PATHOLOGY OF THE URINARY SYSTEM IN PATIENTS WITH CORONAVIRUS PNEUMONIA

PATHOLOGY OF THE URINARY SYSTEM IN PATIENTS WITH CORONAVIRUS PNEUMONIA

Svetlana Alexandrova

Assistant, department of Hospital Therapy with Courses of Endocrinology, Hematology and KLD, Medical institute Peoples’ Friendship University of Russia,

Russia, Moscow

Nikolai Kislyy

Doctor of medical sciences, professor, department of Hospital Therapy with Courses of Endocrinology, Hematology and KLD, Medical institute Peoples’ Friendship University of Russia,

Russia, Moscow

ABSTRACT

The article analyzes the case histories of patients who were in the Moscow hospital for coronavirus pneumonia.

The nature of kidney damage in viral pneumonia was studied, the functional ability of the kidneys was evaluated.

The role of concomitant pathology in the occurrence of kidney damage in pneumonia associated with COVID-19 is shown.

Data on kidney damage in pneumonia associated with COVID-19 from other hospitals and countries are presented.

Keywords: coronavirus infection, pneumonia associated with COVID-19, hypoxia, microthrombosis, acute kidney injury, diabetes mellitus, hypertension, proteinuria, leukocyturia.

Introduction

Coronavirus kidney damage is not uncommon. According to statistics, 30-40% of patients with COVID-19 develop kidney disease [1, 2].

According to various data, from 10% to 15% of patients with pneumonia associated with COVID-19 had kidney damage, manifested as an increase in blood creatinine, a decrease in glomerular filtration; 26-63% of patients had proteinuria, somewhat less often - leukocyturia.

Several versions of the involvement of the kidneys in the pathological process in coronavirus infection are considered.

One of the versions is the presence of receptors in the kidneys, to which the virus attaches, penetrates into them, copies itself and damages the kidney tissue. Another is that hypoxia in coronavirus pneumonia can lead to kidney pathology.

The third version - during the disease, cytokines are produced (often their number is huge), which can lead to the destruction of healthy tissues in the lungs, heart, and also in the kidneys.

The version about the formation of microthrombi, including in the vessels of the kidneys, deserves great attention and study, which, of course, will lead to their damage [3, 4, 5].

An important factor that should also be taken into account is the presence of concomitant diseases. Hypertension, diabetes mellitus, HIV infection, drug use, alcohol abuse, metabolic disorders, a history of kidney disease contribute to the development of urinary tract damage in coronavirus infection [6, 7, 8].

You should always pay attention to what drugs a patient with a coronavirus infection and chronic kidney disease uses to reduce body temperature. Uncontrolled intake of diclofenac, nimesulide and other nonsteroidal drugs can lead to a significant decrease in renal function [9,10,11].

Since coronavirus often causes acute impairment of kidney function, in order to avoid a long-term impairment, experts recommend that all infected people take a urine test, even if there are no complaints, in order to avoid chronicization of acute kidney pathology with timely treatment [12, 13].

More than 1 in 3 patients with COVID-19 develop acute renal failure, some requiring hemodialysis, according to a New York City study of 5,449 patients. Similar studies have been carried out in Singapore. The study included 2702 patients, one in four needed hemodialysis. In China, attention was also paid to the interest of the kidneys in coronavirus pneumonia: protein or blood was often present in the urine. Both indicators indicate that the filtration capacity of the kidneys is impaired, or the work of small tubules through which urine flows [14, 15,16,17].

SARS-CoV-2, by infecting the kidneys, can cause acute kidney injury. Further follow-up of patients with coronavirus infection and kidney disease is needed to better understand the pathology of the disease, acute kidney injury, long-term effects on the kidney, and possible treatments.

The analysis of international registries will be critical to determine the risk factor and the best therapeutic approaches to address COVID-19 disease outcomes [18, 19].

Relevance. The symptoms, pathogenesis, treatment and prevention of a new coronavirus infection are constantly being studied. Diagnostic methods are being improved, treatment is constantly being improved in the light of new data obtained about this infection. Most doctors have not previously dealt with coronavirus infection, which makes it necessary to develop tactics for organizational preventive and therapeutic measures in the process of active work [20, 21].

The purpose of the study: to determine the frequency of renal pathology in coronavirus pneumonia, to assess the nature of kidney damage.

Materials and methods. As part of the pilot project, 40 case histories of patients hospitalized in City Clinical Hospital №  24 for pneumonia associated with COVID-19 were analyzed retrospectively.

Figure 1. Assignment of patients by gender

There were more male patients than female patients (57% and 43%, respectively).

Figure 2. Assignment of patients by age

The largest number of patients were aged 61-70 years (35%) and 51-60 years (35%); there were almost two times fewer patients in the age group from 41 to 50 years (20%); patients aged 31–40 years and older than 70 years accounted for 10%.

Results

In 10 (25%) of them, certain changes in the urinary system were revealed. There were 1,5 times fewer women than men.

Figure 3. Distribution of patients according to the lesion of the urinary system

In these patients with complications from the urinary organs, the area of lung damage varied from 20% to 76%:

- 3 (7,5%) patients had mild pneumonia with «ground glass » areas with an area of ​​pathological changes less than 25%.

- in 4 (10%) patients, pneumonia was of moderate severity with «ground glass » areas with an area of pathological changes less than 25–50%.

- in 2 (5%) patients, pneumonia was of a moderate form with «ground glass » areas with an area of pathological changes of 50–75%.

- 1 patient (2,5%) had a severe form of pneumonia with «ground glass » areas with an area of pathological changes of more than 75% of the lungs.

Figure 4. Detection of proteinuria in patients

In the general analysis of the urine of patients in 100% of cases, a protein from 0,066 g/l to 3,5 g/l was detected.

In 4 patients, proteinuria did not exceed 1 g/l, from 1 g/l to 2 g/l was observed in 4 patients, in 2 patients - over 3,5 g/l.

According to our analysis, in the vast majority of cases (70%), changes in urinalysis were observed with mild to moderate severity of the course of pneumonia associated with COVID-19.

In a clinical blood test in patients with pneumonia associated with COVID-19, the following was noteworthy: 4 patients had leukopenia (leukocyte count below 4000 thousand), lymphopenia (in 5 patients). It was difficult to judge sedimentation rate of erythrocytes, since not all patients had it.

Fast phase protein was significantly increased in 8 patients, in 2 patients the indicators were not reflected in the medical history.

Discussion. According to the data presented, it follows that renal pathology is a frequent complication in patients with coronavirus pneumonia. Patients have a violation of cellular immunity, which can be associated with the viral nature of the underlying disease. Unlike bacterial pneumonia, in which pyelonephritis is the most common complication of the urinary system, in viral pneumonia, the glomerular apparatus of the kidneys is damaged first of all. With the accumulation of data on coronavirus pneumonia, the nature of kidney damage, as well as the causes that influence the occurrence of proteinuria, will be clarified.

Conclusions. As can be seen from the data above, it cannot be concluded that the more severe form of pneumonia is more likely to result in kidney damage. According to our analysis, in the vast majority of cases (70%), changes in urinalysis were observed with mild to moderate severity of the course of pneumonia associated with COVID-19. In the urine tests of patients with coronavirus pneumonia, proteinuria prevailed.

After discharge from the hospital, patients with persistent proteinuria should continue outpatient monitoring with a general practitioner, a nephrologist at the place of residence.

References:

1. Perico L, Benigni A, Remuzzi G. Should COVID-19 concern nephrologists? why and to what extent? the emerging impasse of angiotensin blockade. Nephron. (2020) 144:213–21. doi: 10.1159/000507305
2. Hoffmann M, Kleine-Weber H, Schroeder S, Krüger N, Herrler T, Erichsen S, et al. SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor. Cell. (2020) 181:271–80.e8. doi: 10.1016/j.cell.2020.02.052
3. Reynolds HR, Adhikari S, Pulgarin C, Troxel AB, Iturrate E, Johnson SB, et al. Renin–angiotensin–aldosterone system inhibitors and risk of Covid-19. N Engl J Med. (2020) 382:2441–8. doi: 10.1056/NEJMoa2008975
4. Siddiqi HK, Mehra MR. COVID-19 illness in native and immunosuppressed states: a clinical–therapeutic staging proposal. J Heart Lung Transplant. (2020) 39:405–7. doi: 10.1016/j.healun.2020.03.012
5. Dong L, Hu S, Gao J. Discovering drugs to treat coronavirus disease 2019 (COVID-19). Drug Discov Ther. (2020) 14:58–60. doi: 10.5582/ddt.2020.01012
6. Chistenko, G. N. Coronavirus infection / G. N. Chistenko // World of Medicine. 2020 - № 2 - P. 8–9. - Code in the database M51/2020/2.
7. Bilichenko T.N., Chuchalin A.G. Morbidity and mortality of the population of Russia from acute respiratory viral infections, pneumonia and vaccination. Therapeutic archive   2018. Т. 90. № 1. p. 22-26.
8. Lu X, Zhang L, Du H, et al. SARS-CoV-2 Infection in children. N Engl J Med. 2020 Mar 18. doi: 10.1056/NEJMc2005073
9. M.A. Murashko, A.Yu. Popov. - Prevention, diagnosis and treatment of a new coronavirus infection (2019-ncov), M., 2020 - 52 p.
10.  Ramzy A, McNeil DG. W.H.O. Declares Global Emergency as Wuhan Coronavirus Spreads. The New York Times. Available at https://nyti.ms/2RER70M. January 30, 2020; Accessed: January 30, 2020.
11.  The New York Times. Coronavirus Live Updates: W.H.O. Declares Pandemic as Number of Infected Countries Grows. The New York Times. Available at https://www.nytimes.com/2020/03/11/world/coronavirusnews.html#link-682e5b06. March 11, 2020; Accessed: March 11, 2020
12.  Hui DS, I Azhar E, Madani TA, Ntoumi F, Kock R, Dar O, et al. The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health – the latest 2019 novel coronavirus outbreak in Wuhan, China. Int J Infect Dis 2020;91: 264–6. doi: 10.1016/j.ijid.2020.01.009.
13.  Yang Y, Peng F, Wang R, Guan K, Jiang T, Xu G, et al. The deadly coronaviruses: The 2003 SARS pandemic and the 2020 novel coronavirus epidemic in China. J Au-toimmun 2020; 102434 [Epub ahead of print]. doi: 10.1016/j.jaut.2020.102434.
14.  Decree of the Government of the Russian Federation dated March 16, 2020 №. 634-r «On approval of a member of the Coordinating Council under the Government of the Russian Federation to combat the spread of a new coronavirus infection in the Russian Federation».
15.  Moein S, Hashemian MR, Mansourafshar B, et al. Smell dysfunction: a biomarker for COVID-19. Int Forum Allergy Rhinol. 2020. doi: 10.1002/alr.22587
16.  Akhtar Hussain, Bishwajit Bhowmik, Nayla Cristina do Vale Moreira. COVID-19 and diabetes: knowledge in progress. Diabetes Research and Clinical Practice. 2020;162:108142. doi: 10.1016/ j.diabres.2020.108142.
17.  Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet. 2020;395(10226):809–815. doi: 10.1016/S0140- 6736(20)30360-3.
18.  Ueda M, Martins R, Hendrie PC, et al. Managing cancer care during the COVID-19 pandemic: Agility and collaboration toward a common goal. J Natl Compr Canc Netw. 2020 Mar 20:1- 4. doi: 10.6004/jnccn.2020.7560.
19.  Holshue ML, DeBolt C, Lindquist S, et al. First Case of 2019 Novel Coronavirus in the United States. New England Journal of Medicine 2020;382(10):929-36. doi: 10.1056/NEJMoa2001191.
20.  Fengxiang Song, Nannan Shi, Fei Shan, et al. Emerging 2019 Novel Coronavirus (2019- nCoV) Pneumonia // Raiology 2020; 00:1–8 •
21.  Instructions on the organization of work on the diagnosis of a new coronavirus infection (COVID-19) (letter of Rospotrebnadzor dated March 18, 2020 №. 02 / 4457-2020-27).