To the Editor:
We compliment Xu et al.1 for reporting an interesting case on renal infarction in patients with novel coronavirus disease 2019 (COVID-19), presumably due to hypercoagulable state associated with the infection. Documentation of such case would help the clinicians who involve in the management of patients with COVID-19 to consider renal infarction as one of the differential diagnoses of acute kidney injury. It was encouraging to observe that the condition of the patient improved upon initiation of therapeutic anticoagulation.
Nevertheless, we feel that COVID-19 patients with kidney allograft infarction should have also been considered for revascularization strategies instead of receiving anticoagulation alone. The likelihood of benefit from revascularization can be evaluated through several patient’s factors including the time since onset of ischemia which is determined by the duration of signs and symptoms, the risk of parenchymal damage due to infarction, the present kidney function or estimated glomerular filtration rate, and the patency of the renal vessel (complete or partial occlusion observed on computed tomography angiography).
While COVID-19 patients with kidney allograft infarction who are deemed unlikely to benefit from revascularization can be considered for anticoagulation, those who are deemed likely to benefit from revascularization should be referred immediately for percutaneous endovascular therapy which may include local thrombolysis, thrombectomy, angioplasty, and stent placement.2 , 3 Although the data are sparse, systemic fibrinolytic therapy may be used when vascular interventional services are not available.4 As demonstrated before the COVID-19 era, percutaneous endovascular therapy often leads to successful reperfusion in most patients with kidney infarction without procedural complications.5
Acknowledgments
DISCLOSURE
The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.
REFERENCES
- 1.Xu JJ, Samaha D, Mondhe S, Massicotte-Azarniouch D, Knoll G, Ruzicka M. Renal infarct in a COVID-19-positive kidney-pancreas transplant recipient [published online ahead of print June 1, 2020]. Am J Transplant. 2020. 10.1111/ajt.16089 [DOI] [PMC free article] [PubMed]
- 2.Korzets Z, Plotkin E, Bernheim J, Zissin R. The clinical spectrum of acute renal infarction. Isr Med Assoc J. 2002;4(10):781–784. [PubMed] [Google Scholar]
- 3.Oh YK, Yang CW, Kim Y-L, et al. Clinical characteristics and outcomes of renal infarction. Am J Kidney Dis. 2016;67(2):243–250. doi: 10.1053/j.ajkd.2015.09.019. [DOI] [PubMed] [Google Scholar]
- 4.Chondros K, Karpathakis N, Tsetis D, Sofras F, Mamoulakis C. Systemic thrombolysis with the use of tenecteplase for segmental acute renal in-farction potentially associated with multiple thrombophilic gene polymorphisms. Hippokratia. 2014;18(1):67–70. [PMC free article] [PubMed] [Google Scholar]
- 5.Silverberg D, Menes T, Rimon U, Salomon O, Halak M. Acute renal artery occlusion: Presentation, treatment, and outcome. J Vasc Surg. 2016;64(4):1026–1032. doi: 10.1016/j.jvs.2016.04.043. [DOI] [PubMed] [Google Scholar]