The use of continuous renal replacement therapy in critically ill patients with COVID-19-related acute kidney injury

Violeta Knežević; Tijana Azaševac; Bojana Ljubičić; Ana Lazarević; Dragana Milijašević; Dušan Božić

doi:10.2298/VSP230614070K

Violeta Knežević University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; University Clinical Center of Vojvodina, Clinic for Nephrology and Clinical Immunology Novi Sad, Serbia https://orcid.org/0000-0001-7482-2945
Tijana Azaševac University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; University Clinical Center of Vojvodina, Clinic for Nephrology and Clinical Immunology Novi Sad, Serbia https://orcid.org/0000-0001-8432-0578
Bojana Ljubičić University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; University Clinical Center of Vojvodina, Emergency Center, Department of Emergency Internal Medicine, Novi Sad, Serbia https://orcid.org/0000-0001-8317-6156
Ana Lazarević University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; University Clinical Center of Vojvodina, Emergency Center, Department of Emergency Internal Medicine, Novi Sad, Serbia https://orcid.org/0000-0001-8310-3088
Dragana Milijašević University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; Institute of Public Health of Vojvodina, Novi Sad, Serbia https://orcid.org/0000-0003-1917-5567
Dušan Božić University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; University Clinical Center of Vojvodina, Clinic for Nephrology and Clinical Immunology, Novi Sad, Serbia https://orcid.org/0000-0002-0556-4708

DOI: https://doi.org/10.2298/VSP230614070K

Keywords: acute kidney injury;, continuous renal replacement therapy;, covid-19;, critical illness;, risk factors

Abstract

Background/Aim. Patients with severe clinical COVID-19 are at higher risk of developing acute kidney injury (AKI). The aim of the study was to analyze the risk factors for AKI/AKI on chronic kidney disease (CKD) and the results of treatment using continuous renal replacement therapy (CRRT) in critically ill COVID-19 patients. Methods. The study included 101 COVID-19 patients with AKI treated with CRRT out of a total of 293 patients with AKI. The study was conducted from March 2020 to July 2021 at the University Clinical Center of Vojvodina, Serbia. Results. The average age of patients was 64.69 ± 9.71 years. Out of the total number of patients, 82.2% were male, of whom 75.2% suffered from hypertension. On invasive mechanical ventilation (IMV) were 93.7% of patients, and 92.1% were on vasopressor therapy. The average length of IMV until the beginning of CRRT was 4.65 ± 4.57 days. In the first 24 hrs after starting IMV, 60% of patients had to undergo CRRT. Before administering CRRT, the average Simplified Acute Physiology Score II was 39.13 ± 14.45, creatinine 312 µmol/L [Interquartile Range (IQR) 208.0–437.5], procalcitonin 2.70 ng/L (IQR 0.62–7.20), while 10.9% of patients had SpO₂/FiO₂ index > 200 and 41.6% had anuria. The mean number of procedures was 2.01 ± 1.36. The most frequent modality was hemodiafiltration in 67.3% of patients, and 46% used the oXiris^® membrane. Using binary logistic regression, including demographic parameters, comorbidities, as well as clinical parameters before CRRT, it was found that patients with previous kidney disease were 3.43 times more susceptible to developing AKI, and patients with SpO₂/FiO₂ index ≥ 200 were 69% less susceptible to developing AKI/AKI on CKD requiring CRRT in the first 24 hrs from the start of IMV. Conclusion. Determining the risk factors for AKI/AKI on CKD is important for planning the prevention of these conditions that require the application of CRRT with the correct choice of dialysis modality and dose, membrane/filter type, and anticoagulant dose.

References

Ronco C, Reis T, Husain-Syed F. Management of acute kidney injury in patients with COVID-19. Lancet Respir Med 2020; 8(7): 738–42.

Chan L, Chaudhary K, Saha A, Chauhan K, Vaid A, Baweja M, et al. Acute Kidney Injury in Hospitalized Patients with COVID-19. medRxiv [Preprint] 2020. Update in: J Am Soc Nephrol 2021; 32(1): 151–60.

Mohamed MMB, Lukitsch I, Torres-Ortiz AE, Walker JB, Var-ghese V, Hernandez-Arroyo CF, et al. Acute Kidney Injury As-sociated with Coronavirus Disease 2019 in Urban New Orle-ans. Kidney360 2020; 1(7): 614–22.

Thakkar J, Chand S, Aboodi MS, Gone AR, Alahiri E, Schecter DE, et al. Characteristics, Outcomes and 60-Day Hospital Mortality of ICU Patients with COVID-19 and Acute Kidney Injury. Kidney360 2020; 1(12): 1339–44.

Hirsch JS, Ng JH, Ross DW, Sharma P, Shah HH, Barnett RL, et al. Acute kidney injury in patients hospitalized with COVID-19. Kidney Int 2020; 98(1): 209–18.

Zhou S, Xu J, Xue C, Yang B, Mao Z, Ong ACM. Coronavirus-associated kidney outcomes in COVID-19, SARS, and MERS: a meta-analysis and systematic review. Ren Fail 2020; 43(1): 1–15.

Robbins-Juarez SY, Qian L, King KL, Stevens JS, Husain SA, Ra-dhakrishnan J, et al. Outcomes for Patients With COVID-19 and Acute Kidney Injury: A Systematic Review and Meta-Analysis. Kidney Int Rep 2020; 5(8): 1149–60.

Domecq JP, Lal A, Sheldrick CR, Kumar VK, Boman K, Bolesta S, et al. Outcomes of Patients with Coronavirus Disease 2019 Receiving Organ Support Therapies: The International Viral Infection and Respiratory Illness Universal Study Registry. Crit Care Med 2021; 49(3): 437–48. Erratum in: Crit Care Med 2021; 49(5): e562.

Gupta S, Coca SG, Chan L, Melamed ML, Brenner SK, Hayek SS, et al. AKI Treated with Renal Replacement Therapy in Criti-cally Ill Patients with COVID-19. J Am Soc Nephrol 2021; 32(1): 161–76.

Kooman JP, van der Sande FM. COVID-19 in ESRD and Acute Kidney Injury. Blood Purif 2021; 50(4–5): 610–20.

Nadim MK, Forni LG, Mehta RL, Connor MJ Jr, Liu KD, Oster-mann M, et al. COVID-19-associated acute kidney injury: con-sensus report of the 25th Acute Disease Quality Initiative (ADQI) Workgroup. Nat Rev Nephrol 2020; 16(12): 747–64. Erratum in: Nat Rev Nephrol 2020; 16(12): 765.

Bilan N, Dastranji A, Ghalehgolab Behbahani A. Comparison of the spo2/fio2 ratio and the pao2/fio2 ratio in patients with acute lung injury or acute respiratory distress syndrome. J Car-diovasc Thorac Res 2015; 7(1): 28–31.

Tan BWL, Tan BWQ, Tan ALM, Schriver ER, Gutiérrez-Sacristán A, Das P, et al. Long-term kidney function recovery and mortality after COVID-19-associated acute kidney injury: an international multi-centre observational cohort study. EClinicalMedicine 2022; 55: 101724.

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): 1–138.

Bezerra R, Teles F, Mendonca PB, Damte T, Likaka A, Ferrer-Miranda E, et al. Outcomes of critically ill patients with acute kidney injury in COVID-19 infection: an observational study. Ren Fail 2021; 43(1): 911–8.

Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Cas-telli A, et al. Baseline characteristics and outcomes of 1591 pa-tients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy. JAMA 2020; 323(16): 1574–81. Erra-tum in: JAMA 2021; 325(20): 2120.

Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, Nalla AK, et al. Covid-19 in critically ill patients in the Seattle re-gion - case series. N Engl J Med 2020; 382(21): 2012–22.

Argenziano MG, Bruce SL, Slater CL, Tiao JR, Baldwin MR, Barr RG, et al. Characterization and clinical course of 1000 pa-tients with coronavirus disease 2019 in New York: retrospec-tive case series. BMJ 2020; 369: m1996.

Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA 2020; 323(20): 2052–9. Erratum in: JAMA 2020; 323(20): 2098.

Chan L, Chaudhary K, Saha A, Chauhan K, Vaid A, Zhao S, et al. AKI in Hospitalized Patients with COVID-19. J Am Soc Nephrol 2021; 32(1): 151–60.

Doher MP, Torres de Carvalho FR, Scherer PF, Matsui TN, Am-mirati AL, Caldin da Silva B, et al. Acute Kidney Injury and Renal Replacement Therapy in Critically Ill COVID-19 Pa-tients: Risk Factors and Outcomes: A Single-Center Experi-ence in Brazil. Blood Purif 2021; 50(4–5): 520–30.

Liu Y, Yang Y, Zhang C, Huang F, Wang F, Yuan J, et al. Clini-cal and biochemical indexes from 2019-nCoV infected pa-tients linked to viral loads and lung injury. Sci China Life Sci 2020; 63(3): 364–74.

Husain-Syed F, Slutsky AS, Ronco C. Lung−kidney cross-talk in the critically ill patient. Am J Respir Crit Care Med 2016; 194(4): 402–14.

Van den Akker JP, Egal M, Groeneveld AB. Invasive mechanical ventilation as a risk factor for acute kidney injury in the criti-cally ill: a systematic review and meta-analysis. Crit Care 2013; 17(3): R98.

Barbar SD, Clere-Jehl R, Bourredjem A, Hernu R, Montini F, Bru-yère R, et al. Timing of Renal-Replacement Therapy in Pa-tients with Acute Kidney Injury and Sepsis. N Engl J Med 2018; 379(15): 1431–42.

Gaudry S, Hajage D, Benichou N, Chaïbi K, Barbar S, Zarbock A, et al. Delayed versus early initiation of renal replacement ther-apy for severe acute kidney injury: a systematic review and in-dividual patient data meta-analysis of randomised clinical tri-als. Lancet 2020; 395(10235): 1506–15.

Ostermann M, Joannidis M, Pani A, Floris M, De Rosa S, Kellum JA, et al. Patient Selection and Timing of Continuous Renal Replacement Therapy. Blood Purif 2016; 42(3): 224–37.

Knežević V, Azaševac T, Stražmešter Majstorović G, Marković M, Ružić M, Turkulov V, et al. The importance of anticoagulation in COVID-19-related acute kidney injury requiring continu-ous renal replacement therapy. Srp Arh Celok Lek 2022; 150(1–2): 29–34.