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Mortality rate of acute kidney injury in SARS, MERS, and COVID-19 infection: a systematic review and meta-analysis

Critical Care volume 24, Article number: 439 (2020) Cite this article

A Letter to this article was published on 11 September 2020

Acute kidney injury (AKI), a predictor for poor clinical outcomes, has been reported as a severe complication of different coronavirus infections, including novel coronavirus disease 2019 (COVID-19) [1]. COVID-19 is considered more contagious than previous coronavirus infections, e.g., severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) [2], but comparisons of mortality rates from AKI among these three coronavirus infections remain uninvestigated. We therefore conducted a systematic review and meta-analysis comparing the mortality rate in patients with SARS, MERS, and COVID-19 who developed AKI.

A systematic search of PUBMED and EMBASE from inception to June 5, 2020, included the keywords “coronavirus”, “COVID-19”, “MERS”, “SARS”, “acute kidney injury”, “prognosis”, and “mortality” with suitable MeSH terms to identify observational studies of relevance, e.g., case reports, case series, cross-sectional studies, and cohort studies. Reference lists of included, published, systematic reviews identified in the search were screened for additional studies. We excluded conference abstracts, review articles, or studies without reports of AKI mortality. Two reviewers (YTC, SCS) screened titles and abstracts of search results for relevance and individually and independently assessed the full texts of selected results. The final list of included studies was derived by discussion and unanimous agreement from both authors. Statistical analyses were performed using MedCalc for Windows, version 15.0 (MedCalc Software, Ostend, Belgium). We report the mortality rate from AKI in SARS, MERS, and COVID-19 infections as proportions with 95% confidence interval (CI) based on random effects model, represented by forest plot. We detected heterogeneity among studies using the Cochran Q test, with p value < 0.10 indicating significant heterogeneity, and calculated I2 statistic to determine the proportion of total variation in study estimates attributable to heterogeneity.

After screening 97 records in total, we excluded 74 articles (15 duplicates, 11 irrelevant to study question, 1 conference abstract, 5 review articles and 42 lacking data on AKI mortality). Our final analysis included 23 articles comprising 4, 3 and 16 on SARS, MERS and COVID-19 infection, respectively. Demographic data for included articles are presented in Table 1. Overall, mortality in patients with SARS, MERS and COVID-19 infection, and developing AKI, was 77.4% (95%CI: 64.7–88.0). We found the mortality rate of AKI was highest in SARS (86.6%; 95%CI: 77.7–93.5), followed by COVID-19 (76.5%; 95%CI: 61.0–89.0) and MERS (68.5%; 95%CI: 53.8–81.5). There was no evidence of statistical heterogeneity among studies reporting AKI mortality in SARS (I2: 0.0%, p = 0.589) and MERS (I2: 0.0%, p =v0.758), but there was for COVID-19 infection (I2: 97.0%, p < 0.001) (Fig. 1).

Table 1 Study characteristics
Full size table
Fig. 1
figure 1

Forest plot of AKI mortality in coronavirus infections from included studies: a SARS, b MERS, and c COVID-19

Full size image

The present analyses indicate AKI as a poor prognosis factor in coronavirus infections, whereby AKI mortality in COVID-19 is higher than MERS but lower than SARS infections. Possible mechanisms of higher AKI mortality following coronavirus infections are multifactorial (e.g., severe sepsis-related multi-organ failure, direct kidney involvement, and acute respiratory distress syndrome) [26,27,28], although comparative pathogenesis of kidney involvement among the three infections remains unclear.

To our best knowledge, this is the first systematic review exploring AKI mortality of different coronavirus infections. However, we should be cautious about interpreting causal relationships between coronavirus infections and AKI, given the nature of observational data. Also, clinical heterogeneity between studies should be noted; for example, various healthcare systems of included studies may produce different AKI mortality rates. Coronaviruses are unlikely to be eliminated in the near future, and our synthesis indicates that AKI secondary to coronavirus infection may contribute to higher mortality. Hence, in the current exceptional pandemic, first-line healthcare providers should recognize the importance of timely detection of AKI and consider all available treatment options for maintenance of kidney functions to prevent death in COVID-19 patients [29].

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Not applicable.

Abbreviations

AKI:

Acute kidney injury

CI:

Confidence interval

COVID-19:

Coronavirus disease 2019

MERS:

Middle East respiratory syndrome

SARS:

Severe acute respiratory syndrome

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Author notes

  1. Yih-Ting Chen and Shih-Chieh Shao contributed equally to this work.

Authors and Affiliations

  1. Department of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan

    Yih-Ting Chen & Yung-Chang Chen

  2. Institute of Public Health, School of Medicine, National Yang Ming University, Taipei, Taiwan

    Yih-Ting Chen

  3. School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Shih-Chieh Shao & Edward Chia-Cheng Lai

  4. Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan

    Shih-Chieh Shao

  5. College of Medicine, Chang Gung University, Taoyuan, Taiwan

    Ming-Jui Hung

  6. Section of Cardiology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan

    Ming-Jui Hung

  7. Kidney Research Center, Department of Nephrology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan

    Yung-Chang Chen

  8. Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan

    Yung-Chang Chen

  9. Division of Nephrology, Department of Medicine, Keelung Chang Gung Memorial Hospital, No. 222, Maijin Rd., Anle Dist., Keelung, Taiwan

    Yung-Chang Chen

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Contributions

YCY and SCS contributed equally to this work. YCY and SCS contributed to the critical analysis, interpretation of the data, and drafting of the manuscript. MJH and YCC contributed to the study supervision and administrative, technical, or material support. All authors read and approved the final manuscript.

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Correspondence to Yung-Chang Chen.

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Chen, YT., Shao, SC., Lai, E.CC. et al. Mortality rate of acute kidney injury in SARS, MERS, and COVID-19 infection: a systematic review and meta-analysis. Crit Care 24, 439 (2020). https://doi.org/10.1186/s13054-020-03134-8

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Keywords

  • Acute kidney injury
  • Mortality
  • COVID-19
  • MERS
  • SARS

Critical Care

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