Acute kidney injury in hospitalized patients with COVID-19: A single center experience
Tülin Akagün1, Arzu Ayraler2, Murat Usta3, Süleyman Baylan4, Ahmet Cumhur Dülger5
1Department of Nephrology, Tulin Akagun, Giresun University Faculty of Medicine, Giresun, Türkiye
2Department of Family Medicine, Arzu Ayraler, Giresun University Faculty of Medicine, Giresun, Türkiye
3Department of Biochemistry, Murat Usta, Giresun University Faculty of Medicine, Giresun, Türkiye
4Department of Internal Medicine, Süleyman Baylan, Giresun University Faculty of Medicine, Giresun, Türkiye
5Department of Gastroenterology, Ahmet Cumhur Dülger, Giresun University Faculty of Medicine, Giresun, Türkiye
Keywords: Acute kidney injury, COVID-19, neutrophil lymphocyte ratio, prognostic nutritional index.
Objectives: The aim of this study was to evaluate the clinical features and outcomes of patients with coronavirus disease 2019 (COVID-19) who experienced acute kidney injury (AKI) during intensive care unit (ICU) hospitalization.
Materials and methods: Between March 01, 2020 and June 30, 2020, a total of 49 patients (28 males, 21 females; mean age: 75.5±12.5 years; range, 21 to 92 years) with COVID-19 PCR positive who were hospitalized with COVID-19 pneumonia in the ICU and developed AKI were evaluated with demographics, laboratory data, treatment, and outcome. The prognostic nutritional index (PNI), which is calculated using the serum albumin concentration and the total lymphocytic count was also evaluated. All patients were treated with favipiravir+low molecular weight heparin; laboratory tests were recorded before and after favipiravir treatment.
Results: Nine (18.4%) patients survived to hospital discharge. The mean PNI of the patients who survived was higher than in non-survivors. Lactate dehydrogenase (LDH), procalcitonin, ferritin, and C-reactive protein (CRP) results were higher in non-survivors. When we compare the PNI results, the mean PNI was lower after the favipiravir treatment. Leucocyte, neutrophil count, and neutrophil-lymphocyte ratio results were higher after the treatment. Creatinine, LDH, procalcitonin, ferritin, and CRP results were higher after the treatment in non-survivors.
Conclusion: Acute kidney injury was related to a significant mortality rate in COVID-19 hospitalized patients. Prognostic nutritional index may be a valuable clinical marker for predicting survival in COVID-19 patients.
Preliminary reports indicate that acute kidney injury (AKI) seems to be associated with coronavirus disease 2019 (COVID-19) severity and outcomes. Although the reported incidence of AKI among hospitalized patients with COVID-19 varies widely, AKI among hospitalized patients is associated with poor prognosis.[1-4] The aim of this study was to evaluate the clinical characteristics and outcomes in our COVID-19 patients who developed AKI during intensive care unit (ICU) hospitalization.
Patients and Methods
This retrospective observational study was conducted at the Giresun University Hospital Department of Internal Medicine, Nephrology clinic between March 01, 2020 and June 30, 2020. A total of 49 patients (28 males, 21 females; mean age: 75.5±12.5 years; range, 21 to 92 years) with COVID-19 PCR positive who were hospitalized with COVID-19 pneumonia in the ICU and developed AKI were included in the study. Patients under the age of 18 were excluded from the study.
Acute kidney injury was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. The prognostic nutritional index (PNI) which is calculated using the serum albumin concentration and the total lymphocytic count was also evaluated [PNI=10 x serum albumin (g/dL)+0.005 x total lymphocyte count]. All patients were treated with favipiravir+low molecular weight heparin; laboratory tests were recorded before and after favipiravir treatment.
Statistical analyzes were performed with Number Cruncher Statistical System 2004 (NCSS, Utah, USA) and GraphPad Prism version 9.0.1 (GraphPad Software, LLC, USA). After investigating the conformity of continuous variables to a normal distribution with the Kolmogorov-Smirnov test, variables with Gaussian distribution were shown as mean±SD, while variables with non-gaussian distribution were shown as median (25th-75th percentile). Student's t-test or Mann-Whitney U test was used for independent group comparisons. Pearson's chi-square test or Yates' correction was used to compare group frequencies. Statistical significance was evaluated at the p<0.05 (two-tailed) level.
Demographic and clinical features
Nine (18.4%) patients survived to hospital discharge. Favipiravir, the recommended drug by the Turkish Ministry of Health, was uniformly supplied to all patients. Favipiravir treatment was initiated with two loading doses of 1600 mg each on day one, followed by 600 mg twice daily for 5-10 days. Low-molecular-weight heparin was administered to all patients. Laboratory tests were recorded before and after treatment.
Leucocyte, neutrophil count, and neutrophillymphocyte ratio (NLR) were higher in nonsurvivors. The mean PNI of the patients who survived was higher than in non-survivors. Lactate dehydrogenase (LDH), aspartate transferase (AST), procalcitonin, ferritin, D-dimer and C-reactive protein (CRP) results were higher in non-survivors. There was no statistically significant difference between the mean serum creatinine values of the patients. When we compare the PNI results, the mean PNI was lower after the favipiravir treatment. Leucocyte, neutrophil count, and NLR results were higher after the treatment in the nonsurvived patient group. Serum creatinine, LDH, Troponin T, ferritin, D-dimer, and CRP results were higher after the treatment in non-survivors. The clinical and laboratory parameters of patients are shown in Table 1 and Table 2.
Acute kidney injury is common among patients hospitalized with COVID-19 and is associated with high mortality. Mortality was 50%-60.5% among patients in COVID-19- positive AKI patients.[1,6] In a study by Yan et al. including 882 COVID-19 patients, the mean age of patients was 71, and patients with AKI had higher mortality than those without AKI (59.1% vs. 7.8%; p<0.001). In another study, Li et al. found that patients with AKI had a significantly higher risk for in-hospital mortality than severely and critically ill patients without AKI. Similarly, in another study Xu et al. reported that the risk of in-hospital mortality was highest in patients with COVID-19 and AKI [odds ratio (OR) 80.3, 95% confidence interval (CI) (27.3-235.6)], followed by COVID-19 without AKI [16.3 (6.28-42.4)]. Acute kidney injury is a common and serious complication of COVID-19. Older age and having severe COVID-19 were independent risk factors for AKI. A meta-analysis conducted in 2020 showed that the risk of in-hospital mortality was significantly increased in patients with COVID-19 complicated by AKI. In a study by Ng et al. of the 3,216 patients with AKI, a total of 1,491 (46.4%) died. Acute kidney injury in hospitalized patients with COVID-19 is associated with a significant risk of death. Mortality is higher in our patient group. The high mortality rate of our patients may be due to the fact that the patients are severely ill that they need intensive care follow-up and they are of advanced age.
The prognostic nutritional index, which is calculated from the serum albumin concentration and total lymphocyte count in peripheral blood, is an index that reflects chronic inflammation, immune system, and nutritional status and indicates prognostic significance in different patients. The prognostic nutritional index had been described as a simple and objective indicator of adverse outcomes not only in chronic conditions but also in acute illnesses, including acute coronary syndrome, acute heart failure, and stroke. Although it did not reach statistical significance in our study, PNI values were found to be lower in the non-survivor group at the time of hospital admission (32.1±7.2 vs. 34.6±7.7; p=0.162). This may be due to the small number of our patient group. In our study after favipiravir treatment, the mean PNI of the patients who survived was higher than in non-survivors (32.4±7.2 vs. 25.2±6.3; p=0.049). In a study with a larger number of COVID-19 patients (n=450); a comparison of baseline characteristics showed non-survivors had higher age (p<0.001) and lower PNI (p<0.001). There is no study in the literature investigating the relationship between PNI and mortality in patients with COVID-19-positive AKI. A low prognostic nutritional index was significantly associated with postoperative complications and survival in patients undergoing cardiovascular surgery. Similarly, in another study PNI values ≤34 were associated with a two-fold higher risk of overall mortality and a three-fold higher risk of in-hospital mortality in elderly patients hospitalized for acute heart failure.
The neutrophil-lymphocyte ratio is a common and quick index of inflammation detection in laboratory examination. It is used in the diagnosis, treatment, and prognosis evaluation of pneumonia. In addition, NLR constitutes a novel prognostic marker for oncologic, cardiovascular, and infectious diseases. Based on this, studies investigating the prognostic value of NLR in COVID-19 infection were conducted.[18-20] In our study; leucocyte, neutrophil count, and NLR were higher in non-survivors. Similarly, we found the ferritin, D-dimer, and CRP values to be statistically significantly higher in the non-survivor group. In the study of Wang et al. they found that the patients with a high level of CRP, NLR, or D-dimer performed shorter overall survival time (all p<0.05). They reported that the combination of CRP, NLR, and D-dimer could be an effective predictor for aggravation and death in patients with COVID-19.
There are studies/reviews conducted on the treatment of COVID-19.[22-25] The efficacy of favipiravir treatment is still unclear. In our patient group, all patients were treated with favipiravir. It is not possible to evaluate the efficacy of favipiravir treatment due to the small number of our patients. The small sample size and retrospective nature are the major limitations of our study.
In conclusion, AKI in hospitalized patients with COVID-19 was associated with high mortality. The prognostic nutritional index may be a useful clinical marker that can be used for estimating survival in COVID-19 patients.
Cite this article as: Akagün T, Ayraler A, Usta M, Baylan S, Dülger AC. Acute kidney injury in hospitalized patients with COVID-19: A single center experience. D J Med Sci 2022;8(3):115-119.
The study protocol was approved by the Gumushane University Ethics Committee (date: 23.02.2022, no: 2022/1). The study was conducted in accordance with the principles of the Declaration of Helsinki.
A written informed consent was obtained from each patient.
Data Sharing Statement:
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Idea/design and article writing: T.A.; Literature review: A.A.; Statistical analysis: M.U.; Data collection/data entry: S.B.; Critical review: A.C.D.
The authors declared no conflicts of interest with respect to the authorship and/ or publication of this article.
The authors received no financial support for the research and/or authorship of this article.
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