Effect of COVID-19 on Kidney Disease Incidence and Management

Abstract

The COVID-19 outbreak has had substantial effects on the incidence and management of kidney diseases, including acute kidney injury (AKI), End-Stage Kidney Disease (ESKD), glomerulonephritis, and kidney transplantation. Initial reports from China suggested a lower AKI incidence in patients with COVID-19, but more recent studies from North America reveal a much higher incidence, likely due to higher prevalence of comorbid conditions such as hypertension, diabetes, and chronic kidney disease (CKD). AKI in this setting is associated with worse outcomes, including requirement for vasopressors or mechanical ventilation and death. Performing renal replacement therapy in those with AKI poses challenges such as limiting exposure of staff, preserving PPE, coagulopathy, and hypoxemia due to Acute Respiratory Distress Syndrome. Continuous Renal Replacement Therapy is the preferred modality, with sustained low-efficiency dialysis also an option, both managed without 1:1 hemodialysis nursing support. Regional citrate is the preferred anticoagulation, but systemic unfractionated heparin may be used in cases of coagulopathy. Ultrafiltration rate has to be set carefully, taking into consideration hypotension, hypoxemia, and responsiveness to presser and ventilatory support. Chance of transmission puts in-center chronic hemodialysis and other immunosuppressed patients at particularly increased risk. Limited data show that patients with CKD are also at increased risk for more severe disease if infected. Little is known about the virus's effects on immunocompromised patients with glomerular diseases and kidney transplants, which introduces challenges for management of immunosuppressant regimens. While there are no standardized guidelines regarding the management of immunosuppression, several groups recommend stopping the anti-metabolite in hospitalized transplant patients and continuing a reduced dose of calcineurin inhibitors. This comprehensive review critically appraises the best available evidence regarding the effect of COVID-19 on the incidence and management of kidney diseases. Where evidence is lacking, current expert opinion and clinical guidelines are reviewed and knowledge gaps worth investigation are identified.