Tag Archives: acute kidney injury

Kidney injury in critically ill patients with COVID-19 – From pathophysiological mechanisms to a personalized therapeutic model

Cosmin Balan1, Tudor Ciuhodaru2, Serban-Ion Bubenek-Turconi1,3

1 Prof. Dr. C. C. Iliescu Emergency Cardiovascular Diseases Institute, Bucharest, Romania
2 Prof. Dr. Nicolae Oblu Emergency Clinical Hospital, Iași, Romania
3 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania

DOI: 10.2478/jccm-2023-0023

Acute kidney injury is a common complication of COVID-19, frequently fuelled by a complex interplay of factors. These include tubular injury and three primary drivers of cardiocirculatory instability: heart-lung interaction abnormalities, myocardial damage, and disturbances in fluid balance. Further complicating this dynamic, renal vulnerability to a “second-hit” injury, like a SARS-CoV-2 infection, is heightened by advanced age, chronic kidney disease, cardiovascular diseases, and diabetes mellitus. Moreover, the influence of chronic treatment protocols, which may constrain the compensatory intrarenal hemodynamic mechanisms, warrants equal consideration. COVID-19-associated acute kidney injury not only escalates mortality rates but also significantly affects long-term kidney function recovery, particularly in severe instances. Thus, the imperative lies in developing and applying therapeutic strategies capable of warding off acute kidney injury and decelerating the transition into chronic kidney disease after an acute event. This narrative review aims to proffer a flexible diagnostic and therapeutic strategy that recognizes the multifaceted nature of COVID-19-associated acute kidney injury in critically ill patients and underlines the crucial role of a tailored, overarching hemodynamic and respiratory framework in managing this complex clinical condition.

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Successful Extracorporeal Blood Purification Therapy Using Double Haemoadsorption Device in Severe Endotoxin Septic Shock: A Case Report

Stefano Ferraro1, Stefania Bianzina2, Sonila Mocka3, Francesca Cappadona4, Giovanni Battista Traverso4, Fabio Massarino4, Pasquale Esposito4,5

1 Unità di Nefrologia, San Paolo Hospital, Savona, Italy
2 Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genova, Italy
3 Unità di Nefrologia, Sant’Andrea Hospital, La Spezia, Italy
4 Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy
5 Department of Internal Medicine, University of Genova, Italy

DOI: 10.2478/jccm-2022-0028

Introduction: In patients admitted to the Intensive Care Unit (ICU), sepsis can lead to acute kidney injury (AKI), which may require the initiation of continuous renal replacement therapy (CRRT) in 15-20% of cases. There is no consensus about the best extracorporeal treatment to choose in septic patients with AKI.
Case presentation: We describe the case of a 70-year-old woman admitted to the ICU with a severe endotoxin septic shock due to Neisseria meningitidis serogroup C. Despite prompt medical intervention, including fluid resuscitation, high dose vasopressor, inotrope support, and broad-spectrum antimicrobial treatment, in a few hours patient’s haemodynamic worsened and she developed multi-organ failure, including severe AKI, requiring CRRT. So, continuous veno-venous haemodiafiltration was started, using an oXiris® haemodiafilter set, in series with an adsorber device (CytoSorb®). After 48 hours of this combined extracorporeal treatment, haemodynamic parameters improved, allowing a significant reduction of the vasoactive therapy, with a concomitant decrease in endotoxin and inflammatory markers serum levels. In the following days patient’s conditions still improved and renal function recovered.
Conclusions: Timely extracorporeal blood purification therapy, using a double haemoadsorption device, may be effective in the management of severe septic shock.

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Renal Manifestations and their Association with Mortality and Length of Stay in COVID-19 Patients at a Safety-net Hospital

Sandra Gomez-Paz1, Eric Lam2, Luis Gonzalez-Mosquera2, Diana Cardenas-Maldonado2, Joshua Fogel3, Ellen Gabrielle Kagan2, Sofia Rubinstein1

1 Division of Nephrology and Hypertension, Department of Internal Medicine, Nassau University Medical Center, East Meadow, New York, USA
2 Department of Internal Medicine, Nassau University Medical Center, East Meadow, New York, USA
3 Department of Business Management, Brooklyn College, Brooklyn, New York, USA

DOI: 10.2478/jccm-2022-0010

Background: Renal involvement in COVID-19 leads to severe disease and higher mortality. We study renal parameters in COVID-19 patients and their association with mortality and length of stay in hospital. Methods: A retrospective study (n=340) of confirmed COVID-19 patients with renal involvement determined by the presence of acute kidney injury. Multivariate analyses of logistic regression for mortality and linear regression for length of stay (LOS) adjusted for relevant demographic, comorbidity, disease severity, and treatment covariates. Results: Mortality was 54.4% and mean LOS was 12.9 days. For mortality, creatinine peak (OR:35.27, 95% CI:2.81, 442.06, p<0.01) and persistent renal involvement at discharge (OR:4.47, 95% CI:1.99,10.06, p<0.001) were each significantly associated with increased odds for mortality. Increased blood urea nitrogen peak (OR:0.98, 95%CI:0.97,0.996, p<0.05) was significantly associated with decreased odds for mortality. For LOS, increased blood urea nitrogen peak (B:0.001, SE:<0.001, p<0.01), renal replacement therapy (B:0.19, SE:0.06, p<0.01), and increased days to acute kidney injury (B:0.19, SE:0.05, p<0.001) were each significantly associated with increased length of stay. Conclusion: Our study emphasizes the importance in identifying renal involvement parameters in COVID-19 patients. These parameters are associated with LOS and mortality, and may assist clinicians to prognosticate COVID-19 patients with renal involvement.

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Acute Kidney Injury Following Rhabdomyolysis in Critically Ill Patients

Alvin Saverymuthu, Rufinah Teo, Jaafar Md Zain, Saw Kian Cheah, Aliza Mohamad Yusof, Raha Abdul Rahman

Department of Anaesthesiology & Intensive Care, Hospital Canselor Tuanku Muhriz, University Kebangsaan Malaysia (UKM), Kuala Lumpur, Malaysia

DOI: 10.2478/jccm-2021-0025

Introduction: Rhabdomyolysis, which resulted from the rapid breakdown of damaged skeletal muscle, potentially leads to acute kidney injury.
Aim: To determine the incidence and associated risk of kidney injury following rhabdomyolysis in critically ill patients.
Methods: All critically ill patients admitted from January 2016 to December 2017 were screened. A creatinine kinase level of > 5 times the upper limit of normal (> 1000 U/L) was defined as rhabdomyolysis, and kidney injury was determined based on the Kidney Disease Improving Global Outcome (KDIGO) score. In addition, trauma, prolonged surgery, sepsis, antipsychotic drugs, hyperthermia were included as risk factors for kidney injury.
Results: Out of 1620 admissions, 149 (9.2%) were identified as having rhabdomyolysis and 54 (36.2%) developed kidney injury. Acute kidney injury, by and large, was related to rhabdomyolysis followed a prolonged surgery (18.7%), sepsis (50.0%) or trauma (31.5%). The reduction in the creatinine kinase levels following hydration treatment was statistically significant in the non- kidney injury group (Z= -3.948, p<0.05) compared to the kidney injury group (Z= -0.623, p=0.534). Significantly, odds of developing acute kidney injury were 1.040 (p<0.001) for mean BW >50kg, 1.372(p<0.001) for SOFA Score >2, 5.333 (p<0.001) for sepsis and the multivariate regression analysis showed that SOFA scores >2 (p<0.001), BW >50kg (p=0.016) and sepsis (p<0.05) were independent risk factors. The overall mortality due to rhabdomyolysis was 15.4% (23/149), with significantly higher incidences of mortality in the kidney injury group (35.2%) vs the non- kidney injury (3.5%) [ p<0.001].
Conclusions: One-third of rhabdomyolysis patients developed acute kidney injury with a significantly high mortality rate. Sepsis was a prominent cause of acute kidney injury. Both sepsis and a SOFA score >2 were significant independent risk factors.

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Renal Recovery in Critically Ill Adult Patients Treated With Veno-Venous or Veno-Arterial Extra Corporeal Membrane Oxygenation: A Retrospective Cohort Analysis

Braghadheeswar Thyagarajan1, Mariana Murea2, Deanna N. Jones2, Amit K. Saha3, Gregory B. Russell4, Ashish K. Khanna1,5

1 Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
2 Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
3 Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
4 Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, USA
5 Outcomes Research Consortium, Cleveland, OH, USA

DOI: 10.2478/jccm-2021-0006

Introduction: Patients on extracorporeal membrane oxygenator (ECMO) therapy are critically ill and often develop acute kidney injury (AKI) during hospitalisation. Little is known about the association of exposure to and the effect of the type of ECMO and extent of renal recovery after AKI development. Aim of the study: In patients who developed AKI, renal recovery was characterised as complete, partial or dialysis-dependent at the time of hospital discharge in both the Veno-Arterial (VA) and Veno-Venous (VV) ECMO treatment groups.
Material and methods: The study consisted of a single-centre retrospective cohort that includes all adult patients (n=125) who received ECMO treatment at a tertiary academic medical centre between 2015 to 2019. Data on demographics, type of ECMO circuit, comorbidities, exposure to nephrotoxic factors and receipt of renal replacement therapy (RRT) were collected as a part of the analysis. Acute Kidney Injury Network (AKIN) criteria were used for the diagnosis and classification of AKI. Group differences were assessed using Fisher’s exact tests for categorical data and independent t-tests for continuous outcomes.
Results: Sixty-four patients received VA ECMO, and 58 received VV ECMO. AKI developed in 58(91%) in the VA ECMO group and 51 (88%) in the VV ECMO group (p=0.77). RRT was prescribed in significantly higher numbers in the VV group 38 (75%) compared to the VA group 27 (47%) (p=0.0035). At the time of discharge, AKI recovery rate in the VA group consisted of 15 (26%) complete recovery and 5 (9%) partial recovery; 1 (2%) remained dialysis-dependent. In the VV group, 22 (43%) had complete recovery (p=0.07), 3(6%) had partial recovery (p=0.72), and 1 (2%) was dialysis-dependent (p>0.99). In-hospital mortality was 64% in the VA group and 49% in the VV group (p=0.13).
Conclusions: Renal outcomes in critically ill patients who develop AKI are not associated with the type of ECMO used. This serves as preliminary data for future studies in the area.

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