This Review describes our current understanding of the pathogenic mechanisms involved in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the progression of coronavirus disease 2019 (COVID-19), focusing on the immunological hyper-response and the induction of widespread endothelial damage, complement-associated blood clotting and systemic microangiopathy, as well as the effects of these processes on the kidney. The authors also discuss therapeutic interventions that currently hold most promise.
COVID-19 and nephrology
The COVID-19 pandemic poses important challenges to the care of patients with kidney disease. In addition, a growing body of evidence suggests that COVID-19 can induce kidney damage through both direct and indirect mechanisms. This article series aims to highlight basic, clinical and psychological aspects of COVID-19 in nephrology as well as the impact of the pandemic on research and clinical trials.
Reviews & Consensus Statements
COVID-19-associated acute kidney injury: consensus report of the 25th Acute Disease Quality Initiative (ADQI) Workgroup
COVID-19-associated AKI (COVID-19 AKI) is associated with high mortality and is an independent risk factor for all-cause in-hospital death in patients with COVID-19. This Consensus Statement from the Acute Disease Quality Initiative provides recommendations for the diagnosis, prevention and management of COVID-19 AKI and for areas of future research, with the aim of improving understanding of the underlying processes and outcomes for patients with COVID-19 AKI.
News & comment
The consequences of the COVID-19 pandemic have been devastating; however, evidence suggests that patients with, or at risk of, kidney disease are disproportionally affected. Patients on dialysis and kidney transplant recipients are at higher risk of adverse outcomes from COVID-19, whereas, conversely, patients with severe COVID-19 are at increased risk of acute kidney injury, with short-term and possibly long-term consequences for nephrological care.
A new study reports the seroprevalence of SARS-CoV-2 antibodies among a cross-section of patients on haemodialysis and uses these data to estimate seroprevalence in the general US population. Although this study demonstrates the potential of monitoring infectious disease prevalence in dialysis populations, the findings should be interpreted with caution.
A new study examined post-mortem kidney tissue from 63 patients with COVID-19. The results suggest that SARS-CoV-2 has kidney tropism, including the ability to replicate in kidney cells, and that kidney transduction by SARS-CoV-2 is associated with shorter survival time and increased incidence of acute kidney injury.
Interest in the use of haemoperfusion for severe COVID-19 has been spurred by anecdotal reports of its efficacy and expert reviews suggesting theoretical benefits. However, on the basis of the limited current evidence, haemoperfusion remains an experimental therapy that should only be applied within the context of well-designed randomized trials.
A new study uses the OpenSAFELY health analytics platform to identify risk factors for COVID-19 mortality. This analysis, which includes data for more than 17 million people in the UK, suggests that patients with chronic kidney disease are at higher risk than those with other known risk factors, including chronic heart and lung disease.
Management of kidney transplant recipients requires a sustainable infrastructure that can provide reliable medical care both before and after transplantation. The COVID-19 pandemic has disrupted transplant referral and listing processes, led to decreases in the numbers of transplant procedures and resulted in changes in practice for pre- and post-transplantation management and follow-up.
The COVID-19 pandemic has placed a tremendous strain on sustaining the clinical research enterprise and will also likely affect key study outcomes; these effects must be considered during data analysis and interpretation. Nevertheless, the responses to the pandemic have also introduced innovations that will advance the conduct of clinical research.
Reports of collapsing glomerulopathy in patients of African ancestry and high-risk APOL1 genotype infected with SARS-CoV-2 have emerged during the COVID-19 pandemic. This new entity, which we term COVID-19-associated nephropathy (COVAN), may particularly impact individuals in some regions of the world. Awareness of this potentially ominous complication of COVID-19 must be raised.
Brazil has been severely affected by the novel coronavirus. At a time when the country needs to concentrate on controlling and fighting the virus, President Bolsonaro has minimized the importance of the pandemic and focused on political battles.
Health-care workers involved in the response to the COVID-19 pandemic are often required to work in highly challenging conditions and may therefore be at increased risk of experiencing mental health problems. This Comment sets out a practical approach to protecting the mental health of health-care workers based on contemporary evidence.
The coronavirus disease 2019 (COVID-19) pandemic poses important challenges to the care of patients with immune-mediated kidney diseases and to kidney transplant recipients. Here, we discuss the management of immunosuppression for these patients during the pandemic and suggest potential approaches that could be considered in the absence of validated strategies.
The prevalence of direct kidney involvement in novel coronavirus disease (COVID-19) is low, but such involvement is a marker of multiple organ dysfunction and severe disease. Here, we explore potential pathways of kidney damage and discuss the rationale for extracorporeal support with various blood purification strategies in patients who are critically ill with COVID-19.
Patients on haemodialysis or peritoneal dialysis are likely to be at increased risk of novel coronavirus disease (COVID-19). Preventive strategies must be implemented to minimize the risk of disease transmission in dialysis facilities, including education of staff and patients, screening for COVID-19 and separation of infected or symptomatic and non-infected patients.
The current COVID-19 pandemic is associated with unprecedented morbidity and mortality. Early reports suggested an association between disease severity and hypertension but did not account for sources of confounding. However, the responsible virus — SARS-CoV-2 — gains entry to host cells via angiotensin-converting enzyme 2 (ACE2), highlighting the need to understand the relationship between the virus and the renin–angiotensin system (RAS) and how this might be affected by RAS inhibitors.
eHealth is gaining momentum in nephrology, although evidence for its efficacy remains unclear and challenges to its widespread adoption persist. Successful integration of eHealth into kidney care will require patient engagement to develop effective interventions and issues such as data validity, regulation, oversight and adequate infrastructure to be addressed.