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Observational Study
. 2022 Jan;35(1):99-111.
doi: 10.1007/s40620-021-01100-3. Epub 2021 Jun 25.

Acute kidney injury (AKI) in patients with Covid-19 infection is associated with ventilatory management with elevated positive end-expiratory pressure (PEEP)

Davide Ottolina #  1 , Luca Zazzeron #  2 , Letizia Trevisi  3 , Andrea Agarossi  4 , Riccardo Colombo  4 , Tommaso Fossali  4 , Mattia Passeri  4 , Beatrice Borghi  4 , Elisabetta Ballone  4 , Roberto Rech  4 , Antonio Castelli  4 , Emanuele Catena  4 , Manuela Nebuloni  5   6 , Maurizio Gallieni  5   7
Affiliations
Observational Study

Acute kidney injury (AKI) in patients with Covid-19 infection is associated with ventilatory management with elevated positive end-expiratory pressure (PEEP)

Davide Ottolina et al. J Nephrol. 2022 Jan.

Abstract

Background: Acute kidney injury (AKI) in Covid-19 patients admitted to the intensive care unit (ICU) is common, and its severity may be associated with unfavorable outcomes. Severe Covid-19 fulfills the diagnostic criteria for acute respiratory distress syndrome (ARDS); however, it is unclear whether there is any relationship between ventilatory management and AKI development in Covid-19 ICU patients.

Purpose: To describe the clinical course and outcomes of Covid-19 ICU patients, focusing on ventilatory management and factors associated with AKI development.

Methods: Single-center, retrospective observational study, which assessed AKI incidence in Covid-19 ICU patients divided by positive end expiratory pressure (PEEP) tertiles, with median levels of 9.6 (low), 12.0 (medium), and 14.7 cmH2O (high-PEEP).

Results: Overall mortality was 51.5%. AKI (KDIGO stage 2 or 3) occurred in 38% of 101 patients. Among the AKI patients, 19 (53%) required continuous renal replacement therapy (CRRT). In AKI patients, mortality was significantly higher versus non-AKI (81% vs. 33%, p < 0.0001). The incidence of AKI in low-, medium-, or high-PEEP patients were 16%, 38%, and 59%, respectively (p = 0.002). In a multivariate analysis, high-PEEP patients showed a higher risk of developing AKI than low-PEEP patients (OR = 4.96 [1.1-21.9] 95% CI p < 0.05). ICU mortality rate was higher in high-PEEP patients, compared to medium-PEEP or low-PEEP patients (69% vs. 44% and 42%, respectively; p = 0.057).

Conclusion: The use of high PEEP in Covid-19 ICU patients is associated with a fivefold higher risk of AKI, leading to higher mortality. The cause and effect relationship needs further analysis.

Keywords: AKI; ARDS; Covid-19; Intensive care; PEEP.

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Conflict of interest statement

All authors have nothing to disclose.

Figures

Fig. 1
Fig. 1
Representative post-mortem histological features in kidneys of patients with AKI-associated severe Covid-19. A, B Glomerular tuft collapse to the vascular pole, without hyperplasia or hypertrophy of podocytes. C, D Interstitial edema and tubular casts, without inflammation. Most of the tubules are lytic because of autopsy samples. Thus, tubular epithelial cells are not evaluable. A–D PAS staining, OM × 20
Fig. 2
Fig. 2
Laboratory data, PEEP and hemodynamics in patients who did or did not develop AKI. Trend in A creatinine, B C-reactive protein, C D-Dimer, D mean arterial pressure (MAP), E norepinephrine dose, F PEEP; G creatinine levels over time in patients treated with low (n = 31), medium (n = 32) or high (n = 32) PEEP. Two-way ANOVA. **p < 0.001, *p < 0.01, #p < 0.05. All data represent mean ± SEM
See this image and copyright information in PMC

References

    1. Grasselli G, Pesenti A, Cecconi M. Critical care utilization for the Covid-19 outbreak in Lombardy, Italy: early experience and forecast during an emergency response. JAMA. 2020;323:1545–1546. doi: 10.1001/jama.2020.4031. - DOI - PubMed
    1. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS, China Medical Treatment Expert Group for Covid-19 Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382:1708–1720. doi: 10.1056/NEJMoa2002032. - DOI - PMC - PubMed
    1. Alhazzani W, Moller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M, Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti JE, Citerio G, Baw B, Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes A. Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (Covid-19) Intensive Care Med. 2020;46:854–887. doi: 10.1007/s00134-020-06022-5. - DOI - PMC - PubMed
    1. Gattinoni L, Coppola S, Cressoni M, Busana M, Rossi S, Chiumello D. Covid-19 does not lead to a “typical” acute respiratory distress syndrome. Am J Respir Crit Care Med. 2020;201:1299–1300. doi: 10.1164/rccm.202003-0817LE. - DOI - PMC - PubMed
    1. Marini JJ, Gattinoni L. Management of Covid-19 respiratory distress. JAMA. 2020;323:2329–2330. doi: 10.1001/jama.2020.6825. - DOI - PubMed

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