In COVID-19 fight, AKI becomes new battle front
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At Mt. Sinai Hospital in New York City, which accounts for more than 10,000 deaths in the COVID-19 pandemic in the United States, Osama El Shamy, MD, works with other nephrologists and medical staff trying to make sense of why a growing percentage of patients experience AKI after being hospitalized.
“We have had a number of COVID-19 patients who develop AKI,” El Shamy, a third-year nephrology fellow at Sinai’s Icahn School of Medicine, told Nephrology News & Issues. “In a matter of days, we may see a creatinine of one go to ... as high as 13.”
The cases of AKI have added to the strain on health systems battling COVID-19, with higher demands for dialysis equipment and kidney care staff and ongoing problems with blood clots making dialysis difficult.
“We are seeing patients with preexisting kidney disease being very susceptible to the illness and patients with risk factors, such as diabetes, hypertension – but no renal dysfunction – develop a rapid acute kidney injury in association with their infection,” nephrologist Keith Bellovich, DO, (click here to read his First Word column) told Nephrology News & Issues. “Our acute dialysis teams have been overwhelmed with attempting to meet the demands of sheer numbers of treatments.” Bellovich is part of St. Clair Nephrology PC, a nephrology practice in Roseville, Michigan, which is outside of Detroit. Michigan has had 3,274 deaths due to the virus, as of press time.
Expanding pandemic
The Johns Hopkins University Center for Systems Science and Engineering reported on April 24 that 890,524 people had a positive COVID-19 diagnosis in the United States, with 51,017 recorded deaths. That equates to slightly more than 74,000 newly diagnosed cases per week – each week – since January 20, when the first case was reported, and more than 4,200 deaths per week.
“I have never seen anything like it in my 40-year career as a nurse, which included working during the AIDS epidemic in the 1980s,” Jean Colaneri, ACNP-BC, CNN, a nurse practitioner in dialysis and apheresis at Albany Medical Center Hospital, told Nephrology News & Issues. Her hospital accepted close to 30 patients with COVID-19 from hospitals in New York City. An incident command center, which has been meeting every day since early March, has kept things organized at her hospital, she said.
“I am certain that we will see lasting lung damage in the survivors,” Colaneri said.
The most recent data available in front of from the Kidney Care Emergency Response, a government- and dialysis provider-funded organization that helps the kidney care community prepare for emergencies and natural disasters, shows more than 3,000 dialysis patients have been tested positive for the virus in the United States, and 300 patients with kidney disease have died.
Jeffrey Hymes, MD, chief medical officer for Fresenius Kidney Care and senior vice president of Clinical and Scientific Affairs for Fresenius Medical Care North America, said the effect of the virus on the kidneys is complex. His company’s renal therapies group has stepped up efforts to divert more dialysis equipment and supplies to hard-hit hospitals in New York, Michigan and Louisiana. The company has formed a National Intensive Renal Care Reserve, which includes creating a pool of approximately 150 pieces of equipment that are already located in hospitals across the United States. The equipment can be redeployed to other areas as needed within a week’s notice, the company said in a release. The plan also doubles its tubing set and filter capacity, as well as increases its premixed dialysate fluid capacity by 75%.
“Renal involvement is seen in many viral infections including dengue, hepatitis B and C, cytomegalovirus, Epstein-Barr syndrome, the Ebola virus, and others,” Hymes said. “In the coronavirus, there is evidence that the podocytes and proximal tubules of the kidneys may be injured when a protein on the outer membrane of the coronavirus binds to angiotensin-converting enzyme 2 (ACE2).
“The enzyme is subsequently activated by transmembrane serine proteases (TMPRSSs). Volume depletion seems to be frequent in COVID-19 patients, which along with hypoxemia, and cytokine storm can predispose patients to acute tubular necrosis. There are clearly viral particles seen in the kidneys of patients infected with COVID-19, but it is difficult to be sure if the AKI seen in these ill patients is due to the virus or results from the hemodynamic consequences of the inflammatory storm, acute respiratory distress syndrome, hypoxemia and coagulation defects noted in COVID-19.”
Bellovich agreed, and told Nephrology News & Issues that biopsy studies in other centers “are showing viral inclusions within the tubular cells and abnormal peritubular arterial clot formations.”
A new study undertaken by RenalytixAI at Mt. Sinai may help clinicians understand the sudden increase in AKI among patients with COVID-19. Called the Prediction of Major Adverse Kidney Events and Recovery, or Pred-MAKER, the KidneyIntelX product will generate machine-learning algorithms “to assess predictive blood-based biomarkers to identify patients at highest need of aggressive clinical intervention to slow or prevent progression to kidney failure,” RenalytixAl said in a release.
CDC data show that while people in all age groups with varying health conditions have gotten infected with the COVID-19 virus, certain underlying diseases – as well as older age – create a greater risk. Obesity, cardiovascular disease, diabetes and hypertension, some of the hallmarks of patients who are at risk for chronic kidney disease, and kidney disease itself, which accounts for around 14% cases with underlying conditions, show up often among those who are hospitalized (see chart).
Doug Johnson, MD, vice-chair of the Board for Dialysis Clinic Inc., monitors the company’s 250 dialysis clinics and its acute dialysis program at 147 hospitals. The clinicians in the Hospital Services program have cared for 431 COVID-19 patients; two-thirds of those patients have AKI. Also, said Johnson, 129 of the patients with COVID-19 have died, and 80% had AKI.
“My question is whether some of the acute kidney injury being reported is a part of broader multisystem organ failure,” Johnson told Nephrology News & Issues.
Mary Hobeika, RN, MSN, MBA, chief strategy officer for Dialysis Clinic Inc., said, “We have observed that as oxygenation and hemodynamics improve, patients who survive COVID-19 are often able to recover kidney function rather than progressing to ESRD. That leads us to believe the insult to the kidneys during COVID is related to circulatory collapse and multisystem failure as opposed to the virus specifically attacking the kidneys. Those are the observations we are seeing now, but that could change.”
El Shamy said Mt. Sinai has been able to use peritoneal dialysis to help treat patients with AKI. It remains a small part of the treatment protocol; his 20 cases are a fraction of those patients who went on hemodialysis.
“In order to put patients on PD, you also do need to have someone to place catheters. These are not stable patients, so taking them down to the interventional radiology suite can be difficult.”
El Shamy said he has been able to get surgeons to implant PD catheters at bedside.
Dialysis equipment shortages
In addition to efforts by Fresenius to make more equipment available to the hardest hit regions, Baxter Healthcare is also maximizing production of its continuous renal replacement therapy (CRRT) machines, fluids and sets to help address demand for its acute dialysis products in Europe and the United States. The company said in a press release that it has added multiple work shifts, with all facilities manufacturing products used in COVID-19 patient care running 24 hours a day, 7 days a week.
Baxter has also received emergency use authorization from the FDA for use of the company’s Oxiris filter set, aimed at reducing pro-inflammatory cytokine levels in patients with confirmed COVID-19 who have been admitted to the intensive care unit with confirmed or imminent respiratory failure.
“Oxiris offers a new tool in the COVID-19 fight while supplementing our overall supply of filters for blood purification therapies,” José E. Almeida, chair and CEO of Baxter, said. Oxiris can be used to perform multiple blood purification therapies simultaneously, including CRRT and cytokine removal.
More cases on the horizon
With acute kidney failure being seen in patients with COVID-19 and those with ESKD being at higher risk – new reports are also showing that transplant patients with COVID-19 are at a higher mortality risk because of their compromised immune system - more testing is needed. Alan S. Kliger, MD, co-chairs with Jeffrey Silberzweig, MD, the COVID-19 response team formed by the American Society of Nephrology. Along with the CDC, they have led a series of webinars since March 11 to spread the word about guidelines on how to protect both patients and dialysis staff from the virus.
“We have done so little testing; there is a strong likelihood that the disease will spread,” Kliger said. The Yale nephrologist said more than 30,000 people have attended or downloaded information from the webinars or information on COVID-19 from the ASN’s Nephrologists Transforming Dialysis Safety and CDC websites.
Kliger, Silberzweig and the ASN assisted in getting manufacturers and hospitals together in April to address the desperate need for more dialysis equipment. They were instrumental in getting the companies to shift equipment and supplies to New York City and other pandemic hotspots to handling the increasing number of patients with AKI.
“We have a phone call with the chief medical officers of the dialysis providers each week, and that is helpful,” Kliger said.
“The ASN devoted huge resources to bring information and best-care practices to the challenge of COVID-19 infection, and also helped government reshape public policy in this health care emergency,” Silberzweig said.
If there is concern about a bigger outbreak this fall – as some have indicated may be the case along with the regular flu season – finding staff to care for patients with COVID-19 will be challenging. The American Nephrology Nurses Association (ANNA) has launched a COVID-19 Nephrology Nurse Surge Support interactive map that identifies hotspots across the United States and allows nurses to answer calls for help from facilities.
“The tool works both ways: Nurses search the map by state to quickly identify and contact facilities with openings, and facilities also use the map to provide their name, location, type of health care professionals and specific practice areas they need to fill,” Lillian Pryor, MSN, RN, CNN, ANNA president, said. “We knew we needed to quickly come up with a way to address this need for facilities facing a shortage of front-line providers.” The map can be found at www.annanurse.org/covidhelp.
DaVita, Fresenius and other providers also put together a plan to operate isolation clinics for patients under investigation and diagnosed patients with COVID-19.
“For the most part, providers in the collaboration have been able to treat our collective dialysis patients independently, without relying significantly on contingency plans in any geography. Where needed, the collaboration has been helpful,” Jeffrey Giullian, MD, MBA, FASN, chief medical officer for DaVita Kidney Care, told Nephrology News & Issues. “DaVita has been treating COVID-19 positive patients in isolation in our centers, either in separate shifts or in dedicated treatment centers.”
Giullian said while the aim of DaVita and other providers is to limit the number of patients sent to hospitals to reduce the burden, “the availability of testing across the U.S. remains a barrier to collecting reliable data about COVID-19 positive ESKD patients, though DaVita has been able to increase testing substantially over the past several weeks ... The number of patients who are either COVID-19 positive or persons under investigation is incredibly fluid. Currently, nearly 70% of our COVID-19 positive patients are dialyzing as outpatients. We remain highly focused on helping our nephrologists and care team members safely care for all of our patients, following guidance and infection control practices that meet or exceed guidance from the CDC.”
Albany Medical Center’s Colaneri has spent much of her time on the frontline helping patients understand the risks of getting COVID-19 are real.
“My daily routine is taking my shoes and uniform off in the garage and take a shower when I get home from work. Same thing, every day,” she said. – by Mark E. Neumann
- For more information:
- Keith Bellovich, DO, is with St. Clair Nephrology, PC, a nephrology practice in Roseville, Michigan. He can be reached at kbellovich@scsp.net.
- Jean Colaneri, ACNP-BC, CNN, is a nurse practitioner in Dialysis and Apheresis at Albany Medical Center Hospital and can be reached at colanej@amc.edu.
- Osama El Shamy, MD, is with the Mt. Sinai Icahn School of Medicine and can be reached at omelshamy@gmail.com.
- Jeffrey Giullian, MD, MBA, FASN, can be reached at DaVita Kidney Care, Jeffrey.Giullian@davita.com.
- Mary Hobeika, RN, MSN, MBA, is the chief strategy officer for Dialysis Clinic Inc. and can be reached at mary.hobeika@dciinc.org.
- Jeffrey Hymes, MD, can be reached at Fresenius Medical Care North America, 781-699-9000.
- Doug Johnson, MD, is vice chair of the board of directors for Dialysis Clinic Inc. and can be reached at doug.johnson@dciinc.org.
- Alan S. Kliger, MD, and Jeffrey Silberzweig, MD, are co-chairs of the COVID Response Team and can be reached at alan.kliger@ynhh.org and jis2003@nyp.org, respectively.
- Lillian Pryor, MSN, RN, CNN, is a renal clinical nurse at the Atlanta VA Medical Center, Decatur, Georgia.
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