Incidence of acute kidney injury in COVID-19 infection: a systematic review and meta-analysis
Critical Care volume 24, Article number: 346 (2020)
Coronavirus disease 2019 (COVID-19), primarily affecting respiratory systems, has become pandemic and spread worldwide. Acute kidney injury (AKI) has been reported as a severe complication of COVID-19 with a higher risk of mortality , but the incidence of AKI among those infected with COVID-19 is currently only based on reports from small case series and retrospective studies [2, 3]. Therefore, in this work, we aim to perform a systematic review and meta-analysis of published articles to quantify the incidence of AKI in COVID-19 patients.
We performed a systematic search via PUBMED and EMBASE using the keywords “COVID-19” and “acute kidney injury” to identify relevant observational studies, such as case series and cohort studies published between 2019 and May 11, 2020. We also manually examined the reference lists of included studies and reviewed the AKI reports in epidemiological features and clinical courses of COVID-19 patients in high-profile general medicine journals (e.g., BMJ, JAMA, Lancet, and NEJM). Two independent reviewers (YTC and SCS) assessed articles, including title, abstract, and full text to determine whether studies were eligible for inclusion. In cases of divergences, results were discussed with a third reviewer (YCC). All statistical analyses were performed using MedCalc for Windows, version 15.0 (MedCalc Software, Ostend, Belgium). The incidence of AKI is expressed as proportion and 95% confidence interval (CI) using the random effects model and presented as a forest plot. We used the Cochran Q test to detect heterogeneity among studies, with a p value < 0.10 indicating significant heterogeneity. We calculated I2 statistic to measure the proportion of total variation in study estimates attributed to heterogeneity.
Of 65 articles screened, we excluded 45: 7 studies were duplicates, 8 studies were irrelevant, 9 studies failed to report the number of patients in the study cohort, and 21 studies did not report AKI data. Our final analysis included 20 articles comprising 6945 patients from China, Italy, the UK, and the USA. Demographic data for the included articles are summarized in Table 1. Notably, most of the studies (80%) were reported from China. We found the incidence of AKI was 8.9% (95% CI 4.6–14.5) in COVID-19 patients, but there was evidence of statistical heterogeneity among the studies with I2 = 97.8% and p < 0.001 (Fig. 1).
Previous studies reported the incidence of AKI largely from small case series or cohorts of COVID-19 patients, but our findings indicated that nearly 9 out of 100 developed AKI among a total of 6945 COVID-19 patients. This was close to the incidence rate of AKI in patients with community-acquired pneumonia .
Several mechanisms are possible for AKI in COVID-19 patients, including multi-organ dysfunction syndrome, SARS-CoV-2 direct kidney infection , AKI following acute respiratory distress syndrome (ARDS), infection-related generalized mitochondrial failure, and cytokine storm syndrome. Early recognition and treatment of AKI may limit associated complications such as long-term chronic kidney disease or end-stage kidney disease .
This study has several limitations. First, since the majority of included studies came from China and the USA, the generalizability of our findings into other countries may be limited. Second, clinical heterogeneity between studies should be noted, whereby detailed information on patient characteristics was lacking in the published articles. For example, two studies included patients post kidney transplantation, and the reported incidences of AKI were higher than in other studies which lacked information on how many patients had had kidney transplantation. With the disease burden of COVID-19 still increasing every day, we hope our synthesis can raise clinical awareness, early recognition, and intervention for AKI in patients hospitalized with COVID-19 for first-line healthcare providers.
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Acute kidney injury
Coronavirus disease 2019
Ali H, Daoud A, Mohamed MM, Salim SA, Yessayan L, Baharani J, Murtaza A, Rao V, Soliman KM. Survival rate in acute kidney injury superimposed COVID-19 patients: a systematic review and meta-analysis. Ren Fail. 2020;42(1):393–7.
Ronco C, Reis T. Kidney involvement in COVID-19 and rationale for extracorporeal therapies. Nat Rev Nephrol. 2020;16(6):308–10.
Naicker S, Yang CW, Hwang SJ, Liu BC, Chen JH, Jha V. The novel coronavirus 2019 epidemic and kidneys. Kidney Int. 2020;97(5):824–8.
Alberici F, Delbarba E, Manenti C, Econimo L, Valerio F, Pola A, Maffei C, Possenti S, Zambetti N, Moscato M, et al. A single center observational study of the clinical characteristics and short-term outcome of 20 kidney transplant patients admitted for SARS-CoV2 pneumonia. Kidney Int. 2020;97(6):1083–8.
Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, Lee M. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington state. JAMA. 2020;323(16):1612–4.
Banerjee D, Popoola J, Shah S, Ster IC, Quan V, Phanish M. COVID-19 infection in kidney transplant recipients. Kidney Int. 2020;97(6):1076–82.
Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, Qiu Y, Wang J, Liu Y, Wei Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507–13.
Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, Ma K, Xu D, Yu H, Wang H, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ. 2020;368:m1091.
Cheng Y, Luo R, Wang K, Zhang M, Wang Z, Dong L, Li J, Yao Y, Ge S, Xu G. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int. 2020;97(5):829–38.
Deng Y, Liu W, Liu K, Fang YY, Shang J, Zhou L, Wang K, Leng F, Wei S, Chen L, et al. Clinical characteristics of fatal and recovered cases of coronavirus disease 2019 (COVID-19) in Wuhan, China: a retrospective study. Chin Med J. 2020.
Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708–20.
Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, Wang H, Wan J, Wang X, Lu Z. Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19). JAMA Cardiol. 2020.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497–506.
Lei S, Jiang F, Su W, Chen C, Chen J, Mei W, Zhan LY, Jia Y, Zhang L, Liu D, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. EClinicalMedicine. 2020:100331.
Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, and the Northwell C-RC, Barnaby DP, Becker LB, Chelico JD, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the new York City area. JAMA. 2020.
Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, Gong W, Liu X, Liang J, Zhao Q, et al. Association of Cardiac Injury with Mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol. 2020.
Wang L, Li X, Chen H, Yan S, Li D, Li Y, Gong Z. Coronavirus disease 19 infection does not result in acute kidney injury: an analysis of 116 hospitalized patients from Wuhan, China. Am J Nephrol. 2020;51(5):343–8.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang B, Xiang H, Cheng Z, Xiong Y, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020.
Wang D, Yin Y, Hu C, Liu X, Zhang X, Zhou S, Jian M, Xu H, Prowle J, Hu B, et al. Clinical course and outcome of 107 patients infected with the novel coronavirus, SARS-CoV-2, discharged from two hospitals in Wuhan, China. Crit Care. 2020;24(1):188.
Yang X, Yu Y, Xu J, Shu H, Ja X, Liu H, Wu Y, Zhang L, Yu Z, Fang M, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020;8(5):475–81.
Zhang G, Hu C, Luo L, Fang F, Chen Y, Li J, Peng Z, Pan H. Clinical features and short-term outcomes of 221 patients with COVID-19 in Wuhan, China. J Clin Virol. 2020;127:104364.
Zhang X, Cai H, Hu J, Lian J, Gu J, Zhang S, Ye C, Lu Y, Jin C, Yu G, et al. Epidemiological, clinical characteristics of cases of SARS-CoV-2 infection with abnormal imaging findings. Int J Infect Dis. 2020;94:81–7.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054–62.
Akram AR, Singanayagam A, Choudhury G, Mandal P, Chalmers JD, Hill AT. Incidence and prognostic implications of acute kidney injury on admission in patients with community-acquired pneumonia. Chest. 2010;138(4):825–32.
Zhang H, Penninger JM, Li Y, Zhong N, Slutsky AS. Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: molecular mechanisms and potential therapeutic target. Intensive Care Med. 2020;46(4):586–90.
Hoste EAJ, Kellum JA, Selby NM, Zarbock A, Palevsky PM, Bagshaw SM, Goldstein SL, Cerdá J, Chawla LS. Global epidemiology and outcomes of acute kidney injury. Nat Rev Nephrol. 2018;14(10):607–25.
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Chen, YT., Shao, SC., Hsu, CK. et al. Incidence of acute kidney injury in COVID-19 infection: a systematic review and meta-analysis. Crit Care 24, 346 (2020). https://doi.org/10.1186/s13054-020-03009-y
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