In addition to attacking the respiratory system, COVID-19, an infectious disease caused by the SARS-CoV-2 virus, may also cause severe and persistent damage to other organs, including the kidneys and the heart.
Current research shows that the COVID-19 pandemic disproportionately affected the kidney community, causing substantial challenges in kidney disease management and kidney research. Kidney disease patients faced increased disease severity and infection risk, which was often complicated by acute kidney injury (AKI).
Further research is revealing more about the impact of COVID-19 on kidney health and management.
- Clinicians faced high clinical demands, new ethical dilemmas, and resource shortages in providing patient care during the pandemic.
- Interruptions to routine kidney care have been frequent and widespread, highlighting the advantages of implementing telemedicine and at-home dialysis.
- The impact of the COVID-19 pandemic on CKD provides an opportunity to advance our understanding of how infection-associated acute kidney injury might worsen CKD.
How Does Covid-19 Damage the Kidneys?
The impact of COVID-19 on the kidneys is complex and not completely understood. Current possibilities that clinicians and researchers are exploring include the following:
- Too little oxygen may cause the kidneys to malfunction. In patients with coronavirus, kidney problems may have resulted due to abnormally low levels of oxygen in the blood. Low oxygen levels in the blood resulted from pneumonia, commonly observed in severe cases of COVID-19.
- Coronavirus may target kidney cells. The SARS-CoV-2 virus infects the cells of the kidney. In simple terms, the kidney’s cells have receptors that allow the virus to attach to them. The virus then invades the cell and duplicates itself, which may damage the kidney tissues. Similar cell receptors that the SARs-CoV-2 virus can be found in the lungs and heart.
- Cytokine storms can destroy kidney tissue. The body’s natural response to infection may also be responsible for kidney damage. The immune response to the SARs-CoV-2 virus can vary from one individual to another, but an extreme immune response may lead to a cytokine storm.
When a cytokine storm occurs, the immune system sends an excessive amount of proinflammatory cytokines to fight the infection. However, the excessive amount of cytokines may cause severe inflammation, and in addition to trying to kill the virus, a cytokine storm may also destroy or damage healthy tissue.
- COVID-19 causes blood clots that might block the kidneys. The kidneys function to filter out toxins, waste, and excess water from the blood in the body. COVID-19 can cause blood clots to form in the bloodstream, which may end up blocking blood vessels in the kidneys. Blocked blood vessels in the kidney prevent enough oxygen from reaching them, and they may not function properly due to inadequate blood flow.
While COVID-19 may damage the kidneys, kidney pain is not normally a symptom of kidney damage and is generally associated with kidney infections, kidney stones, hydronephrosis, and polycystic kidney disease.
It is recommended that patients with COVID-19-related kidney damage follow up with their care team to ensure that their kidney function has not decreased. Lasting kidney damage due to COVID-19 may require other therapies or dialysis, even after a patient’s recovery from the virus.
Acute Kidney Injury in COVID-19 Patients
A new observational study shows that patients hospitalized (at both tertiary and community hospitals) with COVID-19 had a higher rate of AKI than previously reported. AKI is a sudden episode of kidney damage or failure that occurs within a few hours or days, and may lead to dialysis, severe illness or, in some cases, be fatal.
While AKI is not related to CKD, it is recommended that patients who have recovered from COVID-19 and suffered an AKI should be seen regularly by a nephrologist. As these patients may now have a higher risk of developing CKD than the general population. It is recommended that COVID-19 patients who had blood or protein in their urine, but did not suffer an AKI, should also be monitored for CKD.
Chronic Kidney Disease and COVID-19
Though the risk of AKI has been characterized, the long-term impact of COVID-19 infection on kidney disease is still largely unknown.
Potential mechanisms driving chronic kidney disease progression after recovery from COVID-19 can be broadly grouped into three categories: micro or macrovascular injury, unresolved tubular injury, and collapsing/podocytopathy glomerulopathy.
There is likely a bidirectional relationship between CKD and COVID-19. I.e. CKD may increase the risk of developing severe COVID-19, and an increased severity of COVID-19 infection may lead to an increased risk of developing acute and chronic kidney dysfunction. Immunosuppressed patients and patients who have high-burden chronic comorbidities may be at an increased risk of both severe COVID-19 and progressive CKD.
Managing CKD in the Time of COVID-19
The COVID-19 pandemic has substantially affected the incidence and management of the kidney disease spectrum. Recent studies from North America have revealed a much higher incidence of AKI in COVID-19 patients compared to initial reports from China. This increased incidence is likely associated with the higher prevalence of comorbidities such as diabetes, hypertension, and CKD.
Major challenges to patient care
- Delivery of in-person and remote care. Comprehensive care and management of kidney disease require access to multiple aspects of healthcare, including a specialized care team, essential medications, diagnostic testing, and functioning healthcare facilities. Due to large-scale lockdowns due to the pandemic, access to healthcare facilities and care was severely disrupted. Patients with pre-existing kidney disease faced disheartening challenges, especially those needing kidney transplants or dialysis.
The pandemic highlighted the advantages of telemedicine and home-based care in limiting the stress on facilities, protecting healthcare workers, and keeping patients safe from COVID-19 infection.
- Inequality in access to diagnostic tests. The pandemic highlighted the shortage of CKD diagnostic tests worldwide. The challenges resulted in delayed diagnosis, late referrals to nephrologists, loss of opportunity to delay or prevent disease progression, and reduced outcomes. Specialized diagnostic testing for CKD, such as biopsies and ultrasounds, was even more limited due to shutdowns and reduced access to healthcare facilities.
- Inequality in the availability of therapeutic options. The pandemic highlighted several shortcomings of medication availability for kidney disease. For example, the interruption in supply chains impacted the availability of heparin. These drug shortages were also exploited by suppliers with inflated prices.
- Ethnic and racial disparities. In the U.S., COVID-19 disproportionately affected ethnic and racial minority populations, with the CDC reporting that 28.8% of all COVID-19 cases occurred in Hispanic or Latino individuals, while they only make up 18.5% of the population. COVID-19-related kidney disease seems to be impacting African American patients disproportionately, as they made up 44.6% of the COVID-19 kidney biopsies, compared to the 15.4% of patients in the U.S. biopsy database. During the pandemic, disparities in post-hospitalization care in minority populations were well documented of the contribution to the CKD burden.
- Pharmocopolitics. Pharmacopolitics refers to the relationship between the government, pharmacy industry, health professionals, regulatory bodies, and the public. Pre-pandemic Pharmacopolitics has impacted the care of kidney disease patients due to challenges in finding the balance between public interest and the claims for profit from the pharmaceutical industry.
It is important to acknowledge the unique challenges faced by the kidney disease community during the COVID-19 pandemic. Some changes in healthcare due to the pandemic are likely to continue post-pandemic, like the shift towards the use of telemedicine, especially in post-discharge care. However, we still need to understand the barriers to telemedicine in some patient groups, such as low socioeconomic populations. Further intervention studies to prevent CKD and disease progression will be important in reducing long-term mortality and morbidity after COVID-19.
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