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Acute Kidney Injury in Pediatric Acute SARS-CoV-2 Infection and Multisystem Inflammatory Syndrome in Children
Manpreet K Grewal1,2, Melissa J Gregory1,2, Amrish Jain1,2
1Division of Nephrology and Hypertension, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, United States.
Insights
Children with COVID-19 and multisystem inflammatory syndrome (MIS-C) face a high risk of acute kidney injury (AKI), especially those with MIS-C. Prompt recognition and renal protective strategies are crucial for recovery in this vulnerable pediatric group.
Area of Science:
- Pediatric Nephrology
- Infectious Diseases
- Critical Care Medicine
Background:
- Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can lead to significant morbidity in children.
- Multisystem inflammatory syndrome in children (MIS-C) is a serious complication associated with SARS-CoV-2.
- Acute kidney injury (AKI) is a potential complication in critically ill children, but its prevalence in SARS-CoV-2 and MIS-C requires further investigation.
Purpose of the Study:
- To determine the incidence of AKI in pediatric patients diagnosed with SARS-CoV-2 infection, with or without MIS-C.
- To identify clinical and laboratory factors associated with the development of AKI in this patient population.
- To understand the distinct pathophysiological mechanisms of AKI in SARS-CoV-2 infection versus MIS-C.
Main Methods:
- Retrospective chart review of 113 pediatric patients admitted with SARS-CoV-2 infection between March and August 2020.
- Data collection included demographics, laboratory results, imaging, echocardiography, and treatment details.
- Statistical analysis, including multivariate analysis, was performed to identify predictors of AKI.
Main Results:
- Of 92 analyzed patients, 24% developed AKI, with 36% of those reaching stage 3 AKI.
- AKI prevalence was significantly higher in patients with MIS-C (54%) compared to those with acute SARS-CoV-2 infection (11%).
- Independent predictors for AKI included inotropic support, African American race, and MIS-C diagnosis. All patients recovered kidney function without requiring renal replacement therapy.
Conclusions:
- Pediatric patients with SARS-CoV-2 infection, particularly those with MIS-C, are at substantial risk for developing AKI.
- AKI in SARS-CoV-2 appears multifactorial, involving renal hypoperfusion and direct damage, while MIS-C related AKI is primarily pre-renal due to cardiac dysfunction and hyperinflammation.
- Clinicians should prioritize renal protective strategies for high-risk pediatric patients with SARS-CoV-2 and MIS-C to ensure optimal kidney recovery and prevent further injury.
Abstract:
Objective: To evaluate the prevalence and factors associated with the risk of acute kidney injury (AKI) in pediatric patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and multisystem inflammatory syndrome in children (MIS-C). Study Design: We performed a retrospective chart review of 113 patients with SARS-CoV-2 infection with or without MIS-C admitted at Children's Hospital of Michigan (CHM) from March to August 2020. Patient demographic details, laboratory data, imaging studies, echocardiography reports, and treatment data were collected. Results: Of the 92 patients included in the final analysis, 22 (24%) developed AKI with 8/22 (36%) developing stage 3 AKI. The prevalence of AKI was much higher in patients with MIS-C 15/28 (54%) vs. those with acute SARS-CoV-2 infection 7/64 (11%), (p < 0.001). Overall, when compared to patients without AKI, patients with AKI were older in age (11 vs. 6.5 years, p = 0.007), African American (86 vs. 58%, p = 0.028), had MIS-C diagnosis (68 vs. 19%, p < 0.001), required ICU admission (91 vs. 20%, p < 0.001), had cardiac dysfunction (63 vs. 16%, p < 0.001), required inotropic support (59 vs. 6%, p < 0.001) and had a greater elevation in inflammatory markers. In a multivariate analysis, requirement of inotropes [Odds Ratio (OR)-22.8, p < 0.001], African American race (OR-8.8, p = 0.023) and MIS-C diagnosis (OR-5.3, p = 0.013) were the most significant predictors for AKI. All patients had recovery of kidney function, and none required kidney replacement therapy. Conclusion: Children with acute SARS-CoV-2 infection and MIS-C are at risk for AKI, with the risk being significantly greater with MIS-C. The pathogenesis of AKI in acute SARS-CoV-2 infection appears to be a combination of both renal hypo-perfusion and direct renal parenchymal damage whereas in MIS-C, the renal injury appears to be predominantly pre-renal from cardiac dysfunction and capillary leak from a hyperinflammatory state. These factors should be considered by clinicians caring for these children with a special focus on renal protective strategies to aid in recovery and prevent additional injury to this high-risk subgroup.
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