Keith Bellovich, DO, explains how SARS-CoV-2–driven inflammation contributes to kidney injury and may reveal previously undiagnosed chronic kidney disease.
A markedly heightened immune response to SARS-CoV-2 compared with influenza may explain the increased risk of kidney failure observed in patients with COVID-19, according to Keith Bellovich, DO, chief nephrologist with Strive Health, in an interview with Pharmacy Times. The discussion centered on new data out of Penn State College of Medicine showing that COVID-19 infection can predict a higher risk of kidney disease, especially compared with influenza.1
Bellovich described how the virus triggers widespread inflammation leading to multisystem organ dysfunction, including acute kidney injury (AKI), shock, and glomerular disease. Although some kidney injury may be reversible, severe immune activation can result in lasting renal damage. Bellovich noted that many cases of chronic kidney disease (CKD) identified after COVID-19 infection likely reflect previously undiagnosed disease, given that approximately 37 million Americans have CKD and most are unaware of their condition. Rather than acting solely as a causative factor, COVID-19 may have exposed underlying kidney dysfunction or triggered processes that brought it to clinical attention, underscoring the complexity of interpreting postinfection renal outcomes.
Pharmacy Times: Can you please introduce yourself?
Keith Bellovich, DO: Sure. I’m Keith Bellovich. I’m a nephrologist from Detroit, Michigan. I’m the chief nephrologist for Strive Health, which is a value-based care company working to help improve quality and care delivery across the country. I was formerly the chief medical officer of an acute care facility within the Henry Ford Health System. Before taking this position, I was deeply involved in COVID-19 relief during our surge in 2020 and so became intimately familiar with the consequences of how we delivered acute care to those patients, as well as our nephrology response.
Pharmacy Times: The study found that patients with COVID-19 are nearly 5 times more likely to develop kidney failure compared with patients with influenza. What makes COVID-19 uniquely damaging to the kidneys?
Bellovich: What we saw in that initial response to the SARS-CoV-2 virus was a very vigorous immune response—far and away much different than even other coronavirus infections that had come through in different seasons, as well as influenza. We know that there’s variation in the genotypes and the phenotypes of these viruses as they evolve. And in this situation, SARS-CoV-2 was just far more vigorous in its response.
As a result, that leads to multisystem organ failure. Not only do we see respiratory failure and a high dependence on ventilatory support from severe viral pneumonia, we also saw multisystem organ failure and shock and renal disease, encephalopathy, meningitis, and a whole host of responses. Certainly, a lot of comparisons were made among previous severe flu epidemics, but this one was much more severe. And when you have such a vigorous immune response, then kidney function can be compromised in that situation.
Pharmacy Times: How long after COVID-19 infection are patients developing chronic kidney disease, and what does this mean for ongoing monitoring?
Bellovich: I think really what we’re looking at is a chicken-or-the-egg argument. We know that there are 37 million Americans who suffer from chronic kidney disease, but 9 out of 10 of those individuals are not even aware that they have it. When patients sought health care who previously had been well without any sort of known conditions and presented with this severe illness, perhaps it even exposed or brought to light many people who had preexisting CKD but did not know it.
There is, as described earlier, the potential for AKI that should be reversible and not lead to significant amounts of kidney injury. But we do know that a vigorous immune response can create a whole variety of renal conditions that any viral infection can cause—inflammation within the tubules, glomerular disease, and also AKI just from the shock alone. When you’re having such a vigorous immune response, any of those manifestations can take hold and may lead to some permanent injury. But in my suspicion, the vast majority—because of the number of people that have the condition but aren’t aware of it—we probably just made people aware that they’re at risk of kidney disease, or it was the trigger that either raised their awareness or triggered an immune response that led to exposing that kidney injury.
Pharmacy Times: Many people had COVID-19 years ago and feel recovered right now. What signs or symptoms should pharmacists tell patients to watch for that might indicate underlying kidney damage?
Bellovich: That’s a situation where, again, highlighting the number of people that are unaware of their disease, looking for the usual, typical signs and symptoms of kidney injury—high blood pressure and/or swelling that can emerge and/or foaming or bubbling of the urine to excess. These are slight indications.
The vast majority of those individuals are probably at risk of having kidney disease in general, with the leading causes of kidney failure in the United States being diabetes and hypertension. If you’re a type 2 diabetic, certainly staying in touch with your health care provider and making sure that you’re getting screened on an annual basis is important. Those who have preexisting high blood pressure are also at risk of having kidney disease, so making sure those individuals are carefully screened for the possibility of any sort of renal condition is important. Other than that, taking someone who had been exposed to COVID[-19] in the past and using that as a sole criterion for kidney screening, I would not advise at this time. It’s more about looking for other signs or symptoms that may predispose them or signal that they have kidney problems.
