AKI Treated with Renal Replacement Therapy in Critically Ill Patients with COVID-19

Shruti Gupta, Steven G Coca, Lili Chan, Michal L Melamed, Samantha K Brenner, Salim S Hayek, Anne Sutherland, Sonika Puri, Anand Srivastava, Amanda Leonberg-Yoo, Alexandre M Shehata, Jennifer E Flythe, Arash Rashidi, Edward J Schenck, Nitender Goyal, S Susan Hedayati, Rajany Dy, Anip Bansal, Ambarish Athavale, H Bryant Nguyen, Anitha Vijayan, David M Charytan, Carl E Schulze, Min J Joo, Allon N Friedman, Jingjing Zhang, Marie Anne Sosa, Eric Judd, Juan Carlos Q Velez, Mary Mallappallil, Roberta E Redfern, Amar D Bansal, Javier A Neyra, Kathleen D Liu, Amanda D Renaghan, Marta Christov, Miklos Z Molnar, Shreyak Sharma, Omer Kamal, Jeffery Owusu Boateng, Samuel A P Short, Andrew J Admon, Meghan E Sise, Wei Wang, Chirag R Parikh, David E Leaf, and the STOP-COVID Investigators, Carl P Walther, Samaya J Anumudu, Justin Arunthamakun, Kathleen F Kopecky, Gregory P Milligan, Peter A McCullough, Thuy-Duyen Nguyen, Shahzad Shaefi, Megan L Krajewski, Sidharth Shankar, Ameeka Pannu, Juan D Valencia, Sushrut S Waikar, Zoe A Kibbelaar, Peter Hart, Shristi Upadhyay, Ishaan Vohra, Adam Green, Jean-Sebastien Rachoin, Christa A Schorr, Lisa Shea, Daniel L Edmonston, Christopher L Mosher, Zaza Cohen, Valerie Allusson, Gabriela Bambrick-Santoyo, Noor Ul Aain Bhatti, Bijal Mehta, Aquino Williams, Patricia Walters, Ronaldo C Go, Keith M Rose, Rebecca Lisk, Amy M Zhou, Ethan C Kim, Kusum S Mathews, Deena R Altman, Aparna Saha, Howard Soh, Huei Hsun Wen, Sonali Bose, Emily A Leven, Jing G Wang, Gohar Mosoyan, Girish N Nadkarni, Pattharawin Pattharanitima, Emily J Gallagher, John Guirguis, Rajat Kapoor, Christopher Meshberger, Katherine J Kelly, Brian T Garibaldi, Celia P Corona-Villalobos, Yumeng Wen, Steven Menez, Rubab F Malik, Carmen Elena Cervantes, Samir C Gautam, Jie Ouyang, Sabu John, Ernie Yap, Yohannes Melaku, Ibrahim Mohamed, Siddhartha Bajracharya, Isha Puri, Mariah Thaxton, Jyotsna Bhattacharya, John Wagner, Leon Boudourakis, Afshin Ahoubim, Leslie F Thomas, Dheeraj Reddy Sirganagari, Pramod K Guru, Yan Zhou, Paul A Bergl, Jesus Rodriguez, Jatan A Shah, Mrigank S Gupta, Princy N Kumar, Deepa G Lazarous, Seble G Kassaye, Tanya S Johns, Ryan Mocerino, Kalyan Prudhvi, Denzel Zhu, Rebecca V Levy, Yorg Azzi, Molly Fisher, Milagros Yunes, Kaltrina Sedaliu, Ladan Golestaneh, Maureen Brogan, Neelja Kumar, Michael Chang, Jyotsana Thakkar, Ritesh Raichoudhury, Akshay Athreya, Mohamed Farag, Soo Jung Cho, Maria Plataki, Sergio L Alvarez-Mulett, Luis G Gomez-Escobar, Di Pan, Stefi Lee, Jamuna Krishnan, William Whalen, Ashley Macina, Sobaata Chaudhry, Benjamin Wu, Frank Modersitzki, Amey Bhivshet, Alexander S Leidner, Carlos Martinez, Jacqueline M Kruser, Richard G Wunderink, Alexander J Hodakowski, Eboni G Price-Haywood, Luis A Matute-Trochez, Anna E Hasty, Muner M B Mohamed, Rupali S Avasare, David Zonies, Erik T Newman, Samah Abu Omar, Kapil K Pokharel, Harkarandeep Singh, Simon Correa, Tanveer Shaukat, Heather Yang Meghan Lee, Ian A Strohbehn, Jiahua Li, Ariel L Mueller, Nicholas S Cairl, Gabriel Naimy, Abeer Abu-Saif, Danyell Hall, Laura Bickley, Chris Rowan, Farah Madhani-Lovely, Vasil Peev, Jochen Reiser, John J Byun, Andrew Vissing, Esha M Kapania, Zoe Post, Nilam P Patel, Joy-Marie Hermes, Amee Patrawalla, Diana G Finkel, Barbara A Danek, Sowminya Arikapudi, Jeffrey M Paer, Peter Cangialosi, Mark Liotta, Jared Radbel, Jag Sunderram, Matthew T Scharf, Ayesha Ahmed, Ilya Berim, Jayanth S Vatson, Shuchi Anand, Joseph E Levitt, Pablo Garcia, Suzanne M Boyle, Rui Song, Ali Arif, Sang Hoon Woo, Xiaoying Deng, Goni Katz-Greenberg, Katharine Senter, Moh'd A Sharshir, Vadym V Rusnak, Muhammad Imran Ali, Terri Peters, Kathy Hughes, Amber S Podoll, Michel Chonchol, Sunita Sharma, Ellen L Burnham, Rana Hejal, Laura Latta, Ashita Tolwani, Timothy E Albertson, Jason Y Adams, Steven Y Chang, Rebecca M Beutler, Etienne Macedo, Harin Rhee, Vasantha K Jotwani, Jay L Koyner, Chintan V Shah, Vishal Jaikaransingh, Stephanie M Toth-Manikowski, James P Lash, Nourhan Chaaban, Yahya Ahmad, Madona Elias, Alfredo Iardino, Elizabeth H Au, Jill H Sharma, Sabrina Taldone, Gabriel Contreras, David De La Zerda, Alessia Fornoni, Hayley B Gershengorn, Pennelope Blakely, Hanna Berlin, Tariq U Azam, Husam Shadid, Michael Pan, Patrick O ' Hayer, Chelsea Meloche, Rafey Feroze, Kishan J Padalia, Abbas Bitar, Elizabeth Anderson, John P Donnelly, Matthew J Tugman, Emily H Chang, Brent R Brown, Ryan C Spiardi, Todd A Miano, Meaghan S Roche, Charles R Vasquez, Natalie C Ernecoff, Sanjana Kapoor, Siddharth Verma, Huiwen Chen, Csaba P Kovesdy, Ambreen Azhar, Mridula V Nadamuni, Shani Shastri, Duwayne L Willett, Kyle B Enfield, Pavan K Bhatraju, A Bilal Malik, Matthew W Semler, Christina Mariyam Joy, Tingting Li, Seth Goldberg, Patricia F Kao, Greg L Schumaker, Anthony J Faugno, Greg L Schumaker, Caroline M Hsu, Asma Tariq, Leah Meyer, Ravi K Kshirsagar, Daniel E Weiner, Jennifer Griffiths, Sanjeev Gupta, Aromma Kapoor, Perry Wilson, Tanima Arora, Ugochukwu Ugwuowo, Shruti Gupta, Steven G Coca, Lili Chan, Michal L Melamed, Samantha K Brenner, Salim S Hayek, Anne Sutherland, Sonika Puri, Anand Srivastava, Amanda Leonberg-Yoo, Alexandre M Shehata, Jennifer E Flythe, Arash Rashidi, Edward J Schenck, Nitender Goyal, S Susan Hedayati, Rajany Dy, Anip Bansal, Ambarish Athavale, H Bryant Nguyen, Anitha Vijayan, David M Charytan, Carl E Schulze, Min J Joo, Allon N Friedman, Jingjing Zhang, Marie Anne Sosa, Eric Judd, Juan Carlos Q Velez, Mary Mallappallil, Roberta E Redfern, Amar D Bansal, Javier A Neyra, Kathleen D Liu, Amanda D Renaghan, Marta Christov, Miklos Z Molnar, Shreyak Sharma, Omer Kamal, Jeffery Owusu Boateng, Samuel A P Short, Andrew J Admon, Meghan E Sise, Wei Wang, Chirag R Parikh, David E Leaf, and the STOP-COVID Investigators, Carl P Walther, Samaya J Anumudu, Justin Arunthamakun, Kathleen F Kopecky, Gregory P Milligan, Peter A McCullough, Thuy-Duyen Nguyen, Shahzad Shaefi, Megan L Krajewski, Sidharth Shankar, Ameeka Pannu, Juan D Valencia, Sushrut S Waikar, Zoe A Kibbelaar, Peter Hart, Shristi Upadhyay, Ishaan Vohra, Adam Green, Jean-Sebastien Rachoin, Christa A Schorr, Lisa Shea, Daniel L Edmonston, Christopher L Mosher, Zaza Cohen, Valerie Allusson, Gabriela Bambrick-Santoyo, Noor Ul Aain Bhatti, Bijal Mehta, Aquino Williams, Patricia Walters, Ronaldo C Go, Keith M Rose, Rebecca Lisk, Amy M Zhou, Ethan C Kim, Kusum S Mathews, Deena R Altman, Aparna Saha, Howard Soh, Huei Hsun Wen, Sonali Bose, Emily A Leven, Jing G Wang, Gohar Mosoyan, Girish N Nadkarni, Pattharawin Pattharanitima, Emily J Gallagher, John Guirguis, Rajat Kapoor, Christopher Meshberger, Katherine J Kelly, Brian T Garibaldi, Celia P Corona-Villalobos, Yumeng Wen, Steven Menez, Rubab F Malik, Carmen Elena Cervantes, Samir C Gautam, Jie Ouyang, Sabu John, Ernie Yap, Yohannes Melaku, Ibrahim Mohamed, Siddhartha Bajracharya, Isha Puri, Mariah Thaxton, Jyotsna Bhattacharya, John Wagner, Leon Boudourakis, Afshin Ahoubim, Leslie F Thomas, Dheeraj Reddy Sirganagari, Pramod K Guru, Yan Zhou, Paul A Bergl, Jesus Rodriguez, Jatan A Shah, Mrigank S Gupta, Princy N Kumar, Deepa G Lazarous, Seble G Kassaye, Tanya S Johns, Ryan Mocerino, Kalyan Prudhvi, Denzel Zhu, Rebecca V Levy, Yorg Azzi, Molly Fisher, Milagros Yunes, Kaltrina Sedaliu, Ladan Golestaneh, Maureen Brogan, Neelja Kumar, Michael Chang, Jyotsana Thakkar, Ritesh Raichoudhury, Akshay Athreya, Mohamed Farag, Soo Jung Cho, Maria Plataki, Sergio L Alvarez-Mulett, Luis G Gomez-Escobar, Di Pan, Stefi Lee, Jamuna Krishnan, William Whalen, Ashley Macina, Sobaata Chaudhry, Benjamin Wu, Frank Modersitzki, Amey Bhivshet, Alexander S Leidner, Carlos Martinez, Jacqueline M Kruser, Richard G Wunderink, Alexander J Hodakowski, Eboni G Price-Haywood, Luis A Matute-Trochez, Anna E Hasty, Muner M B Mohamed, Rupali S Avasare, David Zonies, Erik T Newman, Samah Abu Omar, Kapil K Pokharel, Harkarandeep Singh, Simon Correa, Tanveer Shaukat, Heather Yang Meghan Lee, Ian A Strohbehn, Jiahua Li, Ariel L Mueller, Nicholas S Cairl, Gabriel Naimy, Abeer Abu-Saif, Danyell Hall, Laura Bickley, Chris Rowan, Farah Madhani-Lovely, Vasil Peev, Jochen Reiser, John J Byun, Andrew Vissing, Esha M Kapania, Zoe Post, Nilam P Patel, Joy-Marie Hermes, Amee Patrawalla, Diana G Finkel, Barbara A Danek, Sowminya Arikapudi, Jeffrey M Paer, Peter Cangialosi, Mark Liotta, Jared Radbel, Jag Sunderram, Matthew T Scharf, Ayesha Ahmed, Ilya Berim, Jayanth S Vatson, Shuchi Anand, Joseph E Levitt, Pablo Garcia, Suzanne M Boyle, Rui Song, Ali Arif, Sang Hoon Woo, Xiaoying Deng, Goni Katz-Greenberg, Katharine Senter, Moh'd A Sharshir, Vadym V Rusnak, Muhammad Imran Ali, Terri Peters, Kathy Hughes, Amber S Podoll, Michel Chonchol, Sunita Sharma, Ellen L Burnham, Rana Hejal, Laura Latta, Ashita Tolwani, Timothy E Albertson, Jason Y Adams, Steven Y Chang, Rebecca M Beutler, Etienne Macedo, Harin Rhee, Vasantha K Jotwani, Jay L Koyner, Chintan V Shah, Vishal Jaikaransingh, Stephanie M Toth-Manikowski, James P Lash, Nourhan Chaaban, Yahya Ahmad, Madona Elias, Alfredo Iardino, Elizabeth H Au, Jill H Sharma, Sabrina Taldone, Gabriel Contreras, David De La Zerda, Alessia Fornoni, Hayley B Gershengorn, Pennelope Blakely, Hanna Berlin, Tariq U Azam, Husam Shadid, Michael Pan, Patrick O ' Hayer, Chelsea Meloche, Rafey Feroze, Kishan J Padalia, Abbas Bitar, Elizabeth Anderson, John P Donnelly, Matthew J Tugman, Emily H Chang, Brent R Brown, Ryan C Spiardi, Todd A Miano, Meaghan S Roche, Charles R Vasquez, Natalie C Ernecoff, Sanjana Kapoor, Siddharth Verma, Huiwen Chen, Csaba P Kovesdy, Ambreen Azhar, Mridula V Nadamuni, Shani Shastri, Duwayne L Willett, Kyle B Enfield, Pavan K Bhatraju, A Bilal Malik, Matthew W Semler, Christina Mariyam Joy, Tingting Li, Seth Goldberg, Patricia F Kao, Greg L Schumaker, Anthony J Faugno, Greg L Schumaker, Caroline M Hsu, Asma Tariq, Leah Meyer, Ravi K Kshirsagar, Daniel E Weiner, Jennifer Griffiths, Sanjeev Gupta, Aromma Kapoor, Perry Wilson, Tanima Arora, Ugochukwu Ugwuowo

Abstract

Background: AKI is a common sequela of coronavirus disease 2019 (COVID-19). However, few studies have focused on AKI treated with RRT (AKI-RRT).

Methods: We conducted a multicenter cohort study of 3099 critically ill adults with COVID-19 admitted to intensive care units (ICUs) at 67 hospitals across the United States. We used multivariable logistic regression to identify patient-and hospital-level risk factors for AKI-RRT and to examine risk factors for 28-day mortality among such patients.

Results: A total of 637 of 3099 patients (20.6%) developed AKI-RRT within 14 days of ICU admission, 350 of whom (54.9%) died within 28 days of ICU admission. Patient-level risk factors for AKI-RRT included CKD, men, non-White race, hypertension, diabetes mellitus, higher body mass index, higher d-dimer, and greater severity of hypoxemia on ICU admission. Predictors of 28-day mortality in patients with AKI-RRT were older age, severe oliguria, and admission to a hospital with fewer ICU beds or one with greater regional density of COVID-19. At the end of a median follow-up of 17 days (range, 1-123 days), 403 of the 637 patients (63.3%) with AKI-RRT had died, 216 (33.9%) were discharged, and 18 (2.8%) remained hospitalized. Of the 216 patients discharged, 73 (33.8%) remained RRT dependent at discharge, and 39 (18.1%) remained RRT dependent 60 days after ICU admission.

Conclusions: AKI-RRT is common among critically ill patients with COVID-19 and is associated with a hospital mortality rate of >60%. Among those who survive to discharge, one in three still depends on RRT at discharge, and one in six remains RRT dependent 60 days after ICU admission.

Keywords: COVID-19; acute kidney injury; acute renal failure; clinical epidemiology; dialysis; renal replacement therapy; risk factors.

Copyright © 2021 by the American Society of Nephrology.

Figures

Graphical abstract
Graphical abstract
Figure 1.
Figure 1.
Flowchart of study population. This figure shows the number of patients with and without AKI-RRT and, among those with AKI-RRT, the number of patients who died, were discharged, and were still hospitalized at last follow up.
Figure 2.
Figure 2.
Patients with AKI-RRT have higher 28-day mortality than patients without AKI-RRT. This figure shows the 28-day mortality of patients with AKI-RRT, those with AKI who were not treated with RRT, and those without AKI across categories of age (A), sex (B), race (C), comorbidities (D), and hospital characteristics; number of ICU beds (E) and regional density of COVID-19 (F). CAD, coronary artery disease; CHF, congestive heart failure.
Figure 3.
Figure 3.
Patient- and hospital-level characteristics and AKI-RRT. The frequency of patient- and hospital-level characteristics in the overall cohort (n=3099) is displayed in blue, and the proportion of patients who developed AKI-RRT within 14 days following ICU admission is displayed in red. Smoking includes both current and former smoking. ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; CAD, coronary artery disease; CHF, congestive heart failure; HTN, hypertension; MRA, mineralocorticoid receptor antagonist.
Figure 4.
Figure 4.
Multivariable model for AKI-RRT and RRT/death. This figure shows (left panel) the odds of AKI-RRT and (right panel) the composite of AKI-RRT or death (RRT/death) within 14 days following ICU admission according to patient- and hospital-level characteristics. A total of 637 of 3099 patients (20.6%) developed AKI-RRT. A total of 1205 of 3099 patients (38.9%) developed RRT/death, of whom 413 (34.3%) developed AKI-RRT and did not die, 568 (47.1%) died without AKI-RRT, and 224 (18.6%) both developed AKI-RRT and died. Unless otherwise indicated, severity of illness covariates were selected as the worst value on ICU day 1 or 2. SOFA, Sequential Organ Failure Assessment.
Figure 5.
Figure 5.
The incidence of AKI-RRT varies by hospital. Interhospital variation in AKI-RRT. Risk- and reliability-adjusted rates of AKI-RRT within 14 days following ICU admission. (A) is unadjusted. (B) is adjusted for patient-level characteristics. (C) is adjusted for both patient- and hospital-level characteristics, including number of ICU beds and regional density of COVID-19.
Figure 6.
Figure 6.
Multivariable model for 28-day mortality in patients with AKI-RRT. Unless otherwise indicated, severity of illness covariates were selected on the day of RRT initiation or if unavailable, the day prior. CRRT, continuous RRT; SOFA, Sequential Organ Failure Assessment.
Figure 7.
Figure 7.
Incidence of AKI at 3, 7, and 14 days from ICU admission. For each time period, patients were categorized according to the highest stage of AKI achieved.

Source: PubMed

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