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Practice

Kidney injury associated with COVID-19

Daniel Blum, Alejandro Meraz-Munoz and Ziv Harel
CMAJ September 14, 2020 192 (37) E1065; DOI: https://doi.org/10.1503/cmaj.201553
Daniel Blum
Division of Nephrology (Blum), Jewish General Hospital, Montréal, Que.; Division of Nephrology (Meraz-Munoz, Harel) St. Michael’s Hospital, Toronto, Ont.
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Alejandro Meraz-Munoz
Division of Nephrology (Blum), Jewish General Hospital, Montréal, Que.; Division of Nephrology (Meraz-Munoz, Harel) St. Michael’s Hospital, Toronto, Ont.
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Ziv Harel
Division of Nephrology (Blum), Jewish General Hospital, Montréal, Que.; Division of Nephrology (Meraz-Munoz, Harel) St. Michael’s Hospital, Toronto, Ont.
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As many as 40% of patients admitted to hospital with COVID-19 have acute kidney injury

Acute kidney injury (AKI) is a common complication of coronavirus disease 2019 (COVID-19) and is usually related to disease severity. Accordingly, it typically occurs in patients who are critically ill, those with pre-existing conditions, older adults and Black people.1

Patients commonly present with dipstick-positive hematuria and mild proteinuria1

Uncommon presentations for AKI include nephrotic range proteinuria reflecting glomerular damage and new-onset glucosuria as a result of proximal tubular damage.2 Referral to a nephrologist should be sought for patients with severe COVID-19 who have a greater than 50% increase in their creatinine level compared with baseline, those with urinary protein excretion of more than 1 g/d and for those with a history of chronic kidney disease (estimated glomerular filtration rate < 60).

Hemodynamic insults, immunologic injury, hypercoagulability and microangiopathy drive kidney injury associated with COVID-193

There is no strong evidence that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has direct cytotoxic effects on the kidney despite the abundant expression of angiotensin-converting enzyme 2 (ACE2) in the kidney, which is used by SARS-CoV-2 to enter host tissue.2

Patients on long-term treatment with ACE inhibitors and angiotensin receptor blockers are not at increased risk of COVID-19

Use of ACE inhibitors and angiotensin receptor blockers does not impart a higher risk of COVID-192 or having poor outcomes from the disease, including critical illness and death.4 They should not routinely be stopped in patients with or at risk of COVID-19, unless there are medical indications to do so, such as hyperkalemia or AKI.

Patients receiving dialysis often present atypically with COVID-19

In contrast to the general population, patients receiving renal replacement therapy often present without fever or respiratory symptoms but with fatigue, anorexia and lymphopenia.5 A high index of suspicion because of the range of presentations of COVID-19, the use of universal droplet precautions when caring for patients and a low threshold for testing for SARS-CoV-2 are suggested when managing this population.

CMAJ invites submissions to “Five things to know about …” Submit manuscripts online at http://mc.manuscriptcentral.com/cmaj

Acknowledgments

The authors thank Dr. Ron Wald and Dr. Martin Schreiber for their critique and helpful suggestions in the preparation of this manuscript.

Footnotes

  • Competing interests: None declared.

  • This article has been peer reviewed.

References

  1. ↵
    1. Hirsch JS,
    2. Ng JH,
    3. Ross DW,
    4. et al
    . Acute kidney injury in patients hospitalized with COVID-19. Kidney Int 2020;98: 209–18.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Kudose S,
    2. Batal I,
    3. Santoriello D,
    4. et al
    . Kidney biopsy findings in patients with COVID-19. J Am Soc Nephrol 2020 July 17; ASN.2020060802. [Epub ahead of print]. doi: 10.1681/ASN.2020060802.
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Ronco C,
    2. Reis T
    . Kidney involvement in COVID-19 and rationale for extracorporeal therapies. Nat Rev Nephrol 2020;16: 308–10.
    OpenUrlPubMed
  4. ↵
    1. Mancia G,
    2. Rea F,
    3. Ludergnani M,
    4. et al
    . Renin-angiotensin-aldosterone system blockers and the risk of COVID-19. N Engl J Med 2020;382:2431–40.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Wu J,
    2. Li J,
    3. Zhu G,
    4. et al
    . Clinical features of maintenance hemodialysis patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. Clin J Am Soc Nephrol 2020;15: 1139–45.
    OpenUrlAbstract/FREE Full Text
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Canadian Medical Association Journal: 192 (37)
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Vol. 192, Issue 37
14 Sep 2020
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Kidney injury associated with COVID-19
Daniel Blum, Alejandro Meraz-Munoz, Ziv Harel
CMAJ Sep 2020, 192 (37) E1065; DOI: 10.1503/cmaj.201553

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Kidney injury associated with COVID-19
Daniel Blum, Alejandro Meraz-Munoz, Ziv Harel
CMAJ Sep 2020, 192 (37) E1065; DOI: 10.1503/cmaj.201553
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    • As many as 40% of patients admitted to hospital with COVID-19 have acute kidney injury
    • Patients commonly present with dipstick-positive hematuria and mild proteinuria1
    • Hemodynamic insults, immunologic injury, hypercoagulability and microangiopathy drive kidney injury associated with COVID-193
    • Patients on long-term treatment with ACE inhibitors and angiotensin receptor blockers are not at increased risk of COVID-19
    • Patients receiving dialysis often present atypically with COVID-19
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