Virus may attack kidneys, doctors say
COVID patients show higher rates of injury, a result of possible ‘viral toxicity’
Doctors are unsure why, but COVID-19 patients have turned out to have higher-than-normal rates of kidney injury, but the reasons are not fully understood.
“The virus itself can directly damage the kidney in some patients, and we’re not sure why,” said Dr. Randy Luciano, a nephrologist at Yale New Haven Hospital.
So far, however, there does not appear to be a shortage of dialysis machines needed to remove toxins from the blood of those patients, at least not in Yale New Haven Health’s five hospitals or at Stamford Hospital.
Luciano said a large autopsy study in China showed “direct viral toxicity to the kidney. … I think it’s very possible and I think there’s enough data out there to say that there is direct injury to the kidney.” But he said there isn’t enough information to explain how the coronavirus does its damage.
Any critically ill patient can suffer injury to the kidneys because the blood pressure may drop too low, reducing the amount of blood flowing to the organs, Luciano said. The kidneys may become dehydrated.
Medication and urinary obstructions also can damage the kidneys, he said.
“COVID patients can very well … be affected by the typical things we see in a critically ill patient,” he said. “We don’t know why some people who are COVID-positive and with kidney injury are more susceptible to the virus causing direct kidney injury than non-viral kidney injury.”
While it’s uncertain when COVID-19 admissions will reach their peak, so far Yale New Haven has not faced a shortage of dialysis machines, supplies, including medication, intravenous fluid and tubing, as well as nurses trained to administer dialysis. Earlier this week, Luciano said about 116 of 187 patients in the hospital’s intensive-care unit were positive for coronavirus and, of 15 continuous renal-replacement therapy machines in use, nine were being used for patients with COVID-19. Those function as an artificial kidney and are not commonly needed in criticalcare units, Luciano said.
However, in March, Yale New Haven’s intensive-care unit managers, looking at data from China and Washington state, where the first cases appeared in the
“... (It) showed direct viral toxicity to the kidney. … I think it’s very possible and I think there’s enough data out there to say that there is direct injury to the kidney.”
Dr. Randy Luciano, a nephrologist at Yale New Haven Hospital, about a large autopsy study in China
United States, “estimated … how many beds would be converted to critical-care beds in the hospital,” Luciano said. “We came up with a rough number of 159.”
The team determined they would need 42 dialysis machines and began ordering them. The hospital now has 32, with 10 scheduled to arrive in mid-May.
“We were able to think of the surge and order the appropriate number of machines,” Luciano said. “We came up with a triage protocol where we didn’t want to get into a bind.”
In order to reduce the number of COVID-19 patients who would suffer acute kidney injury, hospital staff have tried to keep fluid from building up in the lungs. More nurses were certified to run the continuous renal replacement therapy machines, and now “well over 250” nurses are trained.
“We’re doing the best we can here. We haven’t had any urgent concerns come up,” Luciano said. “I think over the next several months we’ll get a better history of how these patients are affected.”
Dr. Michael Bernstein, associate director for pulmonary and critical care at Stamford Hospital, said COVID-19 patients are being given more fluids to prevent injury to the kidneys, which is difficult given that too much fluid in the lungs prevents oxygen from getting into the body.
Both saline and a solution with additional salts and sodium lactate, known as lactated Ringer’s, has been used on critically ill patients, Bernstein said. The 20-bed intensive-care unit was increased by potentially 42 additional rooms, but Bernstein said the hospital did not need additional dialysis machines.
He said kidney injury is not technically the same as kidney failure, which is not reversible. However, “whether they’ll completely come back, it’s hard to know.”