#5282 ACUTE KIDNEY INJURY IN INFECTIOUS DISEASE BY CORONAVIRUS IN BRAZIL: A STUDY ON INCIDENCE, RISK FACTORS, AND PROGNOSIS
Authors: Yuasa Bruna , Magalhães Luis , de Oliveira Paula Gabriela Sousa , Yokota Lais , Cardoso Pedro , Zamoner Welder , Balbi Andre , Ponce Daniela 
Published: June 2023

Abstract

Background and Aims
Although diffuse alveolar damage and acute respiratory failure are the main features of COVID-19 disease in its severe form, renal involvement is frequent (4-37%). To assess the incidence of acute kidney injury (AKI) in Brazilian patients hospitalized with COVID-19 and to identify both the risk factors associated with its onset and those associated with its prognosis.

Method
This is a prospective cohort study of patients hospitalized with COVID-19 at a public and tertiary university hospital in São Paulo from March 2020 to May 2021, encompassing the first and second waves of the pandemic. Patients were followed up until the clinical outcome (discharge or death). The evaluation of renal function was performed by measuring serum creatinine and urinary output and the diagnosis of AKI was performed according to the KDIGO 2012 criteria. The occurrence of AKI was established as the dependent variable, using the Chi-Square Test for the comparison of categorical variables and the t Test for continuous variables. Afterwards, a multivariate analysis was performed using the logistic regression model, with calculations of the Odds Ratio (OR), including in the model all the variables that showed association with the outcome (p≤0.20). A similar procedure was performed after establishing death as the dependent variable.

Results
887 patients with COVID-19 were analyzed, 54.6% were admitted to the intensive care unit (ICU) and 45.4% were admitted to the ward. The overall incidence of AKI was 48.1%, more frequent in the ICU (83.8 vs 17.1%, p&lt;0.0001). Upon hospital admission, 487 patients were submitted to urine test I, of which 58.5% had hematuria and 51.5% had proteinuria. The overall mortality was 38.9%. The average time for the diagnosis of AKI was 6 days and AKI KDIGO 3 was the most frequent (60.2%). Acute renal support was indicated in 58.8% of patients. According to logistic regression, the risk factors for AKI were the use of diuretics (OR 2.2, CI 1.2-4.1, p&lt;0.05), mechanical ventilation (OR 12.9, CI 4.3-38.2, p&lt;0.05), VAD (OR 2.7, CI 0.9-7.7, p = 0.06), dyslipidemia (OR 0.54, CI 0.3-1.05, p = 0.07), proteinuria (OR 2, CI 1.1-3.4, p&lt;0.05), hematuria (OR 2, CI 1.1-3.5, p&lt;0.05), CKD (OR 2.6, CI 1.2-5.5, p&lt;0.05), older age (OR 1.03, CI 1-1.07, p&lt;0.05), CPK (OR 1.02, CI 1-1.07, p&lt;0.05) and D-dimer (OR 1.02, CI 1.01-1.09, p&lt;0.05). The risk factors for death were arterial hypertension (OR 1.7, CI 1-3, p = 0.05), use of mechanical ventilation (OR 12.9, CI 4.3-38.2, p&lt;0.05), presence of proteinuria (OR 1.6, CI 0.9-2.7, p = 0.07), presence of AKI (OR 6, CI 2.9-12.2, p&lt;0.05), mainly KDIGO 3 (OR 0.6, CI 0.2-1.3, p = 0.2), high D-dimer (OR 1, CI 1, p = 0.05), SOFA score (1.35, CI 1.1-1.6, p&lt;0.05) and ATN-ISS score (OR 996.4, CI 4.8-203271, p&lt;0.05). Finally, the variables that showed the difference in the profile of patients between the two waves of the pandemic were identified, being less frequent in the second wave male gender (OR 0.51, CI 0.35-0.74, p&lt;0.05) and Caucasian ethnicity (OR 0.47, CI 0.2-0.8, p&lt;0.05), and more frequent in the second wave the use of mechanical ventilation (OR 1.57, CI 1-2.3, p&lt;0.05), proteinuria (OR 1.44, CI 1-2.1, p&lt;0.05), higher D-dimer values (OR 1.09, CI 1-1.1, p&lt;0.05) and ATN-ISS score (OR 40.9, CI 1.7-948.1, p&lt;0.05).

Conclusion
AKI associated with severe COVID-19 in Brazil was more frequent than in the Chinese, European, and North American cohorts, and the risk factors associated with its development are the use of diuretics, mechanical ventilation, VAD, dyslipidemia, proteinuria, hematuria, CKD, older age, elevated CPK and D-dimer. Mortality was high and higher in patients with arterial hypertension, on mechanical ventilation, with proteinuria, with AKI, mainly KDIGO 3, high D-dimer, and higher SOFA and ATN-ISS. In the second wave, AKI severity was greater, but mortality was similar to that of the first wave, which may reflect both the effectiveness of vaccines against SARS-CoV-2, as well as the constant learning that frontline professionals have built throughout the pandemic, to provide greater support to its patients.