Kidney disease is associated with in-hospital death of patients with COVID-19

Yichun Cheng, Ran Luo, Kun Wang, Meng Zhang, Zhixiang Wang, Lei Dong, Junhua Li, Ying Yao, Shuwang Ge, Gang Xu, Yichun Cheng, Ran Luo, Kun Wang, Meng Zhang, Zhixiang Wang, Lei Dong, Junhua Li, Ying Yao, Shuwang Ge, Gang Xu

Abstract

In December 2019, a coronavirus 2019 (COVID-19) disease outbreak occurred in Wuhan, Hubei Province, China, and rapidly spread to other areas worldwide. Although diffuse alveolar damage and acute respiratory failure were the main features, the involvement of other organs needs to be explored. Since information on kidney disease in patients with COVID-19 is limited, we determined the prevalence of acute kidney injury (AKI) in patients with COVID-19. Further, we evaluated the association between markers of abnormal kidney function and death in patients with COVID-19. This was a prospective cohort study of 701 patients with COVID-19 admitted in a tertiary teaching hospital that also encompassed three affiliates following this major outbreak in Wuhan in 2020 of whom 113 (16.1%) died in hospital. Median age of the patients was 63 years (interquartile range, 50-71), including 367 men and 334 women. On admission, 43.9% of patients had proteinuria and 26.7% had hematuria. The prevalence of elevated serum creatinine, elevated blood urea nitrogen and estimated glomerular filtration under 60 ml/min/1.73m2 were 14.4, 13.1 and 13.1%, respectively. During the study period, AKI occurred in 5.1% patients. Kaplan-Meier analysis demonstrated that patients with kidney disease had a significantly higher risk for in-hospital death. Cox proportional hazard regression confirmed that elevated baseline serum creatinine (hazard ratio: 2.10, 95% confidence interval: 1.36-3.26), elevated baseline blood urea nitrogen (3.97, 2.57-6.14), AKI stage 1 (1.90, 0.76-4.76), stage 2 (3.51, 1.49-8.26), stage 3 (4.38, 2.31-8.31), proteinuria 1+ (1.80, 0.81-4.00), 2+∼3+ (4.84, 2.00-11.70), and hematuria 1+ (2.99, 1.39-6.42), 2+∼3+ (5.56,2.58- 12.01) were independent risk factors for in-hospital death after adjusting for age, sex, disease severity, comorbidity and leukocyte count. Thus, our findings show the prevalence of kidney disease on admission and the development of AKI during hospitalization in patients with COVID-19 is high and is associated with in-hospital mortality. Hence, clinicians should increase their awareness of kidney disease in patients with severe COVID-19.

Keywords: COVID-19; acute kidney injury; in-hospital death; kidney disease; pneumonia.

Copyright © 2020 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.

Figures

Graphical abstract
Graphical abstract
Figure 1
Figure 1
Cumulative incidence of acute kidney injury of patients with coronavirus disease 2019 subgrouped by baseline serum creatinine.
Figure 2
Figure 2
Cumulative incidence for in-hospital death of patients with coronavirus disease 2019 subgrouped by kidney disease indicators. Shadows indicate the 95% confidence intervals of the corresponding estimates: (a) proteinuria, (b) hematuria, (c) baseline blood urea nitrogen (BUN), (d) baseline serum creatinine, (e) peak serum creatinine, and (f) acute kidney injury.
Figure 3
Figure 3
Association of kidney disease with in-hospital death in patients with coronavirus disease 2019 (COVID-19). Hazard ratios (HRs) of each variable were obtained using separate proportional hazard Cox models after adjustment for age, sex, disease severity, any comorbidity, and lymphocyte count. The severity was staged based on the guidelines for diagnosis and treatment of COVID-19 (trial fifth edition) published by the Chinese National Health Commission on February 4, 2020. Comorbidities include chronic kidney disease, chronic obstructive pulmonary disease, hypertension, diabetes, and tumor. 95% CI, 95% confidence interval.

References

    1. Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med. 2020;382:1199–1207.
    1. Zhu N., Zhang D., Wang W. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 2020;382:727–733.
    1. Lu R., Zhao X., Li J. Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. Lancet. 2020;395:556–574.
    1. Huang C., Wang Y., Li X. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506.
    1. Chu K.H., Tsang W.K., Tang C.S. Acute renal impairment in coronavirus-associated severe acute respiratory syndrome. Kidney Int. 2005;67:698–705.
    1. Tsang K.W., Ho P.L., Ooi G.C. A cluster of cases of severe acute respiratory syndrome in Hong Kong. N Engl J Med. 2003;48:1977–1985.
    1. Chen N., Zhou M., Dong X. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395:507–513.
    1. Betjes M.G. Immune cell dysfunction and inflammation in end-stage renal disease. Nat Rev Nephrol. 2013;9:255–265.
    1. Cohen-Hagai K., Rozenberg I., Korzets Z. Upper respiratory tract infection among dialysis patients. Isr Med Assoc J. 2016;18:557–560.
    1. Sibbel S., Sato R., Hunt A. The clinical and economic burden of pneumonia in patients enrolled in Medicare receiving dialysis: a retrospective, observational cohort study. BMC Nephrol. 2016;17:199.
    1. Jung J.Y., Park B.H., Hong S.B. Acute kidney injury in critically ill patients with pandemic influenza A pneumonia 2009 in Korea: a multicenter study. J Crit Care. 2011;26:577–585.
    1. Vanmassenhove J., Kielstein J., Jorres A., Biesen W.V. Management of patients at risk of acute kidney injury. Lancet. 2017;389:2139–2151.
    1. Wang D., Hu B., Hu C. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020;323:1061–1069.
    1. Guan W-J, Ni Z-Y, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China [e-pub ahead of print]. N Engl J Med. . Accessed March 14, 2020.
    1. Ge S., Nie S., Liu Z. Epidemiology and outcomes of acute kidney injury in elderly Chinese patients: a subgroup analysis from the EACH study. BMC Nephrol. 2016;17:136.
    1. Yang L., Xing G., Wang L. Acute kidney injury in China: a cross-sectional survey. Lancet. 2015;386:1465–1471.
    1. Xu X., Nie S., Liu Z. Epidemiology and clinical correlates of AKI in Chinese hospitalized adults. Clin J Am Soc Nephrol. 2015;10:1510–1518.
    1. Peiris J.S.M., Chu C.M., Cheng V.C.C. Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet. 2003;361:1767–1772.
    1. Zhou P., Yang X.L., Wang X.G. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature. 2020;579:270–273.
    1. Li Z., Wu M., Guo J. Caution on kidney dysfunctions of 2019-nCoV patients 2020. MedRxiv preprint. Available at: Accessed March 14, 2020.
    1. Kumar A., Zarychanski R., Pinto R. Critically ill patients with 2009 influenza A(H1N1) infection in Canada. JAMA. 2009;302:1872–1879.
    1. Russell C.D., Millar J.E., Baillie J.K. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. Lancet. 2020;395:473–475.
    1. Shang L., Zhao J., Hu Y. On the use of corticosteroids for 2019-nCoV pneumonia. Lancet. 2020;395:683–684.
    1. Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system [e-pub ahead of print]. Nat Rev Cardiol.. Accessed March 14, 2020.
    1. Levey A.S., Stevens L.A., Schmid C.H. CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration): a new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150:604–612.
    1. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group KDIGO clinical practice guideline for Acute Kidney Injury. Kidney Int Suppl. 2012;2:1–138.
    1. Guan W.-J., Liang W.-H., Zhao Y. Comorbidity and its impact on 1,590 patients with COVID-19 in China: a nationwide analysis. MedRxiv preprint. February 27, 2020. Available at: Accessed March 14, 2020.
    1. Tan L., Wang Q., Zhang D. Lymphopenia predicts disease severity of COVID-19: a descriptive and predictive study. MedRxiv preprint. March 3, 2020. Available at: Accessed March 14, 2020.

Source: PubMed

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