Assessment of Acute Kidney Injury and Longitudinal Kidney Function After Hospital Discharge Among Patients With and Without COVID-19

James Nugent,Lama Ghazi,Sherry G Mansour,Dennis G Moledina,Yu Yamamoto,Abinet Aklilu,Aditya Biswas,F Perry Wilson,Jason H Greenberg,Michael Simonov,Fan Li

doi:10.1001/jamanetworkopen.2021.1095

Abstract

Acute kidney injury (AKI) occurs in up to half of patients hospitalized with coronavirus disease 2019 (COVID-19). The longitudinal effects of COVID-19-associated AKI on kidney function remain unknown. To compare the rate of change in estimated glomerular filtration rate (eGFR) after hospital discharge between patients with and without COVID-19 who experienced in-hospital AKI. A retrospective cohort study was conducted at 5 hospitals in Connecticut and Rhode Island from March 10 to August 31, 2020. Patients who were tested for COVID-19 and developed AKI were screened, and those who survived past discharge, did not require dialysis within 3 days of discharge, and had at least 1 outpatient creatinine level measurement following discharge were included. Diagnosis of COVID-19. Mixed-effects models were used to assess the association between COVID-19-associated AKI and eGFR slope after discharge. The secondary outcome was the time to AKI recovery for the subgroup of patients whose kidney function had not returned to the baseline level by discharge. A total of 182 patients with COVID-19-associated AKI and 1430 patients with AKI not associated with COVID-19 were included. The population included 813 women (50.4%); median age was 69.7 years (interquartile range, 58.9-78.9 years). Patients with COVID-19-associated AKI were more likely to be Black (73 [40.1%] vs 225 [15.7%]) or Hispanic (40 [22%] vs 126 [8.8%]) and had fewer comorbidities than those without COVID-19 but similar rates of preexisting chronic kidney disease and hypertension. Patients with COVID-19-associated AKI had a greater decrease in eGFR in the unadjusted model (-11.3; 95% CI, -22.1 to -0.4 mL/min/1.73 m2/y; P = .04) and after adjusting for baseline comorbidities (-12.4; 95% CI, -23.7 to -1.2 mL/min/1.73 m2/y; P = .03). In the fully adjusted model controlling for comorbidities, peak creatinine level, and in-hospital dialysis requirement, the eGFR slope difference persisted (-14.0; 95% CI, -25.1 to -2.9 mL/min/1.73 m2/y; P = .01). In the subgroup of patients who had not achieved AKI recovery by discharge (n = 319), COVID-19-associated AKI was associated with decreased kidney recovery during outpatient follow-up (adjusted hazard ratio, 0.57; 95% CI, 0.35-0.92). In this cohort study of US patients who experienced in-hospital AKI, COVID-19-associated AKI was associated with a greater rate of eGFR decrease after discharge compared with AKI in patients without COVID-19, independent of underlying comorbidities or AKI severity. This eGFR trajectory may reinforce the importance of monitoring kidney function after AKI and studying interventions to limit kidney disease after COVID-19-associated AKI.

Highlights

Acute kidney injury (AKI) is common in patients hospitalized with coronavirus disease 2019 (COVID-19), reported in 24% to 57% of COVID-19 hospitalizations and 61% to 78% of intensive care unit admissions in patients with COVID-19.1-7 Compared with patients without COVID-19, those with COVID-19 develop more severe AKI, have greater dialysis requirements, and experience less in-hospital kidney recovery,[2] which may increase their risk for incident chronic kidney disease (CKD) or progression of existing CKD.[8] the acute effects of COVID-19 on kidney function have been studied,[9,10] the intermediate- and long-term kidney outcomes after COVID-19–associated AKI remain unknown
Patients with COVID-19–associated AKI had a greater decrease in estimated glomerular filtration rate (eGFR) in the unadjusted model (−11.3; 95% CI, –22.1 to −0.4 mL/min/1.73 m2/y; P = .04) and after adjusting for baseline comorbidities (−12.4; 95% CI, –23.7 to −1.2 mL/min/1.73 m2/y; P = .03)
In the subgroup of patients who had not achieved AKI recovery by discharge (n = 319), COVID-19–associated AKI was associated with decreased kidney recovery during outpatient follow-up

Summary

Introduction

Acute kidney injury (AKI) is common in patients hospitalized with coronavirus disease 2019 (COVID-19), reported in 24% to 57% of COVID-19 hospitalizations and 61% to 78% of intensive care unit admissions in patients with COVID-19.1-7 Compared with patients without COVID-19, those with COVID-19 develop more severe AKI, have greater dialysis requirements, and experience less in-hospital kidney recovery,[2] which may increase their risk for incident chronic kidney disease (CKD) or progression of existing CKD.[8] the acute effects of COVID-19 on kidney function have been studied,[9,10] the intermediate- and long-term kidney outcomes after COVID-19–associated AKI remain unknown. Follow-up of COVID-19 survivors with AKI has shown that 32% of patients had not yet recovered baseline kidney function at a median of 21 days after hospital discharge.[7] Because the high incidence of COVID-19–associated AKI has strained health care delivery systems with limited dialysis resources,[11,12,13] understanding the chronic kidney sequelae in this population has important public health implications for resource allocation, CKD screening, and patient counseling.[9]. Owing to their more severe AKI, we hypothesized that patients with COVID-19–associated AKI are at increased risk for eGFR decrease or worsening CKD after discharge compared with patients with AKI who did not have COVID-19

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