Predictors of Mortality in ICU Patients with Severe COVID-19 and Renal Failure - The Lahey Experience

Rationale: Coronavirus disease 2019 (COVID-19) is currently the third leading cause of death in the United States. During the Spring of 2020, the Commonwealth of Massachusetts, USA experienced a surge of COVID-19 ICU cases. Many of these patients developed acute renal failure (ARF) requiring renal replacement therapy (RRT) with hemodialysis (HD) or continuous veno-venous hemofiltration (CVVH) which taxed our hospital's supply of equipment and staff. The goal of our study was to identify predictors of mortality in ICU patients requiring RRT in the setting of COVID-19, should rationing of ICU care became necessary. Methods: Between March 2020 and April 2020, we prospectively collected data on patients admitted to the Lahey ICUs with severe COVID-19 who required RRT and assessed patient characteristics and mortality. Results: Thirty ICU patients were identified with severe COVID-19 requiring RRT. Twenty-seven patients (90%) required acute initiation of CVVH, while three (10%) only utilized intermittent HD during their hospitalization. Only ten (33%) survived their hospitalization. No significant difference was found between survivors and patients who died with respect to age, comorbidities (BMI, CKD, HTN, DM, alcohol use, heart disease, malignancy, COPD, asthma) or baseline creatinine. All 30 patients (100%) required mechanical ventilation (MV) and 25 (83%) developed shock requiring vasopressors prior to initiation of RRT. Seventy percent of survivors (7/10) had been on either an ACE-inhibitor (ACEI) or an Angiotensin Receptor Blocker (ARB) prior to hospitalization, compared to only 20% (4/20) who died (p=0.0147) Survivors were treated with hydroxychloroquine (HC) significantly more frequently (10/10 vs 8/20;p=0.0016) and treated with systemic corticosteroids (CS) significantly less frequently (5/10 vs 20/20;p=0.0018) than those who died. There was no difference in survival between those who received Vancomycin or Tocilizumab and those who did not. The median hospital stay was significantly longer for survivors (46 days) than for those who died (19 days;p =0.0003). Conclusion: The need for RRT in ICU patients with COVID-19 was associated with significant mortality (66%) and a significant need for MV (100%) and vasopressors (83%). The use of an ACEI or ARB prior to admission was significantly associated with improved survival, the use of CS was associated with higher mortality, and the use of HC was associated with improved survival. These latter findings go against current theories of COVID pathophysiology and may be a result of the small number of patients in our study.