COVID-19-associated acute kidney injury: Difference between revisions

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__NOTOC__
__NOTOC__
{{COVID-19}}
{{SI}}
{{Main|COVID-19}}
{{Main|COVID-19}}


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== Overview ==
== Overview ==
[[COVID-19]] can involve many organs leading to [[organ failure]], one of which is [[kidneys]] that manifest with mild [[proteinuria]] to advanced [[acute kidney injury]] ([[AKI]]).
[[COVID-19]] infection can affect many organs and lead to [[organ failure]]. [[Kidneys]] are vital organs that can be affected by [[coronavirus]]. [[Acute kidney injury]] ([[AKI]]), a sudden deficit in [[kidney]] function, is a complication of [[COVID-19]] and associated with a higher risk of mortality. [[AKI]] is frequently seen in critically ill patients with pre-existing conditions. Identifying high-risk patients for [[AKI]] and regular monitoring of [[kidney]] function tests in these patients play a major role in preventing [[AKI]].


==Historical Perspective==
==Historical Perspective==
* Early reports from China revealed that [[COVID-19]] rarely involves the [[kidneys]], as [[acute renal failure]] was not seen among [[COVID-19]] hospitalized patients and mild [[BUN]] or [[creatinine]] rise [10.8%] and mild [[proteinuria]] [7.2%] occurred. <ref name="WangLi2020">{{cite journal|last1=Wang|first1=Luwen|last2=Li|first2=Xun|last3=Chen|first3=Hui|last4=Yan|first4=Shaonan|last5=Li|first5=Dong|last6=Li|first6=Yan|last7=Gong|first7=Zuojiong|title=Coronavirus Disease 19 Infection Does Not Result in Acute Kidney Injury: An Analysis of 116 Hospitalized Patients from Wuhan, China|journal=American Journal of Nephrology|volume=51|issue=5|year=2020|pages=343–348|issn=0250-8095|doi=10.1159/000507471}}</ref>
* Coronavirus disease 2019 ([[COVID-19]]) was first detected in December 2019 in Wuhan, Hubei, China.<ref name="Hui14Jan2020">{{cite journal |vauthors=Hui DS, I Azhar E, Madani TA, Ntoumi F, Kock R, Dar O, Ippolito G, Mchugh TD, Memish ZA, Drosten C, Zumla A, Petersen E |display-authors=6 |title=The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health—The latest 2019 novel coronavirus outbreak in Wuhan, China |journal=International Journal of Infectious Diseases |volume=91 |issue= |pages= 264–266 |date=February 2020 |pmid=31953166 |pmc=7128332 |doi=10.1016/j.ijid.2020.01.009 |doi-access=free}}</ref>
* Early reports from China revealed no association between [[COVID-19]] and [[Acute kidney injury]]. These reports showed [[AKI]] was not seen among [[COVID-19]] hospitalized patients and only a mild rise in [[BUN]] or [[creatinine]] (10.8%) and mild [[proteinuria]] (7.2%) developed. <ref name="WangLi2020">{{cite journal|last1=Wang|first1=Luwen|last2=Li|first2=Xun|last3=Chen|first3=Hui|last4=Yan|first4=Shaonan|last5=Li|first5=Dong|last6=Li|first6=Yan|last7=Gong|first7=Zuojiong|title=Coronavirus Disease 19 Infection Does Not Result in Acute Kidney Injury: An Analysis of 116 Hospitalized Patients from Wuhan, China|journal=American Journal of Nephrology|volume=51|issue=5|year=2020|pages=343–348|issn=0250-8095|doi=10.1159/000507471}}</ref>
* However, recent study found 75.4% of hospitalized patients with [[COVID-19]] [[pneumonia]] developed [[kidney]] [[complications]] such as [[hematuria]], [[proteinuria]], and [[AKI]]. <ref name="PeiZhang2020">{{cite journal|last1=Pei|first1=Guangchang|last2=Zhang|first2=Zhiguo|last3=Peng|first3=Jing|last4=Liu|first4=Liu|last5=Zhang|first5=Chunxiu|last6=Yu|first6=Chong|last7=Ma|first7=Zufu|last8=Huang|first8=Yi|last9=Liu|first9=Wei|last10=Yao|first10=Ying|last11=Zeng|first11=Rui|last12=Xu|first12=Gang|title=Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia|journal=Journal of the American Society of Nephrology|volume=31|issue=6|year=2020|pages=1157–1165|issn=1046-6673|doi=10.1681/ASN.2020030276}}</ref>


* However, recent study found 75.4% of hospitalized patients with [[COVID-19]] [[pneumonia]] developed [[hematuria]], [[proteinuria]], and [[AKI]]. But, these findings are not significantly different from other critical diseases.<ref name="PeiZhang2020">{{cite journal|last1=Pei|first1=Guangchang|last2=Zhang|first2=Zhiguo|last3=Peng|first3=Jing|last4=Liu|first4=Liu|last5=Zhang|first5=Chunxiu|last6=Yu|first6=Chong|last7=Ma|first7=Zufu|last8=Huang|first8=Yi|last9=Liu|first9=Wei|last10=Yao|first10=Ying|last11=Zeng|first11=Rui|last12=Xu|first12=Gang|title=Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia|journal=Journal of the American Society of Nephrology|volume=31|issue=6|year=2020|pages=1157–1165|issn=1046-6673|doi=10.1681/ASN.2020030276}}</ref>


==Classification==
==Classification==
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**[[Prerenal]] [[AKI]]
**[[Prerenal]] [[AKI]]
**[[Rhabdomyolysis]]-induced [[AKI]]
**[[Rhabdomyolysis]]-induced [[AKI]]
**[[Intrinsic]] [[AKI]] is the most common subtype of [[AKI]].
**[[Intrinsic]] [[AKI]] (the most common subtype of [[AKI]].)


==Pathophysiology==
==Pathophysiology==
* [[Angiotensin-converting enzyme 2]] ([[ACE2]]), which is a primary [[receptor]] for [[SARS-CoV-2]] entry into cells, mostly presents in [[renal]] [[tubular]] [[epithelial]] cells as well as [[lungs]] and [[heart]].<ref name="MalhaMueller2020">{{cite journal|last1=Malha|first1=Line|last2=Mueller|first2=Franco B.|last3=Pecker|first3=Mark S.|last4=Mann|first4=Samuel J.|last5=August|first5=Phyllis|last6=Feig|first6=Peter U.|title=COVID-19 and the Renin-Angiotensin System|journal=Kidney International Reports|volume=5|issue=5|year=2020|pages=563–565|issn=24680249|doi=10.1016/j.ekir.2020.03.024}}</ref>
* [[Angiotensin-converting enzyme 2]] ([[ACE2]]), is a primary [[receptor]] for [[SARS-CoV-2]] entry into cells, mostly presents in [[renal]] [[tubular]] [[epithelial]] cells as well as [[lungs]] and [[heart]].<ref name="MalhaMueller2020">{{cite journal|last1=Malha|first1=Line|last2=Mueller|first2=Franco B.|last3=Pecker|first3=Mark S.|last4=Mann|first4=Samuel J.|last5=August|first5=Phyllis|last6=Feig|first6=Peter U.|title=COVID-19 and the Renin-Angiotensin System|journal=Kidney International Reports|volume=5|issue=5|year=2020|pages=563–565|issn=24680249|doi=10.1016/j.ekir.2020.03.024}}</ref>
* Despite [[kidney injury]] following [[COVID-19]] infection is less frequent than severe [[lung]] injury, [[ACE2]]: [[ACE]] ratio is higher in the [[kidneys]] compared to the [[respiratory system]]. (1:1 in the [[kidneys]] VS 1:20 in the [[respiratory system]])<ref name="MalhaMueller2020">{{cite journal|last1=Malha|first1=Line|last2=Mueller|first2=Franco B.|last3=Pecker|first3=Mark S.|last4=Mann|first4=Samuel J.|last5=August|first5=Phyllis|last6=Feig|first6=Peter U.|title=COVID-19 and the Renin-Angiotensin System|journal=Kidney International Reports|volume=5|issue=5|year=2020|pages=563–565|issn=24680249|doi=10.1016/j.ekir.2020.03.024}}</ref>
*[[Kidney injury]] following [[COVID-19]] infection is less frequent than severe [[lung]] injury, however [[ACE2]]:[[ACE]] ratio is higher in the [[kidneys]] compared to the [[respiratory system]]. (1:1 in the [[kidneys]] VS 1:20 in the [[respiratory system]])<ref name="MalhaMueller2020">{{cite journal|last1=Malha|first1=Line|last2=Mueller|first2=Franco B.|last3=Pecker|first3=Mark S.|last4=Mann|first4=Samuel J.|last5=August|first5=Phyllis|last6=Feig|first6=Peter U.|title=COVID-19 and the Renin-Angiotensin System|journal=Kidney International Reports|volume=5|issue=5|year=2020|pages=563–565|issn=24680249|doi=10.1016/j.ekir.2020.03.024}}</ref>
* After [[SARS-CoV-2]] enters through the [[nasal cavity]], it may travel to the [[kidneys]] and enters the bloodstream leading to severe [[inflammatory]] response activation and [[cytokine]] storm.
* After [[SARS-CoV-2]] enters through the [[nasal cavity]], it may travel to the [[kidneys]] and enter the bloodstream leading to severe [[inflammatory]] response activation and [[cytokine]] storm.
**[[Cytokine]] induced [[AKI]] may occur due to [[intrarenal]] [[inflammation]], hyperpermeability of [[vessels]], [[hypovolemia]] and [[cardiomyopathy]], leading to [[cardiorenal syndrome]] type 1 that is characterized by third space [[volume overload]] such as [[pleural effusion]], [[edema]] and [[intravascular]] volume loss ([[hypovolemia]]) and [[hypotension]].<ref name="pmid32273593">{{cite journal| author=Ronco C, Reis T| title=Kidney involvement in COVID-19 and rationale for extracorporeal therapies. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 308-310 | pmid=32273593 | doi=10.1038/s41581-020-0284-7 | pmc=7144544 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32273593  }} </ref>
**[[Cytokine]] induced [[AKI]] may occur due to [[intrarenal]] [[inflammation]], hyperpermeability of [[vessels]], [[hypovolemia]] and [[cardiomyopathy]], leading to [[cardiorenal syndrome]] type 1 that is characterized by third space [[volume overload]] such as [[pleural effusion]], [[edema]] and [[intravascular]] volume loss ([[hypovolemia]]) and [[hypotension]].<ref name="pmid32273593">{{cite journal| author=Ronco C, Reis T| title=Kidney involvement in COVID-19 and rationale for extracorporeal therapies. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 308-310 | pmid=32273593 | doi=10.1038/s41581-020-0284-7 | pmc=7144544 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32273593  }} </ref>
***[[cardiomyopathy]] and [[COVID-19-associated myocarditis]] can lead to [[hypotension]] and reduction in [[renal]] [[perfusion]].
***[[cardiomyopathy]] and [[COVID-19-associated myocarditis]] can lead to [[hypotension]] and reduction in [[renal]] [[perfusion]].
**The major [[cytokine]] is [[IL-6]], which induces [[inflammation]] and [[lung]] [[endothelial cell]] injury, leading to [[ARDS]] and [[hypoxia]] that subsequently cause [[renal]] [[tubular cell]] injury and [[AKI]]. <ref name="pmid27337068">{{cite journal| author=Husain-Syed F, Slutsky AS, Ronco C| title=Lung-Kidney Cross-Talk in the Critically Ill Patient. | journal=Am J Respir Crit Care Med | year= 2016 | volume= 194 | issue= 4 | pages= 402-14 | pmid=27337068 | doi=10.1164/rccm.201602-0420CP | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27337068  }} </ref><ref name="pmid32273593">{{cite journal| author=Ronco C, Reis T| title=Kidney involvement in COVID-19 and rationale for extracorporeal therapies. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 308-310 | pmid=32273593 | doi=10.1038/s41581-020-0284-7 | pmc=7144544 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32273593  }} </ref>
**The major [[cytokine]] is [[IL-6]], which induces [[inflammation]] and [[lung]] [[endothelial cell]] injury, leading to [[ARDS]] and [[hypoxia]] that subsequently cause [[renal]] [[tubular]] cell injury and [[AKI]]. <ref name="pmid27337068">{{cite journal| author=Husain-Syed F, Slutsky AS, Ronco C| title=Lung-Kidney Cross-Talk in the Critically Ill Patient. | journal=Am J Respir Crit Care Med | year= 2016 | volume= 194 | issue= 4 | pages= 402-14 | pmid=27337068 | doi=10.1164/rccm.201602-0420CP | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27337068  }} </ref><ref name="pmid32273593">{{cite journal| author=Ronco C, Reis T| title=Kidney involvement in COVID-19 and rationale for extracorporeal therapies. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 308-310 | pmid=32273593 | doi=10.1038/s41581-020-0284-7 | pmc=7144544 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32273593  }} </ref>
[[File:IL-6-AKI-COVID-19.PNG|600px|center]]
[[File:INTERLEUKIN-6-AKI.PNG|600px|center]]


* Other [[Cytokine]] releasing factors in critically ill patients with [[COVID-19]] include<ref name="pmid32273593">{{cite journal| author=Ronco C, Reis T| title=Kidney involvement in COVID-19 and rationale for extracorporeal therapies. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 308-310 | pmid=32273593 | doi=10.1038/s41581-020-0284-7 | pmc=7144544 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32273593  }} </ref>:
* Other [[Cytokine]] releasing factors in critically ill patients with [[COVID-19]] include:<ref name="pmid32273593">{{cite journal| author=Ronco C, Reis T| title=Kidney involvement in COVID-19 and rationale for extracorporeal therapies. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 308-310 | pmid=32273593 | doi=10.1038/s41581-020-0284-7 | pmc=7144544 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32273593  }} </ref>
**[[Extracorporeal membrane oxygenation]] (ECMO)
**[[Extracorporeal membrane oxygenation]] (ECMO)
**[[Mechanical ventilation]]
**[[Mechanical ventilation]]
**Continuous [[renal replacement therapy]]
**Continuous [[renal replacement therapy]]


* To conclude, [[COVID-19]]-associated [[AKI]] can occur as a result of<ref name="MalhaMueller2020">{{cite journal|last1=Malha|first1=Line|last2=Mueller|first2=Franco B.|last3=Pecker|first3=Mark S.|last4=Mann|first4=Samuel J.|last5=August|first5=Phyllis|last6=Feig|first6=Peter U.|title=COVID-19 and the Renin-Angiotensin System|journal=Kidney International Reports|volume=5|issue=5|year=2020|pages=563–565|issn=24680249|doi=10.1016/j.ekir.2020.03.024}}</ref>:
* To conclude, [[COVID-19]]-associated [[AKI]] can occur as a result of:<ref name="MalhaMueller2020">{{cite journal|last1=Malha|first1=Line|last2=Mueller|first2=Franco B.|last3=Pecker|first3=Mark S.|last4=Mann|first4=Samuel J.|last5=August|first5=Phyllis|last6=Feig|first6=Peter U.|title=COVID-19 and the Renin-Angiotensin System|journal=Kidney International Reports|volume=5|issue=5|year=2020|pages=563–565|issn=24680249|doi=10.1016/j.ekir.2020.03.024}}</ref>
**[[Sepsis]] and [[cytokine]] storm
**[[Sepsis]] and [[cytokine]] storm
**[[Hypovolemia]] and [[Hypotension]]
**[[Hypovolemia]] and [[Hypotension]]
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**Blood [[clots]] formation due to [[hypercoagulable]] state, leading to impaired blood flow in the [[renal]] [[arterioles]].
**Blood [[clots]] formation due to [[hypercoagulable]] state, leading to impaired blood flow in the [[renal]] [[arterioles]].


[[File:AKI physiopathology COVID.PNG|700px|center]]
 
[[File:AKI PATHOPHYSIOLOGY-COVID19.PNG|600px|center]]


== Causes ==
== Causes ==
* [[SARS-CoV-2]] may have a [[Kidney]] tropism. As a recent study found [[SARS-CoV-2]] antigens in renal tubules which suggests the direct damage of [[SARS-CoV-2]] on the [[kidneys]].{{cite web |url=https://www.medrxiv.org/content/10.1101/2020.03.04.20031120v4  |format= |work= |accessdate=}}
* [[COVID-19]] associated [[AKI]] may be caused by [[SARS-CoV-2]], which has a [[Kidney]] tropism.
* Recent study found [[SARS-CoV-2]] antigens in [[renal]] [[tubules]] which suggests the direct damage of [[SARS-CoV-2]] on the [[kidneys]].<ref> {{cite web |url=https://www.medrxiv.org/content/10.1101/2020.03.04.20031120v4  |format= |work= |accessdate=}} </ref>
**[[Angiotensin-converting enzyme 2]] ([[ACE2]]), which is a primary [[receptor]] for [[SARS-CoV-2]] entry into cells, mostly presents in [[Kidneys]] as well as [[lungs]] and [[heart]].<ref name="MalhaMueller2020">{{cite journal|last1=Malha|first1=Line|last2=Mueller|first2=Franco B.|last3=Pecker|first3=Mark S.|last4=Mann|first4=Samuel J.|last5=August|first5=Phyllis|last6=Feig|first6=Peter U.|title=COVID-19 and the Renin-Angiotensin System|journal=Kidney International Reports|volume=5|issue=5|year=2020|pages=563–565|issn=24680249|doi=10.1016/j.ekir.2020.03.024}}</ref>
**[[Angiotensin-converting enzyme 2]] ([[ACE2]]), which is a primary [[receptor]] for [[SARS-CoV-2]] entry into cells, mostly presents in [[Kidneys]] as well as [[lungs]] and [[heart]].<ref name="MalhaMueller2020">{{cite journal|last1=Malha|first1=Line|last2=Mueller|first2=Franco B.|last3=Pecker|first3=Mark S.|last4=Mann|first4=Samuel J.|last5=August|first5=Phyllis|last6=Feig|first6=Peter U.|title=COVID-19 and the Renin-Angiotensin System|journal=Kidney International Reports|volume=5|issue=5|year=2020|pages=563–565|issn=24680249|doi=10.1016/j.ekir.2020.03.024}}</ref>
*** High expression of [[ACE2]] was found in the [[renal]] proximal [[tubular]] cells and rarely in [[podocytes]]. <ref name="pmid17021266">{{cite journal| author=Ye M, Wysocki J, William J, Soler MJ, Cokic I, Batlle D| title=Glomerular localization and expression of Angiotensin-converting enzyme 2 and Angiotensin-converting enzyme: implications for albuminuria in diabetes. | journal=J Am Soc Nephrol | year= 2006 | volume= 17 | issue= 11 | pages= 3067-75 | pmid=17021266 | doi=10.1681/ASN.2006050423 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17021266  }} </ref> <ref name="pmid32203970">{{cite journal| author=Perico L, Benigni A, Remuzzi G| title=Should COVID-19 Concern Nephrologists? Why and to What Extent? The Emerging Impasse of Angiotensin Blockade. | journal=Nephron | year= 2020 | volume= 144 | issue= 5 | pages= 213-221 | pmid=32203970 | doi=10.1159/000507305 | pmc=7179544 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32203970  }} </ref>
*** High expression of [[ACE2]] was found in the [[renal]] proximal [[tubular]] cells and rarely in [[podocytes]]. <ref name="pmid17021266">{{cite journal| author=Ye M, Wysocki J, William J, Soler MJ, Cokic I, Batlle D| title=Glomerular localization and expression of Angiotensin-converting enzyme 2 and Angiotensin-converting enzyme: implications for albuminuria in diabetes. | journal=J Am Soc Nephrol | year= 2006 | volume= 17 | issue= 11 | pages= 3067-75 | pmid=17021266 | doi=10.1681/ASN.2006050423 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17021266  }} </ref> <ref name="pmid32203970">{{cite journal| author=Perico L, Benigni A, Remuzzi G| title=Should COVID-19 Concern Nephrologists? Why and to What Extent? The Emerging Impasse of Angiotensin Blockade. | journal=Nephron | year= 2020 | volume= 144 | issue= 5 | pages= 213-221 | pmid=32203970 | doi=10.1159/000507305 | pmc=7179544 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32203970  }} </ref>
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== Epidemiology and Demographics ==
== Epidemiology and Demographics ==
* [[AKI]] is frequently seen among patients with [[COVID-19]] hospitalized in [[ICU]], with prevalence of 0.6-29% in China {{cite web |url=https://www.esicm.org/blog/?p=2789 |title=Acute Kidney Injury in COVID-19 Patients &#124; COVID-19 |format= |work= |accessdate=}} and 22.2% in the USA.<ref name="pmid32320003">{{cite journal| author=Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW | display-authors=etal| title=Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=32320003 | doi=10.1001/jama.2020.6775 | pmc=7177629 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32320003  }} </ref>
* The prevalence of [[AKI]] among patients with [[COVID-19]] hospitalized in [[ICU]] is approximately 0.6-29% in China <ref> {{cite web |url=https://www.esicm.org/blog/?p=2789 |title=Acute Kidney Injury in COVID-19 Patients &#124; COVID-19 |format= |work= |accessdate=}} </ref> and 22.2% in the USA.<ref name="pmid32320003">{{cite journal| author=Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW | display-authors=etal| title=Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=32320003 | doi=10.1001/jama.2020.6775 | pmc=7177629 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32320003  }} </ref>
* Approximately 43% of critically ill patients with [[COVID-19]] developed [[AKI]] during the admission period. <ref name="pmid32345702">{{cite journal| author=Pei G, Zhang Z, Peng J, Liu L, Zhang C, Yu C | display-authors=etal| title=Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia. | journal=J Am Soc Nephrol | year= 2020 | volume= 31 | issue= 6 | pages= 1157-1165 | pmid=32345702 | doi=10.1681/ASN.2020030276 | pmc=7269350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32345702  }} </ref>
* Approximately 43% of critically ill patients with [[COVID-19]] developed [[AKI]] during the admission period. <ref name="pmid32345702">{{cite journal| author=Pei G, Zhang Z, Peng J, Liu L, Zhang C, Yu C | display-authors=etal| title=Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia. | journal=J Am Soc Nephrol | year= 2020 | volume= 31 | issue= 6 | pages= 1157-1165 | pmid=32345702 | doi=10.1681/ASN.2020030276 | pmc=7269350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32345702  }} </ref>
*In a cohort study on 99 patients with severe [[COVID-19]], [[AKI]] was reported in 42 patients (42.9%) and among them 32 (74.4%) patients had severe [[AKI]] (stage III based on KDIGO definition). <ref name="pmid32533197">{{cite journal| author=Gabarre P, Dumas G, Dupont T, Darmon M, Azoulay E, Zafrani L| title=Acute kidney injury in critically ill patients with COVID-19. | journal=Intensive Care Med | year= 2020 | volume= 46 | issue= 7 | pages= 1339-1348 | pmid=32533197 | doi=10.1007/s00134-020-06153-9 | pmc=7290076 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32533197  }} </ref>
*In a cohort study on 99 patients with severe [[COVID-19]], [[AKI]] was reported in 42 patients (42.9%) and among them 32 (74.4%) patients had severe [[AKI]] (stage III based on KDIGO definition). <ref name="pmid32533197">{{cite journal| author=Gabarre P, Dumas G, Dupont T, Darmon M, Azoulay E, Zafrani L| title=Acute kidney injury in critically ill patients with COVID-19. | journal=Intensive Care Med | year= 2020 | volume= 46 | issue= 7 | pages= 1339-1348 | pmid=32533197 | doi=10.1007/s00134-020-06153-9 | pmc=7290076 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32533197  }} </ref>
* The actual incidence of [[AKI]] in critcally ill patients with [[COVID-19]] is uncertain but estimated between 27-85%. {{cite web |url=https://www.esicm.org/blog/?p=2789 |title=Acute Kidney Injury in COVID-19 Patients &#124; COVID-19 |format= |work= |accessdate=}}
* The actual incidence of [[AKI]] in critcally ill patients with [[COVID-19]] is uncertain but estimated between 27-85%. {{cite web |url=https://www.esicm.org/blog/?p=2789 |title=Acute Kidney Injury in COVID-19 Patients &#124; COVID-19 |format= |work= |accessdate=}}
*Differences of [[AKI]] prevalence among studies could be related to several factors, including<ref name="pmid32533197">{{cite journal| author=Gabarre P, Dumas G, Dupont T, Darmon M, Azoulay E, Zafrani L| title=Acute kidney injury in critically ill patients with COVID-19. | journal=Intensive Care Med | year= 2020 | volume= 46 | issue= 7 | pages= 1339-1348 | pmid=32533197 | doi=10.1007/s00134-020-06153-9 | pmc=7290076 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32533197  }} </ref>:
*Differences of [[AKI]] prevalence among studies could be related to several factors, including:<ref name="pmid32533197">{{cite journal| author=Gabarre P, Dumas G, Dupont T, Darmon M, Azoulay E, Zafrani L| title=Acute kidney injury in critically ill patients with COVID-19. | journal=Intensive Care Med | year= 2020 | volume= 46 | issue= 7 | pages= 1339-1348 | pmid=32533197 | doi=10.1007/s00134-020-06153-9 | pmc=7290076 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32533197  }} </ref>
**Patient characteristics
**Patient characteristics
***[[Comorbidities]]
***[[Comorbidities]]
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***[[Race]]
***[[Race]]
** Severity of [[COVID-19]]  
** Severity of [[COVID-19]]  
** Differences of [[COVID-19]] [[Management]] among countries
** Differences of [[COVID-19]] management among countries


===Age===
*[[AKI]] commonly affects [[elderly]]. The incidence of [[AKI]] increases with age; the mean age at diagnosis is 57.1 years. <ref name="pmid32345702">{{cite journal| author=Pei G, Zhang Z, Peng J, Liu L, Zhang C, Yu C | display-authors=etal| title=Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia. | journal=J Am Soc Nephrol | year= 2020 | volume= 31 | issue= 6 | pages= 1157-1165 | pmid=32345702 | doi=10.1681/ASN.2020030276 | pmc=7269350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32345702  }} </ref>
 
*[[AKI]] is more commonly observed among [[elderly]] patients.(Mean age: 57.1) <ref name="pmid32345702">{{cite journal| author=Pei G, Zhang Z, Peng J, Liu L, Zhang C, Yu C | display-authors=etal| title=Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia. | journal=J Am Soc Nephrol | year= 2020 | volume= 31 | issue= 6 | pages= 1157-1165 | pmid=32345702 | doi=10.1681/ASN.2020030276 | pmc=7269350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32345702  }} </ref>
   
   
===Gender===
*[[Men]] are more commonly affected and have higher risk of [[COVID-19]] complications. <ref name="pmid32373791">{{cite journal| author=Sharma G, Volgman AS, Michos ED| title=Sex Differences in Mortality from COVID-19 Pandemic: Are Men Vulnerable and Women Protected? | journal=JACC Case Rep | year= 2020 | volume=  | issue=  | pages=  | pmid=32373791 | doi=10.1016/j.jaccas.2020.04.027 | pmc=7198137 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32373791  }} </ref>
*[[Men]] are more likely to be affected and have higher risk of [[COVID-19]] complications. <ref name="pmid32373791">{{cite journal| author=Sharma G, Volgman AS, Michos ED| title=Sex Differences in Mortality from COVID-19 Pandemic: Are Men Vulnerable and Women Protected? | journal=JACC Case Rep | year= 2020 | volume=  | issue=  | pages=  | pmid=32373791 | doi=10.1016/j.jaccas.2020.04.027 | pmc=7198137 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32373791  }} </ref>
*57.1% of [[AKI]] cases following [[COVID-19]] were male.<ref name="pmid32345702">{{cite journal| author=Pei G, Zhang Z, Peng J, Liu L, Zhang C, Yu C | display-authors=etal| title=Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia. | journal=J Am Soc Nephrol | year= 2020 | volume= 31 | issue= 6 | pages= 1157-1165 | pmid=32345702 | doi=10.1681/ASN.2020030276 | pmc=7269350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32345702  }} </ref>
*57.1% of [[AKI]] cases following [[COVID-19]] were male.<ref name="pmid32345702">{{cite journal| author=Pei G, Zhang Z, Peng J, Liu L, Zhang C, Yu C | display-authors=etal| title=Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia. | journal=J Am Soc Nephrol | year= 2020 | volume= 31 | issue= 6 | pages= 1157-1165 | pmid=32345702 | doi=10.1681/ASN.2020030276 | pmc=7269350 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32345702  }} </ref>
 
===Race===
*There is no racial predilection to [[COVID-19]] associated [[AKI]].
*There is no racial predilection for [[COVID-19]] associated [[AKI]].




== Risk Factors ==
== Risk Factors ==
* The most potent [[risk factors]] in the development of [[COVID-19]] associated  [[AKI]] include<ref name="pmid32250968">{{cite journal| author=Rabb H| title=Kidney diseases in the time of COVID-19: major challenges to patient care. | journal=J Clin Invest | year= 2020 | volume= 130 | issue= 6 | pages= 2749-2751 | pmid=32250968 | doi=10.1172/JCI138871 | pmc=7259985 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32250968  }} </ref> <ref name="pmid32457068">{{cite journal| author=Selby NM, Forni LG, Laing CM, Horne KL, Evans RD, Lucas BJ | display-authors=etal| title=Covid-19 and acute kidney injury in hospital: summary of NICE guidelines. | journal=BMJ | year= 2020 | volume= 369 | issue=  | pages= m1963 | pmid=32457068 | doi=10.1136/bmj.m1963 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32457068  }} </ref>:
* The most potent [[risk factors]] in the development of [[COVID-19]] associated  [[AKI]] include:<ref name="pmid32250968">{{cite journal| author=Rabb H| title=Kidney diseases in the time of COVID-19: major challenges to patient care. | journal=J Clin Invest | year= 2020 | volume= 130 | issue= 6 | pages= 2749-2751 | pmid=32250968 | doi=10.1172/JCI138871 | pmc=7259985 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32250968  }} </ref> <ref name="pmid32457068">{{cite journal| author=Selby NM, Forni LG, Laing CM, Horne KL, Evans RD, Lucas BJ | display-authors=etal| title=Covid-19 and acute kidney injury in hospital: summary of NICE guidelines. | journal=BMJ | year= 2020 | volume= 369 | issue=  | pages= m1963 | pmid=32457068 | doi=10.1136/bmj.m1963 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32457068  }} </ref>
**[[Elderly]]  
**[[Elderly]]  
*** Age>60 years
*** Age>60 years
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===Diagnostic Study of Choice===
===Diagnostic Study of Choice===
*The diagnosis of [[AKI]] is based on the KDIGO criteria, which includes<ref name="pmid22890468">{{cite journal| author=Khwaja A| title=KDIGO clinical practice guidelines for acute kidney injury. | journal=Nephron Clin Pract | year= 2012 | volume= 120 | issue= 4 | pages= c179-84 | pmid=22890468 | doi=10.1159/000339789 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22890468  }} </ref>:
*The diagnosis of [[AKI]] is based on the KDIGO criteria, which includes:<ref name="pmid22890468">{{cite journal| author=Khwaja A| title=KDIGO clinical practice guidelines for acute kidney injury. | journal=Nephron Clin Pract | year= 2012 | volume= 120 | issue= 4 | pages= c179-84 | pmid=22890468 | doi=10.1159/000339789 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22890468  }} </ref>  
**Elevated serum [[Creatinine]] by ≥0.3 mg/dl (≥26.5 μmol/l) within 48 hours; or
**Elevated serum [[Creatinine]] by ≥0.3 mg/dl (≥26.5 μmol/l) within 48 hours; or
**Elevated serum [[Creatinine]] to ≥1.5 times baseline within the previous 7 days; or
**Elevated serum [[Creatinine]] to ≥1.5 times baseline within the previous 7 days; or
Line 127: Line 126:


=== Physical Examination ===
=== Physical Examination ===
*Physical examination of patients with [[AKI]] is usually remarkable for:
*Physical examination of patients with [[AKI]] is usually remarkable for<ref name="Skorecki">{{cite book |vauthors=Skorecki K, Green J, Brenner BM |veditors=Kasper DL, Braunwald E, Fauci AS |title=Harrison's Principles of Internal Medicine|url=https://archive.org/details/harrisonsprincip00kasp |url-access=limited |edition=16th |year=2005 |publisher=McGraw-Hill |location=New York, NY |isbn=978-0-07-139140-5 |pages=[https://archive.org/details/harrisonsprincip00kasp/page/n1681 1653]–63 |chapter=Chronic renal failure|display-editors=etal}}</ref>:
**Signs of [[dehydration]], such as [[tachycardia]], [[tachypnea]], [[hypotension]], and dry [[mucosa]]
**Signs of [[dehydration]], such as [[tachycardia]], [[tachypnea]], [[hypotension]], and dry [[mucosa]]
**[[Fluid retention]], leading to [[edema]] and swelling of periorbital and [[extremities]]
**[[Fluid retention]], leading to [[edema]] and swelling of periorbital and [[extremities]]
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=== Laboratory Findings ===  
=== Laboratory Findings ===  
* Laboratory findings of COVID-19-associated [[AKI]] include:
* Laboratory findings consistent with the diagnosis of [[COVID-19]]-associated [[AKI]] include<ref name="OstermannJoannidis2016">{{cite journal|last1=Ostermann|first1=Marlies|last2=Joannidis|first2=Michael|title=Acute kidney injury 2016: diagnosis and diagnostic workup|journal=Critical Care|volume=20|issue=1|year=2016|issn=1364-8535|doi=10.1186/s13054-016-1478-z}}</ref>:
**Elevated serum [[creatinine]]
**Elevated serum [[creatinine]]
**Elevated [[BUN]] level
**Elevated [[BUN]] level
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***[[Hyaline casts]] in [[prerenal]] [[AKI]]
***[[Hyaline casts]] in [[prerenal]] [[AKI]]
***[[Granular]] or Muddy brown [[casts]] in intrinsic [[AKI]] or [[acute tubular necrosis]]
***[[Granular]] or Muddy brown [[casts]] in intrinsic [[AKI]] or [[acute tubular necrosis]]
**Several [[biomarkers]] have been found to diagnose and predict [[AKI]] that include<ref name="pmid28076311">{{cite journal| author=Kashani K, Cheungpasitporn W, Ronco C| title=Biomarkers of acute kidney injury: the pathway from discovery to clinical adoption. | journal=Clin Chem Lab Med | year= 2017 | volume= 55 | issue= 8 | pages= 1074-1089 | pmid=28076311 | doi=10.1515/cclm-2016-0973 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28076311  }} </ref> <ref name="pmid27474473">{{cite journal| author=Schrezenmeier EV, Barasch J, Budde K, Westhoff T, Schmidt-Ott KM| title=Biomarkers in acute kidney injury - pathophysiological basis and clinical performance. | journal=Acta Physiol (Oxf) | year= 2017 | volume= 219 | issue= 3 | pages= 554-572 | pmid=27474473 | doi=10.1111/apha.12764 | pmc=5575831 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27474473  }} </ref> <ref name="pmid32050834">{{cite journal| author=Oh DJ| title=A long journey for acute kidney injury biomarkers. | journal=Ren Fail | year= 2020 | volume= 42 | issue= 1 | pages= 154-165 | pmid=32050834 | doi=10.1080/0886022X.2020.1721300 | pmc=7034110 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32050834  }} </ref>:
**Several [[biomarkers]] have been found to diagnose and predict [[AKI]] that include: <ref name="pmid28076311">{{cite journal| author=Kashani K, Cheungpasitporn W, Ronco C| title=Biomarkers of acute kidney injury: the pathway from discovery to clinical adoption. | journal=Clin Chem Lab Med | year= 2017 | volume= 55 | issue= 8 | pages= 1074-1089 | pmid=28076311 | doi=10.1515/cclm-2016-0973 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28076311  }} </ref><ref name="pmid27474473">{{cite journal| author=Schrezenmeier EV, Barasch J, Budde K, Westhoff T, Schmidt-Ott KM| title=Biomarkers in acute kidney injury - pathophysiological basis and clinical performance. | journal=Acta Physiol (Oxf) | year= 2017 | volume= 219 | issue= 3 | pages= 554-572 | pmid=27474473 | doi=10.1111/apha.12764 | pmc=5575831 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27474473  }} </ref><ref name="pmid32050834">{{cite journal| author=Oh DJ| title=A long journey for acute kidney injury biomarkers. | journal=Ren Fail | year= 2020 | volume= 42 | issue= 1 | pages= 154-165 | pmid=32050834 | doi=10.1080/0886022X.2020.1721300 | pmc=7034110 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32050834  }} </ref>
***[[neutrophil gelatinase-associated lipocalin]] ([[NGAL]])
***[[neutrophil gelatinase-associated lipocalin]] ([[NGAL]])
***[[kidney injury molecule 1]] ([[KIM-1]])
***[[kidney injury molecule 1]] ([[KIM-1]])
Line 163: Line 162:


*There are no [[x-ray]] specific findings associated with [[AKI]]. However, [[X-ray]] may be used in the diagnosis of [[AKI]] associated [[volume overload]].
*There are no [[x-ray]] specific findings associated with [[AKI]]. However, [[X-ray]] may be used in the diagnosis of [[AKI]] associated [[volume overload]].
* To view the x-ray finidings on COVID-19, [[COVID-19 x ray|click here]].<br />


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===


*Ultrasound may be helpful in the diagnosis of [[AKI]]. Findings on ultrasound suggestive of [[AKI]] include [[hydrenephrosis]] and reduced [[renal]] [[blood flow]].
*Ultrasound may be helpful in the diagnosis of [[AKI]]. Findings on ultrasound suggestive of [[AKI]] include [[hydrenephrosis]] and reduced [[renal]] [[blood flow]].<ref name="pmid19715540">{{cite journal| author=Kalantarinia K| title=Novel imaging techniques in acute kidney injury. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 12 | pages= 1184-9 | pmid=19715540 | doi=10.2174/138945009789753246 | pmc=2891573 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19715540  }} </ref>


===CT scan===
===CT scan===


* There are no [[CT scan]] findings associated with [[AKI]].
* There are no [[CT scan]] findings associated with [[AKI]].
*To view the CT scan findings on COVID-19, [[COVID-19 CT scan|click here]].


===MRI===
===MRI===


* There are no [[MRI]] findings associated with [[AKI]].
* There are no [[MRI]] findings associated with [[AKI]].
* To view the MRI findings on COVID-19, [[COVID-19 MRI|click here]].<br />


===Other Imaging Findings===
===Other Imaging Findings===


*99m Technetium (Tc) scan may be helpful in the diagnosis of [[AKI]], which shows reduced [[renal]] [[blood flow]] and [[tubular]] function.
*99m Technetium (Tc) scan may be helpful in the diagnosis of [[AKI]], which shows reduced [[renal]] [[blood flow]] and [[tubular]] function.<ref name="pmid19715540">{{cite journal| author=Kalantarinia K| title=Novel imaging techniques in acute kidney injury. | journal=Curr Drug Targets | year= 2009 | volume= 10 | issue= 12 | pages= 1184-9 | pmid=19715540 | doi=10.2174/138945009789753246 | pmc=2891573 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19715540  }} </ref>
* To view other imaging findings on COVID-19, [[COVID-19 other imaging findings|click here]].<br />


===Other Diagnostic Studies===
===Other Diagnostic Studies===


*There are no other diagnostic studies associated with [[AKI]].
*There are no other diagnostic studies associated with [[AKI]].
* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]].<br />


== Treatment ==
== Treatment ==
Line 188: Line 192:
=== Medical Therapy ===
=== Medical Therapy ===


* Management of [[AKI]] following [[COVID-19]] includes [[antiviral]] therapies, identifying [[electrolyte]] disorders, and [[intravenous fluid]] resuscitation.
* Management of [[AKI]] following [[COVID-19]] includes [[antiviral]] therapies, identifying [[electrolyte]] disorders, and [[intravenous fluid]] resuscitation.<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume= 8 | issue= 7 | pages= 738-742 | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769  }} </ref>
** Early diagnosis and treatment of [[AKI]] in patients with [[COVID-19]] can avoid the progression of [[AKI]] into [[ESRD]] and reduce mortality.<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume=  | issue=  | pages=  | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769  }} </ref>
** Early diagnosis and treatment of [[AKI]] in patients with [[COVID-19]] can avoid the progression of [[AKI]] into [[ESRD]] and reduce mortality.<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume=  | issue=  | pages=  | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769  }} </ref>


Line 201: Line 205:
***In [[volume overload]] conditions
***In [[volume overload]] conditions
***[[Diuretics]] should not be used regularly as they predispose patients to [[volume depletion]].
***[[Diuretics]] should not be used regularly as they predispose patients to [[volume depletion]].
=== Interventions ===
=== Interventions ===
* [[renal replacement therapy]]
* [[renal replacement therapy]] is recommended among patients with [[AKI]] who develop <ref name="pmid26498416">{{cite journal| author=National Kidney Foundation| title=KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 update. | journal=Am J Kidney Dis | year= 2015 | volume= 66 | issue= 5 | pages= 884-930 | pmid=26498416 | doi=10.1053/j.ajkd.2015.07.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26498416  }} </ref>
** If [[AKI]] is unresponsive to conservative therapy
**[[volume overload]]
** In [[volume overload]] conditions
** severe [[metabolic acidosis]]
** Modality of choice in [[unstable]] hemodynamic status and [[ESRD]], severe [[metabolic acidosis]], severe [[hyperkalemia]]
**refractory [[hyperkalemia]]
**[[renal replacement therapy]] is associated with hypercoagulation.<ref name="pmid32457068">{{cite journal| author=Selby NM, Forni LG, Laing CM, Horne KL, Evans RD, Lucas BJ | display-authors=etal| title=Covid-19 and acute kidney injury in hospital: summary of NICE guidelines. | journal=BMJ | year= 2020 | volume= 369 | issue=  | pages= m1963 | pmid=32457068 | doi=10.1136/bmj.m1963 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32457068  }} </ref>
**[[uremic complications]]
***[[Pericarditis]]
***[[uremic encephalopathy]]
** If [[AKI]] is unresponsive to supportive therapy
** in hemodynamically [[unstable]] patients
***The [[dialysis]] of choice in hemodynamically unstable patients with [[COVID-19]] is continuous venovenous [[hemodialysis]].
*[[renal replacement therapy]] is associated with hypercoagulation.<ref name="pmid32457068">{{cite journal| author=Selby NM, Forni LG, Laing CM, Horne KL, Evans RD, Lucas BJ | display-authors=etal| title=Covid-19 and acute kidney injury in hospital: summary of NICE guidelines. | journal=BMJ | year= 2020 | volume= 369 | issue=  | pages= m1963 | pmid=32457068 | doi=10.1136/bmj.m1963 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32457068  }} </ref>
* To view COVID-19-associated hemodialysis, [[COVID-19-associated hemodialysis|click here]].<br />
* Sequential [[extracorporeal therapy]]
* Sequential [[extracorporeal therapy]]
**It removes [[cytokines]], which reduces systemic [[inflammation]] and subsequent [[organ failure]].
**It removes [[cytokines]], which reduces systemic [[inflammation]] and subsequent [[organ failure]].<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume= 8 | issue= 7 | pages= 738-742 | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769 }} </ref>
 
== Prevention ==
 
* Patients with [[COVID-19]] should be evaluated for [[intravascular]] [[volume]] status based on [[physical examination]] and fluid balance.<ref name="pmid32457068">{{cite journal| author=Selby NM, Forni LG, Laing CM, Horne KL, Evans RD, Lucas BJ | display-authors=etal| title=Covid-19 and acute kidney injury in hospital: summary of NICE guidelines. | journal=BMJ | year= 2020 | volume= 369 | issue=  | pages= m1963 | pmid=32457068 | doi=10.1136/bmj.m1963 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32457068  }} </ref>
** Serial monitoring of [[BUN]], serum [[creatinine]], and [[electrolytes]] such as [[sodium]], [[potassium]] and [[bicarbonate]] should be considered frequently every 48 hours or more in high risk patients.<ref name="pmid32457068">{{cite journal| author=Selby NM, Forni LG, Laing CM, Horne KL, Evans RD, Lucas BJ | display-authors=etal| title=Covid-19 and acute kidney injury in hospital: summary of NICE guidelines. | journal=BMJ | year= 2020 | volume= 369 | issue= | pages= m1963 | pmid=32457068 | doi=10.1136/bmj.m1963 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32457068  }} </ref>
**[[Isotonic]] [[saline]] is recommended as a prevention strategy for patients who are at increased risk for [[AKI]] by expanding [[intravascular]] [[volume]]. <ref name="pmid22890468">{{cite journal| author=Khwaja A| title=KDIGO clinical practice guidelines for acute kidney injury. | journal=Nephron Clin Pract | year= 2012 | volume= 120 | issue= 4 | pages= c179-84 | pmid=22890468 | doi=10.1159/000339789 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22890468 }} </ref>


=== Surgery ===
Surgical intervention is not recommended for the management of [[COVID-19]] associated [[AKI]].


=== Primary Prevention ===


*Effective measures for the primary prevention of [[AKI]] include:<ref name="KellumLeblanc2006">{{cite journal|last1=Kellum|first1=John A|last2=Leblanc|first2=Martine|last3=Gibney|first3=R T. Noel|last4=Tumlin|first4=James|last5=Lieberthal|first5=Wilfred|last6=Ronco|first6=Claudio|title=Primary prevention of acute renal failure in the critically ill|journal=Current Opinion in Internal Medicine|volume=5|issue=1|year=2006|pages=74–78|issn=1535-5942|doi=10.1097/01.ccx.0000179934.76152.02}}</ref>
**[[Volume resuscitation]]
*** Patients with [[COVID-19]] should be evaluated for [[intravascular]] [[volume]] status based on [[physical examination]] and fluid balance.<ref name="pmid32457068">{{cite journal| author=Selby NM, Forni LG, Laing CM, Horne KL, Evans RD, Lucas BJ | display-authors=etal| title=Covid-19 and acute kidney injury in hospital: summary of NICE guidelines. | journal=BMJ | year= 2020 | volume= 369 | issue=  | pages= m1963 | pmid=32457068 | doi=10.1136/bmj.m1963 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32457068  }} </ref>
***[[Isotonic]] [[saline]] is recommended as a prevention strategy for patients who are at increased risk for [[AKI]] by expanding [[intravascular]] [[volume]]. <ref name="pmid22890468">{{cite journal| author=Khwaja A| title=KDIGO clinical practice guidelines for acute kidney injury. | journal=Nephron Clin Pract | year= 2012 | volume= 120 | issue= 4 | pages= c179-84 | pmid=22890468 | doi=10.1159/000339789 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22890468  }} </ref>
**Monitoring [[renal]] function tests
*** Serial monitoring of [[BUN]], serum [[creatinine]], and [[electrolytes]] such as [[sodium]], [[potassium]] and [[bicarbonate]] should be considered frequently every 48 hours or more in high risk patients.<ref name="pmid32457068">{{cite journal| author=Selby NM, Forni LG, Laing CM, Horne KL, Evans RD, Lucas BJ | display-authors=etal| title=Covid-19 and acute kidney injury in hospital: summary of NICE guidelines. | journal=BMJ | year= 2020 | volume= 369 | issue=  | pages= m1963 | pmid=32457068 | doi=10.1136/bmj.m1963 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32457068  }} </ref>
**Avoidance of [[drugs]] and [[nephrotoxins]] in high risk patients<ref name="LameireVan Biesen2008">{{cite journal|last1=Lameire|first1=N.|last2=Van Biesen|first2=W.|last3=Hoste|first3=E.|last4=Vanholder|first4=R.|title=The prevention of acute kidney injury: an in-depth narrative review Part 1: volume resuscitation and avoidance of drug- and nephrotoxin-induced AKI|journal=Clinical Kidney Journal|volume=1|issue=6|year=2008|pages=392–402|issn=2048-8505|doi=10.1093/ndtplus/sfn162}}</ref>
===Secondary Prevention===
*Effective measures for the secondary prevention of [[AKI]] is using biomarkers for early diagnosis and treatment of [[AKI]] in early stages before it causes significant complications.<ref name="pmid19823082">{{cite journal| author=Pickering JW, Endre ZH| title=Secondary prevention of acute kidney injury. | journal=Curr Opin Crit Care | year= 2009 | volume= 15 | issue= 6 | pages= 488-97 | pmid=19823082 | doi=10.1097/MCC.0b013e328332f66f | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19823082  }} </ref><ref name="pmid28076311">{{cite journal| author=Kashani K, Cheungpasitporn W, Ronco C| title=Biomarkers of acute kidney injury: the pathway from discovery to clinical adoption. | journal=Clin Chem Lab Med | year= 2017 | volume= 55 | issue= 8 | pages= 1074-1089 | pmid=28076311 | doi=10.1515/cclm-2016-0973 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28076311  }} </ref>
<br />
==References==
==References==
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Main article: COVID-19

For COVID-19 frequently asked inpatient questions, click here

For COVID-19 frequently asked outpatient questions, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Nasrin Nikravangolsefid, MD-MPH [2],Sogand Goudarzi, MD [3]

Synonyms and keywords: COVID-19-associated AKI

Overview

COVID-19 infection can affect many organs and lead to organ failure. Kidneys are vital organs that can be affected by coronavirus. Acute kidney injury (AKI), a sudden deficit in kidney function, is a complication of COVID-19 and associated with a higher risk of mortality. AKI is frequently seen in critically ill patients with pre-existing conditions. Identifying high-risk patients for AKI and regular monitoring of kidney function tests in these patients play a major role in preventing AKI.

Historical Perspective


Classification

Pathophysiology


Causes

Differentiating COVID-19-associated acute kidney injury from other Diseases

To review the differential diagnosis of AKI, click here.

Epidemiology and Demographics

  • The prevalence of AKI among patients with COVID-19 hospitalized in ICU is approximately 0.6-29% in China [11] and 22.2% in the USA.[12]
  • Approximately 43% of critically ill patients with COVID-19 developed AKI during the admission period. [4]
  • In a cohort study on 99 patients with severe COVID-19, AKI was reported in 42 patients (42.9%) and among them 32 (74.4%) patients had severe AKI (stage III based on KDIGO definition). [13]
  • The actual incidence of AKI in critcally ill patients with COVID-19 is uncertain but estimated between 27-85%. "Acute Kidney Injury in COVID-19 Patients | COVID-19".
  • Differences of AKI prevalence among studies could be related to several factors, including:[13]
  • AKI commonly affects elderly. The incidence of AKI increases with age; the mean age at diagnosis is 57.1 years. [4]
  • There is no racial predilection to COVID-19 associated AKI.


Risk Factors

Screening

  • Serial monitoring of kidney function tests should be considered in high risk patients.[16]

Natural History, Complications, and Prognosis

Natural History

  • If no improvement occurs during follow-up, it is contributed to higher mortality.[3]

Diagnosis

Diagnostic Study of Choice

  • The diagnosis of AKI is based on the KDIGO criteria, which includes:[18]
    • Elevated serum Creatinine by ≥0.3 mg/dl (≥26.5 μmol/l) within 48 hours; or
    • Elevated serum Creatinine to ≥1.5 times baseline within the previous 7 days; or
    • Urine volume < 0.5 ml/kg/h for >6 hours

Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography or Ultrasound

CT scan

  • There are no CT scan findings associated with AKI.
  • To view the CT scan findings on COVID-19, click here.

MRI

  • There are no MRI findings associated with AKI.
  • To view the MRI findings on COVID-19, click here.

Other Imaging Findings

Other Diagnostic Studies

  • There are no other diagnostic studies associated with AKI.
  • To view other diagnostic studies for COVID-19, click here.

Treatment

Medical Therapy

Interventions

Surgery

Surgical intervention is not recommended for the management of COVID-19 associated AKI.

Primary Prevention

Secondary Prevention

  • Effective measures for the secondary prevention of AKI is using biomarkers for early diagnosis and treatment of AKI in early stages before it causes significant complications.[29][21]


References

  1. ↑ Hui DS, I Azhar E, Madani TA, Ntoumi F, Kock R, Dar O, et al. (February 2020). "The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health—The latest 2019 novel coronavirus outbreak in Wuhan, China". International Journal of Infectious Diseases. 91: 264–266. doi:10.1016/j.ijid.2020.01.009. PMC 7128332 Check |pmc= value (help). PMID 31953166.
  2. ↑ Wang, Luwen; Li, Xun; Chen, Hui; Yan, Shaonan; Li, Dong; Li, Yan; Gong, Zuojiong (2020). "Coronavirus Disease 19 Infection Does Not Result in Acute Kidney Injury: An Analysis of 116 Hospitalized Patients from Wuhan, China". American Journal of Nephrology. 51 (5): 343–348. doi:10.1159/000507471. ISSN 0250-8095.
  3. ↑ 3.0 3.1 3.2 Pei, Guangchang; Zhang, Zhiguo; Peng, Jing; Liu, Liu; Zhang, Chunxiu; Yu, Chong; Ma, Zufu; Huang, Yi; Liu, Wei; Yao, Ying; Zeng, Rui; Xu, Gang (2020). "Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia". Journal of the American Society of Nephrology. 31 (6): 1157–1165. doi:10.1681/ASN.2020030276. ISSN 1046-6673.
  4. ↑ 4.0 4.1 4.2 4.3 Pei G, Zhang Z, Peng J, Liu L, Zhang C, Yu C; et al. (2020). "Renal Involvement and Early Prognosis in Patients with COVID-19 Pneumonia". J Am Soc Nephrol. 31 (6): 1157–1165. doi:10.1681/ASN.2020030276. PMC 7269350 Check |pmc= value (help). PMID 32345702 Check |pmid= value (help).
  5. ↑ 5.0 5.1 5.2 5.3 Malha, Line; Mueller, Franco B.; Pecker, Mark S.; Mann, Samuel J.; August, Phyllis; Feig, Peter U. (2020). "COVID-19 and the Renin-Angiotensin System". Kidney International Reports. 5 (5): 563–565. doi:10.1016/j.ekir.2020.03.024. ISSN 2468-0249.
  6. ↑ 6.0 6.1 6.2 Ronco C, Reis T (2020). "Kidney involvement in COVID-19 and rationale for extracorporeal therapies". Nat Rev Nephrol. 16 (6): 308–310. doi:10.1038/s41581-020-0284-7. PMC 7144544 Check |pmc= value (help). PMID 32273593 Check |pmid= value (help).
  7. ↑ Husain-Syed F, Slutsky AS, Ronco C (2016). "Lung-Kidney Cross-Talk in the Critically Ill Patient". Am J Respir Crit Care Med. 194 (4): 402–14. doi:10.1164/rccm.201602-0420CP. PMID 27337068.
  8. ↑ https://www.medrxiv.org/content/10.1101/2020.03.04.20031120v4. Missing or empty |title= (help)
  9. ↑ Ye M, Wysocki J, William J, Soler MJ, Cokic I, Batlle D (2006). "Glomerular localization and expression of Angiotensin-converting enzyme 2 and Angiotensin-converting enzyme: implications for albuminuria in diabetes". J Am Soc Nephrol. 17 (11): 3067–75. doi:10.1681/ASN.2006050423. PMID 17021266.
  10. ↑ Perico L, Benigni A, Remuzzi G (2020). "Should COVID-19 Concern Nephrologists? Why and to What Extent? The Emerging Impasse of Angiotensin Blockade". Nephron. 144 (5): 213–221. doi:10.1159/000507305. PMC 7179544 Check |pmc= value (help). PMID 32203970 Check |pmid= value (help).
  11. ↑ "Acute Kidney Injury in COVID-19 Patients | COVID-19".
  12. ↑ Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW; et al. (2020). "Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area". JAMA. doi:10.1001/jama.2020.6775. PMC 7177629 Check |pmc= value (help). PMID 32320003 Check |pmid= value (help).
  13. ↑ 13.0 13.1 13.2 Gabarre P, Dumas G, Dupont T, Darmon M, Azoulay E, Zafrani L (2020). "Acute kidney injury in critically ill patients with COVID-19". Intensive Care Med. 46 (7): 1339–1348. doi:10.1007/s00134-020-06153-9. PMC 7290076 Check |pmc= value (help). PMID 32533197 Check |pmid= value (help).
  14. ↑ Sharma G, Volgman AS, Michos ED (2020). "Sex Differences in Mortality from COVID-19 Pandemic: Are Men Vulnerable and Women Protected?". JACC Case Rep. doi:10.1016/j.jaccas.2020.04.027. PMC 7198137 Check |pmc= value (help). PMID 32373791 Check |pmid= value (help).
  15. ↑ Rabb H (2020). "Kidney diseases in the time of COVID-19: major challenges to patient care". J Clin Invest. 130 (6): 2749–2751. doi:10.1172/JCI138871. PMC 7259985 Check |pmc= value (help). PMID 32250968 Check |pmid= value (help).
  16. ↑ 16.0 16.1 16.2 16.3 16.4 16.5 Selby NM, Forni LG, Laing CM, Horne KL, Evans RD, Lucas BJ; et al. (2020). "Covid-19 and acute kidney injury in hospital: summary of NICE guidelines". BMJ. 369: m1963. doi:10.1136/bmj.m1963. PMID 32457068 Check |pmid= value (help).
  17. ↑ 17.0 17.1 17.2 17.3 17.4 Ronco C, Reis T, Husain-Syed F (2020). "Management of acute kidney injury in patients with COVID-19". Lancet Respir Med. doi:10.1016/S2213-2600(20)30229-0. PMC 7255232 Check |pmc= value (help). PMID 32416769 Check |pmid= value (help).
  18. ↑ 18.0 18.1 18.2 Khwaja A (2012). "KDIGO clinical practice guidelines for acute kidney injury". Nephron Clin Pract. 120 (4): c179–84. doi:10.1159/000339789. PMID 22890468.
  19. ↑ 19.0 19.1 Skorecki K, Green J, Brenner BM (2005). "Chronic renal failure". In Kasper DL, Braunwald E, Fauci AS, et al. Harrison's Principles of Internal Medicine (16th ed.). New York, NY: McGraw-Hill. pp. 1653–63. ISBN 978-0-07-139140-5.
  20. ↑ Ostermann, Marlies; Joannidis, Michael (2016). "Acute kidney injury 2016: diagnosis and diagnostic workup". Critical Care. 20 (1). doi:10.1186/s13054-016-1478-z. ISSN 1364-8535.
  21. ↑ 21.0 21.1 Kashani K, Cheungpasitporn W, Ronco C (2017). "Biomarkers of acute kidney injury: the pathway from discovery to clinical adoption". Clin Chem Lab Med. 55 (8): 1074–1089. doi:10.1515/cclm-2016-0973. PMID 28076311.
  22. ↑ Schrezenmeier EV, Barasch J, Budde K, Westhoff T, Schmidt-Ott KM (2017). "Biomarkers in acute kidney injury - pathophysiological basis and clinical performance". Acta Physiol (Oxf). 219 (3): 554–572. doi:10.1111/apha.12764. PMC 5575831. PMID 27474473.
  23. ↑ Oh DJ (2020). "A long journey for acute kidney injury biomarkers". Ren Fail. 42 (1): 154–165. doi:10.1080/0886022X.2020.1721300. PMC 7034110 Check |pmc= value (help). PMID 32050834 Check |pmid= value (help).
  24. ↑ 24.0 24.1 Kalantarinia K (2009). "Novel imaging techniques in acute kidney injury". Curr Drug Targets. 10 (12): 1184–9. doi:10.2174/138945009789753246. PMC 2891573. PMID 19715540.
  25. ↑ Grein J, Ohmagari N, Shin D, Diaz G, Asperges E, Castagna A; et al. (2020). "Compassionate Use of Remdesivir for Patients with Severe Covid-19". N Engl J Med. 382 (24): 2327–2336. doi:10.1056/NEJMoa2007016. PMC 7169476 Check |pmc= value (help). PMID 32275812 Check |pmid= value (help).
  26. ↑ National Kidney Foundation (2015). "KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 update". Am J Kidney Dis. 66 (5): 884–930. doi:10.1053/j.ajkd.2015.07.015. PMID 26498416.
  27. ↑ Kellum, John A; Leblanc, Martine; Gibney, R T. Noel; Tumlin, James; Lieberthal, Wilfred; Ronco, Claudio (2006). "Primary prevention of acute renal failure in the critically ill". Current Opinion in Internal Medicine. 5 (1): 74–78. doi:10.1097/01.ccx.0000179934.76152.02. ISSN 1535-5942.
  28. ↑ Lameire, N.; Van Biesen, W.; Hoste, E.; Vanholder, R. (2008). "The prevention of acute kidney injury: an in-depth narrative review Part 1: volume resuscitation and avoidance of drug- and nephrotoxin-induced AKI". Clinical Kidney Journal. 1 (6): 392–402. doi:10.1093/ndtplus/sfn162. ISSN 2048-8505.
  29. ↑ Pickering JW, Endre ZH (2009). "Secondary prevention of acute kidney injury". Curr Opin Crit Care. 15 (6): 488–97. doi:10.1097/MCC.0b013e328332f66f. PMID 19823082.

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