Preparedness of Kidney Replacement Therapy in the Critically Ill During COVID-19 Surge

• Type of Material: Article
• Authors: Javier A. Neyra, University of Kentucky; Michael Connor Jr, Emory University; Ashita Tolwani, University of Alabama Birmingham
• Language: English
• Date: 2020-06-07
• Publisher: Elsevier
• Publication Version: Final Published Version
• Copyright Statement: © 2020 International Society of Nephrology. Published by Elsevier Inc.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.ekir.2020.05.029
• Title of Journal or Parent Work: Kidney International Reports
• Volume: 5
• Issue: 7
• Start Page: 961
• End Page: 964
• Keywords: acute kidney injury; right to left shunt; hypovolemia; vulnerability assessment; SARS-CoV-2; kidney replacement therapy; intensive care unit; COVID-19; heart; pneumonia; crisis challenges; kidneys; acute respiratory distress syndrome; contingency planning; diuretics; lung recruitability; crisis planning; pandemic; healthcare system; blood; ventilation perfusion mismatch; brain
• Research Categories: Biology, Cell; Health Sciences, Medicine and Surgery; Biology, Virology; Health Sciences, Health Care Management

Abstract

The devastating and rapidly spreading coronavirus disease 2019 (COVID-19) pandemic has challenged the health care system worldwide. COVID-19 primarily affects the lungs and is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); however, multiple other organ systems also may be affected, including kidneys, blood (hypercoagulability), brain, and heart. The incidence of acute kidney injury secondary to COVID-19 is estimated at approximately 15% to 25%,1, 2 and requirement of kidney replacement therapy (KRT) has been variably reported, with many large centers describing an incidence of up to 30% in critically ill patients.3, 4 Further, emerging observations have described 2 phenotypes of COVID-19 pneumonia that may require a more individualized approach of KRT.5 One phenotype has higher lung compliance, ventilation perfusion mismatch, and low lung recruitability (type-L), whereas the other has lower lung compliance, higher right to left shunt, and higher lung recruitability, mimicking acute respiratory distress syndrome (type-H). Therefore, it is possible that patients with type-L are more susceptible to hypovolemia due to dysregulation in pulmonary perfusion, whereas patients with type-H may benefit from timely KRT for fluid management if severe acute kidney injury develops and there is lack of response to diuretics. In this perspectives piece, we complement prior contingency planning recommendations by Burgner et al.,6 with some specific considerations for KRT preparedness in the intensive care unit (ICU) under a model including vulnerability assessment, crisis planning, and crisis challenges.