Management of acute kidney injury in patients with COVID-19

Recommendations InfectiologyAnesthesia-intensive careNephrology
Ronco C et al
Lancet Repir Med

Main result

  • The causes of renal involvement in Covid-19 may be multifactorial. The cardio-renal syndrome, in particular a right ventricular dysfunction secondary to pneumonia due to Covid-19, could lead to renal congestion and consequently acute renal failure. Similarly, left ventricular dysfunction could lead to low cardiac output and hypoperfusion. Autopsies revealed virus particles in renal endothelial cells indicating viremia as a possible cause of endothelial damage in the kidney and as a probable inducer of acute renal failure.
  • In addition, SARS-CoV-2 can directly infect the renal tubular epithelium and podocytes via an angiotensin converting enzyme 2 (ACE2)-dependent pathway and cause mitochondrial dysfunction, acute tubular necrosis, formation of protein reabsorption voids, collapse of glomerulopathy, and protein leakage in Bowman's Capsule.
  • Another potential mechanism of renal failure involves deregulation of the immune response related to SARS-CoV-2, as indicated by observed lymphopenia and cytokine release syndrome (cytokine storm).
  • Rhabdomyolysis, macrophage activation syndrome and the development of microemboli and microthrombi in the context of hypercoagulability and endothelitis could be another hypothesis.


  •  The decision to use extracorporeal therapies should take into account the technical effort and dedicated skills of multidisciplinary staff that are necessary for safe and effective therapy delivery. Careful patient selection for sequential extracorporeal therapies is necessary because age and comorbidities appear to influence outcomes in critically ill patients with COVID-19.
  • Further research is needed to improve the understanding of renal failure secondary to COVID-19, to obtain adequate evidence to support the clinical approaches discussed, and to develop new approaches to monitoring and management.

Strength of evidence Weak



Discussion of current knowledge of the mechanisms of renal involvement in Covid-19.

To provide sets of recommendations for clinical practice based on current clinical experience, including prevention and management of acute renal failure and potential indications for the use of renal replacement therapies.


  • Search for original PubMed articles, reviews, editorials and commentaries published between January 1, 2020 and May 2, 2020, using the following terms: ("renal" OR "kidney") AND/OR ("coronavirus disease 2019" OR "severe acute respiratory syndrome coronavirus 2").
  • Only English-language manuscripts were selected. Relevant guidelines for the management of patients with suspected COVID-19 published by WHO were also reviewed.

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