COVID-19: Issues related to Kidney Failure, Kidney Transplant and Hypertension

Dr. Onyekachi Ifudu

In late 2019, a novel coronavirus (COVID-19) was identified as the cause of pneumonia in several patients in Wuhan, a city in the Hubei Province of China. By 2020, COVID-19 exploded into a worldwide pandemic.

COVID-19 usually begins as a respiratory infection and disproportionately affects patients with pre-existing conditions, such as patients with kidney disease. Detailed herein are issues related to COVID-19 and acute kidney injury, chronic kidney disease, hypertension or kidney transplant.

Does COVID-19 cause kidney failure

Patients with COVID-19 may present with acute kidney injury (AKI) as part of their overall illness. Kidney disease among patients with COVID-19 may also manifest as increased blood or protein in the urine. In patients with COVID-19 infection, AKI is associated with high mortality and serves as an independent risk factor for death in patients hospitalized with COVID-19.

The incidence of AKI among patients with COVID-19 varies depending upon the severity of disease. Evidence suggests that AKI likely affects over 20% of hospitalized COVID-19 patients and over 50% of COVID-19 patients in the intensive care unit.

It remains unclear if AKI in COVID-19 is due to reduced blood flow to the kidneys or direct injury to the kidneys. The presence of virus-like particles has been reported in the kidneys of patients with COVID-19.

While treatment of AKI in non-COVID-19 patients may include aggressive administration of intravenous fluids, in patients with COVID-19 who develop AKI, too much intravenous fluid must be avoided because it may worsen their respiratory function.

Up to 15 percent of patients with AKI may require some form of dialysis. Of note is that peritoneal dialysis can increase intra-abdominal pressure, interfere with respiratory mechanics, and potentially worsen respiratory function. About one-half of the patients with AKI in hospitalized COVID-19 patients did not achieve complete recovery of their kidney function by hospital discharge, thus kidney function should be closely monitored after discharge.

Does having chronic kidney disease increase COVID-19 risk?

Among patients with COVID-19, chronic kidney disease (CKD) is a risk factor for more severe disease. Patients with end-stage renal disease (ESRD) are particularly vulnerable to severe COVID-19 due to the high frequency of other conditions such as diabetes and hypertension, in this population.

Also, most patients with ESRD receive in-center hemodialysis, limiting their ability to observe social distancing. Patients with ESRD may also be at an increased risk of dying from COVID-19.

Can you get COVID-19 from a kidney transplant

There is a very small risk of transmitting COVID-19 from an organ donor to a recipient based upon the detection of viral RNA in organs that can be transplanted. Because of this risk, all organ donors and transplant candidates should be screened for COVID-19.

Clinical manifestations of COVID-19 in kidney transplant recipients are variable and generally similar to those observed in nontransplant patients. However, fever appears to be less common. Management is also like that for the general population, although careful attention should be paid to potential drug-drug interactions and effects on the immunosuppressive regimen.

Adjustments to the immunosuppressive regimen are individualized. Some kidney transplant recipients recover without reduction in immunosuppression. Conversely, continued immunosuppression may enhance the risk of uncontrolled COVID-19 infection.

Does hypertension increase severity of COVID-19 infection

Among patients with COVID-19, hypertension is a risk factor for more severe disease. History of hypertension was more common among those who had severe, as compared with nonsevere COVID-19.

There was speculation that patients with COVID-19 receiving a type of antihypertensive drug called angiotensin-converting enzyme (ACE) inhibitors (e.g., Lisinopril, Enalapril), or angiotensin receptor blockers (ARBs) (e.g., Valsartan, Losartan) may be at increased risk for adverse outcomes.

However, there is no evidence to support discontinuation of these drugs in patients diagnosed with COVID-19. Most studies found no relationship between the use of ACE inhibitors or ARBs and severity of COVID-19.

Should erythropoiesis-stimulating agents be stopped in CKD patients with COVID-19?

Erythropoiesis-stimulating agents (ESAs) are drugs used for the treatment of anemia in patients with CKD – they work by stimulating the bone marrow to make blood, thereby averting blood transfusion. However, ESAs may theoretically increase the risk of formation of blood clots posed by COVID-19. Currently, there are no good studies to guide use of ESAs in CKD patients with COVID-19 infection. The indications and contraindications for ESAs remain the same in patients with active COVID-19 as they are in patients without COVID-19.

Should patients with CKD and kidney transplant recipients get the COVID-19 vaccine?

Patients with CKD, especially those receiving in-center hemodialysis, represent a susceptible population who are at high risk of death from COVID-19. However, such patients were excluded from most COVID-19 vaccine trials, and therefore, information regarding safety and efficacy of the vaccines in this population is lacking.

However, based upon data from the general population, patients with CKD, dialysis patients, kidney transplant recipients and dialysis facility staff are strongly encouraged to get the COVID-19 vaccine.

Finally, since COVID-19 is a new disease entity, information will be changing as we gain more clinical experience and conduct more research, thus practice guidelines will continue to evolve.

*Ifudu wrote in via Dodokinase@gmail.com

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