May 19th, 2020

Podcast 267: Acute kidney injury in COVID-19 — how one New York system dealt with it

(14 votes, average: 3.36 out of 5)

The novel coronavirus obviously has devastating effects on the lungs, but other, less immediately visible attacks occur — notably to the kidneys.

Dr. Steven Fishbane (a nephrologist) and his colleagues have just published their findings based on a survey of some 5500 patients with COVID-19 admitted to a metropolitan New York health system. Acute kidney injury developed in about one third of the group, and it was very common (almost 90%) among those requiring mechanical ventilation.

But beyond these clinical features, I wanted to ask Dr. Fishbane about how he and his staff prepared for the viral onslaught, and especially what lessons he takes from the experience.

Running time: 21 minutes

Links:

Kidney International study

Other interviews in this series on COVID-19

  1. Dr. Anthony Fauci
  2. Dr. Susan Sadoughi
  3. Dr. Matthew Young
  4. Dr. Julian Flores
  5. Dr. Kristi Koenig
  6. Dr. Renee Salas
  7. Drs. Andre Sofair and William Chavey
  8. Dr. Comilla Sasson
  9. Dr. John Jernigan
  10. Dr. Ivan Hung

TRANSCRIPT

Joe Elia:

You’re listening to Clinical Conversations. I’m your host, Joe Elia.

Our first encounters with COVID-19 often focused on the lungs and respirators. Now, that view has widened to take in things like kidney and coagulation disorders.

One large study of kidney complications has recently been published in Kidney International, and we have one of its authors with us. Dr. Steven Fishbane and his colleagues looked at the clinical outcomes in some 5400 COVID-19 patients admitted to roughly a dozen hospitals in the Northwell Health system in metropolitan New York. Their report offers important clinical insights, which we’ll talk about, but it will also be interesting to hear how the group coped with the sudden sharp demand for kidney replacement therapy.

Dr. Fishbane is Chief of Nephrology at Northwell Health. He also serves as Professor of Medicine at Zucker School of Medicine at Hofstra/Northwell.

Welcome to Clinical Conversations, Dr. Fishbane.

Dr. Steven Fishbane:

Thank you. Pleasure to be with you.

Joe Elia:

The Kidney International paper spans roughly one month’s experience — March of this year — with COVID-19. Before we move on to your experience in preparing for it, would you very briefly tell us what you found, clinically, in your…?

Dr. Steven Fishbane:

Right. So, in this study, and to put it in perspective for you, so, COVID-19 moved into New York with such an explosive rate in March, in particular, that you know it greatly overwhelmed the ability of the health systems, which just managed to get their way through, but for us at the time of the writing of this article, it was based on the first 5,449 patients, which now we, as a health system, have treated 15,000 patients, but in the study, the primary findings, I think, which were important to us was first being able to describe the number of patients who have COVID-19 admitted to hospitals. That’s important to describe is that 36.6 percent developed acute kidney injury, and people had been kind of waiting on that number, in that out of China and Italy, the numbers for acute kidney injury look like they were lower, and anecdotally, we, in the US, were experiencing what we thought were higher numbers, and we were just waiting for a rigorous look at it.

So, yeah, and it turned out that we found that a substantially higher number of patients were at least being reported in our study as being higher. That now has come out in some other work out of the United States, and then we had a number of other findings, I think, that were really interesting, as well, but you know, I think the first really important point was to remember, as you pointed out earlier, this is a respiratory illness. It is a remarkably focused, serious respiratory illness, but we are learning that it does affect other organs, as well. So, here, it’s the kidneys that are being demonstrated, as you pointed out, coagulopathic problems. Here, it’s the kidneys that are turning out to be an important secondary problem.

Joe Elia:

So, the number of people with acute kidney injury were found to be roughly the same as yours in a paper being published later today in The Lancet, from New York City, from Columbia. So, same general catchment area and your numbers are very similar.

In reading [your] paper, and I want to focus on the paper a little bit more, 90 percent, roughly 90 percent of patients on mechanical ventilation developed acute kidney injury as opposed to about 20 percent of those not on mechanical ventilation, and so, and the concordance or the concurrence of those things, of people going on mechanical ventilation and requiring or being recognized as having acute kidney injury was pretty close, wasn’t it?

Dr. Steven Fishbane:

Yeah. Right, and so, you know, this is one of those areas in research that I find to be particularly interesting in that, you know, think of it: We are at that point as this research is being conducted, we are so deeply involved with the intense care for these very sick patients. So, you would think that something like that, the concordance of respiratory failure and acute kidney injury would be very self-evident and intuitive and obvious to us, and yet, although I think we might’ve been experiencing that clinically, it wasn’t really until I remember one moment looking at the data where it suddenly occurred to me this is really remarkable.

There’s two things happening. One is that there’s a real concordance in terms of bad kidney injury right about the time that respiratory failure is occurring and that for patients with COVID disease at home, kidney disease is probably not an issue at all. For people with COVID disease who are in the hospital but without respiratory failure, it’s really not a very significant problem, but we found that bad kidney injury, severe kidney injury, kidney injury requiring dialysis was really limited to patients who required mechanical ventilation, and you know that is important in terms of some of the inferences that one can draw based on that. So, a long-winded answer to your question that, yes, very tied together, acute respiratory failure and kidney injury, as well.

Joe Elia:

Well, you know, as I was reading your paper, I was thinking, clinically, when somebody’s evaluating a patient, if that patient is having trouble breathing, you’re not looking at their kidneys. You’re looking at the fact that this patient is apparently drowning, and you’re trying to do something about it, but there were a lot of patients who were admitted to the hospital but who were not part of your study, and the reason for the exclusion was that they had had fewer than two creatinine measurements, I think, during their hospitalization. So, you didn’t feel that it would be fair to evaluate them, and it made me think, “Yeah, the clinicians are focusing on keeping the patient breathing, and those kidney functions are being evaluated in the course of further clinical care.” But I think what you’re saying is clinicians should keep an eye out on kidney function with COVID-19 patients.

Dr. Steven Fishbane:

Right. So, that’s clearly the case that although we need to be laser-focused on the care of the respiratory illness, because ultimately this is such a potent respiratory organism, but it does cause injury to other systems. We’re seeing this unusual syndrome in children right now, but you know to a much greater extent and not in the realm of rare conditions but rather a very common injury that goes along with the respiratory disease is kidney disease. We understand that now. We understand that patients need to be monitored very carefully in terms of the development of kidney disease and then the difficult decisions that go along with management, do you use dialytic support, et cetera.

Joe Elia:

Let’s move away from your findings regarding acute kidney injury and let’s talk about logistics a little bit. When did you realize that this kidney service might be overwhelmed, and how did you prepare for it?

Dr. Steven Fishbane:

So, it was in mid-March that we saw that New York was quickly just having an explosion in infections. New York was essentially becoming what Wuhan was to China in terms of the rate of infection, and you know, at that point, I think people understood the fact that there was a real risk of really overwhelming the health system, and if the virus has another surge in the fall, we’ve got to, again, be very careful with respect to that, but we recognized, I remember the moment when we realized that the rates were increasing so quickly that for the 10 percent of patients that have bad enough disease to require hospitalization and then for the percentage of those that are going to have bad kidney disease with it, we really had to model out what this could look like.

So, as we got into April and May, if it took a relatively benign course, what it might look like, if it took a middle-road course, and if it took a severe road, what it would look like in terms of potential resource needs. So, we modeled it out. It did end up being the most severe possible course that it could have taken, and at that point, we did a lot of purchasing based on our worst scenarios, renting, purchasing, but getting the types of equipment that were going to be very important in terms of being able to provide dialysis services, and the type of dialysis, also, that we do in the most critically ill patients, which is continuous renal replacement therapy, or CRRT therapy, and making sure that our hospitals would have enough of that type of equipment.

And we really strongly went with a mantra from the beginning here that we’ve got to be able to, to the greatest extent possible, try to cure the underlying respiratory infection, the respiratory infection, and we’ll succeed in patients. We won’t succeed in other patients, unfortunately, but that we never want this secondary problem of kidney disease to limit the patient’s outcomes. We want to make sure that we have the resources that we need to be able to treat the kidney part of it, and yet, by the middle of April, I think everybody through New York was running on fumes and came very close to hitting that point of not being able to keep up with the kidney aspects of the disease.

Joe Elia:

Yes, and you had to move clinicians around the system, too, didn’t you, to have enough nephrologists where you needed them?

Dr. Steven Fishbane:

Right. So, you know, I think a lot of health systems experienced this difficult and really painful issue in the New York area. I don’t know if this occurred a lot outside of New York but that there simply were not enough intensivists. There were not enough hospital medicine doctors. So, think of it, you know, this way, our largest hospital out of 23 hospitals is North Shore University Hospital. It’s 865 patients, you know, probably four intensive care units, and before you knew it, the whole hospital was basically an intensive care unit. I mean units that had been classic medical-surgical units were being converted into intensive care units, and there weren’t enough intensivists to be able to care for these patients. So, from specialties that were suddenly less busy, for example, gastroenterologists were not doing a lot of colonoscopies and other procedures, orthopedic surgeons and other surgeons were not doing a lot of elective surgery, and so a lot of people were brought out of necessarily areas of comfort for them.

Tom McGinn, who’s the chairman of medicine and associate chief of staff for the health system, you know, I think in a very touching way, put forth the fact in March that a lot of us were going to have to get out of our comfort zones and get into areas of treating patients, and you know it ended up, I think, for a lot of people that were redeployed into front-line care for intensive care and for hospital medicine care of less sick COVID patients, it ended up, I think, being a really energizing, a very, you know, I think in some ways exciting but very sad, very sad labor that people were involved in. For nephrologists, it was a little bit different. Some of our people got redeployed, but because so much of our work exploded in the hospitals that we were really redeploying our people from office into hospital care.

Joe Elia:

Did you have enough personal protective equipment, PPE, so called, and…?

Dr. Steven Fishbane:

Yes. So, I think that we were fortunate that for all aspects of protective equipment, there was enough. Now, you know, as you probably know, by late March, I think everybody was worried about would there be enough ventilators, would there be enough masks, would there be enough face guards, would there be enough of everything? And you know, I think that New York State was very helpful in this regard. Our health system senior leadership worked very, very hard and long hours to try to make sure that the PPE was there.

So many people, so many doctors, were making a sacrifice, so many nurses making a sacrifice to be at the front lines here and to be able to provide the PPE that was required was so important more in terms of just how people felt about the work and the confidence. So, it’s such an important question, and you know, I think the leadership in New York State, the senior leadership for this health system, and I think for most health systems in New York really did a very good job of keeping us there, but we have to remember, you know, that if you let this pandemic explode out again in too large of a way, there’s always that risk of running short on PPE, and you know I think we saw from some other countries just how bad that can get.

Joe Elia:

If you could advise systems that will be facing a second wave, which we hope will not happen, what lessons did you learn from this wave that you’re going to carry forward with you even into the non-pandemic world?

Dr. Steven Fishbane:

Yeah. So, I think there’s a few lessons here that are important. You know the first is that plan in advance. To the greatest extent possible, don’t try to manage something that is just pulling you along, you know, the proverbial tiger by the tail. Try to stay ahead of it. Use data. I mean we were at the point, at least on the renal side, of every single day, understanding how many nurses did we have available, how many machines, the amount of disposables that are available. At the health system level, that means understanding the number of doctors, nurses that you have to be able to care for critically ill patients.

And you know I would like to add, you know, a third part of it, not just that real-time awareness and management but communication, communication, because it, you know, did come at a time that physician burnout in the United States was already something of an issue, I think it’s fair to say, and having that great physician leadership, which we have a lot of in our health system, to really keep the spirits up of people, and I think, you know, as we’re getting late in the course of this, at least first wave. We had a call last night where we were talking, and there was really a lot of gratitude about the importance of just talking and talking and providing support for not just physicians, of course, but nurses and everybody who’s involved at the front lines of care to be successful. Now, if there should be a second wave, that’s going to be hard, right? That will be you ran on fumes and adrenaline the first time through. The second time through, it’s going to take a tremendous amount of support, but we learned a lot the first time through, I think, to help everybody around the country.

Joe Elia:

If you could say something to the staff that went through these couple of months with you, what would you say?

Dr. Steven Fishbane:

You know I just have learned and have developed such an incredible sense of gratitude for people that have left young children at home, babies at home, that have elderly parents that they’re caring for, that have spouses with medical conditions that have gone willingly to the front lines and very few people that were not willing to do that but just the amazing gratitude for the courage, for the fact that this reenlivens in us the reasons that us as physicians, as nurses, as other healthcare providers, went into healthcare in the first place. It’s terrible that we’ve had to go through this for the patients, most of all, of course, and their families, but you know, I think a real awakening in all of us and you know maybe it takes every once in a while a certain wake-up call about why, why this calling is so important, and I hope young people going into medicine understand that, Joe.

Joe Elia:

I wanted to ask you, Dr. Fishbane, what in your life prepared you for this challenge, do you think?

Dr. Steven Fishbane:

Maybe this is the best answer to your question. You know my training was during the AIDS epidemic, and I think that, at that point in my career, as a trainee, I didn’t really appreciate because this was the normal for me as a trainee, and yet, you know, I think for me and for some of my contemporaries, you know, that was very good preparation, but I think for everybody who has lived through challenges in their lives and they know they can get through it with courage and with, you know, working together, as a team, and feeling that camaraderie and collaboration of working together. It’s so important, right?

Joe Elia:

I want to thank you, so much, Dr. Steven Fishbane, for sharing your experience with us.

Dr. Steven Fishbane:

Great. What a pleasure to speak to you. Thank you.

Joe Elia:

That was our 267th episode. The whole lot is searchable and available free at podcasts.jwatch.org. We come to you from the NEJM group, and our executive producer is Kristin Kelley. I’m Joe Elia. Thanks for listening.

5 Responses to “Podcast 267: Acute kidney injury in COVID-19 — how one New York system dealt with it”

  1. Philip Hooper says:

    Mechanical ventilation itself brings about added system inflammation. Belperio, J. A., Keane, M. P., Lynch, J. P., Strieter, R. M., Ali, T. H. E., & Lung, A. (2006). The Role of Cytokines during the Pathogenesis of Ventilator-Associated and Ventilator-Induced Lung Injury. 1(212), 350–364. https://doi.org/10.1055/s-2006-948289

  2. Manfredo Juarez says:

    Any useful clinical information from a nephrologist clinical
    point of view?

  3. Dr Sunil Rastogi says:

    We are learning from the
    experiences of our colleagues for the management of covid19,it’s challenge to the medical faternity,however mortality
    figures may vary geographically

  4. D. Rudloff says:

    It concerns me that the total of office nephrologists, intensivists, nurse practitioners, and house staff is not enough to manage mass epidemic un-intended kidney injuries, let alone intended ones, say, like a chemical spill or (now that everyone knows) a biochemical weapon attack. Unmentioned, it appears there is no ready reserve of retirees listed by hospitals, technicians, urologists not doing surgery, legal medical witnesses, or the Academies. Nor were “convoys” of out of state volunteers or military assigned mentioned.
    There used to be cross training sufficient as a matter of routine education.
    Are techs cross trained?

  5. Mehrunissa says:

    “Thank you for sharing such great information.
    It has help me in finding out more detail about medical education fellowship

Leave a Reply

Your email address will not be published. Required fields are marked *

Note: This is a moderated forum. By clicking on the "Submit Comment" button below, you agree to abide by the NEJM Journal Watch Terms of Use.

Our physician bloggers cannot respond to requests for personal medical advice, and recommend patients discuss health issues with their individual physicians.

Clinical Conversations

About the Podcast

To subscribe:

Comments, suggestions, and story ideas welcome. Learn more about Clinical Conversations.