Pediatric Nephrologist, #CCMCPedNeph, @NewkidneysOTB, Opinions are my own
Cohen Childrens' Northwell
Joined August 2020
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@rvlevy presenting GSTMI deletion and risk of CKD progression in kids. 🥦🥦🥦🥦 @PAS2023 @ASPNeph @UrmcNephrology
That's all for now.
For a case-based clinical discussion with a pathologist login to @ASPNeph website, Sept webinar.
#Membereducation
Thanks to @drM_sudha @RoshanPGeorgeMD @SwastiThinks & #ASPNFOAMgroup for your help in publishing my first tweetorial!
13/Take Home Points
✔️Pediatric COVID-19 and MIS-C ICU pts have ↑AKI
✔️Most common pathology (adult): ATI, collapsing glomerulopathy & TMA
✔️AKI multifactorial
✔️Limited histopathology
**Epidemiology reported reflects data that precede the recent delta surge across the US
11/What about AKI and MIS-C?
Estimates from single center and systematic reviews vary 10-73%
✔️Systematic review at end of 2020: ~16% of patients with AKI, PMID: 33463127
✔️UK PICU study ~40% AKI, PMID: 33044282
✔️ Inflammation ⬇️ LVEF, ⬇️ albumin associated with AKI
ALT Sethi SK, Rana A, Adnani H, et al. Kidney involvement in multisystem inflammatory syndrome in children: a pediatric nephrologist's perspective. Clin Kidney J. 2021;14(9):2000-2011
10/Currently, evidence of direct infection is less clear:
ISH & RT-PCR inconsistent for viral protein or RNA
✔️EM suggestive of endocytic vesicles, not virus
✔️ Virus needs serine protease TMPRSS2, expressed in distal tubules, separate from ACE2r for entry into cell.
ALT Benedetti C, Waldman M, Zaza G, Riella LV, Cravedi P. COVID-19 and the Kidneys: An Update. Front Med (Lausanne). 2020;7:423. Published 2020 Jul 21. doi:10.3389/fmed.2020.00423
9/It has yet to be determined…. Early in the pandemic, evidence suggested renal tropism
✔️SARS-CoV2 enters cells via ACE2r
✔️↑ ACE2r on proximal tubule
✔️Virus-like particles appreciated on EM
✔️in-situ hybridization (ISH) and RT-PCR from biopsy +SARS-CoV2
ALT Kidney International 2020 98219-227DOI: (10.1016/j.kint.2020.04.003) Copyright © 2020 International Society of Nephrology
7/Thrombotic Microangiopathy is another common pathologic and clinical finding
Clinical Triad:
✔️Thrombocytopenia
✔️Microangiopathic Anemia
✔️Hypertension
One pediatric study shows elevated terminal complements in severe disease and kidney dysfunction PMID: 33290544
ALT Blood Adv. 2020 Dec 8; 4(23): 6051–6063
6/ What about COVID-19 collapsing glomerulopathy everyone is talking about?
Distinct pathology associated with SARS-COV2
Found in pts with high risk APOL-1 genotypes, like “HIVAN”
APOL1 up-regulated by infection and inflammation ✔️podocyte injury
✔️ Proteinuria
PMID: 32753739
3/ Why is AKI so common in COVID-19 patients?
The pathogenesis is likely multifactorial:
✔️systemic consequences of viral infection
✔️initiation of the inflammatory cascade
✔️cross talk between the kidney and directly infected organs.
