospital health records. The data were completely collected from patients’ health records after agreement had been taken from the Department of Statistics and the manger of Merjan Teaching Hospital regarding the data collection. No direct contact was made with patients, but their information was made totally confidential. Data were collected using a predesigned questionnaire form that included: age; gender; history of chronic illnesses (DM, HTN, heart failure, ischemic heart disease, cerebrovascular accidents, asthma, chronic obstructive pulmonary disease, or any lung disease); if female patient, pregnant or not; CT involvement; oxygen saturation; need for CPAP; lab data about urea and SCr 48 h after hospitalization, Complete blood count (white blood cells [WBC], lymphocytes, neutrophils, and platelet counts); renal size by abdominal ultrasound if available; drugs: antibiotics (meropenem, vancomycin, ceftriaxone), anti-viral agents (remdesivir, favipiravir, actemra), steroids, and non-steroidal anti-inflammatory drugs; duration of hospital stay; and finally the fate of the patient if discharged home or dead. The total number of health records during the above mentioned period was 337; only 174 of them were included in the study. Patients had been considered to have AKI when they met the criteria of AKI according to KDIGO, which is defined as an increase in SCr by ≥0.3 mg/dL (≥26.5 μmol/L) within 48 h. In this study, the inclusion criteria included all adult hospitalized patients who tested positive by PCR testing of a nasopharyngeal sample for COVID-19 from May 1 to October 1, 2021, whereas the exclusion criteria included hemodialysis patients; previous diagnosis with CKD (known ultrasound or urine abnormality such as single kidney, cystic kidney, kidney transplants, proteinuria); patients with malignancy; diabetic nephropathy.
Data analysis
SPSS software (version 23.0) was used to perform statistical analysis for this study. Continuous variables were represented as means ± standard deviation (SD), whereas categorical variables were represented as frequencies and percentages. Student’s t-test was used to compare means between two groups, whereas chi-square test was used to assess the relationship between categorical variables. P value of ≤0.05 was considered statistically significant.
Ethical approval
This study was approved by Scientific Committee of Family and Community Medicine Department and approved by ethical committee of University of Babylon, College of Medicine after reviewing the proposal of the study. The study protocol and the subject information and consent form were reviewed and approved by a local ethics committee according to the document number 65 (including the number and the date in 11/5/2022) to get this approval. Additional formal approvals were obtained from the Merjan Teaching Hospital/Department of Statistics. Information collected was treated with confidentiality during data collection and analysis.
| Results | | |
This study included a total of 174 patients confirmed with COVID-19 by PCR. The age of participants ranged from 20 years to 95 years with a mean age of 53.14 ± 15.47 years and a median of 52 years. More than 45% of the patients were within age group 50–59 years. Male patients formed the larger proportion (53.45%), whereas female patients formed the remaining 46.55% of the patients.
Details of a past medical history (hypertension, diabetes mellitus, cardiac diseases, asthma) among study patients are provided in [Table 1].
Patients who had AKI were 14, forming 8.05% of the total study patients. Comparisons between patients with AKI and those with no AKI regarding demographic characteristics are summarized in [Table 2]. | Table 2: Comparisons of demographic characteristics between AKI patients and non-AKI patients
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Comparisons between patients with AKI and those who had no AKI regarding laboratory tests were performed using Student’s t-test [Table 3] and chi-square test [Table 4]. | Table 3: Comparisons of levels of laboratory tests between AKI patients and non-AKI patients
Click here to view |
 | Table 4: Comparisons of laboratory tests between AKI patients and non-AKI patients using chi-square test
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Regarding blood urea, patients with AKI had a significantly higher level of blood urea (22.44 ± 11.74); proportion of patients with elevated blood urea who had AKI was significantly larger than the proportion of patients with normal blood urea who had AKI (14.13% vs. 1.23%).
The level of SCr was also significantly higher among patients with AKI (267.57 ± 87.27); patients with elevated SCr who had AKI formed 63.64% of the total patients with elevated SCr, with P value of <0.001.
No significant differences were observed between patients with AKI and patients with no AKI regarding neither WBC count, lymphocytes, nor platelets.
The need for CPAP was significantly associated with AKI, with P value of 0.007 [Table 5]. Odds ratio for patients with AKI to require CPAP was 4.45, with 95% confidence interval of 1.40–14.15. Patients with AKI were approximately 5 times more likely to require CPAP as compared to those with no AKI.
A significant relationship was observed between the outcome of the patient and the incidence of AKI. More than 19% of the patients who died in the respiratory care unit (RCU) had AKI, whereas less than 5% of those who were discharged home had AKI; P value = 0.003 [Table 6].
| Discussion | | |
In our hospitalized COVID-19 patients, AKI was found in 14 patients forming 8.05% of the total hospitalized patients (n = 174), whereas in other study of 1392 hospitalized patients with COVID-19, AKI occurred in 99 patients (7%).[11]
More than 45% of the patients were within the age group 50–59 years. Patients with AKI were significantly older compared to those with no AKI. The age of participants with AKI was 62.64 ± 19.08 years and 52.31 ± 14.90 years without AKI. Other study showed that the age of patients with AKI and those without AKI as 68.48 ± 13.04 and 58.82 ± 16.14 years, respectively.[12]
This study showed that the male patients formed the larger proportion (53.45%), whereas female patients formed the remaining 46.55% of the patients. Of the AKI group (14 patients), eight were males and six were females. Other study showed men and women as 55% and 45%, respectively. Men are most likely to be infected with COVID-19 than women, maybe due to the fact that men are more outdoors and thus more chance to be infected.[13],[14]
There was no significance association between pregnancy and AKI; this can be explained by the low number of pregnant women admitted during the period specified for the study or due to less pregnant accepting hospitalization.
More than one-third of the patients (36.21%) had a history of hypertension, and more than one-fifth of the patients had a history of diabetes mellitus (22.99%). A history of ischemic heart disease was present in 4.60%, heart failure in 0.57%, asthma in 3.45%, chronic obstructive pulmonary disease in 1.15%, cerebrovascular accidents in 1.75%, and lung fibrosis in 1.15%. More than one-third of the patients (36.21%) had history of hypertension, and more than one-fifth of the patients had history of diabetes mellitus (22.99%). History of IHD was present in 4.60%, HF in 0.57%, asthma in 3.45%, chronic obstructive pulmonary disease in 1.15%, CVA in 1.75% and lung fibrosis in 1.15%. While, in other study 140 patients with COVID-19 and 37.9%, 30.0% of those had history of hypertension and IHD (16.4%), DM (9.7%, 12.1%), COPD (1.4%),[15] while asthma in study from reference[16] showed 0.14% had history of asthma from 102 patients, while heart failure in 11.4% of 70 patients.[17] Difference in comorbidities encountered may be explained by social orientation toward hospitalization.
This study showed no significant difference observed between CT involvement percentage and the incidence of AKI. Patients with AKI the CT percentage range (15%–60%) and the mean ± SD (40.50% ± 17.39%) whereas patients without AKI, CT range (5%–90%) and the mean ± SD (42.39% ± 21.59%). This could alert us not to concentrate only on the CT chest involvement to grade severity of clinical consequences.
This was in concordance with the results of oxygen saturation that showed patients with no AKI had higher SpO2 (88.14% ± 9.96%) compared with AKI patients (82.57% ± 12.79%). However, this difference was not statistically significant (P value = 0.134).
In the lower ranges of oxygen saturation with the need for CPAP, it shows a significant association with AKI; patients with AKI were approximately 5 times more likely to require CPAP compared to those with no AKI. This could be explained being a component of multiple organ failure syndrome or specific renal hypoxia and tubular necrosis.
Regarding renal function tests, patients with AKI had a significantly higher level of blood urea (22.44 ± 11.74) compared to those with no AKI (7.96 ± 3.34). The proportion of patients with elevated blood urea who had AKI was significantly larger than the proportion of patients with normal blood urea who had AKI (14.13% vs. 1.23%). Other study also shows that patients with AKI had a higher level of blood urea nitrogen (BUN) compared to those with no AKI (blood urea = BUN × 2.14).[18]
The level of SCr was also significantly higher among patients with AKI (267.57 ± 87.27) compared to those with no AKI (87.71 ± 23.21). Patients with elevated SCr who had AKI formed 63.64% of the total patients with elevated SCr. Other study also shows that patients with AKI had a higher level of SCr compared to those with no AKI.[19] Other studies also showed that patients with AKI had a higher level of SCr compared to those with no AKI.[19],[20],[21]
Regarding a complete blood count test, no significant differences were observed between patients with AKI and patients with no AKI regarding neither WBC count, lymphocytes, nor platelets.
The proportion of patients with low WBC (leukopenia) who had AKI was larger than the proportion of patients with normal and elevated WBC who had AKI (21.05% vs. 5.05% and 8.93%, respectively).
The proportion of patients with low lymphocytes (lymphopenia) who had AKI was larger than the proportion of patients with normal lymphocytes who had AKI (14.63% vs. 6.06%).
The proportion of patients with low platelets (thrombocytopenia) who had AKI was larger than the proportion of patients with normal and elevated platelets who had AKI (20.00% vs. 8.15% and 5.88%, respectively).
Although in another study of n = 95, 54 patients had AKI with normal leukocytes, lymphocytes, and platelets and 41 patients without AKI had normal leukocytes and lymphocytes but low platelets.[16]
This study showed that a significant relationship was observed between the outcome of the patient and the incidence of AKI. More than 19% of the patients who died in the RCU had AKI, whereas less than 5% of those who were discharged home had AKI. Patients with AKI were approximately 5 times more likely to die in the RCU compared to those with no AKI; 4.65% of the patients with AKI were discharged home and 95.35% with no AKI; 19.05% with AKI died in RCU and 80.95% with no AKI. In other study (n = 1545), 41.08% with AKI discharged home and 90.6% with no AKI, and 58.02% with AKI died in RCU and 9.04% with no AKI, respectively.[12]
| Conclusions | | |
The current study showed a higher risk of mortality and morbidity in COVID-19 patients with AKI. Identifying high-risk groups and earlier diagnosis of AKI in COVID-19 patients can improve results in patients and decrease mortality.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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