Journal Information
Vol. 41. Issue. 1.January - February 2021
Pages 1-90
Vol. 41. Issue. 1.January - February 2021
Pages 1-90
Letter to the Editor
DOI: 10.1016/j.nefroe.2020.04.005
Open Access
Renal infaction in a patient with COVID-19
Infarto renal en paciente con COVID-19
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Guillermo Cuevas Tascóna, Danilo E. Salazar Chiribogab, Rosa Lorente Ramosb, Domingo Díaz Díazc, Covadonga Rodríguez Ruizc, Fabio L. Procaccinid, Esther Torres Aguilerad, Juan A. Martín Navarrod,
Corresponding author
juanmartinnav@hotmail.com

Corresponding author.
, Beatriz Mestre Gómeza, Nuria Muñoz Rivasa, Roberto Alcázar Arroyod
a Servicio de Medicina Interna, Hospital Universitario Infanta Leonor, Madrid, Spain
b Servicio de Radiología, Hospital Universitario Infanta Leonor, Madrid, Spain
c Servicio de Medicina Intensiva, Hospital Universitario Infanta Leonor, Madrid, Spain
d Servicio de Nefrología, Hospital Universitario Infanta Leonor, Madrid, Spain
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Table 1. Blood test results and their progression.
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Dear Editor,

The most recognised renal manifestations of the current COVID-19 pandemic are multifactorial acute renal failure, usually prerenal, associated with the treatments used in severe disease or complications such as sepsis.1,2 Furthermore, as the infection progresses, a procoagulant state develops that increases the risk of thromboembolic events. The most commonly reported are pulmonary and cerebral embolisms. We present the case of a patient with renal infarction.

56-year-old male of Peruvian origin who was admitted from the emergency department on 31/03/2020 due to a five-day history of intense asthenia with general malaise, fever: 38.5 °C, cough and diarrhoea. He had well-controlled type 2 diabetes mellitus, a one-year history of mixed dyslipidaemia, and uncomplicated diverticulosis. He was receiving treatment with dapagliflozin/metformin and plantago ovata and adhering to a low-fat diet. On examination, he had a fever of 37.5 °C, was normotensive, and had moderate tachypnoea and sparse bibasal crackles. Height 174 cm, weight 94 kg (BMI 31). The main blood test results are summarised in Table 1. Chest X-ray with patchy bilateral interstitial alveolar infiltrates. Initiated treatment with hydroxychloroquine, azithromycin, ceftriaxone, enoxaparin 0.5 mg/kg/day and ventilatory support with nasal cannula at 2 bpm. At 24 h, the positive result for SARS-CoV-2 was received following a RT-PCR test on a nasopharyngeal swab. The patient's clinical course was unfavourable, with a greater oxygen requirement, continuous fever and an increase in acute phase reactants, so on the third day IV methylprednisolone boluses were started at 250 mg/day for 3 days, and 40 mg/day thereafter, and on the fourth day a single IV dose of tocilizumab 600 mg was administered. The patient’s condition continued to deteriorate, with clinical, laboratory and radiological progression (Fig. 1). On the sixth day, the enoxaparin dose was increased to 0.8 mg/kg/day. The patient remained stable until the ninth day, when his condition further deteriorated. The tenth day began with intense, continuous, non-radiating pain in the left iliac fossa, without accompanying bladder dysfunction. Intestinal perforation was suspected in relation to anti-interleukin treatment and an abdominal CT scan with intravenous contrast was performed (Fig. 2). Acute diverticulitis was identified and in the left kidney, hypodense, wedge-shaped areas were observed, findings consistent with extensive renal infarction, as well as associated thrombosis of the left renal artery (arrow). Renal function only showed a slight deterioration (sCr: 0.9–1.1 mg/dl and estimated GFR CKD-EPI from greater than 90–67 ml/min/1.73 m2) and the patient, who six months earlier had urine without proteinuria or haematuria and negative microalbuminuria, developed stage A3 microalbuminuria, microhaematuria and subnephrotic proteinuria. He was admitted to the intensive care unit, where he remains at the time of writing. Invasive mechanical ventilation, treatment with norepinephrine and anticoagulation with low molecular weight heparin were required. Spontaneous diuresis greater than 0.5 ml/kg/h and anticoagulation with enoxaparin. The patient’s respiratory status is improving slowly.

Table 1.

Blood test results and their progression.

Values/day  Admission  10  11  12  13  18 
Leukocytes  6.13  5.77  6.71  8.97  9.28  11.95  13.52  12.27  13.27  24.89  22.14  11.9 
Lymphocytes  400  600  400  500  300  400  300  300  200  600  100  700 
Hb  16.5  14.6  15.9  14.9  14.9  14.4  16.5  15.5  15.2  16.5  15.6  12.4 
Platelets  181  196  218  249  287  356  400  310  281  321  173  212 
Activ. PT  82.3  78  76  73  81.9  79.9  71.2  79.4  75  65.8  78  99.6 
APTT  27.4  28.7  30  28.8  24.4  21  22  21.9  21.5  23.4  27.4  27.7 
Fibrinogen  >500  >500  >500  >500  >500  675  487  423  317  414  446  >500 
Creatinine  1.17  1.01  1.14  1.01  1.04  0.94  0.91  0.90  1.17  0.95  1.08  0.97 
eGFR CKD-EPI  69  83  72  83  80  >90  >90  >90  69  89  76  87 
Lactate  2.47    2.06  3.49  2.44  3.09        1.62  1.68  0.99 
CPK  99    160        82  61    104  33  21 
LDH  245  248  311  405  418  450  552  698  1718  461  1975  773 
GPT (ALT)  35  31  31  33  43  51  67  47  99  167  131  44 
GOT (AST)  40  36  44  50  49  49  57  56  202  236  91  50 
CRP  107.5  105  183  191  190  69  17  15  15  28  44  94 
d-dimer  2710    940  1470      5580  1080  1211  1886  8790  3350 
Ferritin      546          475    1053     
IL-6      99          >1000         
aPL Ab                        Negative 
Urinalysis                        Microhaem, PRT 100 mg/dl, isolated leukocyturia 
Spontaneous urine:                        MAu/Cru: 278 
                        PCR: 1870 mg/g Cr 
TT  AZT    MPRN 250 × 3  TOC    ENOX1 mg/kg/12 h  MPRN 40  MEROP         
  HCQ            ANAK  LINEZ         
  CEFT                       
  ENOX 0.5 mg/kg/d                       

ANAK: anakinra; AZT: azithromycin; CEFT: ceftriaxone; ENOX: enoxaparin; HCQ: hydroxychloroquine; LINEZ: linezolid; Mau/Cru: microalbuminuria/creatinine in urine; MEROP: meropenem; MICROHAEM: microhaematuria; MPRN: metal prednisolone; PCR: urine protein creatinine ratio; PRT: proteinuria; TOC: tocilizumab.

Units: leukocytes *10E3/µl; lymphocytes *10E3/µl; haemoglobin g/dl; platelets 10E3/µl; APTT sec; activ. prothrombin (Activ. PT) sec; derived fibrinogen mg/dl; creatinine mg/dl; lactate mmol/l; CPK U/l; LDH U/l; GPT (ALT) U/l; GOT (AST) U/l; estimated glomerular filtration rate [CKD-EPI] ml/min/1.73 m2; C-reactive protein (CRP) mg/l; d-dimer mg/dl; ferritin mg/dl; interleukin 6 (IL-6) ng/ml; SO: urinalysis, aPL Ab: antiphospholipid antibodies (beta-2 glycoprotein 1 IgG IU/ml, beta-2 glycoprotein 1 IgM IU/ml, anticardiolipin IgG GPL/ml and anticardiolipin IgM MPL/ml).

Fig. 1.

Chest X-ray, progression on days 1 (A), 2 (B), 3 (C), 6 (D), 9 (E) and 12 (F).

(0.12MB).
Fig. 2.

Abdominal CT scan on days 10 (A) and 18 (B).

(0.21MB).

Renal infarctions are uncommon lesions that can be seen in various situations: after intrarenal haematoma,3 renal artery dissection in instrumental procedures, dyslipidaemia,4 PR3-ANCA positive vasculitis,5 fibromuscular dysplasia, atherosclerotic disease, connective tissue diseases, embolic heart disease (atrial fibrillation, valvular heart disease, ventricular aneurysms, heart attacks, dilated cardiomyopathies), idiopathic heart disease6 and thrombophilias such as dysfibrinogenemia.7

Various series8,9 have identified the following as the main risk factors: hypertension, smoking, atrial fibrillation, obesity, peripheral vascular disease, previous thromboembolic event, diabetes mellitus and oestroprogestin therapy. There is little consensus on whether the conservative approach with antiplatelet therapy and anticoagulation, or the interventionist approach with fibrinolysis and angioplasty, is more effective.

Coronavirus can directly infect endothelial cells, platelets and megakaryocytes by combining with its receptor CD13,10,11 inducing platelet damage, endotheliitis and apoptosis, which triggers the recruitment of macrophages and granulocytes that will synthesise pro-inflammatory cytokines. If the infection is not controlled, the inflammation progresses, exacerbates tissue and microvascular damage, stimulates the extrinsic pathway of coagulation and inhibits fibrinolysis, which could trigger a hypoxia-aggravated consumption coagulopathy that would induce platelet aggregation, synthesis of thrombopoietin, fibrinogen, VEFG and thrombin, and lead to decreased anticoagulant factors such as antithrombin III and plasminogen activator inhibitor.12–14 This mechanism would be confirmed by increased d-dimer and thrombocytopenia levels. The resulting thromboinflammatory and procoagulant environment12 would trigger thrombotic events in the different affected areas, 4.5% cerebral, 11.4% pulmonary and 20% deep vein thrombosis. Our patient maintained glomerular filtration stability at all times and was treated with anticoagulant doses of enoxaparin. To our knowledge, this is the second reported case of renal artery thrombosis in this context.15

References
[1]
V. Fanelli, M. Fiorentino, V. Cantaluppi, L. Gesualdo, J. Stallone, C. Ronco, et al.
Acute kidney injury in SARS-CoV-2 infected patients.
[2]
S. Richardson, J.S. Hirsch, M. Narasimhan, J.M. Crawford, T. McGinn, K.W. Davidson, The Northwell COVID-19 Research Consortium.
Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City Area.
[3]
S. Park, G.H. Lee, K. Jin, K.M. Park, Y.W. Kim, B.S. Park.
Renal infarction caused by isolated spontaneous renal artery intramural hematoma.
Am J Case Rep, 16 (2015), pp. 832-836
[4]
A. El Barzouhi, M. van Buren, C. van Nieuwkoop.
Renal and Splenic infarction in a patient with familial hypercholesterolemia and previous cerebral infarction.
Am J Case Rep, 19 (2018), pp. 1463-1466
[5]
M.J. Bottomley, M. Gibson, B. Alchi.
PR3 vasculitis presenting with symptomatic splenic and renal infsrction: a case report and literature review.
BMC Nephrol, 20 (2019), pp. 84
[6]
Z. Eren, H. Koyuncu.
Renal Infarction in a Young Man.
[7]
K. Keinath, T. Church, Fogarty, B. Sadowski, J. Perkins.
Acute renal artery infarction secondary to dysfibrinogenemia.
[8]
P. Mesiano, C. Rollino, G. Beltrame, M. Ferro, G. Quattrocchio, R. Fenoglio, et al.
Acute renal infarction: a single center experience.
J Nephrol, 30 (2017), pp. 103-107
[9]
F. Caravaca-Fontán, S. Pampa Saico, S. Elías Triviño, C. Galeano Álvarez, A. Gomis Couto, I. Pecharromán de las Heras, et al.
Acute renal infarction: clinical characteristics and prognostic factors.
Nefrologia, 36 (2016), pp. 141-148
[10]
H. Han, L. Yang, R. Liu, F. Liu, K.L. Wu, J. Li, et al.
Prominent changes in blood coagulation of patients with SARS-CoV-2 infection.
Clin Chem Lab Med, (2020),
[11]
Z. Varga, A.J. Flammer, P. Steiger, M. Haberecker, R. Andermatt, A.S. Zinkernagel, et al.
Endothelial cell infection and endotheliitis in COVID-19.
Lancet, 395 (2020), pp. 1417-1418
[12]
J.M. Connors, J.H. Levy.
Thromboinflammation and the hypercoagulability of COVID-19.
J Thromb Haemost, (2020),
[13]
H. Mei, Y. Hu.
Characteristics, causes, diagnosis and treatment of coagulation dysfunction in patients with COVID-19.
Zhonghua Xue Ye Xue Za Zhi, 41 (2020), pp. E002
[14]
S. Yin, M. Huang, D. Li, N. Tang.
Difference of coagulation features between severe pneumonia induced by SARS-COV2 and non- SARS-CoV2.
J Thromb Thrombolysis, (2020),
[15]
N. Lushina, J.S. Kuo, H.A. Shaikh.
Pulmonary, cerebral, and renal thromboembolic disease associated with COVID-19 infection radiology.

Please cite this article as: Cuevas Tascón G, Salazar Chiriboga DE, Lorente Ramos R, Díaz Díazc D, Rodríguez Ruiz C, Procaccini FL, et al. Infarto renal en paciente con COVID-19. Nefrologia. 2021;41:84–87.

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