Skip to main content
NCBI home page
Critical Care logoLink to Critical Care
letter
. 2020 Jul 16;24:439. doi: 10.1186/s13054-020-03134-8

Mortality rate of acute kidney injury in SARS, MERS, and COVID-19 infection: a systematic review and meta-analysis

Yih-Ting Chen 1,2,#, Shih-Chieh Shao 3,4,#, Edward Chia-Cheng Lai 3, Ming-Jui Hung 5,6, Yung-Chang Chen 1,7,8,9,✉
PMCID: PMC7364133  PMID: 32677972

Acute kidney injury (AKI), a predictor for poor clinical outcomes, has been reported as a severe complication of different coronavirus infections, including novel coronavirus disease 2019 (COVID-19) [1]. COVID-19 is considered more contagious than previous coronavirus infections, e.g., severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) [2], but comparisons of mortality rates from AKI among these three coronavirus infections remain uninvestigated. We therefore conducted a systematic review and meta-analysis comparing the mortality rate in patients with SARS, MERS, and COVID-19 who developed AKI.

A systematic search of PUBMED and EMBASE from inception to June 5, 2020, included the keywords “coronavirus”, “COVID-19”, “MERS”, “SARS”, “acute kidney injury”, “prognosis”, and “mortality” with suitable MeSH terms to identify observational studies of relevance, e.g., case reports, case series, cross-sectional studies, and cohort studies. Reference lists of included, published, systematic reviews identified in the search were screened for additional studies. We excluded conference abstracts, review articles, or studies without reports of AKI mortality. Two reviewers (YTC, SCS) screened titles and abstracts of search results for relevance and individually and independently assessed the full texts of selected results. The final list of included studies was derived by discussion and unanimous agreement from both authors. Statistical analyses were performed using MedCalc for Windows, version 15.0 (MedCalc Software, Ostend, Belgium). We report the mortality rate from AKI in SARS, MERS, and COVID-19 infections as proportions with 95% confidence interval (CI) based on random effects model, represented by forest plot. We detected heterogeneity among studies using the Cochran Q test, with p value < 0.10 indicating significant heterogeneity, and calculated I2 statistic to determine the proportion of total variation in study estimates attributable to heterogeneity.

After screening 97 records in total, we excluded 74 articles (15 duplicates, 11 irrelevant to study question, 1 conference abstract, 5 review articles and 42 lacking data on AKI mortality). Our final analysis included 23 articles comprising 4, 3 and 16 on SARS, MERS and COVID-19 infection, respectively. Demographic data for included articles are presented in Table 1. Overall, mortality in patients with SARS, MERS and COVID-19 infection, and developing AKI, was 77.4% (95%CI: 64.7–88.0). We found the mortality rate of AKI was highest in SARS (86.6%; 95%CI: 77.7–93.5), followed by COVID-19 (76.5%; 95%CI: 61.0–89.0) and MERS (68.5%; 95%CI: 53.8–81.5). There was no evidence of statistical heterogeneity among studies reporting AKI mortality in SARS (I2: 0.0%, p = 0.589) and MERS (I2: 0.0%, p =v0.758), but there was for COVID-19 infection (I2: 97.0%, p < 0.001) (Fig. 1).

Table 1.

Study characteristics

Author and year Country/city AKI male (%) AKI age (median) Settings Total case numbers AKI case numbers Baseline serum creatinine (mg/dL) RRT/AKI case (%) AKI mortality (%) Overall mortality (%)
SARS
 Huang 2005 [3] Taiwan/Taipei 77 65* Hospitalization 78 13 1.20 38 77 19
 Wu 2004 [4] Taiwan/Taipei 50 58* Hospitalization 2 2 1.05 NA 100 100
 Chu 2005 [5] China/Hong Kong 69 54 Hospitalization 536 36 1.06 28 92 14
 Choi 2003 [6] China/Hong Kong NA NA Hospitalization 267 15 NA NA 87 12
MERS
 Saad 2014 [7] Saudi Arabia NA NA Hospitalization 70 30 NA NA 70 60
 Alsaad 2017 [8] Saudi Arabia 100 33 Intensive care unit 1 1 NA 0 100 100
 Cha 2015 [9] Korea 63 73* Hospitalization 30 8 1.60 38 63 17
COVID-19
 Alberici 2020 [10] Italy/Brescia 67 58* Kidney transplantation/hospitalization 20 6 3.13 17 17 25
 Hirsch 2020 [11] USA/New York 64 69 Hospitalization 5449 1993 1.24 14 35 16
 Lei 2020 [12] China/Wuhan NA NA Hospitalization 34 2 NA NA 100 21
 Chen 2020 [13] China/Wuhan NA NA Hospitalization 274 29 NA 10 97 41
 Deng 2020 [14] China/Wuhan NA NA Hospitalization 225 20 NA NA 100 48
 Wang 2020 [15] China/Wuhan NA NA Hospitalization 107 14 NA NA 100 18
 Yang 2020 [16] China/Wuhan NA NA Hospitalization 52 15 NA 60 80 62
 Gopalakrishnan 2020 [17] USA 100 49 Hospitalization 1 1 1.00 100 100 100
 Suwanwongse 2020 [18] USA/New York 100 88 Hospitalization 1 1 1.16 0 0 0
 Banerjee 2020 [19] UK/London 25 59* Kidney transplantation/hospitalization 7 4 2.54 75 25 14
 Zhou 2020 [20] China/Wuhan NA NA Hospitalization 191 28 NA 36 96 28
 Wang 2020 [21] China/Wuhan NA NA Hospitalization 339 27 NA NA 63 19
 Richardson 2020 [22] USA/New York NA NA Hospitalization 2351 523 NA 15 66 20
 Wang 2020 [23] China/Wuhan NA NA Intensive care unit 344 86 NA 10 93 39
 Ruan 2020 [24] China/Wuhan NA NA Hospitalization 150 23 NA 22 91 45
 Cao 2020 [25] China/Wuhan NA NA Hospitalization 102 20 NA 30 75 17
Open in a new tab

AKI acute kidney injury, NA not available, RRT renal replacement therapy

*Age was represented by the mean value

Fig. 1.

Fig. 1

Open in a new tab

Forest plot of AKI mortality in coronavirus infections from included studies: a SARS, b MERS, and c COVID-19

The present analyses indicate AKI as a poor prognosis factor in coronavirus infections, whereby AKI mortality in COVID-19 is higher than MERS but lower than SARS infections. Possible mechanisms of higher AKI mortality following coronavirus infections are multifactorial (e.g., severe sepsis-related multi-organ failure, direct kidney involvement, and acute respiratory distress syndrome) [26–28], although comparative pathogenesis of kidney involvement among the three infections remains unclear.

To our best knowledge, this is the first systematic review exploring AKI mortality of different coronavirus infections. However, we should be cautious about interpreting causal relationships between coronavirus infections and AKI, given the nature of observational data. Also, clinical heterogeneity between studies should be noted; for example, various healthcare systems of included studies may produce different AKI mortality rates. Coronaviruses are unlikely to be eliminated in the near future, and our synthesis indicates that AKI secondary to coronavirus infection may contribute to higher mortality. Hence, in the current exceptional pandemic, first-line healthcare providers should recognize the importance of timely detection of AKI and consider all available treatment options for maintenance of kidney functions to prevent death in COVID-19 patients [29].

Acknowledgements

None.

Abbreviations

AKI

Acute kidney injury

CI

Confidence interval

COVID-19

Coronavirus disease 2019

MERS

Middle East respiratory syndrome

SARS

Severe acute respiratory syndrome

Authors’ contributions

YCY and SCS contributed equally to this work. YCY and SCS contributed to the critical analysis, interpretation of the data, and drafting of the manuscript. MJH and YCC contributed to the study supervision and administrative, technical, or material support. All authors read and approved the final manuscript.

Funding

None.

Availability of data and materials

Not applicable.

Ethics approval and consent to participate

Not applicable.

Consent for publication

This original article has not been published and is not under consideration by another journal.

Competing interests

None.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Yih-Ting Chen and Shih-Chieh Shao contributed equally to this work.

References

  • 1.Chen Y-T, Shao S-C, Hsu C-K, Wu I-W, Hung M-J, Chen Y-C. Incidence of acute kidney injury in COVID-19 infection: a systematic review and meta-analysis. Critical Care. 2020;24(1):346. [DOI] [PMC free article] [PubMed]
  • 2.Naicker S, Yang CW, Hwang SJ, Liu BC, Chen JH, Jha V. The novel coronavirus 2019 epidemic and kidneys. Kidney Int. 2020;97(5):824–828. doi: 10.1016/j.kint.2020.03.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Huang JW, Chen KY, Tsai HB, Wu VC, Yang YF, Wu MS, Chu TS, Wu KD. Acute renal failure in patients with severe acute respiratory syndrome. J Formos Med Assoc. 2005;104(12):891–96. [PubMed] [Google Scholar]
  • 4.Wu VC, Hsueh PR, Lin WC, Huang JW, Tsai HB, Chen YM, Wu KD. SARS. Research Group of the National Taiwan University College of Medicine and National University Hospital: Acute renal failure in SARS patients: more than rhabdomyolysis. Nephrol Dial Transplant. 2004;19(12):3180–182. [DOI] [PMC free article] [PubMed]
  • 5.Chu KH, Tsang WK, Tang CS, Lam MF, Lai FM, To KF, Fung KS, Tang HL, Yan WW, Chan HWH, et al. Acute renal impairment in coronavirus-associated severe acute respiratory syndrome. Kidney Int. 2005;67(2):698–705. doi: 10.1111/j.1523-1755.2005.67130.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Choi KW, Chau TN, Tsang O, Tso E, Chiu MC, Tong WL, Lee PO, Ng TK, Ng WF, Lee KC, et al. Outcomes and prognostic factors in 267 patients with severe acute respiratory syndrome in Hong Kong. Ann Intern Med. 2003;139(9):715–23. doi: 10.7326/0003-4819-139-9-200311040-00005. [DOI] [PubMed] [Google Scholar]
  • 7.Saad M, Omrani AS, Baig K, Bahloul A, Elzein F, Matin MA, Selim MA, Al Mutairi M, Al Nakhli D, Al Aidaroos AY, et al. Clinical aspects and outcomes of 70 patients with Middle East respiratory syndrome coronavirus infection: a single-center experience in Saudi Arabia. Int J Infect Dis. 2014;29:301–06. doi: 10.1016/j.ijid.2014.09.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Alsaad KO, Hajeer AH, Al Balwi M, Al Moaiqel M, Al Oudah N, Al Ajlan A, AlJohani S, Alsolamy S, Gmati GE, Balkhy H, et al. Histopathology of Middle East respiratory syndrome coronovirus (MERS-CoV) infection - clinicopathological and ultrastructural study. Histopathology. 2018;72(3):516–24. doi: 10.1111/his.13379. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Cha RH, Joh JS, Jeong I, Lee JY, Shin HS, Kim G, Kim Y. Critical Care Team of National Medical Center: Renal Complications and Their Prognosis in Korean Patients with Middle East Respiratory Syndrome-Coronavirus from the Central MERS-CoV Designated Hospital. J Korean Med Sci. 2015;30(12):1807–814. doi: 10.3346/jkms.2015.30.12.1807. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Alberici F, Delbarba E, Manenti C, Econimo L, Valerio F, Pola A, Maffei C, Possenti S, Zambetti N, Moscato M, et al. A single center observational study of the clinical characteristics and short-term outcome of 20 kidney transplant patients admitted for SARS-CoV2 pneumonia. Kidney Int. 2020;97(6):1083–88. doi: 10.1016/j.kint.2020.04.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Hirsch JS, Ng JH, Ross DW, Sharma P, Shah HH, Barnett RL, Hazzan AD, Fishbane S, Jhaveri KD. Acute kidney injury in patients hospitalized with COVID-19. Kidney Int. 2020;98(1):209–18. [DOI] [PMC free article] [PubMed]
  • 12.Lei S, Jiang F, Su W, Chen C, Chen J, Mei W, Zhan LY, Jia Y, Zhang L, Liu D, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. E Clinical Medicine. 2020;23:100385. doi: 10.1016/j.eclinm.2020.100331. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, Ma K, Xu D, Yu H, Wang H, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ. 2020;368:m1091. doi: 10.1136/bmj.m1091. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Deng Y, Liu W, Liu K, Fang YY, Shang J, Zhou L, Wang K, Leng F, Wei S, Chen L, et al. Clinical characteristics of fatal and recovered cases of coronavirus disease 2019 in Wuhan, China: a retrospective study. Chin Med J (Engl) 2020;133(11):1261–267. doi: 10.1097/CM9.0000000000000824. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Wang D, Yin Y, Hu C, Liu X, Zhang X, Zhou S, Jian M, Xu H, Prowle J, Hu B, et al. Clinical course and outcome of 107 patients infected with the novel coronavirus, SARS-CoV-2, discharged from two hospitals in Wuhan. China. Crit Care. 2020;24(1):188. doi: 10.1186/s13054-020-02895-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Yang X, Yu Y, Xu J, Shu H. Xia Ja, Liu H, Wu Y, Zhang L, Yu Z, Fang M et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020;8(5):475–81. doi: 10.1016/S2213-2600(20)30079-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Gopalakrishnan A, Mossaid A, Lo KB, Vasudevan V, McCullough PA, Rangaswami J. Fulminant Acute Kidney Injury in a Young Patient with Novel Coronavirus 2019. Cardiorenal Med. 2020;10(4):217–22. [DOI] [PMC free article] [PubMed]
  • 18.Suwanwongse K, Shabarek N. Rhabdomyolysis as a Presentation of 2019 Novel Coronavirus Disease. Cureus. 2020;12(4):e7561.Suwanwongse K, Shabarek N: Rhabdomyolysis as a Presentation of 2019 Novel Coronavirus Disease. Cureus. 2020;12(4):e7561. [DOI] [PMC free article] [PubMed]
  • 19.Banerjee D, Popoola J, Shah S, Ster IC, Quan V, Phanish M. COVID-19 infection in kidney transplant recipients. Kidney Int. 2020;97(6):1076–82. [DOI] [PMC free article] [PubMed]
  • 20.Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1038. [DOI] [PMC free article] [PubMed]
  • 21.Wang L, He W, Yu X, Hu D, Bao M, Liu H, Zhou J, Jiang H. Coronavirus disease 2019 in elderly patients: Characteristics and prognostic factors based on 4-week follow-up. J Infect. 2020;80(6):639–45. doi: 10.1016/j.jinf.2020.03.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, Barnaby DP, Becker LB, Chelico JD, Cohen SL, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. 2020;323(20):2052–59. doi: 10.1001/jama.2020.6775. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Wang Y, Lu X, Li Y, Chen H, Chen T, Su N, Huang F, Zhou J, Zhang B, Yan F, et al. Clinical Course and Outcomes of 344 Intensive Care Patients with COVID-19. Am J Respir Crit Care Med. 2020;201(11):1430–434. doi: 10.1164/rccm.202003-0736LE. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Ruan Q, Yang K, Wang W, Jiang L, Song J. Correction to: Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan. China. Intensive Care Med. 2020;46(6):1294–297. doi: 10.1007/s00134-020-06028-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Cao J, Tu WJ, Cheng W, Yu L, Liu YK, Hu X, Liu Q: Clinical Features and Shortterm Outcomes of 102 Patients with Corona Virus Disease 2019 in Wuhan, China. Clin Infect Dis. 2020;ciaa243. [DOI] [PMC free article] [PubMed]
  • 26.Eckerle I, Müller MA, Kallies S, Gotthardt DN, Drosten C. In-vitro renal epithelial cell infection reveals a viral kidney tropism as a potential mechanism for acute renal failure during Middle East Respiratory Syndrome (MERS) Coronavirus infection. Virol J. 2013;10:359. doi: 10.1186/1743-422X-10-359. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Puelles VG, Lütgehetmann M, Lindenmeyer MT, Sperhake JP, Wong MN, Allweiss L, Chilla S, Heinemann A, Wanner N, Liu S, et al. Multiorgan and renal tropism of SARS-CoV-2. N Engl J Med. 2020. 10.1056/NEJMc2011400. [DOI] [PMC free article] [PubMed]
  • 28.Singer M. The role of mitochondrial dysfunction in sepsis-induced multi-organ failure. Virulence. 2014;5(1):66–72. doi: 10.4161/viru.26907. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Ronco C, Reis T, Husain-Syed F. Management of acute kidney injury in patients with COVID-19. Lancet Respir Med. 2020;8(7):738–42. [DOI] [PMC free article] [PubMed]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Not applicable.

Articles from Critical Care are provided here courtesy of BMC

RESOURCES