COVID-19 and cardiorenal medicine

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High rates of AKI in COVID-19 patients in ICU

Recent reports have highlighted high rates of renal complications in patients with COVID-19 infection, notably acute kidney injury (AKI). Up to 30% of patients with the infection in the intensive care unit (ICU) may suffer from AKI, with resulting death rates as high as 50%.

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Notably work conducted by nephrologist Dr Daniel Batlle, (Northwestern University Feinberg School of Medicine, Division of Nephrology and Hypertension, Chicago, Illinois) and co-authors,1 who – having reviewed two recent studies from China – hypothesise it is conceivable that the hypercoagulable state that appears to be a characteristic complication of severe COVID-19 could, in some cases, foster the evolution of acute tubular necrosis to cortical necrosis and, therefore, irreversible kidney failure.

The effects of coronavirus on the kidneys are also reviewed in a comprehensive editorial in Kidney International2 which suggests, that although the exact mechanism of kidney involvement is unknown, sepsis leading to a cytokine storm syndrome, might be a further mechanism. It underlines that “the current treatment of COVID-19 with AKI includes general and supportive management and kidney replacement therapy”.

UK shortages in dialysis equipment

The UK Renal Association (RA) says in its recent statement on COVID-19 related AKI,3 that in patients with a COVID-19 infection that requires treatment on an ICU, over 25% of patients on ventilators develop severe AKI and require dialysis support. It warns that “there is now a critical national shortage of the material required for the usual treatment in ICU. There are major efforts underway with all providers to source more tubing sets and fluid bags”.

Kidney professionals across the UK are working with the NHS to try to ensure that patients on an ICU who need treatment for AKI can receive it. It is working in regional renal and critical care NHS networks set up to help deliver treatment for patients with kidney disease. This ensures that hospitals are helping each other in a coordinated way by sharing capacity and equipment.

Intermittent dialysis regimen

An alternative to the usual ICU treatment is the shorter, more efficient, treatment currently used by many thousands of people in the UK who attend a dialysis unit two or three times a week or treat themselves at home. The RA is encouraging ICUs that can use intermittent treatment to do so where possible.

This ‘intermittent’ treatment is very widely used, so the RA does not expect this to lead to a shortage of the tubing sets or fluids. It does, however, require the installation of additional equipment and staff training to be able to deliver it in ICUs. Some ICUs are already set up to deliver this treatment and are doing so, while others are adapting their structure to enable this. Staff in dialysis units are currently training ICU colleagues to be able to deliver the intermittent treatment.

New AKI guidance from NICE

The National Institute for Health and Care Excellence (NICE) has also just published new guidance on COVID-19 and AKI in hospital.4 The purpose of this guideline is to help healthcare professionals prevent, detect and manage acute kidney injury in adults in hospital with known or suspected COVID-19. This is important to improve outcomes and reduce the need for renal replacement therapy. This guideline “focuses on what you need to stop or start doing during the COVID-19 pandemic”.

Other articles from COVID-19 Bulletin 2:

COVID-19 and immunology

  • vaccine development
  • expert report on COVID-19 and immunology research

COVID-19 and primary care

  • a review of current telemedicine platforms

COVID-19 and diabetes

  • Diabetes UK position statement
  • COVID-19 diagnostic glucose/lactate sensor in development

COVID-19 and mental health

COVID-19 and heart valve disease

References

  1. Batlle D, Soler MJ, Sparks MA et al. Acute Kidney injury in COVID-19:emerging evidence of a distinct pathophysiology. JASN 2020;ASN.2020040419. https://doi.org/10.1681/ASN.2020040419
  2. Naicker S, Yang C-W, Hwang S-J, Liu B-C, Chen J-H, Jha V. The novel coronavirus 2019 epidemic and kidneys. Kidney International 2020;97: 824–8. https://doi.org/10.1016/j.kint.2020.03.001
  3. The Renal Association. Statement on COVID-19 related acute kidney injury and intensive care capacity. https://renal.org/statement-covid-19-related-acute-kidney-injury-intensive-care-capacity/ (last accessed 13th May 2020)
  4. National Institute for Health and Care Excellence (NICE). COVID-19 rapid guideline: acute kidney injury in hospital [NG175]. Published 6th May 2020. https://www.nice.org.uk/guidance/ng175 (last accessed 13th May 2020).
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