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'''Complication 1: Acute Kidney Injury in COVID-19'''<br><br>
'''For patient information, click [[Xyz (patient information)|here]]'''
{{SK}} [[Acute Kidney Injury]], [[Acute Renal Failure]], [[AKI]], [[ARF]]
==[[AKI overview|Overview]]==
=[[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>
*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>
* 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.
*It is thought that [[AKI]] following COVID-19 is the 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]]
**[[Hypovolemia]] and Hypotension
**Hypoxemia
**Blood clots formation, leading to impaired blood flow in the renal arterioles.
*[[AKI]] often occurs at later stages in critically ill patients with [[COVID-19]] following multiple organ failure.
[[File:AKI physiopathology COVID.PNG|600px|center]]
=[[AKI epidemiology and demographics|Epidemiology and Demographics]]=
*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>
*However, recent study found 75.4% of hospitalized patients with COVID-19 pneumonia developed [[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> But, these findings are not significantly different from other critical diseases.
=[[AKI Natural history|Natural history]]=
*Severe [[COVID-19]] pneumonia and [[severe acute respiratory distress syndrome]] are associated with developing [[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>
*Approximately half of the new AKI cases following COVID-19 is mild with good short-term prognosis.
*If no improvement occurs during follow-up, it is contributed to higher mortality.<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>


=[[AKI History and Symptoms|History and Symptoms]]=


*Patients in the early stages of kidney failure may be asymptomatic. If left untreated, patients may progress to develop [[Azotemia]] and [[Uremia]], which occur due to the buildup of waste materials in the blood.
'''History and Symptoms'''
*Symptoms of kidney injury include<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>:
**Nausea and Vomiting
**Weakness
**Fatigue
**Confusion
**Weight loss
**Loss of appetite
**[[Oliguria]] or [[Anuria]]
**Fluid retention, leading [[edema]] and swelling of face, extremities
**Electrolyte imbalance; High level of [[Potassium]] which leads to [[cardiac arrhythmia]]


'''Physical Examination'''
{{familytree/start}}{{familytree | | | | | | | | | A01 | | | | | |A01=  [[COVID-19]]  }}
{{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree | |  C01  | | | | | | | | | | | | C02 |C01=  '''30-40%'''   <br> [[Asymptomatic]]|C02=  '''60-70%''' <br> [[Symptomatic]]}}
{{familytree | | |!| | | | | | | | | |,|-|-|-|+|-|-|-|-|.|}}
{{familytree | | E01 | | | | | | | | E02 | | E03 | | | E04 |E01=[[Asymptomatic carrier]]|E02='''80%''' <br> Mild symtoms|E03='''14%''' <br> Severe symptoms|E04='''6%''' <br> Critically ill}}
{{familytree | | | | | | | | | | | | |!| | | |!| | | | |!| | }}
{{familytree | | | | | | | | | | | | F01 | | F02 | | | F03 |F01=[[Fever]]<br> [[Chills]]<br> [[Cough]]<br> [[Headache]]<br> [[Sore throat]]<br> [[Nasal congestion]] or secretion <br> [[Fatigue]]<br> [[Body aches]]<br> [[loss of taste]] or [[smell]]
<br> [[Nausea]] or [[vomiting]] <br> [[Diarrhea]]<br> |F02=Severe [[Dyspnea]]<br> [[Chest pain]]<br> Severe [[weakness]] <br> new [[Confusion]]<br> Central [[Cyanosis]]
|F03=Death}}
{{familytree/end}}


=[[AKI Diagnosis|Diagnosis]]=


'''Laboratory Findings'''
*Laboratory findings consistent with the diagnosis of [[AKI]] include:
**Elevated [[BUN]] level
**Based on KDIGO definition for the diagnosis of AKI<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 to ≥1.5 times baseline within the previous 7 days; or
***Urine volume < 0.5 ml/kg/h for >6 hours


'''Electrocardiogram'''
{| class="wikitable"
*There are no specific ECG findings associated with AKI. However, electrolyte disturbances such as hyperkalemia might lead to various ECG findings.
! colspan=4 style="background: #4479BA; color: #FFFFFF; " align="center"|CT manifestations of COVID-19
|-
!style="background: #4479BA; color: #FFFFFF; " align="center" |CT findings
!style="background: #4479BA; color: #FFFFFF; " align="center" |Definition
!style="background: #4479BA; color: #FFFFFF; " align="center" |CT picture
|-
|style="background: #DCDCDC; |'''[[Ground glass opacity]]'''
|
*Hazy opacity in the lungs with well defined bronchial and vascular margins 
*the most common imaging finding
*due to infection, chronic interstitial lung disease, and acute lung injury


'''Ultrasound Finding'''
|[[File:Covid-19-pneumonia-26.jpg|200px|thumb|center]]
|-
|style="background: #DCDCDC; |'''[[Consolidation]]'''
|
*a parenchymal density with ill-defined bronchial and vascular margins
*filling with infectious material [fluid, cells, tissue]
* due to cellular exudates in alveoli
|[[file
|-
|style="background: #DCDCDC; |''' [[Crazy paving pattern]] '''
|
* Septal thickening of inter and intra-lobar regions
* with the background of the Ground glass opacity
* Similar to paving stones
* Due to alveolar edema and acute inflammation of the lung
* Sign of progression
|[[File:Covid-19-pneumonia-122.jpg|200px|thumb|center]]


'''Other Diagnostic Studies'''


=Treatment=
|-
|style="background: #DCDCDC; |''' [[Reticuldar]] pattern '''
|
*Linear opacities in the lungs
*Due to Interstitial thickening of inter and intralobular septa


*Management of [[AKI]] following [[COVID-19]] includes treatment of infection, identifying electrolyte disorders, and [[intravenous fluid]] administration.
|[[file


'''AKI Medical Therapy'''
|-
*Treatment of [[AKI]] following [[COVID-19]] includes<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>:
|style="background: #DCDCDC; |'''[[Air bronchogram]] '''
**Correction of hypovolemia and hypotension by the administration of adequate [[intravenous fluid]]
|
**Correction of electrolyte disturbances
* Air-filled bronchi
**[[Renal Replacement Therapy]]
*Low attenuated areas in the lung
***If AKI is unresponsive to conservative therapy
|[[file
***In volume overload conditions
***Modality of choice in unstable hemodynamic status
**Anticoagulants in hypercoagulable conditions
**Sequential extracorporeal therapy
==References==
{{Reflist|2}}


[[Category:Disease]]
|-
[[Category:Emergency medicine]]
|style="background: #DCDCDC; |''' [[Bronchiectasis]] '''
[[Category:Kidney diseases]]
|
[[Category:Nephrology]]
*irreversible dilatation of the lung airways
* Bronchus diameter more than 1.5 cm
*due to inflammation, obstruction and impaired clearance
|[[file
|}

Latest revision as of 13:33, 15 July 2020



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




 
 
 
 
 
 
 
 
COVID-19
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
30-40%
Asymptomatic
 
 
 
 
 
 
 
 
 
 
 
60-70%
Symptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asymptomatic carrier
 
 
 
 
 
 
 
80%
Mild symtoms
 
14%
Severe symptoms
 
 
6%
Critically ill
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fever
Chills
Cough
Headache
Sore throat
Nasal congestion or secretion
Fatigue
Body aches
loss of taste or smell
Nausea or vomiting
Diarrhea
 
Severe Dyspnea
Chest pain
Severe weakness
new Confusion
Central Cyanosis
 
 
Death


CT manifestations of COVID-19
CT findings Definition CT picture
Ground glass opacity
  • Hazy opacity in the lungs with well defined bronchial and vascular margins
  • the most common imaging finding
  • due to infection, chronic interstitial lung disease, and acute lung injury
Consolidation
  • a parenchymal density with ill-defined bronchial and vascular margins
  • filling with infectious material [fluid, cells, tissue]
  • due to cellular exudates in alveoli
[[file
Crazy paving pattern
  • Septal thickening of inter and intra-lobar regions
  • with the background of the Ground glass opacity
  • Similar to paving stones
  • Due to alveolar edema and acute inflammation of the lung
  • Sign of progression


Reticuldar pattern
  • Linear opacities in the lungs
  • Due to Interstitial thickening of inter and intralobular septa
[[file
Air bronchogram
  • Air-filled bronchi
  • Low attenuated areas in the lung
[[file
Bronchiectasis
  • irreversible dilatation of the lung airways
  • Bronchus diameter more than 1.5 cm
  • due to inflammation, obstruction and impaired clearance
[[file