Acute kidney injury in patients hospitalized with COVID-19

      The rate of acute kidney injury (AKI) associated with patients hospitalized with Covid-19, and associated outcomes are not well understood. This study describes the presentation, risk factors and outcomes of AKI in patients hospitalized with Covid-19. We reviewed the health records for all patients hospitalized with Covid-19 between March 1, and April 5, 2020, at 13 academic and community hospitals in metropolitan New York. Patients younger than 18 years of age, with end stage kidney disease or with a kidney transplant were excluded. AKI was defined according to KDIGO criteria. Of 5,449 patients admitted with Covid-19, AKI developed in 1,993 (36.6%). The peak stages of AKI were stage 1 in 46.5%, stage 2 in 22.4% and stage 3 in 31.1%. Of these, 14.3% required renal replacement therapy (RRT). AKI was primarily seen in Covid-19 patients with respiratory failure, with 89.7% of patients on mechanical ventilation developing AKI compared to 21.7% of non-ventilated patients. 276/285 (96.8%) of patients requiring RRT were on ventilators. Of patients who required ventilation and developed AKI, 52.2% had the onset of AKI within 24 hours of intubation. Risk factors for AKI included older age, diabetes mellitus, cardiovascular disease, black race, hypertension and need for ventilation and vasopressor medications. Among patients with AKI, 694 died (35%), 519 (26%) were discharged and 780 (39%) were still hospitalized. AKI occurs frequently among patients with Covid-19 disease. It occurs early and in temporal association with respiratory failure and is associated with a poor prognosis.

      Graphical abstract


      To read this article in full you will need to make a payment
      ISN Member Login
      Login with your ISN username and password.
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • World Health Organization
        Novel coronavirus—China. January 2020.
        (Available at:)
      1. COVID-19 Dashboard by the Center for Systems Science and Engineering at Johns Hopkins University.
        (Available at:)
        • Holshue M.L.
        • DeBolt C.
        • Lindquist S.
        • et al.
        First case of 2019 novel coronavirus in the United States.
        N Engl J Med. 2020; 382: 929-936
        • CDC COVID-19 Response Team
        Geographic differences in COVID-19 cases, deaths, and incidence—United States, February 12–April 7, 2020.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 465-471
        • Bhatraju P.K.
        • Ghassemieh B.J.
        • Nichols M.
        • et al.
        Covid-19 in critically ill patients in the Seattle region—case series.
        N Engl J Med. 2020; 382: 2012-2022
        • CDC COVID-19 Response Team
        Severe outcomes among patients with coronavirus disease 2019 (COVID-19)—United States, February 12–March 16, 2020.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 343-346
        • Guan W.-J.
        • Ni Z.-Y.
        • Hu Y.
        • et al.
        Clinical characteristics of coronavirus disease 2019 in China.
        N Engl J Med. 2020; 382: 1708-1720
        • Wang D.
        • Hu B.
        • Hu C.
        • et al.
        Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China.
        JAMA. 2020; 323: 1061-1069
        • Huang C.
        • Wang Y.
        • Li X.
        • et al.
        Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
        Lancet. 2020; 395: 497-506
        • Chen N.
        • Zhou M.
        • Dong X.
        • et al.
        Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.
        Lancet. 2020; 395: 507-513
      2. Diao B, Wang C, Wang R, et al. Human kidney is a target for novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection [preprint]. medRxiv. Accessed April 19, 2020.

        • Zhou F.
        • Yu T.
        • Du R.
        • et al.
        Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.
        Lancet. 2020; 395: 1054-1062
        • Cheng Y.
        • Luo R.
        • Wang K.
        • et al.
        Kidney disease is associated with in-hospital death of patients with COVID-19.
        Kidney Int. 2020; 97: 829-838
        • Chen T.
        • Wu D.
        • Chen H.
        • et al.
        Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study.
        BMJ. 2020; 368: m1091
        • Yang X.
        • Yu Y.
        • Xu J.
        • et al.
        Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study.
        Lancet Respir Med. 2020; 8: 475-481
        • Arentz M.
        • Yim E.
        • Klaff L.
        • et al.
        Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington state.
        JAMA. 2020; 323: 1612-1614
      3. Abelson R, Fink S, Kulish N, Thomas K. An overlooked, possibly fatal coronavirus crisis: a dire need for kidney dialysis. New York Times. April 18, 2020. Available at: Accessed May 2, 2020.

      4. Simonnet A, Chetboun M, Poissy J, et al. High prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation [e-pub ahead of print]. Obesity (Silver Spring). Accessed April 19, 2020.

      5. Chen R, Liang W, Jiang M, et al. Risk factors of fatal outcome in hospitalized subjects with coronavirus disease 2019 from a nationwide analysis in China [e-pub ahead of print]. Chest. Accessed April 22, 2020.

        • Jordan R.E.
        • Adab P.
        • Cheng K.K.
        Covid-19: risk factors for severe disease and death.
        BMJ. 2020; 368: m1198
      6. Zhang J, Wang X, Jia X, et al. Risk factors for disease severity, unimprovement, and mortality of COVID-19 patients in Wuhan, China [e-pub ahead of print]. Clin Microbiol Infect. Accessed April 19, 2020.

        • Johns Hopkins Coronavirus Resource Center
        Racial data transparency: states that have released breakdowns of Covid-19 data by race.
        (Available at:)
      7. New York State Department of Health. Fatalities.
        (Available at:)
        • Vaduganathan M.
        • Vardeny O.
        • Michel T.
        • McMurray J.J.V.
        • Pfeffer M.A.
        • Solomon S.D.
        Renin-angiotensin-aldosterone system inhibitors in patients with Covid-19.
        N Engl J Med. 2020; 382: 1653-1659
        • Fang L.
        • Karakiulakis G.
        • Roth M.
        Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?.
        Lancet Respir Med. 2020; 8: e21
        • Esler M.
        • Esler D.
        Can angiotensin receptor-blocking drugs perhaps be harmful in the COVID-19 pandemic?.
        J Hypertens. 2020; 38: 781-782
        • Diaz J.H.
        Hypothesis: angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may increase the risk of severe COVID-19.
        J Travel Med. 2020; 27: taaa041
        • Su H.
        • Yang M.
        • Wan C.
        • et al.
        Renal histopathological analysis of 26 postmortem findings of patients with COVID-19 in China.
        Kidney Int. 2020; 97: 219-227
        • Richardson S.
        • Hirsch J.S.
        • Narasimhan M.
        • et al.
        Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.
        JAMA. 2020; 323: 2052-2059
        • Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Workgroup
        KDIGO clinical practice guideline for acute kidney injury.
        Kidney Int Suppl. 2012; 2: 1-138
        • NHS England
        Acute kidney injury (AKI) algorithm.
        (Available at:)
        • Levey A.S.
        • Stevens L.A.
        Estimating GFR using the CKD Epidemiology Collaboration (CKD-EPI) creatinine equation: more accurate GFR estimates, lower CKD prevalence estimates, and better risk predictions.
        Am J Kidney Dis. 2010; 55: 622-627
        • Jalal K.
        • Anand E.J.
        • Venuto R.
        • Eberle J.
        • Arora P.
        Can billing codes accurately identify rapidly progressing stage 3 and stage 4 chronic kidney disease patients: a diagnostic test study.
        BMC Nephrol. 2019; 20: 260
        • Benchimol E.I.
        • Smeeth L.
        • Guttmann A.
        • et al.
        The Reporting of Studies Conducted Using Observational Routinely-Collected Health Data (RECORD) statement.
        PLoS Med. 2015; 12e1001885
        • EQUATOR Network
        The Reporting of Studies Conducted Using Observational Routinely-Collected Health Data (RECORD) statement.
        (Available at:)

      Linked Article

      • Thrombotic microangiopathy in a patient with COVID-19
        Kidney InternationalVol. 98Issue 2
        • Preview
          We describe a patient with coronavirus disease 2019 (COVID-19) and clinically significant kidney biopsy-proven thrombotic microangiopathy.
        • Full-Text
        • PDF
      • Time-dependent effect, immortal bias, and competing risk: 3 components that should be handled to assess the impact of covariates on occurrence of acute kidney injury
        Kidney InternationalVol. 98Issue 5
        • Preview
          We read with great interest the study from Hirsch et al. in the July 2020 issue of Kidney International.1 In that study, the authors aimed to identify risk factors of acute kidney injury (AKI) in patients admitted for coronavirus disease 2019. They compared characteristics of 5449 patients according to AKI occurrence and performed multivariable logistic regression to adjust for covariates. The authors have identified 2 risk factors occurring during the hospital stay: the need for mechanical ventilation (odds ratio = 31.6 [25.8–38.6] in univariate analysis and odds ratio = 10.7 [6.81–16.7] in multivariable analysis) and vasopressor medication (odds ratio = 31.4 [25.6–38.4] in univariate analysis and odds ratio = 4.5 [2.9–7.1] in multivariable analysis).
        • Full-Text
        • PDF
      • The authors reply
        Kidney InternationalVol. 98Issue 5
        • Preview
          We thank Jamme and Geri for their comments.1 When we first embarked on this study in mid-April 2020, the data on acute kidney injury (AKI) among patients hospitalized with coronavirus disease 2019 in the United States were sparse.2 Thus, our primary research question was to (i) determine the rates of AKI among these patients, and (ii) investigate the effects of potential explanatory variables on the occurrence of AKI.2 The goal was not to determine time-to-AKI, nor to make causal inferences about how mechanical ventilation causes AKI.
        • Full-Text
        • PDF