Prolonged Intermittent Renal Replacement Therapy for Acute Kidney Injury in COVID-19 Patients with Acute Respiratory Distress Syndrome

Blood Purif. 2021;50(3):355-363. doi: 10.1159/000510996. Epub 2020 Oct 26.

Abstract

Introduction: Patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19 frequently develop severe acute kidney injury (AKI). Although continuous renal replacement therapy is the standard of care for critically ill patients, prolonged intermittent renal replacement therapy (PIRRT) may be a feasible option. We aimed to describe the tolerability and security of PIRRT treatments in COVID-19 patients with ARDS who required mechanical ventilation and developed severe AKI.

Methods: We prospectively analyzed patients who underwent PIRRT treatments at a COVID-19 reference hospital in Mexico City. Intradialytic hypotension was defined as a systolic blood pressure decrease of ≥20 mm Hg or an increase of 100% in vasopressor dose.

Results: We identified 136 AKI cases (60.7%) in 224 patients admitted to the intensive care unit. Among them, 21 (15%) underwent PIRRT (130 sessions) due to stage 3 AKI. The median age of the cohort was 49 (range 36-73) years, 17 (81%) were male, 7 (33%) had diabetes, and the median time between symptoms onset and PIRRT initiation was 12 (interquartile range [IQR] 7-14) days. The median of PIRRT procedures for each patient was 5 (IQR 4-9) sessions. In 108 (83%) PIRRT sessions, the total ultrafiltration goal was achieved. In 84 (65%) PIRRT procedures, there was a median increase in norepinephrine dose of +0.031 mcg/kg/min during PIRRT (IQR 0.00 to +0.07). Intradialytic hypotensive events occurred in 56 (43%) procedures. Fifteen (12%) PIRRT treatments were discontinued due to severe hypotension. Vasopressor treatment at PIRRT session onset (OR 6.2, 95% CI 1.4-28.0, p: 0.02) and a pre-PIRRT lactate ≥3.0 mmol/L (OR 4.63, 95% CI 1.3-12.8, p: 0.003) were independently and significantly associated with the risk of hypotension during PIRRT. During follow-up, 11 patients (52%) recovered from AKI and respiratory failure and 9 (43%) died. Several adaptations to our PIRRT protocol during the COVID-19 outbreak are presented.

Conclusions: PIRRT was feasible in the majority of COVID-19 patients with ARDS and severe AKI, despite frequent transitory intradialytic hypotensive episodes. PIRRT may represent an acceptable alternative of renal replacement therapy during the COVID-19 outbreak.

Keywords: Acute respiratory distress syndrome; Hybrid therapies; Renal failure; SARS-CoV-2; Sustained low-efficiency dialysis.

Publication types

  • Comparative Study
  • Observational Study

MeSH terms

  • Acute Kidney Injury / etiology
  • Acute Kidney Injury / therapy*
  • Adult
  • Aged
  • COVID-19 / complications*
  • COVID-19 / epidemiology
  • Comorbidity
  • Continuous Renal Replacement Therapy
  • Critical Care / methods*
  • Diabetes Complications / epidemiology
  • Female
  • Humans
  • Hypertension / epidemiology
  • Hypotension / etiology
  • Intermittent Renal Replacement Therapy* / adverse effects
  • Male
  • Middle Aged
  • Norepinephrine / therapeutic use
  • Prospective Studies
  • Respiration, Artificial
  • Respiratory Distress Syndrome / etiology*
  • Respiratory Distress Syndrome / therapy
  • SARS-CoV-2*
  • Treatment Outcome
  • Vasoconstrictor Agents / therapeutic use

Substances

  • Vasoconstrictor Agents
  • Norepinephrine