Risk factors associated with acute kidney injury in a cohort of hospitalized patients with COVID-19

In this cohort of 1584 patients hospitalized with COVID-19, conducted in a middle-income country, the incidence of AKI was 46.5%, similar to that reported in other American cohorts [19]. The risk factors for AKI in this scenario were male gender, age, having comorbidities such as hypertension and CKD, onset with qSOFA greater than 1, receiving inpatient treatment with vancomycin or piperacillin tazobactam and the use of vasopressor support, findings consistent with what has been published recently in other cohorts [7,8,9, 20, 21]. As protective factors, female gender, previous use of statins, and interaction with hypertension and previous treatment with antihypertensives were found.

AKI is a clinically important entity due to its impact on costs, morbidity and mortality, findings that are clearly described and documented in critically ill patients [22] that are increasingly more robust in patients with COVID-19 [19, 23].

Obesity and smoking did not reach statistical significance as determinant risk factors for the appearance of AKI lesions, as has been documented in other studies [23]. In this cohort, the obesity variable had a high rate of data loss, which can affect the results and explain this finding.

Regarding the severity of AKI found in our population, we explained that most AKI cases are KDIGO 1 because most patients did not have comorbidities, nor were they critically ill. However, the patients in whom the disease advanced to severe forms ended up developing severe AKI up to KDIGO 3, with very few reaching only AKI KDIGO 2. We also found that most people consulted the first week after the onset of symptoms, facilitating early initiation of treatment, including nephroprotection measures.

The length of hospital stay, requirement of vasopressor support and mechanical ventilation were higher in the AKI subgroup, as were infections associated with health care, which increases the requirement for the use of antibiotics with nephrotoxic potential, such as vancomycin and piperacillin tazobactam [24]. Higher qSOFA scores, lower PAFI values, elevated levels of D-dimer and CRP, and low platelet counts were found, findings that reaffirm what has been documented in other studies that patients with AKI and COVID-19 are more inflamed. No difference was found in the previous use of immunosuppressive treatment or in the history of immunosuppressive conditions, which is like previous studies [7,8,9, 18,19,20, 24, 25].

The timing and modality of RRT was at the discretion of the nephrologist. CRRT was the most used, under indication of hemodynamic instability, in accordance with the large proportion of vasopressor use reported in the subgroup with AKI.

This study has the usual limitations of a retrospective cohort, which can generate biases. Urinary output was not considered for the diagnosis of AKI, which could underestimate the incidence of the condition; however, this is a limitation in real life given the underreporting of this variable. The low frequency of recording weight and height led to the loss of the obesity variable, which is a known risk factor for severity in COVID-19. We had fewer patients than initially calculated, we run into the risk that this study would not have enough power to find differences between the groups; however, we had the advantage of finding a higher AKI frequency, which was more than double that used for the calculation of the sample size. Therefore, the smaller number of patients included does not generate limitations.

As strengths, the inclusion of two university institutions with a diverse population and a larger sample size than other previously published cohorts are highlighted.

In conclusion, AKI is a frequent clinical entity in patients hospitalized for COVID-19 in Colombia. Male sex, age, history of HBP and CKD, presentation with elevated qSOFA and requirement of vasopressor support and exposure to piperacillin, tazobactam and vancomycin were the main risk factors. Identifying patients with greater AKI allows for early introduction of nephroprotection measures, such as limiting the use of nephrotoxins and preventing or mitigating the compromise of renal function. This identification of risk can contribute to times of contingency to refer these patients to more complex centers to provide timely care.

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