COVID-19 Among Hospitalized Patients With Kidney Disease: Experience At A U.S. Midwestern Academic Medical Center

Abstract We sought to characterize the clinical profiles and outcomes of patients with coronavirus disease 2019 and comorbid kidney disease hospitalized at urban, Midwestern tertiary care hospitals. 

Material and Methods: In this single-center observational study, we describe 205 patients with acute kidney injury (n=98), dialysis-dependent chronic kidney disease stage 5 (n=54), or kidney transplant (n=53), admitted during the first surge of the local pandemic from March 19 2020, to July 31 2021. 

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Results: Most patients in the cohort were African American (acute kidney injury, 51%; dialysis-dependent chronic kidney disease stage 5, 82%; kidney transplant, 62%), and obesity was common (acute kidney injury, 53%; dialysis-dependent chronic kidney disease stage 5, 44%; kidney transplant 56%). Mechanical ventilation was required in 50% of the acute kidney injury, 22% of the dialysis-dependent chronic kidney disease stage 5, and 13% of the kidney transplant recipients. Nearly half of the acute kidney injury patients (46%) died and 49% required replacement therapy, while in-hospital mortality was 24% in the dialysis-dependent chronic kidney disease stage 5 patients and 9% in the kidney transplant recipients. Logistic regression analysis identified older age and patient group as leading correlates of mortality, with lower death risk in the kidney transplant (24%; odds ratio (OR), 0.17; 95% CI 0.06–0.47) and dialysis-dependent chronic kidney disease stage 5 (9%; OR, 0.36; 95% CI 0.16–0.78) patients compared to acute kidney injury patients (46%). Obesity was associated with a 5-fold increased mortality risk in the coronavirus disease 2019 patients with acute kidney injury (OR, 5.32; 95% CI 1.41–20.03) but not in dependent dialysis chronic kidney disease stage 5 and kidney transplant patients. 

Conclusion: During the first surge of the pandemic, kidney patients hospitalized with COVID-19 experienced high mortality, especially those with acute kidney injury, older age, and obesity. Identifying those at the highest risk for adverse outcomes may direct preventative strategies including counseling on vaccination. 

Keywords:Acute kidney injury; Coronavirus Disease-2019; COVID-19; dialysis; mortality; obesity; transplant

INTRODUCTION

The novel coronavirus disease-2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has profoundly impacted communities across the world. However, certain sub-groups including patients with chronic kidney disease (CKD) and kidney transplant (KTx) recipients are particularly vulnerable to adverse outcomes from COVID-19.1–7 Coronavirus disease-2019 incidence and outcomes within the general population, as well as patients with kidney diseases, has varied by geography, age, race, and ethnicity.3,8 The pandemic has disproportionally affected certain populations including racial and ethnic minorities and patients with some comorbidities and social risk factors.8–10 As nephrology providers caring for kidney patients at an urban, Midwestern tertiary care hospital, we sought to characterize the clinical profiles and outcomes of patients with COVID-19 and co-morbid kidney disease hospitalized at our center.

METHODS Data Source and Study Population 

In this single-center observational study, we examined the characteristics, presentations, treatment, and in-hospital outcomes of patients with kidney diseases admitted to Hospitals with COVID-19 during the first surge of the local pandemic from March 19, 2020, to July 31, 2021. Included patients were aged 18 years or older, found to have COVID-19, and hospitalized at the Hospital during the observation period. The electronic health record (EHR) was reviewed for information on patient demographic and clinical characteristics (age, sex, ethnicity, primary kidney disease, body mass index (BMI), comorbid conditions, replacement therapy (RT) modalities, date of KTx and donor type), laboratory findings, medications, and outcomes. Diagnosis of COVID-19 was ascertained by a positive result on polymerase chain reaction assay of nasal and/or pharyngeal swab specimens performed in our health system or by a COVID-19 in the EHR.

Patients were categorized into acute kidney injury (AKI), dialysis-dependent CKD stage 5 (CKD-5D), or KTx groups. Acute kidney injury was defined according to Kidney Disease Improving Global Outcomes criteria of an increase in serum creatinine by 0.3 mg/dL or more within 48 hours or an increase in serum creatinine at least 1.5 times baseline within the last 7 days.11 The study was approved by the University Institutional Review Board (Protocol #31323). Given the retrospective and low-risk nature of the study, approval included a waiver of individual informed consent.

RESULTS Cohort and Characteristics

We identified 205 patients with AKI (n=98), CKD-5D (n=54), or KTx (n=53) admitted during the first surge of the local pandemic (Table 1). Monthly hospitalized cases of COVID-19 in kidney patients at our center ranged from 6 at the start of the pandemic to a peak of 35 cases in December 2020, and then began to decline at the end of the first surge (Figure 1A). The mean age in the AKI, CKD-5D, and KTx groups was 63.3±14.2, 62.6±13.9, and 54.1 ±13.0 years, respectively. Women comprised 37% of AKI cases, 44% of CKD-5D cases, and 42% of the affected KTx recipients. The majority of patients (62%) were African American (51% in AKI, 82% in CKD-5D, and 62% in KTx groups). Mean BMI was 32.0±9, 29.1±7.1, and 31.9±6.4 kg/m2 , and obesity (BMI ≥30 kg/m2 ) was present in 53%, 44% and 58% of the AKI, CKD-5D, and KTx groups, respectively. 

All kidney patients in the cohort had at least one additional comorbidity, including hypertension (78.9%), diabetes (50.7%), congestive heart failure (25.4%), underlying lung disease (22.9%), or coronary artery disease (18%). Among the patients with AKI, 31% had underlying CKD, predominantly due to diabetic nephropathy and hypertension, and diabetic nephropathy was also the most common cause of kidney failure (61%) in patients with CKD-5D. 

Clinical Presentations and Treatments 

The most common presenting symptoms included shortness of breath in 67% of AKI and 46% of CKD-5D patients, and cough in 49% of KTx recipients (Table 2). Among the kidney transplant recipients, immunosuppression at presentation included steroids in 91%, calcineurin inhibitors in 96%, and mycophenolic acid (MPA) in 53%. The most common medical COVID-19 treatment was dexamethasone, administered to 58% of those with AKI, 41% with CKD-5D, and 38% of KTx patients. Remdesivir was used in 20%, 4%, and 13% of the AKI, CKD-5D, and KTx patients, respectively.

Outcomes 

The mean length of hospital stay was 20+15, 13+15, and 8+13 days in the AKI, CKD-5D, and KTx patients, including intensive care requirements in 67%, 28%, and 17%, respectively. Approximately half of the AKI patients required RRT and 8% were treated with extracorporeal membrane oxygenation (ECMO) (Table 3). Twelve percent of KTx recipients received intermittent or continuous dialysis. Mechanical ventilation was required in 50% of the AKI, 22% of the CKD-5D, and 13% of the KTx recipients (Figure 1B). Nearly half of the AKI group (46%) died, while in-hospital mortality was 24% in the CKD-5D patients and 9% in the KTx recipients (Table 3). Logistic regression analysis identified older age (OR per decade, 1.57; 95% CI 1.18–2.07; p=0.002) and patient group as significant correlates of mortality in hospitalized kidney patients with COVID-19 mortality, with lower death risk in the KTx (OR, 0.17; 95% CI 0.06–0.47; P=0.0007) and CKD-5D (OR, 0.36; 95% CI 0.16–0.78; P=0.01) compared to AKI patients. Obesity defined as BMI >30 kg/m2 (vs BMI 18.5 to <25) was associated with mortality risk in COVID-19 patients with AKI (OR, 5.32; 95% CI 1.41–20.03; P=0.01) but not in CKD-5D (OR, 0.40; 95% CI 0.08–2.11) KTx patients (OR, 1.21; 95% CI 0.10–14.09). 

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