To the editor
Since the first wave of COVID-19, the management of patients with severe COVID-19 in intensive care unit (ICU) has changed with the widespread use of dexamethasone (DXM) in severe patients [1]. Indeed, RECOVERY trial [2] showed a decrease in both mortality at day 28 and the number of patients who received renal replacement therapy (RRT) with DXM. We have previously reported a higher than usual incidence of acute kidney injury (AKI) (80%) in severe COVID-19 patients treated in ICU [3]. Like lung injury, specific SARS-CoV-2 inflammatory process was previously suggested in AKI pathogenesis [4, 5] and is susceptible to be improved by DXM. Besides, in another report, we recently described a 15% incidence of chronic kidney disease (CKD) at 3 months after COVID-19-induced AKI [6], all of these patients developing acute kidney disease (AKD) before CKD. The aim of this report was to assess the independent clinical effect of DXM on the prevention of severe COVID-19-induced AKI.
We carried out a prospective study in the medical ICU of the University Hospital of Bordeaux (France) from March 17, 2020, to December 20, 2020. All patients admitted for a severe COVID-19 were included. DXM was exclusively used during the second wave starting in Bordeaux (France) on August 6 at 6 mg per day for 10 days at ICU admission. Patients who presented AKI at ICU admission were excluded from the analysis.
Patients characteristics (Table 1)
From March 17, 2020, 126 patients were admitted in our unit, 26/126 patients (21%) were excluded because of AKI at ICU admission (5 and 21 patients, in first and second waves, respectively). DXM was used in all patients in the second wave and in none of the first wave. In the 100 patients included, median age was 63 ± 11 years, 59/100 (59%) had hypertension, 10/100 (10%) suffered from CKD and 48/100 (48%) required mechanical ventilation (MV) in the first 24 h. In the study population, 56/100 (56%) patients developed AKI: 39/52 (75%) and 17/48 (35%) patients (p < 0.001), in the first and second waves, respectively. AKD was observed in 24/100 (24%) of patients: 14/52 (27%) patients in the first wave and 10/48 (21%) in the second wave (p = 0.49).
In univariate analysis, the use of DXM (OR = 0.18 [0.07–0.42]), hypertension (OR = 2.31 [1.03–5.29]), SAPSII (OR = 1.04 [1.01–1.07]), MV (OR = 8.92 [3.65–23.66]) and intravenous fluid therapy (OR = 1.67 [1.20–2.47]) were significantly associated with AKI. In multivariate analysis, MV (OR = 5.02 [1.68–15.78]) and DXM use (OR = 0.31 [0.09–0.99]) remained significantly associated with AKI.
Risk factors for AKI (Table 2)
Risk factors for AKD
In univariate analysis, prior CKD (OR = 13.8 [3.14–97.44]), chronic respiratory disease (OR = 5.16 [1.54–19.19]), immunosuppression (OR = 7.67 [1.60–55.75]) were significantly associated with AKD. In multivariate analysis, only prior CKD (OR = 17.73 [2.91–108.08]) was significantly associated with AKD (DXM use, OR = 1.10 [0.32–3.81]).
Our study suggests an independent effect of DXM to prevent from AKI in severe COVID-19 patients. This result needs to be confirmed in larger studies.
High rate of vasopressors and greater intravenous fluid therapy reported during the first wave imaged the earlier and more frequent use of MV, without reflecting the patients' severity admitted in our ICU. Indeed, patients admitted during the second wave had more comorbidities and were older, which explains the increased mortality trend observed in our study.
Lack of effect of DXM on RRT in our study can be explained by a lack of power and by the too weak effect of corticosteroids on AKI.
Our results could indicate an important impact of inflammatory state in the pathogenesis of COVID-19-induced AKI. These results support the hypothesis that corticosteroid therapy can reduce “inflammatory” AKI incidence (specific of COVID-19 infection) but has no impact on "maladaptive repair" lesions secondary to AKI that can lead to an AKD.
Availability of data and materials
The dataset used and analyzed for the current study is available from the corresponding author on reasonable request.
References
Contou D, et al. Comparison between first and second wave among critically ill COVID-19 patients admitted to a French ICU: no prognostic improvement during the second wave? Crit Care. 2021;25:3.
The RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with Covid-19. N Engl J Med. 2021;384:693–704.
Rubin S, et al. Characterization of acute kidney injury in critically ill patients with severe coronavirus disease 2019. Clin Kidney J. 2020. https://doi.org/10.1093/ckj/sfaa099.
Gabarre P, et al. Acute kidney injury in critically ill patients with COVID-19. Intensive Care Med. 2020;46:1339–48.
Nadim MK, et al. COVID-19-associated acute kidney injury: consensus report of the 25th Acute Disease Quality Initiative (ADQI) Workgroup. Nat Rev Nephrol. 2020. https://doi.org/10.1038/s41581-020-00356-5.
Orieux A, et al. Severe COVID-19 induced AKI: a 3-month follow-up. Clin Kidney J. 2021. https://doi.org/10.1093/ckj/sfab028.
Acknowledgements
We thank all doctors and residents who took care of the patients.
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AO, SR and AB conceived and designed the study, analyzed the data and drafted the manuscript. AO was responsible for data acquisition. PK, RP and DG helped to conduct the study. All authors read and approved the final manuscript.
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Patients data were routinely collected in dedicated electronic health records during their entire hospital stay. According to French law and the French Data Protection Authority, the handling of these data for research purposes was declared to the Data Protection Officer of the University Hospital of Bordeaux. Patients (or their relatives, if any) were notified about the anonymized use of their health care data via the department’s booklet.
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Orieux, A., Khan, P., Prevel, R. et al. Impact of dexamethasone use to prevent from severe COVID-19-induced acute kidney injury. Crit Care 25, 249 (2021). https://doi.org/10.1186/s13054-021-03666-7
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DOI: https://doi.org/10.1186/s13054-021-03666-7