A recent study on Acute Kidney Injury and COVID-19: Challenges and Management

Journal of Nephrology and Urology is an Open Access peer-reviewed publication that discusses current research and advancements in diagnosis and management of kidney disorders, urinary tract infections as well as related epidemiology, pathophysiology and molecular genetics.

Acute kidney injury (AKI) is common among COVID-19 patients in the intensive care unit (ICU), and it is challenging to manage. The American Society of Nephrology (ASN) recently conducted a webinar on the topic with recommendations for in-hospital management. Other studies and news reports highlight demands and shortages for dialysis supplies in hard-hit areas.

AKI develops in 40% to 60% of COVID-19 ICU patients, including 20% to 30% who require renal replacement therapy (RRT). Multiple factors may contribute to AKI in a COVID-19 patient, he said. Patients may become dehydrated even before hospitalization because they have not been eating or drinking, have diarrhea, and are battling fever. Aggressive diuresis can induce hypovolemia. “Acute tubular necrosis” (ATN) may ensue from a cytokine storm and respiratory failure. There are also anecdotal reports of glomerular or vascular involvement. Low perfusion or venous congestion can follow cardiogenic shock with low ejection fraction or high positive end-expiratory pressure (PEEP) in mechanically ventilated patients. Direct viral invasion of the renal epithelium as well as nephrotoxicity from some of the experimental COVID-19 therapies are also possible.

Early AKI management should focus on determining true volume status using physical examination, passive leg raise, pulse-wave analysis, and point-of-care ultrasound with the goal of returning the patient to euvolemia.

The indications to start RRT are similar to other patients with AKI, according to an ASN recommendations statement. Some early reports suggest that delayed RRT initiation is safe, but this remains controversial. Loop diuretics may be used in the management of volume overload, per the treating physician’s discretion.

On general hospital floors, hemodialysis nurses can conduct intermittent hemodialysis in individual negative pressure rooms or for several COVID-19 patients isolated on one floor provided electronic monitoring is nearby.

For COVID-19 patients in the ICU, the preferred RRT modalities are continuous renal replacement therapy (CRRT) and prolonged intermittent renal replacement therapy (PIRRT), according to ASN. In cases of high demand, ASN suggested using CRRT machines for prolonged intermittent treatments (eg, 10 hours instead of continuous) with higher flow rates (eg, 40-50 mL/kg/h) and then using the machine for another patient, after terminal cleaning.

Optimal vascular access appears paramount, COVID-19 infection seems to induce a hypercoagulable state and CRRT circuit clotting has been occurring frequently.

Contact Details

Alex Stewart
Managing editor
Journal of Nephrology and Urology