Platelets

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Platelets and renal failure in the SARS-CoV-2

syndrome

Muhanad Taha , Dahlia Sano , Samer Hanoudi , Zahia Esber , Morvarid Elahi ,
Ali Gabali , Teena Chopra , Sorin Draghici & Lobelia Samavati

To cite this article: Muhanad Taha , Dahlia Sano , Samer Hanoudi , Zahia Esber , Morvarid Elahi ,
Ali Gabali , Teena Chopra , Sorin Draghici & Lobelia Samavati (2020): Platelets and renal failure in
the SARS-CoV-2 syndrome, Platelets, DOI: 10.1080/09537104.2020.1817361

To link to this article: https://doi.org/10.1080/09537104.2020.1817361

Published online: 06 Sep 2020.

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Platelets, Early Online: 1–8

© 2020 Taylor & Francis Group, LLC. DOI: https://doi.org/10.1080/09537104.2020.1817361

Platelets and renal failure in the SARS-CoV-2 syndrome

Muhanad Taha1, Dahlia Sano2, Samer Hanoudi3, Zahia Esber1, Morvarid Elahi4, Ali Gabali5, Teena Chopra5,
Sorin Draghici3, & Lobelia Samavati 1,6
1
Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University, School of Medicine and Detroit
Medical Center, Detroit, MI, USA, 2Department of Internal Medicine, Division Hematology and Oncology; Wayne State University, School of Medicine
and Detroit Medical Center, Detroit, MI, USA, 3Department of Computer Science, Wayne State University, Detroit, MI, USA, 4Department of Pathology,
Wayne State University, School of Medicine and Detroit Medical Center, Detroit, MI, USA, 5Division of Infectious Diseases, Wayne State University,
Detroit, MI, USA, and 6Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, USA

Abstract Keywords
The coronavirus disease 19 (COVID-19) is a highly transmittable viral infection caused by the AKI, COVID-19, D-Dimer, hypercoagulable,
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SARS-CoV-2 utilizes metallo­ mean platelet volume, renal failure, SARS-
carboxyl peptidase angiotensin receptor (ACE) 2 to gain entry into human cells. Activation of CoV-2
several proteases facilitates the interaction of viral spike proteins (S1) and ACE2 receptor. This
leads to cleavage of host ACE2 receptors. ACE2 activity counterbalances the angiotensin II History
effect, its loss may lead to elevated angiotensin II levels with modulation of platelet function,
Received 27 June 2020
size and activity.
Revised 3 August 2020
COVID-19 disease encompasses a spectrum of systemic involvement far beyond respiratory
Accepted 22 August 2020
failure alone. Several features of this disease, including the etiology of acute kidney injury (AKI)
Published online xx xxx xxxx
and the hypercoagulable state, remain poorly understood. Here, we show that there is a high
incidence of AKI (81%) in the critically ill adults with COVID-19 in the setting of elevated
D-dimer, elevated ferritin, C reactive protein (CRP) and lactate dehydrogenase (LDH) levels.
Strikingly, there were unique features of platelets in these patients, including larger, more
granular platelets and a higher mean platelet volume (MPV). There was a significant correlation
between measured D-dimer levels and MVP; but a negative correlation between MPV and
glomerular filtration rates (GFR) in critically ill cohort. Our data suggest that activated platelets
may play a role in renal failure and possibly hypercoagulability status in COVID19 patients.

Introduction SARS‐CoV‐2 is single-stranded positive-sense RNA virus,

containing an approximately 26–32 kilobase (kb) genome [6].
The coronavirus disease 19 (COVID-19) is a highly transmittable
Similar to other CoV, during viral entry into the host cell the
viral infection caused by the severe acute respiratory syndrome
spike proteins (S) on the envelope of SARS‐CoV‐2 are cleaved
coronavirus 2 (SARS-CoV-2) [1]. On presentation, most infected
into S1 and S2 subunits [7]. Through the S1 receptor-binding
individuals exhibit dry cough, dyspnea, and bilateral ground‐glass
domain (RBD), S1 directly binds to the peptidase domain (PD) of
opacities on radiographic images [2]. While the critical impor­
metallocarboxyl peptidase angiotensin receptor (ACE) 2 to gain
tance of respiratory derangement in COVID-19 is well appre­
entry into human cells [7–9]. ACE receptors (ACE and ACE2)
ciated, several clinical features of COVID-19 infection remain
are expressed in almost all tissues and ACE2 is expressed pre­
poorly understood including the increased incidence of throm­
dominantly on the alveolar epithelial type II cells and capillary
boembolic disease despite being on prophylactic anticoagulation
endothelial cells [10,11]. ACE and ACE2 regulate vascular tone,
and acute renal injury requiring renal replacement therapy. For
fibrinolysis and the coagulation cascade [12,13]. ACE activity
instance, based on our observation and those of others, several
increases vascular tone and activates the coagulation cascade by
patients rapidly decompensate days after stabilization of oxygena­
promoting the generation of angiotensin (Ang) II. In contrast,
tion during or after cessation of mechanical ventilation. Findings
ACE2 receptor activity decreases vascular tone and inhibits acti­
of micro and macrothrombi are common in these patients [3].
vation of the coagulation cascade by generating Ang [1–7], which
Others have documented cerebral ischemic infarcts in these sub­
activates a MAS/G protein receptor. SARS‐CoV‐2 infection leads
jects [4]. Microvascular thrombosis appears to be one defining
to loss of function of ACE2 and increased angiotensin II levels
feature of novel SARS-CoV-2 infection [5]. Formation of vascular
[14]. Activation of the renin-angiotensin–aldosterone system
thrombi in association with progressive severe endothelial injury
(RAAS) plays critical role in renal injury [15]. Angiotensin II is
in COVID-19-infected subjects may determine case fatality and
a potent vasoconstrictor and activates the coagulation cascade by
renal dysfunction in this disease.
increasing platelet activation and size, inducing microvascular
thrombosis [12,16].
Correspondence: Lobelia Samavati Department of Internal Medicine, The coagulation cascade, fibrinolytic system and the comple­
Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State ment system closely collaborate to control a wide range of biolo­
University School of Medicine, Detroit, MI 48201, USA gical and pathological functions including immune responses to
ay6003@wayne.edu
2 Platelets, Early Online: 1–8
pathogens, cell migration and tissue hemostasis. A variety of
microorganisms can trigger endothelial injury, alternative com­
plement activation and hence activate the coagulation pathway
perpetuating inflammation and organ dysfunction. We hypothe­
sized that platelet activation through multiple mechanisms plays
an important role in COVID-19 associated coagulopathy and
acute kidney injury (AKI). Our data indicate significant increase
incidence of AKI in critically ill patients due to COVID-19
infection. Here we show evidence that mean platelet volume
(MPV) reflects platelet activation and activation of coagulation
cascades and plays a major role in the development of acute renal
failure.
Methods
Study Design and Data Collection
We included adult patients with laboratory-confirmed COVID-19
infection admitted to the intensive care units (ICU) at Harper
University Hospital in Metro Detroit between March 15 to
April 20, 2020. A confirmed case of COVID-19 was defined by
a positive result on a reverse-transcriptase–polymerase-chain-
reaction (RT-PCR) assay of a specimen collected on
a nasopharyngeal swab. Only laboratory-confirmed cases were
included. Eighty-one adults (18 years of age or older) were
identified. Informed consent was waived, and researchers ana­
lyzed only deidentified (anonymized) data. Data from each insti­
tution’s electronic medical record were obtained through
a research form. We obtained demographic data, information on
clinical symptoms or signs at presentation, laboratory, and radi­
ologic results. Furthermore, we reviewed the peripheral blood
smears of patients during ICU admission. All laboratory tests
were performed at the discretion of the treating physicians. This
study was reviewed and approved by the Detroit Medical Center
and the Wayne State University Institutional Review Boards.
Specimen Collection and Testing
Clinical specimens for COVID-19 diagnostic testing were
obtained in accordance with Centers for Disease Control and
Prevention (CDC) guidelines. Nasal swabs were performed in
all patients using a real-time RT-PCR assay developed by the
CDC at the Michigan State Public Health Laboratory to detect the
virus.
Laboratory Data
All laboratory data were part of routine clinical data obtained
during hospitalization and ICU admission. The following data
were analyzed: total white blood cell counts (WBC), absolute
lymphocytes counts (ALC), granulocyte count, platelets,
D-dimer, fibrinogen, prothrombin time (PT), partial prothrombin
time (PTT), international normalized ratio (INR). C reactive pro­
tein (CRP), alanine aminotransferase (ALT), aspartate transami­
nase (AST), lactate dehydrogenase (LDH); creatine kinase (CPK)
and mean platelet volume (MPV). Glomerular filtration rates
(GFR) were calculated based on creatinine clearance, gender
and race.
Statistical Analysis
Categorical data are presented as frequency and percentage.
Continuous data are presented either as box plots (WBC, LDH,
CRP, D-D1, D-D2 and ferritin) or line plots with error bars
between two groups. Independent unpaired t-tests were used for
analyzes of continuous variables and the bivariate Spearman’s
rank correlation coefficient was calculated to measure the
relationship between the clinical variables (including AKI) and
coagulation profiles. Acute kidney injury is defined as per guide­
lines of American society of Nephrology [17]. For all analyses,
p-values <0.05 were considered significant. For the GFR data,
a trend analysis was performed on the data from each day for up
to 8 days. Furthermore, trend analysis was performed on the daily
data for GFR and MPV. Each interval represents data from every
3 day except for the last interval, which includes all data beyond
16 days. We compared the presence and absence of AKI and
tested the significance of each interval. A similar analysis was
applied on the daily MPV data. Statistical analyses were per­
formed using SPSS statistical software (Version 27, Chicago,
IL) and the programing language R.
Results
During early March through April 15 we reviewed the charts of
81 subjects who were positive for COVID-19 based on the PCR
assay. Among 81 subjects, 41 (51%) were female. Mean age was
60 ± 13.8 y (range 24–95 y). Almost all subjects in our study had
hypertension (95%), over half (57%) had diabetes mellitus (DM)
and many had a combination of both (55%). Patients demo­
graphics are shown in Table I. The mean body mass index
(BMI) was 33 ± 8.9 kg·m−2. Overall mortality in our study was
65%. Among study subjects, 66 patients (81%) developed acute
renal injury and 49% required renal replacement therapy. As
shown in Table II, we followed a wide range of laboratory para­
meters, including CRP, ferritin, CPK and LDH. We also evaluated
D-dimer levels at two distinct time points during the ICU stay.
D-dimer 1 (D1) is the first reported result after ICU admission
and D-dimer 2 (D2) was drawn approximately 5 days later. In
total, 45 patients had elevated D-dimer levels on the day of ICU-
admission. Therapeutic anticoagulation, either intravenous
unfractionated heparin (IV-UFH) or low molecular weight
heparin (Enoxaparin 1 mg/kg every 12 − 24 h depending on
creatinine clearance) was administered to 18 patients in this
study. All other ICU patients were on pharmacologic venous
thromboembolism prophylaxis with subcutaneous UFH.
There was a significant increase in D2 ranging from 0.25 to
35 mg/dl with a mean±SD of 6.1453 ± 0.98 compared to D1 that
was ranging from 0.9 to 35 mg/dl with a mean±SD of
13.6 ± 1.38. Platelet counts varied among patients, ranging
from 52,000 to 482,000/µL, however, most patients had normal
to high platelet levels. Only one patient had baseline thrombocy­
topenia with a platelet count of 52,000 µL, likely from his
Table I. Clinical characteristics patients.
Characteristic All Patients (N = 81)
Age (y, Mean ± SD) 60 ± 13.8
BMI (Mean ± SD) 32 ± 11.9
Gender, N (%)
Female 41 (50.9)
Male 40 (49.1)
Race, N (%)
African American 63(78%)
Caucasian 3 (3.7%)
Hispanic 1(1.7%)
Unknown 14 (17.3%)
Smoking history, N (%) 14(6%)
Coexisting disorder, N (%)
Hypertension 75 (92%)
Diabetes 46 (57%)
Chronic kidney disease 19 (23%)
Cardiovascular diseases 19 (23%)
Respiratory diseases 13 (16%)
Cancer 2 (2%)
DOI: https://doi.org/10.1080/09537104.2020.1817361 3
Table II. Initial laboratory findings. creatinine values in AKI group were 2.3 ± 1.9 (mg/dL) versus
1.38 ± 1.1 (mg/dL) in the group without AKI. Figure 1 shows the
Variable Mean ± SD No. Reference GFR trends during 8 days of ICU stay between two groups:
ranges absence of AKI (Figure 1A) and presence of AKI (Figure 1B).
White blood cell count, K/CUMM 8.3 ± 4.5 81 3.5–10.6
Platelet count, K/CUMM 229 ± 90 81 150–450 A Student t-test was performed to detect differences in outcome
C-reactive protein, mg/L 189.8 ± 121.4 81 0.0–5.0 variables of selected laboratory values between the group with
Ferritin, ng/mL 1036 ± 1189 79 24–336 and without AKI. Figure 1 shows Box plots overlaid with dot
Alanine aminotransferase, U/L 38 ± 35 72 7–52 plots illustrating mean±SD of the relevant laboratory data com­
Aspartate aminotransferase, U/L 58 ± 53 73 13–39 paring subjects, who developed AKI versus, who did not. As seen
Alkaline phosphatase, U/L 69 ± 29 61 45–115 in Figure 2, we found no significant differences in mean±SD of
Lactate dehydrogenase, U/L 569 ± 313 56 140–271
WBC (Figure 2A) between two groups. Similarly, there were no
Creatine phosphokinase, U/L 565 ± 1404 61 30–223
D-Dimer 1, mg/L* 6.15 ± 8.27 70 0.0–0.50 significant differences in the neutrophil and lymphocytes counts
D-Dimer 2 mg/L ** 13.5 ± 11.2 65 0.0–0.50 between two groups (data not shown). In contrast, we observed
Partial thromboplastin 31.7 ± 7.9 58 23.1–33.1 significant differences (p < .05) in CRP values (Figure 2B),
time, second(s) ferritin (Figure 2C), and LDH (Figure 2D), between these two
Prothrombin time, second(s) 12.2 ± 3.4 59 9.4–11.7 groups. Among patients who required renal replacement therapy,
Fibrinogen, mg/dL 482 ± 236 42 186–466 we observed a high number of subjects (65%), who exhibited
Mean platelet volume, FL 11.4 ± 1.6 81 7.3–11.4
*D-Dimer 1: At day 1 admission
circuit clotting and clotting in central lines, requiring heparin or
**D-Dimer 2: At day 5 admission alteplase treatment. Most striking, we found that patients, who
developed AKI had significantly higher D-dimer levels upon ICU
Abbreviation: WBC: White blood cell count; CRP: C reactive protein; admission (D1) (Figure 2E). Interestingly, the differences in
ALT: Alanine aminotransferase; AST: Aspartate transaminase; LDH: D-dimer levels were more pronounced, when we used the
lactate dehydrogenase; CPK: Creatine kinase; DD1: D-Dimer 1; DD2 D-dimer 2 (D2), which was measured on average at 5th
D-Dimer 2. PTT: Partial Prothrombin time; PT: Prothrombin time.
MPV: Mean platelet volume.
ICU day. Figure 1F shows the mean±SD of D2 between the two
groups. Given the important role of platelets and prothrombin
time in the activation of the coagulation pathway, we analyzed the
underlying cancer and chemotherapy. Similarly, we observed data to identify parameters that correlate with D1and D2. Next,
a wide variation in other laboratory values, including CRP, we performed non-parametric Spearman Correlation Test to iden­
LDH, and ferritin as shown in Table II. Interestingly, we observed tify laboratory parameters correlating with D-dimer levels. We
elevated fibrinogen levels among patients with COVID-19 as used all laboratory data, including PT, PTT, fibrinogen, CRP, Hb,
shown in Table II. ferritin, platelet count, and mean platelet volume (MPV). We
Acute renal injury (AKI) has been associated with worse out­ found a significant correlation between D1 and CRP (r = 0.32;
comes in patients with COVID-19, therefore we analyzed labora­ p < .05), as well as D2 and CRP (r = 0.558; p < .01). Strikingly,
tory data based on the presence or absence of AKI. There were we found a significant correlation of D1 and MVP (0.454;
significant differences (p value< .05:CI<0.095) in renal function p < .01) but we found no correlation between the number of
between subjects with and without AKI. In the AKI group the platelets and D1. When we used D2, we found a significant
mean±SD of blood urea nitrogen (BUN) was 39 ± 24 (mg/dL) correlation of D2 with ferritin (r = 0.303; p < .05), CRP
versus 17 ± 11 (mg/dL) in the group without AKI. The mean±SD (r = 0.475; p < .01), and MPV (r = 0.420; p < .01). Again, we

Figure 1. GFR trend among COVID-19 subjects from day one to day eight of ICU- stay. (A) Mean± SD of GFR (y-axis) in COVID-19 patients without
AKI from day one of admission plotted against time, showing the GFR trend. (B) The trend of GFR among COVID-19 patients with AKI from day1-8
of ICU-stay. There was a significant difference between AKI and non- AKI group in terms of GFR. Trend of GFR during ICU admission among
patients with COVID-19 infection for each day. Error bars plots to show the trend of GFR (y-axis) in COVID-19 patients without acute renal injury (A)
and with acute renal injury (B) during ICU stay. Each error bars plot shows the data from each day. The trend line connects the means of each day, and
the caps represent the SD. The GFR plot shows a continuous deterioration for patients with AKI starting from day 3, in contrast the GFR of patients
without AKI shows continuous improvement.
4 Platelets, Early Online: 1–8

Figure 2. Box blots of main laboratory values among COVID-19 subjects with and without renal failure. Mean± SEM levels of altered laboratory
values among COVID −19 patients who developed acute renal failure as compared to subjects who did not. (A) total WBC count (C/dL). (B)
C reactive Protein (CRP) mg/L. (C) Ferritin (ng/mL). (D) Lactate dehydrogenase (LDH) (U/L). E) D-Dimer 1 (mg/L) at ICU admission. (F) D-Dimer 2
(mg/L). The bottom and top of the boxes represent the 25th and 75th percentile, respectively. The top and bottom bars represent the entire stretch of the
data points for the subjects, except the extreme points, which are indicated with circles (o). The hyphen indicates the median value. The y-axis
represents the concentrations of the laboratory values.

found no significant correlation between D2 and PT, PTT, fibri­
nogen, or platelet counts. In order to further determine the kinetic
of GFR variation in a time-dependent manner during ICU admis­
sion, we collected the daily GFR values of all study subjects and
compare the kinetics of GFR based on the presence and absence
of AKI. Figure 3A shows violin plots for GFR in a time-
dependent manner based on presence and absence of AKI. As
expected, there was a significant difference between GFRs of
subjects with AKI versus no AKI, and deterioration in most
patients occurred within 4–7 days of ICU stay. Similarly, most
patients with AKI died despite renal replacement therapy. Only
six patients, who showed improvement of GFR after 16 days,
survived. We performed similar analysis using MPV. As shown in
Figure 3B, COVID-19 subjects with AKI exhibited significantly

Figure 3. Trend of GFR and MPV during ICU stay among patients with COVID-19 infection. (A) The GFR trend presented as line plot with error bars
to show GFR (y-axis) in COVID-19 patients with and without acute renal injury in time-dependent manner (X-axis) during every 3 days of ICU stay.
Patients with AKI (red) versus without AKI (black). B) MPV trend of patients with AKI (red) without AKI (black). Days of admission (x-axis). Each
error bars plot shows the data of every 3 days. The dot represents the mean, and the cap represents the SD. The FDR p-values of each comparison are
shown at the bottom of the plots. The GFR plot shows a deterioration after day 3 for patients with AKI. After 16 days, this trend showed upwards as
some of the patients were either discharged or expired. The MPV plot shows a consistently higher level in AKI patients when compared to patients
without AKI. After 16 days, this trend of MPV showed downwards. At each time point for GFR and MPV, the comparisons of AKI patients and
without AKI were significant as shown of p-value on the bottom of each interval.
DOI: https://doi.org/10.1080/09537104.2020.1817361 5

larger platelets based on MPV. It is important to mention that all
subjects with COVID-19 have higher MPV values (see normal
value), however, in the AKI group the MPV was significantly
higher. MVP values in our study patients did fluctuate day by day
but on average, a higher MVP correlated with the presence
of AKI.
Because automated platelet counts may be unprecise, espe­
cially with varying platelets size, we reviewed patients’ peripheral
blood smears, which consistently showed findings of large plate­
lets. Figure 4A-F shows representative blood smears of six dif­
ferent subjects. As shown in Figure 4, most patients had enlarged
platelets and several patients had giant platelets (Figure 3C).
Furthermore, we analyzed the data to identify correlation between
laboratory data and outcome of AKI. We found that elevation of
D-dimer at ICU admission or during ICU stay highly correlated
with the development of AKI with a significantly lower false
discovery rate (FDR) of 2.11E-09 for D-dimer 2 as compared
with FDR = 0.000 for the correlation of AKI with D-dimer
values. This suggests rising D-Dimer levels during ICU stay
may be viewed as a poor prognostic marker.
Discussion
Our study showed that 81% of critically ill COVID-19 patients
developed AKI during their ICU course and half of these patients
required renal replacement therapy. Furthermore, the mortality
among the critically ill cohort of COVID-19 patients, who devel­
oped AKI was significantly higher. Previously, a large study
reported the AKI incidence of 17% in critically ill patients
admitted to ICU due to H1N1influenza infection [18]. The inci­
dence of AKI in bacterial sepsis and ARDS has been reported
between 23% and 41% during ICU stay [19,20]. Our data indicate
that the prevalence of AKI in COVID-19 infected individuals was
substantially higher as compared to AKI incidence due to H1N1
or bacterial sepsis. In COVID-19 infection multiple mechanisms
may lead to microcirculatory alterations such as endothelial
injury, autonomic nervous system response, activation of the
coagulation cascade and RAAS pathway.
Soon after the onset of the COVID-19 pandemic, reports of
increased activation of the coagulation pathway and thrombotic
events emerged [21,22]. Patients may present with acute pul­
monary embolism, deep venous thrombosis, acute ischemic
events, or exhibit clotting of arterial and venous lines. Recent
autopsy results confirmed the presence of thrombosis in many
organs including lungs [23]. Our data indicate that a COVID-
19 infection leads to unique patterns of hypercoagulability and
platelet activation play a major role in initiation of coagulation
cascade. These patterns seem to be distinct to the usual DIC
pattern reported in other forms of dysfunctional coagulation
pathways in severe gram-negative sepsis and Acute Respiratory

Figure 4. Peripheral blood smears of subjects with COVID-19 infection. Peripheral blood smear showing (A) platelets with variation in granulation,
shape, and size including large platelets (thin arrow), Wright-Giemsa stain, Objective 100x, immersion oil; (B) large platelets clumps (thin arrow),
Wright-Giemsa stain, Objective 100x, immersion oil (C) giant platelet that is larger than a normal red blood cell and showing a pseudo-nucleus (thin
arrow), Wright-Giemsa stain, Objective 100x, immersion oil; (D) platelets with variation in granulation, shape, and size, Wright-Giemsa stain,
Objective 100x, immersion oil; (E) several large platelets (thin arrow) with variation in shape and size partially adherent to a myelocytes (thick arrow)
(platelet satellitism), Wright-Giemsa stain, Objective 100x, immersion oil; (F) reactive plasmacytoid lymphocytes (thick arrow), Wright-Giemsa stain,
Objective 100x, immersion oil.
6 Platelets, Early Online: 1–8
Distress Syndrome (ARDS) [24,25]. One criterion for DIC is
decreased fibrinogen levels and presence of fibrin monomers
[26]. In the contrary to DIC, we observed increased fibrinogen
level, elevated D-dimers, but normal platelet counts in these
subjects. Our data corroborate with previous reports that
patients with COVID-19 have elevated fibrinogen levels. In
a limited number of subjects, the level of protein C and protein
S was decreased, which is consistent with consumption coagu­
lopathy. Strikingly, we observed a unique feature of platelets in
these patients, including larger, granular platelets with a higher
MPV and increased frequency of large platelets clumps in the
presence of normal platelet counts. This has been defined as
a sign of platelet activation and indicator of increased throm­
bopoiesis [27]. Interestingly, we found increased immature
platelet fraction IPF (IPF>7) in COVID-19-infected subjects,
who had evidence of elevated D-dimers and AKI. Immature
platelets usually have larger size and are considered to be more
reactive and increased IPF has been associated with smoking-
related cardiovascular disease and inflammation [28,29]. Day
to day variation in MVP can be related to various factors,
including misinterpretation of the true platelet size due to
platelets clumps, and some more activated platelets will be
consumed in clot formation and not counted by automatic
reader. It has been shown that larger platelets have denser α-
granules, which store biologically active molecules such as
GPIIb/IIIa, fibrinogen, and von Willebrand factor (vWf)
which can initiate the coagulation cascade [30]. Dense granules
store a variety of molecules which are secreted during platelet
activation; including catecholamines, serotonin, calcium, ade­
nosine 5′-diphosphate (ADP), and adenosine 5′-triphosphate
(ATP) that involved in initiating coagulation cascade during
inflammation [31]. Higher MPV is also seen with DIC and it
has been shown that MPV plays an important role in activation
of coagulation and/or hyperfibrinolysis. If hyperfibrinolysis is
the predominant feature, it is associated with remarkable bleed­
ing rather than increased vascular thrombosis. Reductions in
the levels of natural anticoagulants, such as antithrombin III
and protein C are common in patients with DIC.
Hyperfibrinolysis with subsequent increased bleeding is asso­
ciated with an increase in the levels of cytokines which further
induces plasminogen activator inhibitor I (PAI-I). In viral
hemorrhagic fevers, including in Ebola and Hantavirus pulmon­
ary syndrome, aberrant coagulation and bleeding have been
reported [20,21]. The infection with Ebola virus is associated
with elevated PAI-I levels with increased bleeding [32],
Elevated PIA-I is associated with high mortality in these
patients [33]. Other predominant features of Ebola virus infec­
tion are thrombocytopenia, coagulation factor deficiencies and
elevated D-dimers. In contrast to viral hemorrhagic fevers,
COVID-19 has not been associated with hemorrhage. Soon
after the reports of activation of coagulation and increased
incidence of pulmonary embolisms and DVT emerged, many
centers adopted guidelines to initiate therapy with unfractio­
nated or low molecular weight heparin in patients with
COVID-19 infection. However, our observation and others
suggest that some of these patients continue to be in a pro-
coagulable state as indicated by clinical observations of
ongoing thrombotic disease and laboratory data, for example
increased in D-dimers, despite therapeutic anticoagulation [34].
Experimental data in animals suggested that neither heparin nor
hirudin can overcome the thrombogenic effects of Angiotensin
II (Ang II). Interestingly antithrombin III could reverse the Ang
II associated prothrombotic state in experimental animal model
[12]. It was reported by Llitjos et al. that 56% of patients
infected with COVID-19, who were receiving full dose antic­
oagulation developed VTE [35]. These observations suggest
a limited efficacy of conventional anticoagulant therapy in
COVID-19 associated coagulopathy, warranting to evaluate
the efficacy of antiplatelet drug therapy in this disease.
SARS‐CoV‐2 utilizes the novel ACE 2 receptor to gain
entry into human cells [9]. This process leads to shedding of
host ACE2 receptor and the loss of ACE2 function [22].
Because ACE2 counterbalances the deleterious effect of the
RAAS, through effect of Angiotensin [1–7,36,37], the loss of
ACE2 function amplifies the deleterious effect of angiotensin II
(Ang II). It has been shown that Ang II stimulation leads to
increased platelet size and activation, and that aspirin does not
prevent such activation [16,38]. Other experimental models
suggested that heparin has minimal effect on the Ang II
induced platelet activation [12,38]. In contrast, ACE2 activity
or activation of the MAS receptor promotes antithrombotic
activity and analogues of Angiotensin [1–7] prevent thrombosis
formation [13,36,39]. Alteration of ACE2 function and
increased Ang II have been associated with chronic kidney
disease and diabetes nephropathy [40]. Furthermore, SARS‐
CoV‐2 infection causes endothelial injury, which amplifies
platelet activation. Limited available renal autopsy results of
COVID-19 deceased subjects showed presence of micro­
thrombi and fibrin thrombi in glomerular capillaries [41].
Several studies have shown that hypertension, diabetes and
obesity are associated with dysregulation of Ang II and
ACE2 [42]. In both diseases increased platelet size and activa­
tion have been reported [16,43,44]. It is important to note that
75% of our patients had hypertension and 58% had diabetes
mellitus. The SARS‐CoV‐2 infection and the loss of function
of ACE2 may potentiate the existing prothrombotic state of
subjects with diabetes and hypertension. The unique features
of COVID-19 infection are therefore, the loss of ACE2 func­
tion and increased Ang II activity promote severe endothelial
dysfunction, platelet activation, an increased burden of micro­
vascular thrombosis, and subsequent microcirculatory compro­
mise in many organs including lungs, heart, CNS, and kidney
associated with fatal outcome.
Acknowledgements
This work was supported by a grant (R01HL150474 (LS) as well as the
Department of Medicine, Wayne State University School of Medicine
(LS).
Funding
This work was supported by the National Heart, Lung, and Blood
Institute [R01HL150474].
Author Contributions
MT and ME collected clinical data and contributed in writing the
manuscript. DS and AG reviewed the peripheral blood smear and
contributed in writing the manuscript. SH and SD performed the
statistical analysis of data. TC contributed to data interpretation and
writing the manuscript. LS conceived and designed the study, partici­
pated in all areas of the research such as patients’ selection, data
analysis and writing of the manuscript.
Competing Financial Interests
None of the authors of this manuscript had any financial relationship with
a commercial company.
ORCID
Lobelia Samavati http://orcid.org/0000-0002-3327-2585
DOI: https://doi.org/10.1080/09537104.2020.1817361
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https://doi.org/10.1186/s13613-020-00734-z

RESEARCH Open Access

Acute kidney injury in patients

with SARS‑CoV‑2 infection
Adrien Joseph1, Lara Zafrani1,3*, Asma Mabrouki1, Elie Azoulay1,2 and Michael Darmon1,2

Abstract 
Background:  Acute Kidney Injury (AKI) is a frequent complication of severe SARS-CoV-2 infection. Multiple mecha-
nisms are involved in COVID-19-associated AKI, from direct viral infection and secondary inflammation to comple-
ment activation and microthrombosis. However, data are limited in critically-ill patients. In this study, we sought to
describe the prevalence, risk factors and prognostic impact of AKI in this setting.
Methods:  Retrospective monocenter study including adult patients with laboratory confirmed SARS-CoV-2 infec-
tion admitted to the ICU of our university Hospital. AKI was defined according to both urinary output and creatinine
KDIGO criteria.
Results:  Overall, 100 COVID-19 patients were admitted. AKI occurred in 81 patients (81%), including 44, 10 and 27
patients with AKI stage 1, 2 and 3 respectively. The severity of AKI was associated with mortality at day 28 (p = 0.013).
Before adjustment, the third fraction of complement (C3), interleukin-6 (IL-6) and ferritin levels were higher in AKI
patients. After adjustment for confounders, both severity (modified SOFA score per point) and AKI were associated
with outcome. When forced in the final model, C3 (OR per log 0.25; 95% CI 0.01–4.66), IL-6 (OR per log 0.83; 95% CI
0.51–1.34), or ferritin (OR per log 1.63; 95% CI 0.84–3.32) were not associated with AKI and did not change the model.
Conclusion:  In conclusion, we did not find any association between complement activation or inflammatory mark-
ers and AKI. Proportion of patients with AKI during severe SARS-CoV-2 infection is higher than previously reported and
associated with outcome.
Keywords:  Acute kidney injury, COVID-19, Complement system proteins, Interleukin-6, Outcome, Intensive care units

Background the critically ill (23%; 14–35%) [2–4]. Different applica-

Since December 2019, severe acute respiratory coronavi-
rus 2 (SARS-CoV-2) has spread worldwide, causing more
than 6.6 million cases and 390 000 deaths [1]. This pan-
demic has put unprecedented pressure on healthcare sys-
tems and especially on intensive care units (ICUs).
Acute Kidney Injury (AKI) is a frequent complication
of severe SARS-CoV-2 infection but data are scarce in
ICUs. AKI has been previously reported with an average
incidence of 11% (8–17%) overall, with highest ranges in
*Correspondence: lara.zafrani@aphp.fr
1
Service de médecine Intensive et de réanimation médicale, Hôpital
Saint-Louis, Assistance-Publique Hôpitaux de Paris, Paris University, 1
avenue Claude Vellefaux, 75010 Paris, France
Full list of author information is available at the end of the article
tions of the Kidney Disease Improving Global Outcomes
(KDIGO) criteria for AKI, in particular different methods
to estimate missing baseline creatinine and handling uri-
nary output, can cause important variations of estimated
incidence [5, 6] and may contribute to the discrepancies
among these studies.
Multiple mechanisms are involved in COVID-19-as-
sociated AKI, ranging from direct viral infection of
the kidney and secondary inflammation to comple-
ment activation and microthrombosis [7]. In particular,
severe COVID-19 is associated with uncontrolled sys-
temic inflammatory response with high levels of IL-6
[8] that could potentially lead to intrarenal inflamma-
tion and increased vascular permeability and share sev-
eral features with hyperferritinemic syndromes such as

© The Author(s) 2020. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and
the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material
in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material
is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the
permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat​iveco​
mmons​.org/licen​ses/by/4.0/.
Joseph et al. Ann. Intensive Care (2020) 10:117
macrophage activation syndrome [9]. Furthermore, unre-
strained activation of complement leads to endothelial
cell dysfunction and intravascular coagulation that could
participate in COVID-19-associated AKI [10]. Both IL-6
[11] and complement [12] have been proposed as thera-
peutic targets and understanding their role in COVID-
19-associated AKI is therefore a priority.
However, most of the studies performed to date gave
little data regarding definition of AKI or influence of
inflammation and complement markers on AKI.
In this study, we sought to describe the prevalence, risk
factors and prognostic impact of AKI during COVID-19
in the ICU.
Methods
Study design and cohort
We conducted a retrospective monocenter study includ-
ing adult patients with laboratory confirmed SARS-
CoV-2 infection admitted to the ICU of our university
Hospital. All adult patients (age ≥ 18  years) who tested
positive by polymerase chain reaction testing of a naso-
pharyngeal sample for COVID-19 and were hospitalized
from March 1, 2020 to June 1, 2020 were eligible.
This study was approved by an institutional review
board (French Intensive Care Society—CE SRLF n°20–
32). Need for informed consent was waived as regard to
the study observational design and in accordance with
the French law. This study was conducted in accordance
with the principles of the Declaration of Helsinki.
Data collection, definitions and measurements
All data were obtained from medical records and
patients’ charts. Baseline patients’ characteristics were
collected, including demographics and comorbidities
before ICU admission. The variables recorded regarding
ICU admission and treatments were relative to clinical
presentation, reason for ICU admission, diagnosis, thera-
pies implemented and outcomes.
Blood sampling and routine biological testing were per-
formed on the day of admission according to the stand-
ard laboratory protocols.
All samples were immediately centrifuged at 3000 rpm
at 4 °C for 10 min, separated from the cells and stored at
−80 °C until biochemical assays of complement proteins
C3, C4 (nephelometry) and sC5B9 (ELISA), IL-6 (ELISA)
were performed. The primary outcome was mortality at
day 28.
Definition of AKI
AKI was defined according to both urinary output and
serum creatinine KDIGO criteria [13] as follows: stage
1—increase in serum creatinine by 0.3  mg/dl within
48  h or a 1.5–1.9 times increase in serum creatinine
Page 2 of 8
from baseline or urinary output < 0.5 ml/kg/h for 6–12 h
within 7 days; stage 2—2.9 times increase in serum cre-
atinine or urinary output < 0.5 ml/kg/h for ≥ 12 h within
7 days; stage 3—3 times or more increase in serum cre-
atinine or to ≥ 4.0  mg/dl or initiation of RRT or urinary
output < 0.3 ml/kg/h for ≥ 24 h or anuria for ≥ 12 h within
7  days. Patients were stratified according to the highest
AKI stage attained during the first 7 days of ICU stay.
Baseline creatinine was defined as the best value in the
3 preceding months or if unavailable as the lowest value
during ICU stay or was back calculated based on a glo-
merular filtration rate of 60 mL/min/1.73m2 with MDRD
equation in patients without known chronic kidney dis-
ease. Chronic kidney disease (CKD) was defined accord-
ing to the KDIGO definition.
Modified SOFA was defined as SOFA score [14] exclud-
ing the renal component.
Statistical analysis
Continuous variables were described as median (inter-
quartile range [IQR]) and compared between groups
using the non-parametric Wilcoxon rank-sum test. Cat-
egorical variables were described as frequency (percent-
ages) and compared between groups using Fisher’s exact
test. Mortality was assessed using survival analysis.
Independent risk factors of day 28 mortality were
assessed using Cox model. Conditional stepwise vari-
able selection was performed with 0.2 as the critical
p-value for entry into the model, and 0.1 as the p-value
for removal. Interactions and correlations between the
explanatory variables were carefully checked. Validity of
proportional hazards assumption, influence of outliers,
and linearity in relationship between the log hazard and
the covariates were carefully checked.
Independent risk factors of AKI were assessed using
logistic regression. Conditional backward stepwise vari-
able selection was performed with 0.2 as the critical
p-value for entry into the model, and 0.1 as the p-value
for removal. Interactions and correlations between the
explanatory variables were carefully checked. Influence
of outliers, and linearity in relationship between the
log hazard and the covariates were carefully checked. It
was preplanned to force, one by one, in the final model
inflammation biomarker, ferritin, complement pathway
dosage and PEEP level at admission should these variable
not be selected.
Kaplan–Meier graphs were used to express the prob-
ability of death from inclusion to day 28. Comparisons
were performed using the log-rank test.
Overall, rate of missing data was 6.6% with rate of miss-
ing data among major outcome or covariates was < 5%. As
regard to completeness of the dataset, no imputation of
missing data was performed.
 Joseph et al. Ann. Intensive Care (2020) 10:117
Statistical analyses were performed with R statistical
software, version 3.6.2 (available online at https​://www.r-
proje​ct.org/) and the ‘Survival’ package was used. A p
value < 0.05 was considered significant.
Results
Patients’ characteristics
Overall, 100 COVID-19 patients were admitted in our
ICU between March and May 2020 and included in this
study. Patients’ characteristics are described in Table  1.
Median age was 59  years [53–67] and 70 patients (70%)
were of male gender. Only 15 patients (15%) had no
underlying disease. Hypertension (n = 56, 56%), diabetes
(n = 30, 30%) and chronic kidney disease (n = 29, 29%)
were the main comorbidities. Thirty-six patients were
obese (n = 21, 21%) or overweight (n = 25, 25%) and 30
(30%) were treated with angiotensin converting enzyme
inhibitors or angiotensin-receptor blockers. Median
SOFA score at admission was 4 [2–7]. Median modified
SOFA score [without the renal component] was 3 [2–7].
Fifty-six patients (55%) required mechanical ventilation
and 51 (51%) vasopressor therapy.
Risk factors of AKI in COVID‑19 patients
Rate of patients with missing baseline serum creatinine
was 67% (n = 67) and did not differ between AKI and
patients without AKI (74 vs. 65% respectively; p = 0.67).
AKI occurred in 81 patients (81%), including 44
patients, 10 patients, 27 patients with AKI stage 1, 2 and
3 respectively. Among patients with AKI, 33 (41%) met
only urinary output KDIGO criteria, 28 (35%) met only
creatinine criteria and 20 (25%) met both. Urinary output
criteria alone was more frequently involved in diagno-
sis of milder stage of AKI (AKI stage 1 (n = 20, 45%) and
stage 2 (n = 6, 60%) compared to 26% in stage 3 (n = 7,
p = 0.007). Thirteen (13%) required renal replacement
therapy during the first 7 days in ICU.
Before adjustment, C3 (p = 0.01), IL-6 (p = 0.03) and
ferritin levels (p = 0.03) were associated with AKI sever-
ity, whereas soluble C5b9 fraction was not different
(p = 0.42) (Fig. 1).
In a multivariate model incorporating baseline chronic
kidney disease, only modified SOFA was significantly
associated with the development of AKI (OR per point
1.29; 95% CI 1.04–1.70).
When forced in the final model, C3 (OR per log 0.25;
95% CI 0.01–4.66), IL-6 (OR per log 0.83; 95% CI 0.51–
1.34), ferritin (OR per log 1.63; 95% CI 0.84–3.32), or
PEEP level (OR per mmHg 1.04; 95% CI 0.91–1.22) were
not associated with AKI and did not change the model.
However, after adjustment for modified SOFA and
CKD, C3 value higher than median was significantly
Page 3 of 8
associated with a lower risk for AKI stage 2 or 3, com-
pared to no AKI or AKI stage 1 (OR 0.17 95% CI [0.05–
0.54], p = 0.004), while the association between AKI stage
2 or 3 and IL-6, Ferritin, sC5b9 and PEEP levels did not
reach statistical significance (Additional file  1: Table  S1
and Figure S1).
Outcome analysis
Twenty-nine (29%) patients had died by day 28, 28
(35%) patients with AKI and 1 (5%) patient without AKI
(p = 0.02). More than half of the patients with AKI stage
2 (n = 5, 50%) and 3 (n = 15, 56%) died before day 28. The
severity of AKI was associated with mortality at day 28
(p = 0.013) (Fig. 2 and Additional file 1: Figure S2).
Patients who died were older (66 versus 57  years,
p = 0.001), suffered more frequently from chronic kid-
ney disease (52 versus 20%, p = 0.003), had higher SOFA
score (8 versus 2, p < 0.001), ferritin levels (1805 versus
1148 mg/L, p = 0.004) and IL-6 levels (204 versus 103 ng/
mL, p = 0.02), and were less often immunocompetent (46
versus 18%, p = 0.01). Neither comorbidities nor BMI
were associated with death at day 28. Patients who died
more often required mechanical ventilation (90 versus
41%, p < 0.001), vasopressors (90 versus 36%, p < 0.001)
and renal replacement therapy (31 versus 6%, p = 0.002).
After adjustment for confounders, both AKI and sever-
ity (modified SOFA score per point) were associated with
survival (Table 2).
There was a similar trend towards poorer survival
in patients with (n = 33) and without (n = 67) baseline
serum creatinine (Additional file 1: Figure S3).
We also tested the interaction between missing baseline
serum creatinine and reported results and did not find
any significant interaction (Additional file 1: Table S2).
Treatments with lopinavir/ritonavir (n = 10), tocili-
zumab (n = 1), eculizumab (n = 2) or chloroquine (n = 3)
were associated neither with mortality nor with the
development of AKI.
Discussion
In this study, we describe the incidence of AKI in 100
COVID-19 patients admitted to the ICU, and the link
between AKI, inflammation markers and complement
levels. The main results of this case series are the higher
than previously reported incidence of AKI and its lack
of association with IL-6, ferritin or complement fac-
tors C3 and sC5B9. The importance of AKI in COVID-
19 patients has been increasingly recognized. If initial
reports from China reported rates of AKI as low as 2.9–
8% in severe patients [2, 15, 16], incidences from later
studies ranged between 15% [17] and 44% [18] in criti-
cally ill patients. Most reports lack a clear operational
AKI definition [19–21], but even in studies that used
Joseph et al. Ann. Intensive Care (2020) 10:117 Page 4 of 8

Table 1  Patients’ characteristics according to AKI

Overall No AKI AKI p value
n = 100 n = 19 n = 81

Age (year) 59 [53–67] 54 [45–61] 60 [54–68] 0.05

Male gender 70 (70%) 11 (58%) 59 (73%) 0.32
Absence of underlying comorbidity 15 (15%) 6 (32%) 9 (11%) 0.06
Chronic Obstructive Pulmonary Disease 2 (2%) 0 (0) 2 (3%) 1.00
Asthma 8 (8%) 2 (11%) 6 (8%) 1.00
History of hypertension 56 (56%) 8 (42%) 48 (60%) 0.25
Diabetes 30 (30%) 3 (16%) 27 (34%) 0.21
Immunocompromized 26 (26%) 4 (21%) 22 (28%) 0.78
Heart failure 15 (15%) 0 (0) 15 (19%) 0.09
Chronic kidney disease 29 (29%) 2 (11%) 27 (33%) 0.09
Body Mass Index (Kg/m2) 28 [24–31] 26 [23–31] 28 [24–31] 0.48
Obesity and overweight 0.37
Overweight 25 (25%) 3 (16%) 22 (27%)
Obese 21 (21%) 3 (16%) 18 (22%)
Other 54 (54%) 13 (68%) 41 (51%)
Chronic use of ACE/ARB 30 (30%) 3 (16%) 27 (33%) 0.22
Baseline serum creatinine (µmol/L) 65 [50–93] 63 [48–70] 67 [50–100] 0.22
SOFA score 4 [2–7] 2 [2, 3] 5 [2–7] 0.003
Nonsteroidal anti-inflammatory drugs (%) 1 (1%) 0 (0) 1 (1%) 1.00
Invasive mechanical ventilation 55 (55%) 6 (32%) 49 (61%) 0.04
PEEP at day 1 0 [0–10] 0 [0–4] 8 [0–10] 0.04
Renal replacement therapy 13 (13%) 0 (0) 13 (16%) 0.14
Vasopressors 51 (51%) 7 (37%) 44 (55%) 0.24
IL6 at day 0 (ng/mL) 118 [67–287] 136 [63–292] 113 [69–287] 0.98
C3 at day 0 (ng/mL) 1305 [1173–1550] 1495 [1285, 1630] 1260 [1160–1543] 0.06
C4 at day 0 (ng/mL) 348 [275–418] 351 [282–493] 348 [272–416] 0.69
sC5b9 at day 0 (ng/mL) 373 [270–471] 425 [317–516] 363 [266–450] 0.22
Ferritin at day 0 (mg/L) 1272 [636–2234] 1182 [495–1584] 1311 [695–2322] 0.12
Fibrinogen at day 0 (g/L) 6.8 [5.8–7.8] 7.2 [5.4–7.7] 6.7 [5.8–7.8] 0.94
Acute kidney injury - 81 (81%) 0 (0) 81 (100%)  < 0.001
KDIGO stage  < 0.001
No AKI 19 (19%) 19 (100%) 0 (0)
Stage 1 44 (44%) 0 (0) 44 (54%)
Stage 2 10 (10%) 0 (0) 10 (12%)
Stage 3 27 (27%) 0 (0) 27 (33%)
KDIGO criteria fulfilled  < 0.001
Creatinine criteria alone 28 (28%) 0 (0) 28 (35%)
Oliguria alone 33 (33%) 0 (0) 33 (41%)
Both criteria 20 (20%) 0 (0) 20 (25%)
None 19 (19%) 19 (100%) 0 (0)
Day-28 mortality 29 (29%) 1 (5%) 28 (35%) 0.02
Specific treatment during ICU stay 0.35
Chloroquine or Hydroxychloroquine 3 (3%) 0 (0) 3 (4%)
Eculizumab 2 (2%) 0 (0) 2 (3%)
Lopinavir/ritonavir 10 (10%) 0 (0) 10 (12%)
Tocilizumab 1 (1%) 0 (0) 1 (1%)
None 84 (84%) 19 (100%) 65 (80%)
Results are presented as median (interquartile) or n (%)
ACE angiotensin converting enzyme inhibitors, ARB angiotensin receptor blockers
 Joseph et al. Ann. Intensive Care (2020) 10:117 Page 5 of 8

Fig. 1  Boxplots depicting relationship between AKI severity and C3 [ng/mL] (p = 0.01) (a), IL-6 [ng/mL] (p = 0.02) (b), sC5b9 [ng/mL] (p = 0.42) (c)
and ferritin levels [mg/L] (p = 0.03) (d) levels

Fig. 2  Kaplan–Meier curves for day-28 survival in patients with (n = 81) and without AKI (n = 19) (a) and with AKI stage 1 (n = 44), 2 (n = 10) and 3
(n = 27) (b)

KDIGO serum creatinine criteria, diuresis was inconsist- With 81% of patients diagnosed with AKI, the rate of AKI
ently taken into account, and none of them reported AKI in our study is much higher than previously reported.
stages. Our study is the largest published to date report- Interestingly, one of the largest cohort from the United
ing incidence of AKI specifically in critically ill patients. States reported a prevalence of AKI in COVID-19
Joseph et al. Ann. Intensive Care (2020) 10:117
Table 2  Factors associated with survival censored at day 28 (Cox Model) and risk of AKI (logistic regression)
Model 1 (survival censored at day 28)
 Modified SOFA score at admission (per point)
 Acute Kidney Injury
Model 2 (acute kidney injury)
 Chronic kidney disease
 Modified SOFA score at admission (per point)
Model selection was performed according to forward variable selection conditioned on p value (critical entry p value < 0.2, critical exit p value < 0.1)
patients requiring mechanical ventilation of 80% [22],
close to our finding of 90%.
One strength of our study is the rigorous use of KDIGO
criteria, including urinary output. Furthermore, given
that many patients will present with AKI without a reli-
able baseline serum creatinine on record, estimation of
the latter is of tremendous importance. Several methods
to estimate missing baseline creatinine can lead to varia-
tions in incidence of AKI up to 15% [6]. Using complete
KDIGO definition we found a 80% incidence of AKI dur-
ing the first 7  days of ICU stay and a 90% incidence in
patients requiring mechanical ventilation.
We also tested the hypotheses that COVID-19-as-
sociated-AKI is linked to the elevation of cytokines
induced by SARS-CoV-2 infection [23], complement
dysregulation [12] induced by SARS-CoV-2 infection
or mechanical ventilation settings. High levels of IL-6
have been associated with the development of severe
disease [24, 25] and acute respiratory distress syn-
drome [8] during COVID-19 infection, but the role
of inflammation markers in COVID-19-induced-AKI
remains speculative [7]. The deleterious role of IL-6 has
been demonstrated in different models of AKI, includ-
ing ischemic AKI, nephrotoxin-induced AKI and sep-
sis-induced AKI [26, 27]. In our study, IL-6 and ferritin
levels correlated with severity but were not indepen-
dently associated with AKI. The complement system
represents the first response of the host immune sys-
tem. It participates in the development of AKI [28] and
has also been suspected to play a role in AKI in the
context of SARS-CoV-2 infection [10, 12]. Recent stud-
ies showed a strong immunohistochemical staining of
complement cascade components in the lungs [29] and
kidneys [30] of severe COVID-19 patients. However,
even if C3 levels were associated with AKI severity in
univariate analysis, the association did not persist when
forced into a multivariate model, and soluble C5b9
showed no association with AKI. C3 level was only
independently associated with AKI stage 2 and 3 com-
pared to no AKI or AKI stage 1. Overall, our results
do not support a role for complement dysregulation
Page 6 of 8
Estimate 95% CI p value
Hazard ratio
1.23 1.04–1.45 0.01
3.08 1.12–8.45 0.03
Odds ratio
3.91 0.97–26.20 0.09
1.29 1.04–1.70 0.04
in COVID-19-induced-AKI, even though complement
dysregulation may be involved in the most severe forms
of AKI.
Although our study did not include extensive coagu-
lation explorations [31], the lack of difference in fibrin-
ogen levels in patients with AKI when compared to
patients without AKI does not support the evidence
of a role of hypercoagulability in COVID-19-induced-
AKI, suggested by the presence of thrombi in glomeru-
lar loops described by others [32, 33]. Last, high levels
of PEEP in COVID-19 patients [34, 35] have also been
suggested as a potential factor for increased AKI in
severe COVID-19 patients [36]. In our study, PEEP lev-
els were not independently associated with the devel-
opment of AKI, but the lack of statistical power and
longitudinal data on PEEP levels does not allow for any
definite conclusion.
Our study also has limitations. First, despite being the
largest focusing on COVID-19-induced-AKI in the ICU,
the limited number of patients can translate into a lack
of statistical power. Nevertheless, rate of AKI and sample
size allow confirming a high AKI incidence with a rea-
sonable level of confidence (81%; 95% CI 72–89). In addi-
tion, the monocenter design may have limited external
validity of our findings. The proportion of missing base-
line serum creatinine value (67%) may also be an issue.
Missing baseline creatinine value is a common problem
in research focusing on AKI, and although most studies
do not report the proportion of missing baseline values,
rates as high as 85% are common [22]. We provide sensi-
tivity analyses (Additional file 1: Figure S3 and Table S2)
to show that back calculation of missing baseline creati-
nine values unlikely results in a significant bias. Last, lack
of association between inflammation biomarker, IL-6 or
complement component do not preclude participation
of these mechanisms to AKI. They only underline that
in this setting and when adjusted to severity, these fac-
tors have little influence on AKI rate. Additional stud-
ies, assessing levels of proteinuria and hematuria [22,
37], pathological findings and translational research are
needed to further explore different mechanisms that may
participate to AKI during severe SARS-CoV-2 infection.
 Joseph et al. Ann. Intensive Care (2020) 10:117
In conclusion, we did not find any association between
complement activation or inflammatory markers and
AKI. Our study suggests a tremendously high incidence
of AKI in our cohort of critically ill COVID-19 patients,
along with an independent association between AKI and
outcome. Because of its marked influence on outcome,
AKI should be identified promptly during SARS-CoV-2
infection.
Supplementary information
Supplementary information accompanies this paper at https​://doi.
org/10.1186/s1361​3-020-00734​-z.
Additional file 1: Figure S1. Boxplots depicting relationship between AKI
stage 2 and 3 and C3 [ng/mL] (A), IL-6 [ng/mL] (B), sC5b9 [ng/mL] (C) and
ferritin levels [mg/L] (D) levels, and predicted probabilities of severe AKI
according to ferritin (E) and C3 (F) deciles (per log). Figure S2. Kaplan-
Meier curve for day-28 survival in patients without AKI or with AKI stage
1 (n=63) compared to AKI stage 2 or 3 (n= 37). Figure S3. Kaplan-Meier
curves for day-28 survival according to AKI (A and B) and AKI stages (C and
D) in patients with (n=33, B and D) and without (n= 67, A and C) baseline
creatinine value. Table S1. Factors associated with risk of AKI stage 2 and
3, compared to no AKI or AKI stage 1, after adjustment for modified SOFA
and chronic kidney disease (logistic regression). Table S2. Interaction
between missing baseline serum creatinine and reported results.
Abbreviations
ACE2: Angiotensin-converting enzyme 2; AKI: Acute kidney injury; COVID-19:
Coronavirus disease 2019; ICU: Intensive care unit; KDIGO: Kidney disease
improving global outcome; PEEP: Positive end expiratory pressure; SARS-
COV-2: Severe acute respiratory coronavirus 2.
Authors’ contributions
MD, LZ and EA contributed to the study conception and design. AJ, MD, AM
and LZ performed the data collection and the initial data analysis. AJ, LZ and
MD prepared the first draft of the manuscript. All authors contributed to the
data analysis and to the critical revision. All authors read and approved the
final manuscript.
Ethics approval and competing interests
MD declares having received grant from MSD, speaker fees from MSD, Astelas
and Gilead-Kite and having attended an advisory board for Gilead-Kite. LZ
declares having received research grant from Jazz Pharmaceuticals. The other
authors have no conflict of interest to declare.
Consent for publication
Not applicable.
Author details
1
 Service de médecine Intensive et de réanimation médicale, Hôpital Saint-
Louis, Assistance-Publique Hôpitaux de Paris, Paris University, 1 avenue Claude
Vellefaux, 75010 Paris, France. 2 ECSTRA Team, UMR 1153, Center of Epidemiol-
ogy and Biostatistics, INSERM, Université de Paris, Paris, France. 3 INSERM U976,
Université de Paris, Paris, France.
Received: 11 June 2020 Accepted: 27 August 2020
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 CLINICAL RESEARCH www.jasn.org

Clinicopathological Features and Outcomes of Acute

Kidney Injury in Critically Ill COVID-19 with Prolonged
Disease Course: A Retrospective Cohort
Peng Xia,1 Yubing Wen,1 Yaqi Duan,2,3 Hua Su,4 Wei Cao,5 Meng Xiao,6 Jie Ma,1
Yangzhong Zhou,1 Gang Chen,1 Wei Jiang,7 Huanwen Wu,8 Yan Hu,1 Sanpeng Xu,2
Hanghang Cai,2 Zhengyin Liu,5 Xiang Zhou,9 Bin Du ,7 Jinglan Wang,10 Taisheng Li,5
Xiaowei Yan,11 Limeng Chen,1 Zhiyong Liang,8 Shuyang Zhang,11 Chun Zhang ,4
Yan Qin ,1 Guoping Wang,2,3 and Xuemei Li1
Due to the number of contributing authors, the affiliations are listed at the end of this article.

ABSTRACT
Background The incidence, severity, and outcomes of AKI in COVID-19 varied in different reports. In patients
critically ill with COVID-19, the clinicopathologic characteristics of AKI have not been described in detail.
Methods This is a retrospective cohort study of 81 patients critically ill with COVID-19 in an intensive care
unit. The incidence, etiologies, and outcomes of AKI were analyzed. Pathologic studies were performed in
kidney tissues from ten deceased patients with AKI.
Results A total of 41 (50.6%) patients experienced AKI in this study. The median time from illness to AKI
was 21.0 (IQR, 9.5–26.0) days. The proportion of Kidney Disease Improving Global Outcomes (KDIGO)
stage 1, stage 2, and stage 3 AKI were 26.8%, 31.7%, and 41.5%, respectively. The leading causes of AKI
included septic shock (25 of 41, 61.0%), volume insufficiency (eight of 41, 19.5%), and adverse drug effects
(five of 41, 12.2%). The risk factors for AKI included age (per 10 years) (HR, 1.83; 95% CI, 1.24 to 2.69;
P50.002) and serum IL-6 level (HR, 1.83; 95% CI, 1.23 to 2.73; P50.003). KDIGO stage 3 AKI predicted
death. Other potential risk factors for death included male sex, elevated D-dimer, serum IL-6 level, and
higher Sequential Organ Failure Assessment score. The predominant pathologic finding was acute tubular
injury. Nucleic acid tests and immunohistochemistry failed to detect the virus in kidney tissues.
Conclusions AKI was a common and multifactorial complication in patients critically ill with COVID-19 at
the late stage of the disease course. The predominant pathologic finding was acute tubular injury. Older
age and higher serum IL-6 level were risk factors of AKI, and KDIGO stage 3 AKI independently predicted death.

JASN 31: 2205–2221, 2020. doi: https://doi.org/10.1681/ASN.2020040426

Received April 9, 2020. Accepted July 22, 2020.

Coronavirus disease 2019 (COVID-19) is a new
contagious disease caused by severe acute respi-
ratory syndrome coronavirus 2 (SARS-CoV-2),
causing .10 million cases and 500,000 deaths
worldwide.1,2 Most of patients had mild cases of
the disease which primarily presented as acute re-
spiratory illness.3–7 About 15.7%–26.0% of the
COVID-19 cases were classified as severe or criti-
cally ill, with mortality as high as 60%.3,7,8 Based on
the published studies, the median time from illness
to death in early severe cases was 16–18.5 days.3,7,9
Early reports suggested the renal involvement in
P.X., Y.W., Y.D., H.S., and W.C. contributed equally to this work.
Published online ahead of print. Publication date available at www.jasn.org.
Correspondence: Dr. Yan Qin, Department of Nephrology, Pe-
king Union Medical College Hospital, Chinese Academy of
Medical Sciences, No.1 Shuaifuyuan, Wangfujing Street, Beijing
100730, China, or Dr. Guoping Wang, Institute of Pathology,
Tongji Hospital, Tongji Medical College, Huazhong University of
Science and Technology, No.1095 Jie Fang Avenue, Hankou,
Wuhan 430030, China and Department of Pathology, School of
Basic Medical Science, Tongji Medical College, Huazhong Uni-
versity of Science and Technology, Wuhan 430030, China.
E-mail: qinyanbeijing@126.com or wanggp@hust.edu.cn
Copyright © 2020 by the American Society of Nephrology

JASN 31: 2205–2221, 2020 ISSN : 1046-6673/3109-2205 2205

 CLINICAL RESEARCH www.jasn.org
patients with COVID-19 might not be very common.7,10,11
Recent studies showed the incidence of AKI in severe cases
varied from 2.9% to 50%, due to different definitions and
clinical situations.7,8,10,12–14 The detection of SARS-CoV-2
in urine samples and kidney tissues of patients with
COVID-19 also showed varying results (B. Diao, C. Wang,
R. Wang, Z. Feng, Y. Tan, H. Wang, et al.: Human kidney is
a target for novel severe acute respiratory syndrome corona-
virus 2 [SARS-CoV-2] infection, 2020; doi:10.1101/2020.03.
04.20031120).15–19 Elevated inflammatory markers, such as
high-sensitivity C-reactive protein and IL-6, in patients with
COVID-19 were described.7,8 It is reasonable to raise the con-
cern that kidney damage might be related to direct viral in-
fection of the kidney and the following hyperinflammation
process.20 So far, the limited evidence of kidney histologic
changes in COVID-19 cases revealed mainly tubular in-
jury.10,18,21 Electron microscopic (EM) evidence of virus in-
fection in kidney was also under debate.18,22,23 In summary, it
is a pressing demand to improve our understanding of the
kidney involvement in COVID-19 in different clinical con-
texts, especially in patients who are critically ill with a relative-
ly long disease course. In this study, we provide a detailed
description of the clinical data from 81 patients who were
critically ill, and renal pathologic findings from ten deceased
patients with AKI in intensive care unit (ICU) settings.
METHODS
Study Design and Participants
This is a single-center, retrospective study conducted in an
ICU designated for patients critically ill with COVID-19 at
the Sino-French New City Campus of Tongji Hospital in Wu-
han, China, which is run by the medical team from Peking
Union Medical College Hospital (PUMCH). All of the pa-
tients in ICU who met the criteria of having a critical case of
the disease from February 5 to March 20, 2020 were
included in this study. The deceased adult patients whose
family member had provided oral consent for a minimally
invasive autopsy received needle autopsies of the kidneys.
The written consent was waived due to the visiting restric-
tions during the epidemic. This study was approved by the
PUMCH Institutional Review Board (ZS-2328, SK-1197).
The diagnosis of COVID-19 was made according to the
Guideline of Chinese National Health Commission (Fifth
Trial Edition).24 The clinical diagnosis criteria were as fol-
lows: (1) fever or respiratory symptoms, (2) leukopenia or
lymphopenia, and (3) computerized tomography scan
showing radiographic abnormalities in lung. Those with
two or more clinical diagnosis criteria and a positive result
to high-throughput sequencing or RT-PCR assay of SARS-
CoV-2 were diagnosed with COVID-19.
Critically ill COVID-19 cases were defined as including at
least one of the following: septic shock, respiratory failure
2206 JASN
Significance Statement
Coronavirus disease 2019 (COVID-19) is a new contagious disease.
Previous studies reported AKI with varying results regarding the
incidence, severity, and outcomes. This study provides detailed
clinical data of 81 patients critically ill with COVID-19 and a prolonged
disease course, and provides renal pathologic findings from ten de-
ceased patients with AKI in a single intensive care unit in Wuhan,
China. The incidence of AKI was 50.6%, with 41.5% of cases of AKIs
were Kidney Disease Improving Global Outcomes (KDIGO) stage 3.
The primary pathological findings were those of acute tubular injury.
Nucleic acid tests and immunohistochemistry failed to detect the virus
in kidney tissues. Older age and serum IL-6 levels were risk factors of
AKI. KDIGO stage 3 AKI independently predicted death.
requiring mechanical ventilation, and a combination of other
organ failures and admission to ICU.
Data Collection and Definitions
The electronic medical records, laboratory results, and medical
order lists were carefully reviewed to extract the data. AKI was
diagnosed according to the Kidney Disease Improving Global
Outcomes (KDIGO) clinical practice guidelines.25 For those
who had no baseline serum creatinine (sCr) data, the diagnosis
was made by the clinical evaluations of three independent ne-
phrologists. eGFR was calculated based on the CKD–
Epidemiology Collaboration equation using sCr. Volume
insufficiency–induced AKI was diagnosed based on the history
of poor intake and/or volume loss and rapid recovery of AKI
after volume supplementation. Fever was defined as an axillary
temperature of at least 37.3°C. Sepsis and septic shock were
defined according to the 2016 Third International Consensus
Definitions for Sepsis and Septic Shock.26 Acute respiratory
distress syndrome (ARDS) was diagnosed according to the Ber-
lin definition.27 Cardiac injury was diagnosed if serum levels of
cardiac biomarkers (e.g., high-sensitivity cardiac troponin I)
were above the 99th percentile upper reference limit. Coagul-
opathy was defined as a 3-second extension of prothrombin
time (PT) or a 5-second extension of activated partial throm-
boplastin time. Hypoalbuminemia was defined as serum albu-
min ,25 g/L. The primary outcome was defined as death in
hospital before March 20, 2020.
Minimally Invasive Needle Autopsy of Kidneys
The minimally invasive needle autopsies were performed by
the nephrologists using the 16-guage biopsy needle (BARD
MN1620) under ultrasound guidance. The autopsies were
performed in the right kidneys of the deceased patients. The
first slices of kidney tissues were sent for PCR tests of SARS-
CoV-2. Other samples were fixed in 4% neutral formaldehyde
and 2.5% glutaraldehyde for further pathologic processing.
Light Microscopic Examinations and Transmission EM
Examinations
Specimens were fixed with 4% neutral formaldehyde and em-
bedded in paraffin wax. Sections (2 mm thick) were cut;
JASN 31: 2205–2221, 2020
 www.jasn.org CLINICAL RESEARCH

Table 1. Demographic and clinical characteristics of patients

Presence of AKI Survival
All Patients
Characteristics Non-AKI P Nonsurvivors Survivors
(n581) AKI (n541) P Value
(n540) Value (n560) (n521)
Clinical characteristics
Age (yr), mean6SD 66.6611.4 69.669.3 63.6612.7 0.02a 68.2610.4 62.0613.3 0.03a
Sex, n (%)
Female 27 (33.3%) 11 (26.8%) 16 (40.0%) 0.21 15 (25.0%) 12 (57.1%) 0.007a
Male 54 (66.7%) 30 (73.2%) 24 (60.0%) – 45 (75.0%) 9 (42.9%) –
APACHE II score on ICU day 1, 15 (11–19) 16 (12–22) 14 (10–16) 0.02a 16 (12–20) 12 (10–16) 0.01a
median (IQR)
SOFA score on ICU day 1, median 6 (4–8) 7 (5–10) 6 (4–8) 0.03a 7 (5–10) 4 (3–5) ,0.001a
(IQR)
Median arterial pressure (mm Hg), 93 (82–103) 93 (82–104) 92 (82–103) 0.79 90 (80–103) 97 (89–104) 0.16
median (IQR)
Comorbidity, n (%)b
Hypertension 43 (53.1%) 23 (56.1%) 20 (50.0%) 0.58 30 (50.0%) 13 (61.9%) 0.35
Diabetes mellitus 19 (23.5%) 11 (26.8%) 8 (20.0%) 0.47 12 (20.0%) 7 (33.3%) 0.22
Coronary heart disease 17 (21.0%) 8 (19.5%) 9 (22.5%) 0.74 12 (20.0%) 5 (23.8%) 0.71
Cerebrovascular disease 11 (13.6%) 2 (4.9%) 9 (22.5%) 0.02a 6 (10.0%) 5 (23.8%) 0.11
CKD 3 (3.7%) 1 (2.4%) 2 (5%) 0.62 1 (1.6%) 2 (9.5%) 0.16
Current smoker, n (%)c 12 (16.0%) 7 (18.4%) 5 (13.5%) 0.56 9 (16.7%) 3 (14.3%) .0.99
Complications, n (%)
ARDS 77 (95.1%) 37 (90.2%) 40 (100.0%) – 57 (95.0%) 20 (95.2%) .0.99
Septic shock 51 (63.0%) 28 (68.3%) 23 (57.5%) 0.32 44 (73.3%) 7 (33.3%) 0.001a
Altered mental status 39 (48.1%) 19 (46.3%) 20 (50.0%) 0.74 30 (50.0%) 9 (42.9%) 0.57
Cardiac injury 61 (79.0%) 33 (80.5%) 31 (77.5%) 0.74 51 (85.0%) 13 (61.9%) 0.03a
Arrythmias 29 (35.8%) 17 (41.5%) 12 (30.0%) 0.28 25 (41.7%) 4 (19.0%) 0.07
Coagulopathy 51 (63.0%) 30 (73.2%) 21 (52.5%) 0.05 43 (71.7%) 8 (38.1%) 0.006a
Liver injury 32 (39.5%) 19 (46.3%) 13 (32.5%) 0.20 28 (46.7%) 4 (19.0%) 0.03a
Hypercapnia 44 (54.3%) 26 (63.4%) 18 (45.0%) 0.10 37 (61.7%) 7 (33.3%) 0.03a
Secondary infection 47 (58.0%) 26 (63.4%) 21 (52.5%) 0.32 34 (56.7%) 13 (61.9%) 0.68
Pneumothorax 7 (8.6%) 5 (12.2%) 2 (5.0%) 0.43 7 (11.7%) 0 (0.0%) –
AKI 41 (50.6%) – – – 34 (56.7%) 7 (33.3%) 0.07
Initial symptoms, n (%)
Fever 72 (88.9%) 34 (82.9%) 38 (95.0%) 0.08 54 (90.0%) 18 (85.7%) 0.69
Cough 63 (77.8%) 33 (80.5%) 30 (75.0%) 0.55 46 (76.7%) 17 (81.0%) 0.77
Sputum 33 (40.7%) 15 (36.6%) 18 (45.0%) 0.44 22 (36.7%) 11 (52.4%) 0.21
Fatigue 46 (56.8%) 21 (51.2%) 25 (62.5%) 0.31 34 (56.7%) 12 (57.1%) 0.97
Anorexia 26 (32.1%) 11 (26.8%) 15 (37.5%) 0.30 22 (36.7%) 4 (19.0%) 0.18
Vomit 8 (9.9%) 4 (9.8%) 4 (10.0%) 0.97 5 (8.3%) 3 (14.3%) 0.42
Diarrhea 20 (24.7%) 9 (22.0%) 11 (27.5%) 0.56 17 (28.3%) 3 (14.3%) 0.25
Headache 9 (11.1%) 6 (14.6%) 3 (7.5%) 0.48 8 (13.3%) 1 (4.8%) 0.43
Myalgia 15 (18.5%) 6 (14.6%) 9 (22.5%) 0.36 8 (13.3%) 7 (33.3%) 0.04a
Dyspnea 55 (67.9%) 29 (70.7%) 26 (65.0%) 0.58 42 (70.0%) 13 (61.9%) 0.49
a
P,0.05.
b
Hypertension and diabetes histories were diagnosed based on self-reports from patients or family members. Coronary heart disease was diagnosed based the self-
reports from patients or family members about the coronary angiography results or histories of coronary stenting. Cerebrovascular disease was diagnosed based on
the self-reports from patients or family members about the histories of ischemic or hemorrhagic cerebrovascular incidents and positive image findings. CKD was
defined as abnormalities of kidney structure or function for at least 3 months.
c
All patients, n575; AKI, n538; non-AKI, n537; nonsurvivors, n554; survivors, n521.

stained with hematoxylin and eosin, Periodic acid–Schiff, Pe-
riodic acid–silver methenamine, and Masson trichrome; and
scanned as high-resolution digital images (Nanozoomer Dig-
ital Pathology, NDP-2.0RS; Hamamatsu Photonics, Hama-
matsu, Japan).
For EM examination, tissues were fixed in 2.5% glutaral-
dehyde before the following procedures. After osmium
tetroxide postfixation and gradient dehydration, Epon-
embedded, Toluidine Blue–stained semithin sections were
examined, and selected areas were chosen for thin sections.
Thin sections were then cut and stained with uranyl acetate
and lead citrate. EM grids were then viewed with a trans-
mission electron microscope (HT-7800; Hitachi, Tokyo,
Japan).

JASN 31: 2205–2221, 2020 AKI Outcome in Critically Ill COVID-19 2207
 CLINICAL RESEARCH www.jasn.org

Table 2. The laboratory findings of patients

Presence of AKI Survival
All Patients
Laboratory Findings Nonsurvivors P
(n581) AKI (n541) Non-AKI (n540) P Value Survivors (n521)
(n560) Value
White blood cell count 12.20 13.11 11.60 0.41 13.05 9.93 (6.40–15.13) 0.05a
(3109/L), median (IQR) (9.00–17.29) (9.88–17.81) (8.66–15.30) (10.20–18.30)
.10, n (%) 56 (69.1%) 30 (73.2%) 26 (65.0%) 0.43 46 (76.7%) 10 (47.6%) 0.01a
4–10, n (%) 24 (29.6%) 11 (26.8%) 13 (32.5%) – 13 (21.7%) 11 (52.4%) –
,4, n (%) 1 (1.2%) 0 (0.0%) 1 (2.5%) – 1 (1.7%) 0 (0.0%) –
Neutrophil count (3109/L), 11.13 12.49 10.65 0.31 11.89 9.22 (5.64–13.10) 0.03a
median (IQR) (8.14–16.02) (9.14–16.43) (7.80–14.42) (9.33–16.87)
Lymphocytes (3109/L), 0.54 (0.34–0.74) 0.50 (0.34–0.60) 0.65 (0.34–0.88) 0.02a 0.53 (0.32–0.70) 0.69 (0.42–0.94) 0.10
median (IQR)
,0.4, n (%) 24 (29.6%) 13 (31.7%) 11 (27.5%) 0.08 19 (31.7%) 5 (23.8%) 0.59
0.4–0.8, n (%) 39 (48.1%) 23 (56.1%) 16 (40.0%) – 30 (50.0%) 9 (42.9%) –
Hemoglobin (g/L), 122.1622.8 124.5625.6 119.8619.5 0.36 124.8621.5 114.7625.2 0.08
mean6SD
Anemia, n (%) 29 (35.8%) 14 (34.1%) 15 (37.5%) 0.75 19 (31.7%) 10 (47.6%) 0.19
Platelets (3109/L), median 159.0 145.0 176.5 0.03a 153.0 202.0 0.03a
(IQR) (100.0–225.5) (77.5–209.5) (122.5–268.0) (82.5–210.8) (138.0–271.0)
,100, n (%) 19 (23.5%) 12 (29.3%) 7 (17.5%) 0.21 17 (28.3%) 2 (9.5%) 0.13
Serum albumin (g/L), 28.5 (26.1–31.0) 28.4 (25.2–31.8) 28.7 (26.2–31.0) 0.87 27.9 (24.1–30.4) 29.0 (28.1–33.0) 0.06
median (IQR)
,25, n (%) 18 (22.2%) 10 (24.4%) 8 (20.0%) 0.64 17 (28.3%) 1 (4.8%) 0.03a
ALT (U/L), median (IQR) 29.0 (19.5–45.0) 32.0 (19.0–52.5) 25.0 (20.2–39.8) 0.44 29.5 (20.2–45.8) 24.0 (16.5–38.5) 0.33
AST (U/L), median (IQR) 33.0 (20.5–63.5) 37.0 (28.0–59.0) 29.0 (19.0–68.0) 0.27 33.5 (21.0–68.2) 33.0 (20.0–54.5) 0.38
LDH (U/L), median (IQR) 523.0 562.0 504.5 0.45 558.0 373.0 0.01a
(373.5–700.5) (382.5–688.0) (345.2–742.5) (417.2–742.5) (274.5–618.5)
Total bilirubin (mmol/L), 12.9 (8.6–20.6) 12.2 (8.2–21.6) 13.4 (8.8–20.6) 0.81 14.5 (9.8–21.7) 10.3 (7.6–17.0) 0.05a
median (IQR)
sCr (mmol/L), median (IQR) 80.0 (58.0–113.0) 104.0 65.5 (48.0–80.0) ,0.001a 85.5 (65.0–114.5) 61.0 (43.5–82.0) 0.02a
(74.0–188.5)
Elevated sCr, n (%) 24 (29.6%) 21 (51.2%) 3 (7.5%) ,0.001a 20 (33.3%) 4 (19.0%) 0.27
Cystatin C (mg/L), median 1.26 (0.99–2.01) 1.74 (1.22–2.44) 1.06 (0.86–1.28) ,0.001a 1.32 (0.95–2.01) 1.22 (1.05–1.82) 0.96
(IQR)b
.1.55, n (%) 23 (35.3%) 20 (60.6%) 3 (9.1%) ,0.001a 17 (36.2%) 6 (31.6%) 0.72
eGFR (ml/min per 1.73 m2), 83.2 (50.1–99.6) 53.0 (27.0–85.8) 96.0 (79.8–107.8) ,0.001a 78.3 (45.2–97.4) 94.8 (64.5–115.9) 0.06
median (IQR)
,60, n (%) 26 (32.1%) 22 (53.7%) 4 (10.0%) ,0.001a 21 (35.0%) 5 (23.8%) 0.34
BUN (mmol/L), median 9.6 (6.4–15.4) 12.5 (8.6–27.8) 7.1 (5.5–10.6) ,0.001a 10.2 (7.0–17.8) 7.3 (5.2–10.9) 0.02a
(IQR)
Serum potassium (mmol/L), 4.37 (3.88–5.01) 4.50 (4.09–5.04) 4.19 (3.78–4.82) 0.16 4.48 (3.96–5.04) 4.16 (3.76–4.60) 0.18
median (IQR)
.5.5, n (%) 12 (14.8%) 6 (14.6%) 6 (15.0%) 0.96 9 (15.0%) 3 (14.3%) .0.99
3.5–5.5, n (%) 62 (76.5%) 31 (75.6%) 31 (77.5%) – 46 (76.7%) 16 (76.2%) –
,3.5, n (%) 7 (8.6%) 4 (9.8%) 3 (7.5%) – 5 (8.3%) 2 (9.5%) –
Serum sodium (mmol/L), 142.6 144.4 139.9 0.10 144.2 137.8 0.001a
median (IQR) (138.0–146.2) (138.9–148.2) (137.5–145.1) (139.4–146.9) (135.2–140.0)
.145, n (%) 28 (34.6%) 18 (43.9%) 10 (25.0%) 0.07 25 (41.7%) 3 (14.3%) 0.03a
135–145, n (%) 43 (53.1%) 18 (43.9%) 25 (75.0%) – 29 (48.3%) 14 (66.7%) –
,135, n (%) 10 (12.3%) 5 (12.2%) 5 (12.5%) – 6 (10.0%) 4 (19.0%) –
Serum calcium (mmol/L), 2.10 (1.96–2.29) 2.12 (1.98–2.26) 2.09 (1.95–2.29) 0.77 2.08 (1.96–2.22) 2.24 (1.98–2.34) 0.05a
median (IQR)
Serum phosphorus 0.98 (0.84–1.24) 1.12 (0.84–1.48) 0.94 (0.82–1.09) 0.09 0.99 (0.86–1.32) 0.92 (0.74–1.14) 0.14
(mmol/L), median (IQR)c
,0.81, n (%) 16 (21.9%) 8 (22.2%) 8 (21.6%) 0.95 9 (17.0%) 7 (35.0%) 0.08

2208 JASN JASN 31: 2205–2221, 2020

 www.jasn.org CLINICAL RESEARCH

Table 2. Continued

Presence of AKI Survival

All Patients
Laboratory Findings Nonsurvivors P
(n581) AKI (n541) Non-AKI (n540) P Value Survivors (n521)
(n560) Value
Serum uric acid (mmol/L), 201.0 289.5 164.0 ,0.001a 208.0 187.0 0.28
median (IQR)d (137.5–327.0) (184.8–448.8) (119.2–219.2) (147.0–346.0) (125.0–259.0)
Proteinuria at admission to
ICU, n (%)e
.21 11 (15.5%) 6 (18.2%) 5 (13.2%) 0.78 10 (19.2%) 1 (5.3%) 0.27
611 50 (70.4%) 23 (69.7%) 27 (71.1%) – 37 (71.2%) 13 (68.4%) –
Negative 10 (14.1%) 4 (12.1%) 6 (15.8%) – 5 (9.6%) 5 (26.3%) –
Hematuria at admission to
ICU, n (%)e
.21 23 (32.4%) 11 (33.3%) 12 (31.6%) 0.75 20 (38.5%) 3 (15.8%) 0.09
611 24 (33.8%) 12 (36.4%) 12 (31.6%) – 18 (34.6%) 6 (31.6%) –
Negative 24 (33.8%) 10 (30.3%) 14 (36.8%) – 14 (26.9%) 10 (52.6%) –
Proteinuria at hospital
presentation, n (%)f
.21 5 (13.9%) 3 (15.8%) 2 (11.8%) .0.99 5 (17.9%) 0 (0.0%) –
611 26 (72.2%) 14 (73.7%) 12 (70.6%) – 20 (71.4%) 6 (75%) –
Negative 5 (13.9%) 2 (10.5%) 3 (17.6%) – 3 (10.7%) 2 (25.0%) –
Hematuria at hospital
presentation, n (%)f
.21 10 (25.0%) 6 (31.6%) 4 (23.5%) 0.72 9 (32.1%) 1 (12.5%) 0.40
611 17 (47.2%) 9 (47.4%) 8 (47.4%) – 14 (50.0%) 3 (37.5%) –
Negative 9 (27.8%) 4 (21.1%) 5 (21.1%) – 5 (17.9%) 4 (50.5%) –
ESR (mm/h), median (IQR)g 40.5 (27.8–65.5) 47.5 (32.0–72.0) 35.0 (22.0–61.8) 0.10 38.5 (24.5–58.5) 67.0 (31.0–91.0) 0.02a
hsCRP (mg/L), median 105.5 109.0 66.0 (36.1–140.7) 0.10 108.9 66.0 (29.0–122.5) 0.06
(IQR)h (50.8–142.2) (66.8–147.9) (58.8–149.4)
IL-6 (pg/ml), median (IQR)i 59.0 (31.0–167.2) 100.4 36.8 (20.3–103.2) 0.01a 93.2 (35.5–214.9) 31.8 (22.1–69.5) 0.002a
(36.4–265.6)
Ferritin (mg/ml), median 1386.4 1301.8 1484.8 0.62 1469.0 973.3 0.34
(IQR)j (758.7–2207.8) (758.7–2207.8) (765.2–2229.8) (831.3–2261.3) (649.7–2207.8)
PT (s), median (IQR) 16.3 (15.3–18.1) 17.2 (15.3–18.5) 16.0 (15.1–17.2) 0.04a 17.0 (15.3–18.2) 15.6 (14.6–16.2) 0.006a
aPTT (s), median (IQR) 41.0 (37.2–45.5) 41.7 (37.4–46.8) 40.9 (35.9–43.6) 0.37 40.7 (37.0–45.9) 43.0 (38.2–45.4) 0.48
Fibrinogen (g/L), median 3.95 (3.08–5.56) 4.08 (2.92–5.57) 3.92 (3.10–5.55) 0.88 3.86 (2.77–5.52) 4.60 (3.42–5.62) 0.21
(IQR)
INR, median (IQR) 1.29 (1.19–1.48) 1.40 (1.20–1.52) 1.26 (1.18–1.36) 0.02a 1.36 (1.20–1.49) 1.24 (1.08–1.28) 0.009a
D-dimer (mg/ml FEU), n (%)
.21.0 36 (44.4%) 19 (46.3%) 17 (42.5%) 0.73 32 (53.3%) 4 (19.0%) 0.01a
5.0–21.0 19 (23.5%) 10 (24.4%) 9 (22.5%) – 14 (23.3%) 5 (23.8%) –
0.5–5.0 26 (32.1%) 12 (29.3%) 14 (35.0%) – 14 (23.3%) 12 (57.1%) –
,0.5 0 0 0 – 0 0 –
cTnI (pg/ml), median (IQR)k 62.6 (15.1–520.4) 69.8 (18.8–320.8) 52.4 (8.3–555.8) 0.49 67.1 (19.1–653.2) 20.5 (3.9–167.4) 0.02a
NT-proBNP (pg/ml), 992.0 1902.0 843.0 0.03a 1021.5 992.0 0.74
median (IQR)l (402.0–3589.0) (617.0–5590.0) (320.2–2929.2) (486.0–3634.5) (193.0–3808.0)
ALT, alanine aminotransferase; AST, aspartate aminotransferase; LDH, lactate dehydrogenase; ESR, erythrocyte sedimentation rate; hsCRP, high-sensitivity
C-reactive protein; aPTT, activated partial thromboplastin time; INR, international normalized ratio; FEU, fibrinogen equivalent units; cTnI; cardiac troponin I;
NT-proBNP, N-terminal prohormone of brain natriuretic peptide.
a
P#0.05.
b
All patients, n566; AKI, n533; non-AKI, n533; nonsurvivors, n547; survivors, n519.
c
All patients, n573; AKI, n536; non-AKI, n537; nonsurvivors, n553; survivors, n520.
d
All patients, n580; AKI, n540; non-AKI, n540; nonsurvivors, n559; survivors, n521.
e
All patients, n571; AKI, n533; non-AKI, n538; nonsurvivors, n552; survivors, n519.
f
All patients, n536; AKI, n519; non-AKI, n517; nonsurvivors, n528; survivors, n58.
g
All patients, n558; AKI, n530; non-AKI, n528; nonsurvivors, n542; survivors, n516.
h
All patients, n577; AKI, n539; non-AKI, n538; nonsurvivors, n556; survivors, n521.
i
All patients, n564; AKI, n532; non-AKI, n532; nonsurvivors, n545; survivors, n519.
j
All patients, n563; AKI, n531; non-AKI, n532; nonsurvivors, n548; survivors, n515.
k
All patients, n580; AKI, n540; non-AKI, n540; nonsurvivors, n559; survivors, n521.
l
All patients, n579; AKI, n539; non-AKI, n540; nonsurvivors, n558; survivors, n521.

JASN 31: 2205–2221, 2020 AKI Outcome in Critically Ill COVID-19 2209
 CLINICAL RESEARCH www.jasn.org

Table 3. The treatment and outcome of patients during the hospitalization

Presence of AKI Survival
Treatment and Outcome Total (n581) Non-AKI P Nonsurvivors Survivors
AKI (n541) P Value
(n540) Value (n560) (n521)
Therapies, n (%)
Glucocorticoids 71 (87.7%) 34 (82.9%) 37 (92.5%) 0.31 54 (90.0%) 17 (81.0%) 0.28
Antiviral medication 66 (81.5%) 33 (80.5%) 33 (82.5%) 0.82 49 (81.7%) 17 (81.0%) 0.94
Antibiotics 75 (92.6%) 38 (92.7%) 37 (92.5%) .0.99 57 (95.0%) 18 (85.7%) 0.18
Intravenous Ig 66 (81.5%) 33 (80.5%) 33 (82.5%) 0.82 48 (80.0%) 18 (85.7%) 0.75
Blood transfusion 22 (27.2%) 14 (34.1%) 8 (20.0%) 0.15 18 (30.0%) 4 (19.0%) 0.40
Anticoagulation 41 (50.6%) 21 (51.2%) 20 (50.0%) 0.91 29 (48.3%) 12 (57.1%) 0.49
Anti-inflammatory therapies 13 (16.0%) 8 (19.5%) 5 (12.5%) 0.39 9 (15.0%) 4 (19.0%) 0.73
Life-sustaining treatment, n (%)
Invasive mechanic ventilation 66 (81.5%) 36 (87.8%) 30 (75.0%) 0.14 53 (88.3%) 13 (61.9%) 0.007
ECMO 5 (6.2%) 2 (4.9%) 3 (7.5%) 0.68 3 (5.0%) 2 (9.5%) 0.60
Vasopressors 63 (77.8%) 36 (87.8%) 27 (67.5%) 0.03a 56 (93.3%) 7 (33.3%) ,0.001a
CRRT 8 (9.9%) 8 (19.5%) 0 (0.0%) – 8 (13.3%) 0 (0.0%) –
Outcome, n (%)
Death 60 (74.1%) 34 (82.9%) 26 (65.0%) 0.07 – – –
Survive before this study 21 (25.9%) 7 (17.1%) 14 (35.0%) – – – –
Time from illness to admission (d), 9.0 (5.5–13.5) 8.0 (5.0–11.0) 10.5 (7.0–16.0) 0.09 9.0 (5–11.8) 11.0 (6.0–16.5) 0.11
median (IQR)
Time from illness to intubation (d), 15.5 14.0 17.0 0.13 16.0 (12.5–21.0) 13.0 0.65
median (IQR)b (12.0–21.0) (11.0–20.8) (13.0–23.5) (10.0–22.5)
Time of mechanic ventilation (d), 9.5 (3.8–16.5) 10.0 9.0 (4.0–15.0) 0.89 8 (3.0–13.5) 27.0 ,0.001a
median (IQR)b (3.0–18.0) (13.5–41.0)
Time from illness to AKI (d), median 21.0 21.0 – – 20.5 (9.0–24.2) 21.0 0.40
(IQR)c (9.5–26.0) (9.5–26.0) (15.0–35.0)
Time from illness to death (d), median 24.0 24.0 24.5 0.96 24.0 (18.0–31.8) – –
(IQR)d (18.0–31.8) (18.0–32.2) (18.8–31.0)
Time of hospitalization (d), median 17.0 18.0 15.5 (9.5–23.8) 0.76 14.0 (9.2–22.8) 29.0 ,0.001a
(IQR) (10.0–26.0) (10.0–28.0) (14.5–39.0)
Disease course before this study (d), 28.0 26.0 28.5 0.42 24.0 (18.0–31.8) 39.0 ,0.001a
median (IQR) (19.0–36.0) (18.0–36.0) (19.2–38.2) (29.0–52.5)
ECMO, extracorporeal membrane oxygenation.
a
P,0.05.
b
All patients, n566; AKI, n530; non-AKI, n536; nonsurvivors, n553; survivors, n513.
c
All patients, n541; nonsurvivors, n534; survivors, n57.
d
All patients, n560; AKI, n534; non-AKI, n526.

Immunohistochemistry Staining
Formalin-fixed, paraffin-embedded sections were heated in the
pressure cooker in 1003 Tris-EDTA buffer (pH 9.0) for 2 minutes
to allow antigen retrieval. Standard immunohistochemistry (IHC)
was performed using the EnVision Detection System (K5007;
Dako) according to the manufacturer’s protocol. The primary an-
tibodies used were as follows: anti-CD3 (clone number F7.2.38,
1:400; DAKO), anti-CD4 (clone number UMAB64, ready to use;
ZSGB-BIO), anti-CD8 (clone number SP16, ready to use;
ZSGB-BIO), anti-CD20 (clone number L28, 1:400; DAKO),
anti-CD34 (clone number QBend-10, 1:400; DAKO), anti-
CD68 (clone number KP1, 1:400; DAKO), anti-CD138 (ready
to use; ZSGB-BIO), anti-granzyme B (polyclonal, ready to use;
ZSGB-BIO), anti-angiotensin converting enzyme 2 (anti-
ACE2; polyclonal, 1:1600; Proteintech), anti-SARS-CoV-2
spike (clone number HA14FE2402, 1:1000; Sino Biologic).
Paracarcinoma normal kidney tissue from a patient with clear
cell renal carcinoma was used as control for ACE2 staining.
Lung tissue from an included patient was used as control for
staining of SARS-CoV-2.
Nucleic Acid Tests of SARS-CoV-2 in Urine Samples and
Kidney Tissues
Patients’ urine samples were extracted on a Nextractor auto-
matic extraction system (Genolution Pharmaceuticals, Seoul,
South Korea) with the manufacturer’s RNA extraction kits.
Kidney tissues were extracted manually with Qiagen RNeasy
Plus Universal Mini Kit (Thermo Fisher Scientific, Dreieich,
Germany) following the manufacturer’s instructions. RT-PCR
of SARS-CoV-2 was performed using the commercially avail-
able kit targeting the SARS-CoV-2-specific N-gene (BGI Bio-
technology [Wuhan] Co., Ltd., Wuhan, China) that has been
approved by the Chinese National Medical Products Admin-
istration on the ABI 7500 system (Applied Biosystems,

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Table 4. Risk factors for AKI identified by multivariate Cox proportional hazards models
Thermo Fisher Scientific). Any positive or suspected positive
results were repeated for a second time for confirmation.
Statistical Analyses
Categoric variables were described as frequency and percent-
age, and continuous variables were described as using mean,
median, and interquartile range (IQR) values. When the data
were normally distributed, independent t tests were used to
compare the means of continuous variables. Otherwise, the
Mann–Whitney test was used. Although the Fisher exact test
was used with limited data, the chi-squared test was used to
compare the proportion of categoric variables. Cox propor-
tional hazards models were used to identify the potential risk
factors. Time trends of creatinine and eGFR for different
groups of patients with AKI were calculated by a cubic poly-
nomial regression model based on least square means fit using
GraphPad Prism 6.0. All statistical analyses were performed
using SPSS version 22.0 software. A P value of ,0.05 is statis-
tically significant.
RESULTS
Clinical Characteristics of Patients Critically Ill with
COVID-19
A total of 1752 patients with COVID-19 were admitted to
the Sino-French New City Campus of Tongji Hospital from
February 5 to March 20, 2020. Of these, 95 were transferred
to our ICU. Five patients transferred for non-COVID-19-
related conditions, and nine patients missing important
data were excluded. Finally, 81 patients were included.
The mean age of these patients was 66.6611.4 years. Male/
female ratio was 2:1. Comorbidities were present in over half
of the patients, with hypertension being the most common
(Table 1). Neutrophil-predominant leukocytosis complicated
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with lymphocytopenia occurred in .70% of the patients.
Significant elevation of D-dimer and inflammatory mark-
ers, including high-sensitivity C-reactive protein, IL-6, and
ferritin, were also observed (Table 2). The median Acute
Physiology and Chronic Health Evaluation II (APACHE
II) and Sequential Organ Failure Assessment (SOFA) scores
were 15 (IQR, 11–19) and 6 (IQR, 4–8), respectively, on ICU
day 1 (Table 1). ARDS, septic shock, and coagulopathy were
present in 95.1%, 63.0%, and 68.0% of the patients. A total
of 58.0% of patients experienced secondary infections
after hospitalization (Supplemental Figure 1). Aggressive
treatment including glucocorticoids, antiviral medication,
antibiotics, and intravenous Ig were deployed. Invasive me-
chanical ventilation and vasopressors were required in
81.5% (66/81) and 77.8% (63/81) of the patients. Five patients
received extracorporeal membrane oxygenation support
(Table 3).
A total of 60 patients died in hospital before conclusion of
the study. The median time from illness onset to death was
24.0 (IQR, 18.0–31.8) days. Nonsurvivors were mainly male
(45/60, 75.0%). They were also of an older age, had a higher
white blood cell count, prolonged PT and international nor-
malized ratio, higher baseline sCr and serum IL-6 levels, and
higher APACHE II and SOFA scores (Table 1). They also
displayed higher prevalence of organ dysfunction including
septic shock, liver injury, cardiac injury, and coagulopathy
(Table 1). At the time of this study, 57.2% (12/21) of the
survivors had been discharged, 23.8% (5/21) of them had
been transferred to general wards, and 19.0% (4/21) of them
were still in ICU.
Elevated sCr and eGFR ,60 ml/min per 1.73 m2 were pre-
sent in 29.6% and 35.3% of patients, respectively, at admission
to ICU. Of the tested patients, 15.5% had proteinuria .21,
whereas 32.4% had hematuria .21. AKI occurred in 41/81
(50.6%) of patients. Patients with AKI were of an older age,
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Table 5. Different multivariate Cox proportional hazards models for risk factors of in-hospital death

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Death within 21 days

400
Death between 21-35 days
350 Death after 35 days
Survivors with AKI
300
sCr (umol/L)
250

200

150

100

50

0
0 7 14 21 28 35 42 49 56 63
Days

Death within 21 days

120 Death between 21-35 days
Death after 35 days
100 Survivors with AKI
eGFR(ml/min.1.73m2)

80

60

40

20

0
0 7 14 21 28 35 42 49 56 63
Days

Figure 1. The patients with AKI who had a shorter disease course before death showed faster decline of renal function. Cubic
polynomial regression of (A) sCr and (B) eGFR of patients with AKI who died within 21 days (n511), between 21 and 35 days (n517),
after 35 days (n56), and those who survived (n57).

had lower lymphocyte and platelet counts, slightly prolonged SOFA score (HR, 1.08; 95% CI, 1.01 to 1.15; P50.03) predic-
PT, and higher serum IL-6 levels (Table 2). ted death (Table 5).

Risk Factors of AKI and Death
The risk factors for AKI included older age (per 10 years)
(hazard ratio [HR], 1.83; 95% CI, 1.24 to 2.69; P50.002)
and serum IL-6 levels (ng/ml) (HR, 1.83; 95% CI, 1.23 to
2.73; P50.003) (Supplemental Table 1, Table 4). Univariate
Cox proportional hazards models showed that older age, male
sex, elevated baseline sCr, reduced eGFR, leukocytosis, hypo-
albuminemia, hypernatremia, elevated D-dimer, and higher
APACHE II and SOFA scores were associated with death
(Supplemental Table 2). Different multivariate Cox propor-
tional hazards models demonstrated that, besides male sex
and KDIGO stage 3 AKI, serum IL-6 levels (ng/ml) (HR,
2.12; 95% CI, 1.27 to 3.53; P50.004), higher levels of
D-dimer (HR, 1.57; 95% CI, 1.13 to 2.18; P50.008), and
Trends of sCr, AKI Staging, and Etiologies during the
Disease Course
The median time from illness to AKI was 21.0 (IQR, 9.5–26.0)
days. Cubic polynomial regressions suggested the decline of
renal function was faster in patients with AKI who died within
shorter course of the disease (Figure 1). Seven of the 81 (8.6%)
patients had AKI at hospital presentation, whereas 21.0% (17/
81) of the patients had AKIs at ICU admission. The proportion
of KDIGO stage 1, stage 2, and stage 3 AKI cases were 26.8%,
31.7%, and 41.5%, respectively. Eight patients with AKI re-
quired continuous RRT (CRRT). Most of the KDIGO stage 3
AKI cases occurred in the first 4 weeks (Figure 2A). Various
AKI etiologies were identified: 61.0% (25/41) of the AKIs oc-
curred either on the same day of septic shock, or within

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A 12
KDIGO Stage I
KDIGO Stage II
10 KDIGO Stage III

4
8
Patients

3
6 2
5
4
4 2
4
1 1
2
2 3 3
2 2
1 1
0
1 2 3 4 5 6 7
Weeks

B 12
Other
Drug Adverse Effect
1 Volume Insufficiency
10
Shock
2

8
1 1
2
Patients

1 1
6
3 1 1

4
6
5 5 1
2 4
3
2
1
0
1 2 3 4 5 6 7
Weeks

Figure 2. The compositions of AKI stages and etiologies during the disease course. (A) The proportion of KDIGO stage 1, stage 2, and
stage 3 AKI were 26.8%, 31.7%, and 41.5%, respectively. Most stage 3 AKI occurred in the first 4 weeks. KDIGO stage 1: increase in sCr
to 1.5–1.9 times baseline within 7 days or $0.3 mg/dl ($26.5 mmol/L) increase within 48 hours, or urine output ,0.5 ml/kg per hour for
6–12 hours. KDIGO stage 2: increase in sCr to 2.0–2.9 times baseline within 7 days, or urine output ,0.5 ml/kg per hour for $12 hours.
KDIGO stage 3: increase in sCr to three or more times baseline, or increase in sCr to $4.0 mg/dl ($353.6 mmol/L) within 7 days, or initiation of
RRT, or anuria for $12 hours. (B) Various AKI etiologies were identified: 61.0% (25/41) of the AKIs were considered to be related to septic
shock; eight patients (19.5%) had histories of poor intake or volume loss before AKI; 12.2% (5/41) of AKIs occurred after administration of
antiviral drugs or antibiotics, and no other triggers were identified. In general, AKI caused by septic shock and adverse drug effects occurred
throughout the whole disease course, whereas volume insufficiency usually occurred in the early phase of the disease.

24 hours after septic shock. Four patients with septic shock
had AKI complicated with possible rhabdomyolysis (signifi-
cant elevated serum myoglobin and lactate dehydrogenase).
Eight patients (19.5%) had histories of poor intake or volume
loss (high fever, vomit, diarrhea, or diuresis) before AKI; most
of these patients (6/8) recovered from AKI quickly after vol-
ume supplementations consisting of isotonic fluids and
enteral nutrition support. Five (12.2%) of the AKIs occurred
after the administration of antiviral drugs or antibiotics, and
no other triggers were identified. One patient experienced di-
abetic ketoacidosis before AKI. One patient who had received
kidney transplantation 6 years previously suffered AKI possi-
bly caused by acute rejection and cardiac failure. One patient
with AKI had positive anti-phospholipid antibodies and a

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Table 6. Light microscopic pathologic findings of kidney tissues from ten deceased patients critically ill with COVID-19 and
AKI
Sex/ Baseline sCr Peak sCr Disease Glomerular
Patient PMH Tubulointerstitial Changes Vascular Changes
Age (mmol/L) (mmol/L) Course (d) Changes
1 M/62 HTN N/A 427 33 Endothelial CV, focal TA and IF, crystallization Intimal hyperplasia
swollen casts, inflammatory cells
infiltration
2 M/82 DM 115 136 14 NR CV, focal ATI NR
3 M/62 – 73 220 29 NR CV, focal ATI Intimal hyperplasia
4 M/78 HTN 93 197 30 Focal ischemic CV, focal TA and IF Intimal hyperplasia,
sclerosis hyalinosis
5 M/73 HTN, HBV 70 147 24 NR CV, focal TA and IF, focal ATI Intimal hyperplasia,
venous
thrombosis
6 M/59 HTN 48 139 39 Hypertrophy CV, focal ATI Intimal hyperplasia,
hyalinosis
7 M/86 HTN, CAD 82 195 45 NR CV, focal ATI Intimal hyperplasia,
hyalinosis
8 M/66 – 68 121 48 Focal ischemic CV, focal ATI, focal TA and IF Intimal hyperplasia,
sclerosis hyalinosis
9 F/57 – 32 128 36 NR CV, focal ATI NR
10 F/66 DM 80 125 35 NR CV, focal ATI NR
M, male; PMH, past medical history; HTN, hypertension; DM, diabetes Mellitus; CAD, coronary artery disease; HBV, Hepatitis B virus infection; N/A, not available;
CV, cytoplasmic vacuolization; TA, tubular atrophy, IF, interstitial fibrosis; NR, nonremarkable; ATI, acute tubular injuries; F, female.

probable cerebrovascular incident; his renal pathology showed
venous thrombosis. In general, AKI caused by septic shock and
adverse drug effects occurred throughout the disease course,
whereas volume insufficiency usually occurred in the early
phase of the disease (Figure 2B).
Pathologic Findings in Ten Deceased Patients with
COVID-19 and AKI
Kidney pathologic findings of ten deceased patients with AKI
are summarized in Table 6. The autopsied patients with AKI
had comparable demographic and clinical characteristics with
other patients with AKI (Supplemental Table 3). All of the
patients showed differing degrees of tubular injury and cyto-
plasmic vacuolization in tubular epithelial cells (Figure 3A).
Patient 1 developed anuric AKI requiring CRRTafter receiving
antiviral medications. Crystallizations were observed in the
proximal tubular cells and casts (Figure 3B), which suggested
drug-induced AKI. Localized inflammatory cell infiltration
was present in the interstitial area (Figure 3C). Glomerular
lesions were not remarkable, except swollen endothelial cells
and wrinkling of the glomerular basement membrane with
double contours were occasionally observed (Figure 4, A and
B). Arteriolar hyalinosis and intimal fibrosis were observed in
several patients (Figure 4, C and D). Patient 5 had high titers
of positive anti-phospholipid antibodies and probable cere-
brovascular incidents before death. His renal pathology re-
vealed venous thrombosis (Figure 3D).
The IHC staining of CD3, CD4, CD8, CD20, and CD68
displayed scattered distributed lymphocytes and macrophages
in the interstitial area (Figures 3, E–H and 4E). CD3-positive
lymphocytes were also occasionally seen within the glomerulus
(Figure 4F). Strong ACE2 expression was seen in both parietal
epithelial cells of glomeruli and tubular epithelial cells
(Figure 5A), which was not significantly different from normal
kidney tissues (Figure 5B). SARS-CoV-2 was not detected by
IHC in kidney tissues (Figure 5C).
A few particles of a diameter of about 60–100 nm were
observed in the cytoplasm of renal proximal tubular epithelial
cells under EM (Figure 6A). Some of these particles were en-
closed in vesicles (Figure 6B). Wrinkling of the glomerular
basement membrane, varying degrees of foot process efface-
ment, and subendothelial space expansion were present occa-
sionally (Figure 6C). Cytoplasmic vacuolization and remnants
of mitochondrial cristae at the periphery were observed in
proximal tubular epithelial cells (Figure 6D). Peritubular cap-
illary lumens were obstructed by abundant erythrocytes.
Nucleic Acid Tests of Urine Samples and Kidney Tissues
Kidney tissues from nine patients with AKI (except patient 8 in
Table 6) were sent for nucleic acid RT-PCR tests for SARS-
CoV-2, and the results were all negative. The PCR results of
urine samples from another nine patients were also negative.
The median time from disease onset to these tests was 29.0
(26.0–35.0) days.
DISCUSSION
COVID-19 is currently a worldwide pandemic affecting .10
million people, causing .500,000 deaths. Most previous stud-
ies were conducted in patients with a short disease course
(median time from illness to death was 16–18.5 days).3,7,9 As

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A B

C D

E F

G H

Figure 3. Pathologic findings in kidney tissues from patients critically ill with COVID-19 and AKI. (A) Diffuse tubular injury and cyto-
plasmic vacuolization in tubular epithelial cells (black arrow). (B) Crystallizations in casts and proximal tubular cells in a patient (black
arrows). (C) Localized inflammatory cell infiltration was present in the interstitial area (black arrow). (D) Venous thrombosis in a patient
with positive anti-phospholipid antibodies. (E–G) Scattered distribution of CD3-, CD20-, and CD8-positive lymphocytes in the in-
terstitial area (black arrows). (H) Scattered distribution of CD68-positive macrophages in the interstitial area (black arrows). HE, he-
matoxylin and eosin.

a multidisciplinary medical team that had been taking care of
patients critically ill with COVID-19 in ICU since early Febru-
ary, we feel obligated to share our experience with the medical
community. This study described the clinical characteristics of
81 patients who were old (mean age 66.6 years) and critically ill
(rate of intubation .80%), with a relatively long disease
course (median time from illness to death was 24 days).
Hopefully, our study can provide helpful information to
any physicians who are fighting against COVID-19
worldwide.

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A B

C D

E F

Figure 4. Pathologic findings in kidney tissues from patients critically ill with COVID-19 and AKI (continued). (A) Glomerulus with
nonremarkable changes. (B) Glomerulus with swollen endothelial cells (white arrow), wrinkling of the glomerular basement membrane
with double contours (black arrows), which was consistent with chronic glomerular ischemia. (C) Arteriolar hyalinosis (black arrow). (D)
Intimal hyperplasia in interlobular artery. (E) CD4-positive cells around a glomerulus. (F) CD3 was occasionally positive within the
glomerulus (black arrows). HE, hematoxylin and eosin; PAS, Periodic acid–Schiff.

Our data showed that, in patients critically ill with COVID-
19 in the ICU, the incidence of AKI was 50.6%, and .40% of
these AKIs were KDIGO stage 3. These patients had a very high
rate of invasive mechanical ventilation and multiple critical
complications requiring aggressive management. Pei et al.28
also reported distinct incidences of AKI between patients non-
critically ill with COVID-19 and those who were critically ill
(4.0% versus 42.9%), supporting our findings. These findings
were also consistent with the incidence of AKI in patients with
non-COVID-19 ARDS (49.0%–68.3%).29,30
AKI is a common complication of patients in ICU set-
tings, which can be caused by various conditions.31 Septic
shock happened in .60% of our patients and was the lead-
ing cause for AKI, which was confirmed by the medical his-
tory and the pathologic findings of acute tubular injury
(Figure 3, Table 6). Several patients with AKI had a history
of poor intake and volume loss, and most of them recovered
from AKI after fluid supplementation. Great attention
should be paid to the hemodynamics and volume balance
of patients with COVID-19.
A variety of antiviral drugs are being tested for their efficacy
against COVID-19 worldwide.32,33 All types of antibiotics
were also used to manage the secondary bacterial infections.
In this study, three patients had AKI after receiving antiviral
medications. One of them recovered from AKI after discontin-
uing the suspicious drug, and the other two patients required
CRRT support. The pathologic findings of crystallizations in
the proximal tubular cells and casts highly implies drug-
induced AKI in one patient (Figure 3B). Another two pa-
tients experienced AKI after antibiotic treatment. One of
them received vancomycin, and the other one received
piperacillin-sulbactam, which are both well known renal-toxic

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A B

C D

Figure 5. Immunochemistry staining of ACE2 and SARS-CoV-2. (A) ACE2 was strongly expressed in both parietal epithelial cells of
glomeruli and tubular epithelial cells (brown area). (B) ACE expression in paracarcinoma normal kidney tissue from a patient with clear
cell renal carcinoma. (C) IHC failed to detect SARS-CoV-2 in kidney tissues of patients with COVID-19. (D) Positive SARS-CoV-2 de-
tection in both alveolar pneumocytes and macrophages in lung tissues (black arrows) of a patient with AKI (patient 5 in Table 6).

antibiotics. These findings indicate that we should carefully se-
lect treatments and closely monitor the renal functions of pa-
tients with COVID-19.
Another concern is the possible direct attack by SARS-
CoV-2 to the kidney because of the abundant expression of
ACE2 in kidney tissues (Figure 5A). However, the current ev-
idence of SARS-CoV-2 infecting the kidney are not universally
agreed (B. Diao, C. Wang, R. Wang, Z. Feng, Y. Tan, H. Wang,
et al.: Human kidney is a target for novel severe acute respi-
ratory syndrome coronavirus 2 [SARS-CoV-2] infection,
2020; doi:10.1101/2020.03.04.20031120).19,34–36 Our EM ex-
aminations of kidney tissues revealed particles that greatly re-
semble the structures found in a recent report of virus-like
particles.18 However, some pathologists suspected these par-
ticles were clathrin-coated vesicles or multivesicular bodies
based on the ultrastructural features and virus morphology
and morphogenesis.22,23,37 Additional tools including immu-
nogold labeling and in situ hybridization might be useful for
further identification.38 Furthermore, the RT-PCR and IHC
tests of kidney tissues in this study were all negative. A pre-
vious study suggested the median time of virus shedding was
20 days.3 Viral load in tissues other than the lungs were also
reported to be either negative or much lower.19,36 Considering
the median disease course of the ten patients who were autop-
sied was 34 days (IQR, 28–40), this might account for the lack
of virus detection in the kidneys. Regardless, the renal patho-
logic changes were predominately acute tubular injury rather
than glomerulopathy or interstitial nephritis. These changes
were more likely caused by ischemia rather than viral
infection.
The hypothesis that inflammatory cytokines might con-
tribute to the immunologic disorders and multiorgan dys-
functions of patients with COVID-19 has been proposed.20,39
We found significantly elevated serum IL-6, lower platelet
count, and prolonged international normalized ratio in pa-
tients with AKI (Tables 1 and 2). Serum IL-6 levels were also
associated with both AKI and death (Tables 4 and 5). It is
believed that rigorous inflammatory reactions could activate
the platelets and injure the endothelial cells, leading to clots,
coagulopathy, and microvascular dysfunction.32,40 Antiphos-
pholipid syndrome was recently reported in COVID-19.41 We
also found one patient with suspected antiphospholipid syn-
drome who presented with AKI and venous thrombosis in
kidney tissues (Figure 3D). Considering potential correlations
between inflammation and organ dysfunctions (Table 5), we
speculated that inflammation-mediated vascular endothelial
injury and a dysregulated immune response might play an
important role in patients critically ill with COVID-19. Blood
purification therapies targeting inflammatory molecules were
delivered to several patients and their serologic response
turned out to be promising.42
AKI served as a risk factor for mortality of patients with
COVID-19 in Cheng et al.’s12 study. Due to the limited size of
samples, different Cox proportional hazards models were
tested. The results showed that KDIGO stage 3 AKI was asso-
ciated with death in this group of patients (Table 5).

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A B

C D

Figure 6. EM findings in patients with AKI. (A) EM studies showed small particles (black arrows) in the cytoplasm in renal proximal
tubular epithelium. The diameter of these particles varied from about 60 to 100 nm. (B) Particles in vesicles (black arrows) in proximal
tubular epithelium. (C) Wrinkling of the glomerular basement membrane (black arrow), subendothelial space expansion, and varying
degrees of foot process effacement were present occasionally. (D) Remnants of mitochondrial cristae at the periphery (black arrows)
were observed in proximal tubular epithelial cells.

Supporting this finding, the patients with AKI who died within
a shorter disease course also had a faster decline of renal func-
tion. Other potential risk factors for death included male sex,
elevated D-dimer, higher serum IL-6 levels, and higher SOFA
scores, which is consistent with another report.3
Our study does have several limitations. The number of
enrolled patients were limited. A small proportion of the pa-
tients had no baseline sCr value available, which might lead to
misestimation of AKI, although three nephrologists from
PUMCH reviewed the medical records independently to gen-
erate the consensual diagnosis. The tests of tubular functions
were lacking and we failed to collect enough data from urine
protein/creatinine results.
In conclusion, we reported the clinicopathologic charac-
teristics and prognosis of AKI in patients critically ill with
COVID-19 who had a long disease course. AKI was a com-
mon and multifactorial complication in the late stage of
patients critically ill with COVID-19 in the ICU. Patients
with AKI were of an older age, had a lower lymphocyte and
platelet count, and a tendency for coagulopathy and hyper-
inflammation. Acute tubular injury was predominant in re-
nal pathology. Older age and higher serum IL-6 level were
associated with AKI. KDIGO stage 3 AKI independently
predicted death. The early involvement of nephrologists
might improve the outcome of AKI in critical patients
with COVID-19.
DISCLOSURES
All authors have nothing to disclose.
FUNDING
This work was supported by National Natural Sciences Foundation of China
grant 81970621 (to Y. Qin); Foundation of Tongji Hospital of Tongji Medical
College, Huazhong University of Science and Technology grant
XXGZBDYJ010 (to G. Wang); and Fundamental Research Funds for the
Central Universities grant 3332019029 (to P. Xia).
ACKNOWLEDGMENTS
We wish to thank Ms. Cynthia S. Goldsmith, US Centers for Disease Control
and Prevention for her kind help in reviewing the EM images and providing
inspiring suggestions. We thank Dr. Xiaoyin Bai, Dr. Siyuan Fan, and Dr. Hua
Zheng from PUMCH for their advice and assistance. We wish to thank all of
the patients and their family members included in this study.
P. Xia, Y. Wen, W. Cao, G. Wang, and Y. Qin designed this study; S. Zhang,
X. Yan, T. Li, B. Du, Z. Liu, X. Zhou, Y. Qin, J. Wang, J. Ma, and P. Xia cared for
the included patients; P. Xia, J. Ma, Y. Zhou, G. Chen, W. Jiang, and Y. Hu
extracted the clinical data; Y. Duan, S. Xu, H. Cai, H. Wu, Z. Liang, W. Cao, and
G. Wang performed the light microscope and IHC studies; H. Su and C. Zhang
performed the EM studies; and Y. Qin, G. Wang, L. Chen, C. Zhang, and X. Li
critically reviewed the manuscript.

JASN 31: 2205–2221, 2020 AKI Outcome in Critically Ill COVID-19 2219
 CLINICAL RESEARCH www.jasn.org
SUPPLEMENTAL MATERIAL
This article contains the following supplemental material online at http://
jasn.asnjournals.org/lookup/suppl/doi:10.1681/ASN.2020040426/-/
DCSupplemental.
Supplemental Table 1. Risk factors for AKI tested by univariate cox pro-
portional hazards models.
Supplemental Table 2. Risk factors predicting death tested by univariate cox
proportional hazards model.
Supplemental Table 3. The autopsied patients had comparable demo-
graphic and clinical features with other patients.
Supplemental Figure 1. Compositions of secondary infections.
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AFFILIATIONS

1
Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
2
Institute of Pathology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
3
Department of Pathology, School of Basic Medical Science, Tongji Medical College, Huazhong University of Science and Technology,
Wuhan, China
4
Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
5
Department of Infectious Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
6
Department of Laboratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
7
Department of Medical ICU, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
8
Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
9
Department of Intensive Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
10
Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences,
Beijing, China
11
Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China

JASN 31: 2205–2221, 2020 AKI Outcome in Critically Ill COVID-19 2221
Supplemental material Contents

Table S1 Risk Factors for AKI Tested by Univariate Cox Proportional Hazards Models

Table S2 Risk Factors Predicting Death Tested by Univariate Cox Proportional Hazards Model

Table S3 The Autopsied AKI Patients Had Comparable Demographic and Clinical Features with Other AKI Patients

Figure S1 Compositions of Secondary Infections

Table S1 Risk Factors for AKI Tested by Univariate Cox Proportional Hazards Models

Univariate Cox proportional hazards model

β RR (95% CI) P

Demographics

Age (per 10 years) 0.529 1.697 (1.238, 2.327) 0.001

Male 0.681 1.977 (0.983, 3.974) 0.056

Past Medical History

Pre-existing Hypertension 0.273 1.314 (0.708, 2.438) 0.387

Diabetes 0.234 1.263 (0.627, 2.545) 0.513

Coronary Heart Disease -0.304 0.738 (0.340, 1.601) 0.442

Symptoms

Fever -0.688 0.502 (0.219, 1.155) 0.105

Anorexia -0.402 0.669 (0.334, 1.338) 0.256

Vomit -0.585 0.557 (0.197, 1.574) 0.269

Diarrhea -0.390 0.677 (0.323, 1.422) 0.303

Lab Tests Findings

Anemia -0.268 0.765 (0.399, 1.464) 0.418

Thrombocytopenia 0.465 1.593 (0.809, 3.134) 0.178

Serum IL-6 (ng/ml)1 0.587 1.798 (1.216, 2.661) 0.003

D-dimer Categories2 0.273 1.314 (0.905, 1.909) 0.151

hsCRP (mg/L)3 0.003 1.003 (0.998, 1.007) 0.252

Complications

Shock 0.455 1.561 (0.801, 3.042) 0.191

Cardiac Injuries 0.090 1.094 (0.504, 2.373) 0.820

Coagulopathy 0.550 1.733 (0.867, 3.466) 0.120

Secondary Infections -0.218 0.804 (0.423, 1.531) 0.507

Glucocorticoid -0.483 0.617 (0.273, 1.396) 0.246

Treatment

Anti-viral medications -0.089 0.915 (0.422, 1.983) 0.822

Antibiotics -0.044 0.957 (0.295, 3.109) 0.942

IVIG -0.542 0.581 (0.267, 1.268) 0.173

Vasopressors 0.480 3.129 (1.220, 8.024) 0.018

IVIG: Intravenous Immunoglobin; hsCRP: high-sensitive C reactive protein; IL-6: interleukin 6

1
64 patients (32 AKIs) were included in the analysis.
2
D-dimer levels were classified into 4 categories: <0.5 as category 1, 0.5-5.0 as category 2, 5.0-21.0 as category 3 and >21.0

as category 4
3
77 patients (39 AKIs) were included in the analysis.
Shock was defined hypotension requiring vasopressor therapy to maintain mean BP 65 mm Hg or greater and having a
serum lactate level greater than 2 mmol/L after adequate fluid resuscitation.
Table S2 Risk Factors Predicting Death Tested by Univariate Cox Proportional Hazards Models

Univariate Cox proportional hazards model

β RR (95% CI) P

Demographics

Age (per 10 years) 0.265 1.303 (1.009, 1.683) 0.042

Male 0.913 2.492 (1.377, 4.507) 0.003

Past Medical History

Pre-existing Hypertension 0.069 1.072 (0.645, 1.780) 0.789

Diabetes -0.146 0.864 (0.456, 1.635) 0.653

Coronary Heart Disease -0.244 0.783 (0.416, 1.476) 0.450

Lab Tests Findings

Leukocytosis 0.618 1.855 (1.019, 3.377) 0.043

Anemia -0.370 0.691 (0.401, 1.191) 0.183

Thrombocytopenia 0.497 1.644 (0.935, 2.889) 0.084

Hypernatremia 0.744 2.103 (1.252, 3.535) 0.005

Serum IL-6 (ng/ml)1 0.543 1.720 (1.238, 2.391) 0.001

D-dimer Categories2 0.791 2.205 (1.357, 3.585) 0.001

hsCRP (mg/L)3 0.001 1.001 (0.998, 1.005) 0.459

Elevated sCr 0.593 1.810 (1.048, 3.125) 0.033

eGFR (ml/min/1.73m2) -0.008 0.992 (0.985, 0.999) 0.034

Complications

ARDS -0.574 0.563 (0.173, 1.835) 0.341

Shock 0.540 1.717 (0.966, 3.050) 0.065

Cardiac Injury 0.494 1.638 (0.806, 3.330) 0.172

Coagulopathy 0.461 1.586 (0.903, 2.785) 0.108

Hypercapnia 0.015 1.015 (0.603, 1.709) 0.956

All AKI 0.365 1.441 (0.864, 2.402) 0.162

KDIGO Stage 3 AKI 0.745 2.107 (1.181, 3.760) 0.012

Clinical Evaluations

APACHE II score 0.037 1.038 (1.006, 1.072) 0.021

SOFA score 0.111 1.118 (1.053, 1.187) <0.001

Treatment
 Corticosteroids 0.275 1.316 (0.566, 3.061) 0.524

Anti-viral medications -0.015 0.985 (0.511, 1.898) 0.964

Antibiotics 0.304 1.361 (0.425, 4.360) 0.604

IVIG -0.731 0.481 (0.253, 0.917) 0.026

1
64 patients (56 deaths) were included in the analysis, IL-6 was calculated in ng/ml.
2
D-dimer levels were classified into 4 categories: <0.5 as category 1, 0.5-5.0 as category 2, 5.0-21.0 as category 3 and >21.0

as category 4
3
77 patients (45 deaths) were included in the analysis.
Table S3 The Autopsied AKI Patients Had Comparable Demographic and Clinical Features with Other AKI Patients

Autopsied Patients Other AKI Patients

P Value
(n=10) (n=31)

Age (years) 68.8±10.2 69.9±9.1 0.765

Male : Female 8:2 22:9 0.700

Hypertension 5 (50.0%) 17 (54.8%) 0.655

Diabetes 2 (20.0%) 9 (29.0%) 0.700

Serum Creatinine (μmol/L) 107.0 (56.2-202.8) 104.0 (82.0-171.0) 0.867

eGFR (ml/min/1.73m2) 59.4 (26.6-97.1) 53.0 (32.8-82.5) 0.638

IL-6 (pg/ml) 150.5 (57.7-385.0) 78.8 (32.6-215.4) 0.290

Shock 6 (60.0%) 22 (71.0%) 0.698

Vasopressors 8 (80.0%) 28 (90.3%) 0.580

Corticosteroids 8 (80.0%) 26 (83.9%) 1.000

Anti-viral Medications 8 (80.0%) 25 (80.6%) 1.000

Antibiotics 10 (100.0%) 28 (90.3%) --

IVIG 9 (90.0%) 24 (77.4%) 0.653

IVIG: Intravenous Immunoglobin; IL-6: interleukin 6.

Figure S1 Compositions of Secondary Infections

47 patients experienced 49 episodes of secondary infections. Secondary bacterial pneumonia and blood stream infections were

the most common. Bacterial pneumonia was diagnosed based on the symptom of newly onset fever, yellow sputum and image

changes (Chest X-ray or CT scan). Blood stream infections was diagnosed based on the newly onset fever and positive blood

culture. One patient’s chest CT scan showed pulmonary abscess with cavities and gas-fluids levels inside. One patient who

had fever, signs of peritoneal irritations after several days of diffuse bowel obstruction was diagnosed bacterial peritonitis.

One patient who had newly onset of fever accompanied with cloudy urine and positive urine culture afterward was diagnosed

of urinary tract infection. One patient had fever and signs of cellulitis on her left foot. All these infections happened after the

hospital presentation.