有 COVID-19 和没有 COVID-19 的重症患者的肾脏预后以及肾小管损伤和功能轨迹。

Q4 Medicine Critical care explorations Pub Date : 2024-06-26 eCollection Date: 2024-07-01 DOI:10.1097/CCE.0000000000001109
Michael L Granda, Frances Tian, Leila R Zelnick, Pavan K Bhatraju, Julia Hallowell, Mark M Wurfel, Andrew Hoofnagle, Eric Morrell, Bryan Kestenbaum
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引用次数: 0

摘要

重要性:COVID-19 可能会通过激活宿主的炎症反应和/或病毒的直接浸润而损伤肾小管。大多数关于 COVID-19 肾损伤的研究缺乏同期对照或在单一时间点测量肾脏生物标志物:为了更好地了解 COVID-19 急性肾损伤的机制,我们比较了前瞻性入组的有 COVID-19 和无 COVID-19 的重症成人肾脏结局以及肾小管损伤、存活率和功能的轨迹:COVID-19宿主反应和结果研究前瞻性地招募了华盛顿州重症监护病房收治的有下呼吸道感染症状的患者,在患者到达时通过核酸扩增确定其COVID-19状态:我们对 330 名患者的主要肾脏不良事件(MAKE)进行了评估,主要肾脏不良事件的定义是血清肌酐翻倍、肾脏替代治疗或死亡。在有生物样本的 181 名患者中,我们测定了尿液肾损伤分子-1(KIM-1)和上皮细胞生长因子(EGF)的变化轨迹,以及肾小管分泌清除率内源性标记物的尿液与血浆比率:入住重症监护室时,患者平均年龄为 55 ± 16 岁,45% 需要机械通气,平均血清肌酐浓度为 1.1 mg/dL。COVID-19 与 MAKE 发生率增加 70% 相关(相对风险 1.70;95% CI,1.05-2.74),与 KRT 发生率增加 741% 相关(相对风险 7.41;95% CI,1.69-32.41)。生物标志物队列的随访测量中位数为三次。在 COVID-19 阴性组中,尿 EGF、分泌清除率和估计肾小球滤过率(eGFR)随时间推移而增加,但在 COVID-19 阳性组中则保持不变。相比之下,两组的尿液KIM-1浓度在研究过程中均无明显变化:结论:在重症成人中,尽管肾脏损伤程度相似,但 COVID-19 与近端肾小管功能障碍的病程更长和 eGFR 降低有关。
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Kidney Outcomes and Trajectories of Tubular Injury and Function in Critically Ill Patients With and Without COVID-19.

Importance: COVID-19 may injure the kidney tubules via activation of inflammatory host responses and/or direct viral infiltration. Most studies of kidney injury in COVID-19 lacked contemporaneous controls or measured kidney biomarkers at a single time point.

Objectives: To better understand mechanisms of acute kidney injury in COVID-19, we compared kidney outcomes and trajectories of tubular injury, viability, and function in prospectively enrolled critically ill adults with and without COVID-19.

Design, setting, and participants: The COVID-19 Host Response and Outcomes study prospectively enrolled patients admitted to ICUs in Washington State with symptoms of lower respiratory tract infection, determining COVID-19 status by nucleic acid amplification on arrival.

Main outcomes and measures: We evaluated major adverse kidney events (MAKE) defined as a doubling of serum creatinine, kidney replacement therapy, or death, in 330 patients after inverse probability weighting. In the 181 patients with available biosamples, we determined trajectories of urine kidney injury molecule-1 (KIM-1) and epithelial growth factor (EGF), and urine:plasma ratios of endogenous markers of tubular secretory clearance.

Results: At ICU admission, the mean age was 55 ± 16 years; 45% required mechanical ventilation; and the mean serum creatinine concentration was 1.1 mg/dL. COVID-19 was associated with a 70% greater occurrence of MAKE (relative risk 1.70; 95% CI, 1.05-2.74) and a 741% greater occurrence of KRT (relative risk 7.41; 95% CI, 1.69-32.41). The biomarker cohort had a median of three follow-up measurements. Urine EGF, secretory clearance ratios, and estimated glomerular filtration rate (eGFR) increased over time in the COVID-19 negative group but remained unchanged in the COVID-19 positive group. In contrast, urine KIM-1 concentrations did not significantly change over the course of the study in either group.

Conclusions: Among critically ill adults, COVID-19 is associated with a more protracted course of proximal tubular dysfunction and reduced eGFR despite similar degrees of kidney injury.

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