COVID-19-associated acute kidney injury: consensus report of the 25th Acute Disease Quality Initiative (ADQI) Workgroup

Mitra K Nadim, Lui G Forni, Ravindra L Mehta, Michael J Connor Jr, Kathleen D Liu, Marlies Ostermann, Thomas Rimmelé, Alexander Zarbock, Samira Bell, Azra Bihorac, Vincenzo Cantaluppi, Eric Hoste, Faeq Husain-Syed, Michael J Germain, Stuart L Goldstein, Shruti Gupta, Michael Joannidis, Kianoush Kashani, Jay L Koyner, Matthieu Legrand, Nuttha Lumlertgul, Sumit Mohan, Neesh Pannu, Zhiyong Peng, Xose L Perez-Fernandez, Peter Pickkers, John Prowle, Thiago Reis, Nattachai Srisawat, Ashita Tolwani, Anitha Vijayan, Gianluca Villa, Li Yang, Claudio Ronco, John A Kellum, Mitra K Nadim, Lui G Forni, Ravindra L Mehta, Michael J Connor Jr, Kathleen D Liu, Marlies Ostermann, Thomas Rimmelé, Alexander Zarbock, Samira Bell, Azra Bihorac, Vincenzo Cantaluppi, Eric Hoste, Faeq Husain-Syed, Michael J Germain, Stuart L Goldstein, Shruti Gupta, Michael Joannidis, Kianoush Kashani, Jay L Koyner, Matthieu Legrand, Nuttha Lumlertgul, Sumit Mohan, Neesh Pannu, Zhiyong Peng, Xose L Perez-Fernandez, Peter Pickkers, John Prowle, Thiago Reis, Nattachai Srisawat, Ashita Tolwani, Anitha Vijayan, Gianluca Villa, Li Yang, Claudio Ronco, John A Kellum

Abstract

Kidney involvement in patients with coronavirus disease 2019 (COVID-19) is common, and can range from the presence of proteinuria and haematuria to acute kidney injury (AKI) requiring renal replacement therapy (RRT; also known as kidney replacement therapy). COVID-19-associated AKI (COVID-19 AKI) is associated with high mortality and serves as an independent risk factor for all-cause in-hospital death in patients with COVID-19. The pathophysiology and mechanisms of AKI in patients with COVID-19 have not been fully elucidated and seem to be multifactorial, in keeping with the pathophysiology of AKI in other patients who are critically ill. Little is known about the prevention and management of COVID-19 AKI. The emergence of regional 'surges' in COVID-19 cases can limit hospital resources, including dialysis availability and supplies; thus, careful daily assessment of available resources is needed. In this Consensus Statement, the Acute Disease Quality Initiative provides recommendations for the diagnosis, prevention and management of COVID-19 AKI based on current literature. We also make recommendations for areas of future research, which are aimed at improving understanding of the underlying processes and improving outcomes for patients with COVID-19 AKI.

Conflict of interest statement

L.G.F. has received grant and/or research support from Baxter and speaker’s honoraria from bioMérieux and Ortho Clinical diagnostics. R.L.M. has received grant and/or research support from Fresenius and Fresenius-Kabi and consulting fees from AM-Pharma, Sphingotec, Akebia, GE healthcare, Indalo, bioMérieux, Intercept, Baxter, Medtronic and Mallinckrodt. M.J.C. has received grant and/or research support from NIH and Potrero Medical Inc. K.D.L. has received consulting fees from bioMérieux and Durect. M.O. has received grant and/or research support from Baxter. T. Rimmelé has received grant and/or research support from Baxter and consulting fees from Baxter, Fresenius Medical Care, bioMérieux, Braun and Nikkiso. A.Z. has received grant and/or research support from Astute Medical, Fresenius, Baxter, Astellas, DFG, EK and consulting fees from Baxter, Astute Medical, bioMérieux, La Jolla Pharmaceuticals, Fresenius, Braun, AM-Pharma, Astellas and Radiopharma. S.L.G. has grant and/or research support and consulting fees from ExThera, BioPorto, Baxter and SeaStar, speaker’s honoraria from Baxter and Fresenius and is a stockholder for MediBeacon. S.G. has received consulting fees from GlaxoSmithKline. M.J. has received grant and/or research support from Baxter. J.L.K. has received grant and/or research support from NxStage, Satellite Health Care, and consulting fees from Astute Medical, Baxter, Sphingotec, and honoraria from the American Society of Nephrology. M.L. has received grant and/or research support from Sphingotec and consulting fees from Novartis. S.M. has received consulting fees from Angion Biomedica. X.L.P.-F. has received speaker’s honoraria from Baxter. P.P. has received travel and consulting fees from AM-Pharma, EBI and Sphingotec. J.P. has received grant and/or research support from bioMérieux, consulting fees from Quark Pharmaceutical and Medibeacon Inc., and speaker’s honoraria from Nikkiso Europe GmbH, Baxter, Braun Medical Ltd, Fresenius Medical Care and Fresenius-Kabi UK. T. Reis. has received consulting fees from Baxter and Eurofarma and speaker’s honoraria from Baxter and Braun. N.S. has received grant and/or research support from Baxter. A.T. has received consulting fees and speaker’s honoraria from Baxter and has a patent on 0.5% citrate solution for continuous renal replacement therapy. A.V. has received consulting fees for NxStage and has received other fees from Boehringer Ingelheim. G.V. has received grant and/or research support from Baxter SpA. C.R. has received consulting fees from Baxter, Jfron, bioMérieux, Medtronic and speaker’s honoraria from GE, OCD, and Cytosorbents. J.A.K. has received grant and/or research support from Astellas, Astute Medical, Baxter, bioMérieux, Cytosorbents, RenalSense, consulting fees from Astellas, Astute Medical, Baxter, bioMérieux, Cytosorbents, RenalSense, DaVita, Fresenius, Mallinckrodt, NxStage, Potrero, and has licensing of intellectual property for Astute Medical and Cytosorbents. The other authors declare no competing interests.

Figures

Fig. 1. Pathogenesis of COVID-19 AKI.
Fig. 1. Pathogenesis of COVID-19 AKI.
a,b | The pathogenesis of AKI in patients with COVID-19 (COVID-19 AKI) is likely multifactorial, involving both the direct effects of the SARS-CoV-2 virus on the kidney and the indirect mechanisms resulting from systemic consequences of viral infection or effects of the virus on distant organs including the lung, in addition to mechanisms relating to the management of COVID-19. AKI, acute kidney injury. Adapted from Acute Disease Quality Initiative 25, www.ADQI.org, CC BY 2.0 (https://creativecommons.org/licenses/by/2.0/).
Fig. 2. Stage-based management of COVID-19 AKI.
Fig. 2. Stage-based management of COVID-19 AKI.
The pathogenesis of acute kidney injury (AKI) in patients with COVID-19 (COVID-19 AKI) likely involves direct viral effects, indirect effects and sequelae from disease management. There is no specific evidence to suggest that COVID-19 AKI should be managed differently from other causes of AKI in critically ill patients; however, the possible underlying disease mechanisms should be taken into account when considering approaches to the management of COVID-19 AKI throughout the disease course. Adapted with permission from ref., Elsevier, and Acute Disease Quality Initiative 25, www.ADQI.org, CC BY 2.0 (https://creativecommons.org/licenses/by/2.0/).
Fig. 3. Step-wise plan to prepare for…
Fig. 3. Step-wise plan to prepare for a surge in RRT demand during a pandemic or disaster.
A sudden spike in cases of COVID-19 disease might cause unforeseen shortages of renal replacement therapy (RRT) devices and/or RRT disposables and fluids. In addition, supply chain security might be compromised, further contributing to local shortages. As part of a local surge response, use of a wider variety of acute RRT modalities may be needed to maximize the number of patients who can receive RRT. Adapted from Acute Disease Quality Initiative 25, www.ADQI.org, CC BY 2.0 (https://creativecommons.org/licenses/by/2.0/).
Fig. 4. Potential extracorporeal blood purification treatment…
Fig. 4. Potential extracorporeal blood purification treatment options based on underlying COVID-19 pathophysiology.
Extracorporeal blood purification (EBP) has been proposed as a possible adjuvant therapy for critically ill patients with COVID-19 on the basis that removal of circulating immunomodulatory factors, that might contribute to disease processes and/or the development of multiple organ failure, might improve outcomes. Of note, the efficacy of EBP in patients with COVID-19 and/or COVID-19 AKI has not been tested, and all therapeutic options must therefore be tested in clinical trials in the context of COVID-19. EBP therapies should be considered complementary to pharmacological support. EBP therapies may also be considered in sequence or as separate entities according to current evidence or pathophysiological rationale, as changes in pathophysiology over the disease course might indicate different treatment approaches. AKI, acute kidney injury; ARDS, acute respiratory distress syndrome; COVID-19, coronavirus disease 2019; DAMPs, damage-associated molecular patterns; HCO, high cut-off; HP, haemoperfusion; MCO, medium cut-off; PAMPs, pathogen-associated molecular patterns; RRT, renal replacement therapy; TPE, therapeutic plasma exchange. Adapted from Acute Disease Quality Initiative 25, www.ADQI.org, CC BY 2.0 (https://creativecommons.org/licenses/by/2.0/).

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Source: PubMed

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