Coronavirus disease 2019: acute Fanconi syndrome precedes acute kidney injury

Raphaël Kormann, Audrey Jacquot, Asma Alla, Alice Corbel, Matthieu Koszutski, Paul Voirin, Matthieu Garcia Parrilla, Sybille Bevilacqua, Evelyne Schvoerer, Jean-Louis Gueant, Farès Namour, Bruno Levy, Luc Frimat, Abderrahim Oussalah, Raphaël Kormann, Audrey Jacquot, Asma Alla, Alice Corbel, Matthieu Koszutski, Paul Voirin, Matthieu Garcia Parrilla, Sybille Bevilacqua, Evelyne Schvoerer, Jean-Louis Gueant, Farès Namour, Bruno Levy, Luc Frimat, Abderrahim Oussalah

Abstract

Background: Recent data have shown that severe acute respiratory syndrome coronavirus 2 can infect renal proximal tubular cells via Angiotensin Converting Enzyme 2 (ACE2) . Our objective was to determine whether Fanconi syndrome is a frequent clinical feature in coronavirus disease 2019 (COVID-19) patients.

Methods: A retrospective cohort of 42 laboratory-confirmed COVID-19 patients without history of kidney disease hospitalized in University Hospital of Nancy was investigated. Patients were admitted to the intensive care unit (ICU) (n = 28) or the Medical department (n = 14) and were screened at least once for four markers of proximal tubulopathy.

Results: The mean (standard deviation) follow-up was 19.7 (±12.2) days. Of the patients, 75% (30/40) showed at least two proximal tubule abnormalities (incomplete Fanconi syndrome). The main disorders were proteinuria (88%, n = 35), renal phosphate leak defined by renal phosphate threshold/glomerular filtration rate (TmPi/GFR) <0.77 (55%, n = 22), hyperuricosuria (43%, n = 17) and normoglycaemic glycosuria (30%, n = 12). At the time of the first renal evaluation, ICU patients presented more frequent (96 versus 62%, P = 0.0095) and more severe (844 ± 343 versus 350 ± 221 mg/g, P = 0.0001) proteinuria, and a trend for an increased number of proximal tubule abnormalities (P = 0.038). During follow-up, they presented a lower nadir of serum phosphate [median (interquartile range) 0.68 (0.43-0.76) versus 0.77 (0.66-1.07) mmol/L, P = 0.044] and Acute kidney Injury (AKI) during the hospitalization (P = 0.045). Fanconi syndrome preceded severe AKI KDIGO Stages 2 and 3 in 88% (7/8) of patients. Proximal tubular abnormalities (such as proteinuria, TmPi/GFR and glycosuria in five, two and two patients, respectively) were not detected anymore in recovering patients before hospital discharge.

Conclusion: Incomplete Fanconi syndrome is highly frequent in COVID-19 patients and precedes AKI or disappears during the recovery phase.

Keywords: COVID-19; Fanconi syndrome; SARS-CoV-2; acute kidney injury; acute proximal tubule injury; hypophosphataemia.

© The Author(s) 2020. Published by Oxford University Press on behalf of ERA-EDTA.

Figures

FIGURE 1
FIGURE 1
Focus at the time of the first renal evaluation of proximal tubule injury. (A) The trend of number of attacks compatible with tubular proximal diagnosis was significantly different between ICU patients and other inpatients (P = 0.038). The dotted red line defines the diagnosis of proximal tubulopathy. (B) Excluding the two patients with nephrotic-range proteinuria in the ICU, the proteinuria/creatininuria value was significantly more important in ICU patients versus other inpatients (P < 0.0001).

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Source: PubMed

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