Epidemiologia da injúria renal aguda nos anos de pandemia: padrões de gravidade e recuperação em pacientes com e sem COVID-19 em hospitais público e privado no Rio de Janeiro

Abstract

The pandemic of the disease associated with the coronavirus 2019 (COVID-19) imposed substantial challenges on global health systems, marked by increased mortality and healthcare costs, as well as economic and social impacts. One of the most severe complications, besides pulmonary affliction, was acute kidney injury (AKI). This complication raised significant concerns due to its impact on the morbidity and mortality of patients with COVID-19, and it has been extensively studied over the three years of the pandemic. However, some gaps in the understanding of the epidemiology of AKI remained, including the comparison of AKI among patients with and without COVID-19, admitted at the same time during critical periods of the pandemic, and the detailed epidemiology of AKI in this context, in emerging countries such as Brazil. Another unstudied aspect was the potential impact of the type of hospital management (public vs. private) on the evolution of AKI in COVID-19, which could reveal economic disparities in the outcomes of these patients. To address these gaps, we conducted a retrospective study using prospectively collected data from patients admitted to intensive care units (ICU) of two major hospitals in Rio de Janeiro, one public and one private. The EPIMED platform was used for data collection from March 2020 to April 2022. Using logistic regression methods and Kaplan-Meier survival analyses, we initially analyzed 9,112 ICU admissions, of which 2,333 patients (25.6%) were diagnosed with COVID-19. Patients with COVID-19 had a more extended ICU stay (9 vs. three days), a higher need for mechanical ventilation (47.3% vs. 20.2%, p<0.001), and an increased incidence of AKI (79.7% vs. 52.6%, p<0.001). The recovery of renal function was significantly lower in patients with COVID-19 (32.7% vs. 55.4%, p<0.001), with a higher risk for acute kidney disease (unrecovered AKI) at hospital discharge (OR 1.99; CI 1.74–2.28). Analyzing only the 2,333 patients diagnosed with COVID-19 and comparing the epidemiology between the institutions, we observed that the incidence of AKI did not differ significantly between public and private hospitals (80.4% vs. 78.8%, p=0.385). However, the use of ICU resources was higher in the private hospital. Mortality was higher in the public hospital (46.7% vs. 31.3%, p<0.001), with an adjusted odds ratio of 4.44 (CI 3.36–5.93). We conducted sensitivity analyses to address the potential bias from late referral pathways of patients in the public hospital, which did not significantly change the findings. This study highlights the distinct effects of severe COVID-19, which differ from other causes of AKI in the ICU. It underscores the importance of improving pandemic preparedness and developing effective health strategies to protect renal health against future adversities. Additionally, our findings indicate a potential for disparity in the disease outcome according to the type of hospital, with possibly worse outcomes in public hospitals, in the face of a challenge of such magnitude in public health.