Abstract
BackgroundAcute 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.PurposeTo describe the clinical course and outcomes of Covid-19 ICU patients, focusing on ventilatory management and factors associated with AKI development.MethodsSingle-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).ResultsOverall 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).ConclusionThe 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.Graphic abstract
Highlights
The severity of the disease caused by the novel ‘severe acute respiratory distress syndrome coronavirus 2’ (SARS-CoV-2) varies largely from asymptomatic cases to more severe presentations
Whether there is any relationship between ventilatory management and Acute kidney injury (AKI) development in Covid-19 intensive care unit (ICU) patients has not been established yet. In this single-center retrospective study, we describe the clinical course and outcome of 101 Covid-19 ICU patients, focusing on ventilator management and factors associated with AKI development
Inflammatory markers on admission, including C-reactive protein (CRP), lactate dehydrogenase (LDH), and D-dimer, were elevated, but there was no significant difference between survivors and non-survivors (Table 1)
Summary
The severity of the disease caused by the novel ‘severe acute respiratory distress syndrome coronavirus 2’ (SARS-CoV-2) varies largely from asymptomatic cases to more severe presentations. To explain the severe hypoxemia conflicting with the respiratory system mechanics and CT findings, alternative mechanisms such as impairment of hypoxic pulmonary vasoconstriction and microthrombi formation in the pulmonary circulation have been proposed [5] Based on these observations, specific ventilatory management, including low PEEP (8–10 cmH2O) and more liberal Vt (7–8 mL/kg), has been proposed [5, 6]. Severe Covid-19 fulfills the diagnostic criteria for acute respiratory distress syndrome (ARDS); it is unclear whether there is any relationship between ventilatory management and AKI development in Covid-19 ICU patients. Conclusion The use of high PEEP in Covid-19 ICU patients is associated with a fivefold higher risk of AKI, leading to higher mortality.
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