University Of Queensland Study Warns That Millions of SARS-CoV-2 Infected Individuals Are Not Aware That They May Have Undiagnosed Acute Kidney Injury!

SARS-CoV-2 And Acute Kidney Injury(AKI) : A new study led by researchers from the University of Queensland-Australia along with scientists from the University of Oxford-UK, Monash University-Australia and University of Southern California-USA has found that globally, millions of SARS-CoV-2 infected individuals are unaware that they might be having undiagnosed acute kidney injury!


 
Acute kidney injury (AKI), also known as acute renal failure (ARF), is a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days or even months. AKI causes a build-up of waste products in the blood and makes it hard for the kidneys to keep the right balance of fluid in the body. AKI can also affect other organs such as the brain, heart, and lungs and ultimately cause death!
 
Signs and symptoms of acute kidney injury differ depending on the cause and may include:

-Too little urine leaving the body
-Swelling in legs, ankles, and around the eyes
-Fatigue or tiredness
-Shortness of breath
-Confusion
-Nausea
-Seizures or coma in severe cases
-Chest pain or pressure
 
In some cases, AKI causes no symptoms and is only found through other tests done by a healthcare provider.
 
Acute kidney injury (AKI) is one of the most common and significant problems in patients with COVID-19. However, little is known about the incidence and impact of AKI occurring in the community or early in the hospital admission.
 
The traditional Kidney Disease Improving Global Outcomes (KDIGO) definition can fail to identify patients for whom hospitalization coincides with recovery of AKI as manifested by a decrease in serum creatinine (sCr).
 
The study team hypothesized that an extended KDIGO (eKDIGO) definition, adapted from the International Society of Nephrology (ISN) 0by25 studies, would identify more cases of AKI in patients with COVID-19 and that these may correspond to community-acquired AKI (CA-AKI) with similarly poor outcomes as previously reported in this population.
 
All study participants were recruited using the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC)–World Health Organization (WHO) Clinical Characterization Protocol (CCP) and admitted to 1,609 hospitals in 54 countries with SARS-CoV-2 infection from February 15, 2020 to February 1, 2021.
 
Data were collected and analyzed for the duration of a patient’s admission. Incidence, staging, and timing of AKI were evaluated using a traditional and eKDIGO definition, which incorporated a commensurate decrease in sCr. Patients within eKDIGO diagnosed with AKI by a decrease in sCr were labelled as deKDIGO. Clinical characteristics and outcomes in intensive care unit (ICU) admission, invasive mechanical ventilation, and in-hospital death were compared for all 3 groups of patients. The relationship between eKDIGO AKI and in-hospital death was assessed using survival curves and logistic regression, adjusting for disease severity and AKI susceptibility.
 
A total of 75,670 patients were included in the final analysis cohort. Media n length of admission was 12 days (interquartile range [IQR] 7, 20). There were twice as many patients with AKI identified by eKDIGO than KDIGO (31.7% versus 16.8%). Those in the eKDIGO group had a greater proportion of stage 1 AKI (58% versus 36% in KDIGO patients). Peak AKI occurred early in the admission more frequently among eKDIGO than KDIGO patients. Compared to those without AKI, patients in the eKDIGO group had worse renal function on admission, more in-hospital complications, higher rates of ICU admission (54% versus 23%) invasive ventilation (45% versus 15%), and increased mortality (38% versus 19%). Patients in the eKDIGO group had a higher risk of in-hospital death than those without AKI (adjusted odds ratio: 1.78, 95% confidence interval: 1.71 to 1.80, p-value < 0.001). Mortality and rate of ICU admission were lower among deKDIGO than KDIGO patients (25% versus 50% death and 35% versus 70% ICU admission) but significantly higher when compared to patients with no AKI (25% versus 19% death and 35% versus 23% ICU admission) (all p-values <5 × 10−5). Limitations include ad hoc sCr sampling, exclusion of patients with less than two sCr measurements, and limited availability of sCr measurements prior to initiation of acute dialysis.
 
The study showed that an extended KDIGO definition of AKI resulted in a significantly higher detection rate in this population. These additional cases of AKI occurred early in the hospital admission and were associated with worse outcomes compared to patients without AKI.
 
The study findings show that the current biochemical criteria used to diagnose AKI may be insufficient to capture AKI that develops in the community and is recovering by the time a patient presents to hospital.
 
The use of an extended definition that can identify AKI both during its development and recovery phase may allow us to identify more patients with AKI. These patients may benefit from early management strategies to improve long-term outcomes.
 
Importantly, the study findings showed that the extended definition identified almost twice as many cases of AKI than the traditional definition (31.7% versus 16.8%).
 
These additional cases of AKI were generally less severe and occurred earlier in the hospital admission. Nevertheless, they were associated with worse outcomes, including intensive care unit (ICU) admission and in-hospital death (adjusted odds ratio: 1.78, 95% confidence interval: 1.71 to 1.8, p-value < 0.001) than those with no AKI.
 
The current clinical definition of AKI fails to identify a large group of patients with AKI that appears to develop in the community or early in the hospital admission. Given the finding that these cases of AKI are associated with worse admission outcomes than those without AKI, identifying and managing them in a timely manner are enormously important.
 
The study findings were published in the peer reviewed journal: PLOS Medicine. https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003969
 
The study findings alarmingly imply that millions of COVID-19 infected individuals may have undiagnosed acute kidney injury (AKI) and are not even aware of it!
 
Typically, AKI is a condition where the kidneys suddenly fail to filter waste from the blood, which can lead to serious illness or even death.
 
Current data indicates approximately 20 per cent of patients admitted to hospital with COVID-19 develop AKI, rising to roughly 40 per cent for those in intensive care.
 
However, University of Queensland PhD candidate and kidney specialist Dr Marina Wainstein said the true numbers could be double those figures.
 
Typically, most physicians only look at the amount of urine a patient passes and the level of a compound called creatinine in the blood, which rises when the kidneys aren't working well.
 
Dr Wainstein told Thailand Medical News, “Importantly however, if that creatinine rise occurs before a patient presents to hospital, most doctors can miss the AKI diagnosis and fail to manage the patient appropriately in those early, critical days of hospitalization."
 
She said that when the researchers also measured the fall in creatinine levels, which often follows the initial rise, the rate of AKI diagnosis in COVID-19 patients doubled.
 
She added, "That was a pretty shocking finding!”
 
She warned, “Missing AKI diagnosis in COVID-19 patients is dangerous. Even though the AKI is already starting to improve in hospital, our research shows that these patients have worse in-hospital outcomes and are more likely to die compared to patients with no AKI.”
 
She added that treatment for AKI can be as simple as checking a patient's hydration level and stopping medications that can be toxic to the kidneys.
 
Research supervisor Dr Sally Shrapnel, from University of Queensland School of Mathematics and Physics, said collecting and analyzing data for the project during the pandemic proved challenging.
 
Dr Shrapnel said, "Typically data scientists work with complete, well curated registry data, but in this project, it was collected by hospital staff working under extremely onerous conditions in a variety of different resource settings. Curating and cleaning the data turned out to be a significant part of the project.
 
She said the study team were able to include data from resource-poor countries, where community-acquired AKI is also more common.
 
She said, "These people have limited access to healthcare and are more likely to present late in the disease process."
 
The study team stresses that a more comprehensive definition of AKI ie one which can detect cases that develop in the community needs to be implemented as soon as possible.
 
The study team said, "Now we have the data showing a large gap in AKI diagnosis exists, it's time to test this definition in a clinical trial so we can identify all AKI patients early and hopefully prevent these awful outcomes."
 
Thailand Medical News would like to stress that most Post COVID patients should request for detailed kidney screening regularly with their healthcare provider.
 
The healthcare provider should run different tests if he or she suspects that you may have AKI. It is important that AKI is found as soon as possible because it can lead to chronic kidney disease, or even kidney failure.  It may also lead to heart disease or death.
 
The following tests may be done:
 
-Measuring urine output: Your healthcare provider will track how much urine you pass each day to help find the cause of your AKI.
 
-Urine tests: Your healthcare provider will look at your urine (urinalysis) to find signs of kidney failure
 
-Blood tests: Blood tests will help find levels of creatinine, urea nitrogen phosphorus and potassium should be done in addition to blood tests for protein in order to look at kidney function. 
 
-GFR: Your blood test will also help find your GFR (glomerular filtration rate) to estimate the decrease in kidney function
-Imaging tests: Imaging tests, such as ultrasound, may help your doctor see your kidneys and look for anything abnormal.
 
-Kidney biopsy:  In some situations, your healthcare provider will do a procedure where a tiny piece of your kidney is removed with a special needle, and looked at under a microscope
 
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