World J Nephrol Urol
World Journal of Nephrology and Urology, ISSN 1927-1239 print, 1927-1247 online, Open Access
Article copyright, the authors; Journal compilation copyright, World J Nephrol Urol and Elmer Press Inc
Journal website https://www.wjnu.org

Letter to the Editor

Volume 9, Number 2, December 2020, pages 52-55


Renal Injury in Severe Acute Respiratory Syndrome Coronavirus 2 Infection: An Additional Concern to the Clinicians

Farjana Islam

Department of Biochemistry and Molecular Biology, Shahjalal University of Science and Technology, Sylhet 3114, Bangladesh

Manuscript submitted September 25, 2020, accepted October 24, 2020, published online November 25, 2020
Short title: Renal Injury in SARS-CoV-2 Infection
doi: https://doi.org/10.14740/wjnu418

To the Editor▴Top 

The coronavirus disease 2019 (COVID-19) pandemic is a global concern for public health worldwide. Lung injury is the major outcome of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection; however, damage can occur in multiple organs including the kidney [1, 2]. Previously, it has been shown that SARS virus may be capable of infecting multiple cell types in several organs; pulmonary epithelium and immune cells were identified as the main sites of injury [3]. Organ systems like the lungs, heart, liver, and kidneys rely on and assist one another’s functions, so when the virus causes injury in one area, others might be at risk. Moreover, patients with pre-existing illness are at high risk of infection and severe course of COVID-19. Therefore, renal injury is considered as an additional concern in patients with severe COVID-19.

Currently, there are limited data that link underlying kidney dysfunction with severe cases of COVID-19. At this point, it remains unclear to what extent the new coronavirus itself affects kidney function versus contribution from other factors resulting in kidney injury in patients with COVID-19. Some patients with severe COVID-19 showed signs of kidney damage, even those who had no pre-existing kidney disease before they were infected with the SARS-CoV-2 [4]. The prevalence of kidney dysfunction was found up to 16.7% of patients with severe COVID-19 (Table 1) [2, 4-18]. In the relevant COVID-19 studies, serum levels of creatinine and blood urea nitrogen (BUN) were found at increased levels in patients admitted to the intensive care unit (ICU) than other patients [4-8]. In a study, the prevalence of elevated BUN and serum creatinine was 13.1% and 14.4%, respectively in hospitalized COVID-19 patients [4]. The authors observed that patients with increased baseline serum creatinine were more likely to be admitted to the ICU and required mechanical ventilation; indicating that pre-existing kidney dysfunction on admission increases the disease severity [4]. Moreover, the prevalence of kidney injury on admission and the progression of acute kidney disease during hospitalization was high and was correlated with in-hospital death [4].

Table 1.
Click to view
Table 1. Renal Function Abnormalities in COVID-19 Patients
 

In a retrospective cohort study consisting of 81 patients critically ill with COVID-19 in an ICU, 50.6% patients experienced acute kidney disease (AKI) [9]. Older age and higher level of serum interleukin 6 (IL-6) were identified as risk factors of AKI in this study. In the USA, a hospital study indicated that 49.3% of the COVID-19 patients had AKI and the patients with AKI had significantly lower baseline estimated glomerular filtration rate (eGFR) [19]. In another study in the USA, AKI was more frequent in COVID-19 patients with respiratory abnormalities, with 89.7% of patients on mechanical ventilation support developed AKI compared to 21.7% of non-ventilated patients [20]. In another study in the same country, AKI was found about 22.2% of hospitalized COVID-19 patients [21]. In New York, of 3,993 hospitalized COVID-19 patients, AKI occurred in 46% patients; among patients with AKI, 19% needed dialysis, and about half of them were died in the hospital [10]. In a retrospective study, it has been observed that patients with acute kidney injury (AKI) and COVID-19 were more likely than patients without COVID-19 to require registered respiratory therapist (RRT), ICU admission, and mechanical ventilation; and were more likely to experience in-hospital death [22].

Although the impact of COVID-19 on the kidney remains unclear, some possible mechanisms could explain the kidney damage in patients with COVID-19. First, immune-mediated inflammation, such as cytokines storm and pneumonia-related hypoxia may cause damage to the kidney cells. Second, acute tubular necrosis (ATN) due to severe infection and hypotension is likely the most common reason for kidney dysfunction in patients with COVID-19. Third, collapsing focal segmental glomerulosclerosis (FSGS) is a rare but well described entity with coronavirus. Fourth, COVID-19-related microangiopathy and hemophagocytic macrophage activation may also cause kidney injury. Fifth, there is a possibility that extremely low levels of oxygen in the blood of severe patients may cause kidney problems. Sixth, the uses of certain medications at high doses may affect kidney functions in COVID-19 patients. In a recent study, it has been observed that patients with acute kidney disease were more likely to have an increased proportion of glucocorticoid and diuretics treatment on admission [4]. Lastly, the virus itself infects the kidney cells. In a recent study, it has been shown that SARS-CoV-2 uses angiotensin-converting enzyme 2 (ACE2) as a receptor to entry into target cells [23]. Recent data on human tissue RNA-sequencing suggested that ACE2 is more highly expressed in the kidney than in the lungs and heart [24]. Therefore, kidney damage might be caused by the virus through the ACE2-dependent pathway. Although, kidney dysfunction directly by the virus is still debatable and there are some studies that did not find the presence of SARS-CoV-2 in the biopsied kidney tissue [25-27].

Despite the limited data on kidney involvement in COVID-19, acute kidney injury appears to multifactorial and involve a complex process driven by the virus itself, cytokine storm, microangiopathy, hypercoagulation, and drugs effects. It is known that hypertension and diabetes can damage blood vessels of the kidneys; therefore, coexisting of these disease conditions can increase hospital mortality from COVID-19. Therefore, severe COVD-19 patients with renal injury require more attention during hospitalization. While kidney injury in COVID-19 is still not well understood, further research is needed to explore the exact causes of kidney damage in patients with SARS-CoV-2 infection.

Acknowledgments

None to declare.

Financial Disclosure

No funding was provided for this work.

Conflict of Interest

The author declares no conflict of interest.

Informed Consent

Not applicable.

Author Contributions

FI conceived the idea and drafted the letter.

Data Availability

The author declares that data supporting the findings of this study are available within the article.


References▴Top 
  1. Ali N. Is SARS-CoV-2 associated with liver dysfunction in COVID-19 patients? Clin Res Hepatol Gastroenterol. 2020;44(4):e84-e86.
    doi pubmed
  2. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, Qiu 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):507-513.
    doi
  3. Gu J, Gong E, Zhang B, Zheng J, Gao Z, Zhong Y, Zou W, et al. Multiple organ infection and the pathogenesis of SARS. J Exp Med. 2005;202(3):415-424.
    doi pubmed
  4. Cheng Y, Luo R, Wang K, Zhang M, Wang Z, Dong L, Li J, et al. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int. 2020;97(5):829-838.
    doi pubmed
  5. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708-1720.
    doi pubmed
  6. Liu J, Li S, Liu J, Liang B, Wang X, Wang H, Li W, et al. Longitudinal characteristics of lymphocyte responses and cytokine profiles in the peripheral blood of SARS-CoV-2 infected patients. EBioMedicine. 2020;55:102763.
    doi pubmed
  7. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang B, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020;323(11):1061-1069.
    doi pubmed
  8. Xu XW, Wu XX, Jiang XG, Xu KJ, Ying LJ, Ma CL, Li SB, et al. Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: retrospective case series. BMJ. 2020;368:m606.
    doi pubmed
  9. Xia P, Wen Y, Duan Y, Su H, Cao W, Xiao M, Ma J, et al. Clinicopathological features and outcomes of acute kidney injury in critically ill COVID-19 with prolonged disease course: a retrospective cohort. J Am Soc Nephrol. 2020;31(9):2205-2221.
    doi pubmed
  10. Chan L, Chaudhary K, Saha A, Chauhan K, Vaid A, Zhao S, Paranjpe I, et al. AKI in Hospitalized Patients with COVID-19. J Am Soc Nephrol. 2020.
    doi pubmed
  11. 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):1612-1614.
    doi pubmed
  12. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506.
    doi
  13. Mo P, Xing Y, Xiao Y, Deng L, Zhao Q, Wang H, Xiong Y, et al. Clinical characteristics of refractory COVID-19 pneumonia in Wuhan, China. Clin Infect Dis. 2020.
    doi pubmed
  14. Regina J, Papadimitriou-Olivgeris M, Burger R, Filippidis P, Tschopp J, Desgranges F, Viala B, et al. Epidemiology, risk factors and clinical course of SARS-CoV-2 infected patients in a Swiss university hospital: an observational retrospective study. Infectious Diseases (except HIV/AIDS). 2020.
    doi
  15. RUBIN S, Orieux A, Prevel R, Garric A, Bats M-L, Dabernat S, Camou F, et al. Characterisation of acute kidney injury in critically ill patients with severe coronavirus disease-2019 (COVID-19). Nephrology. 2020.
    doi
  16. Shi H, Han X, Jiang N, Cao Y, Alwalid O, Gu J, Fan Y, et al. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. Lancet Infect Dis. 2020;20(4):425-434.
    doi
  17. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, Wu Y, 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):475-481.
    doi
  18. Zhao XY, Xu XX, Yin HS, Hu QM, Xiong T, Tang YY, Yang AY, et al. Clinical characteristics of patients with 2019 coronavirus disease in a non-Wuhan area of Hubei Province, China: a retrospective study. BMC Infect Dis. 2020;20(1):311.
    doi pubmed
  19. Pelayo J, Lo KB, Bhargav R, Gul F, Peterson E, DeJoy Iii R, Salacup GF, et al. Clinical characteristics and outcomes of community- and hospital-acquired acute kidney injury with COVID-19 in a US Inner City Hospital System. Cardiorenal Med. 2020;10(4):223-231.
    doi pubmed
  20. Hirsch JS, Ng JH, Ross DW, Sharma P, Shah HH, Barnett RL, Hazzan AD, et al. Acute kidney injury in patients hospitalized with COVID-19. Kidney Int. 2020;98(1):209-218.
    doi pubmed
  21. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, the Northwell C-RC, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City Area. JAMA. 2020;323(20):2052-2059.
    doi pubmed
  22. Fisher M, Neugarten J, Bellin E, Yunes M, Stahl L, Johns TS, Abramowitz MK, et al. AKI in hospitalized patients with and without COVID-19: a comparison study. J Am Soc Nephrol. 2020;31(9):2145-2157.
    doi pubmed
  23. Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, Si HR, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature. 2020;579(7798):270-273.
    doi pubmed
  24. Li Z, Wu M, Yao J, et al. Caution on kidney dysfunctions of COVID-19 patients [Internet]. Infectious Diseases (except HIV/AIDS); 2020 [cited 2020 May 17]. Available from: http://medrxiv.org/lookup/doi/10.1101/2020.02.08.20021212.
  25. Delsante M, Rossi GM, Gandolfini I, Bagnasco SM, Rosenberg AZ. Kidney involvement in COVID-19: need for better definitions. J Am Soc Nephrol. 2020;31(9):2224-2225.
    doi pubmed
  26. Kudose S, Batal I, Santoriello D, Xu K, Barasch J, Peleg Y, Canetta P, et al. Kidney biopsy findings in patients with COVID-19. J Am Soc Nephrol. 2020;31(9):1959-1968.
    doi pubmed
  27. Sharma P, Uppal NN, Wanchoo R, Shah HH, Yang Y, Parikh R, Khanin Y, et al. COVID-19-associated kidney injury: a case series of kidney biopsy findings. J Am Soc Nephrol. 2020;31(9):1948-1958.
    doi pubmed


This article is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


World Journal of Nephrology and Urology is published by Elmer Press Inc.

 

Browse  Journals  

     

Journal of Clinical Medicine Research

Journal of Endocrinology and Metabolism

Journal of Clinical Gynecology and Obstetrics

World Journal of Oncology

Gastroenterology Research

Journal of Hematology

Journal of Medical Cases

Journal of Current Surgery

Clinical Infection and Immunity

Cardiology Research

World Journal of Nephrology and Urology

Cellular and Molecular Medicine Research

Journal of Neurology Research

International Journal of Clinical Pediatrics

 

 

 

 

 

World Journal of Nephrology and Urology, quarterly, ISSN 1927-1239 (print), 1927-1247 (online), published by Elmer Press Inc.                     
The content of this site is intended for health care professionals.
This is an open-access journal distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Creative Commons Attribution license (Attribution-NonCommercial 4.0 International CC-BY-NC 4.0)


This journal follows the International Committee of Medical Journal Editors (ICMJE) recommendations for manuscripts submitted to biomedical journals,
the Committee on Publication Ethics (COPE) guidelines, and the Principles of Transparency and Best Practice in Scholarly Publishing.

website: www.wjnu.org   editorial contact: editor@wjnu.org
Address: 9225 Leslie Street, Suite 201, Richmond Hill, Ontario, L4B 3H6, Canada
© Elmer Press Inc. All Rights Reserved.