Acute Kidney Injury by SARS-CoV-2 virus in patients with COVID-19: an integrative review

Moitinho, Matheus Santos; Belasco, Angélica Gonçalves da Silva; Barbosa, Dulce Aparecida; Fonseca, Cassiane Dezoti da

doi:10.1590/0034-7167-2020-0354

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Revista Brasileira de Enfermagem

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Sumário

REVIEW • Rev. Bras. Enferm. 73 (suppl 2) • 2020 • https://doi.org/10.1590/0034-7167-2020-0354 copy

Acute Kidney Injury by SARS-CoV-2 virus in patients with COVID-19: an integrative review

Lesión Renal Aguda por virus de SARS-CoV-2 en pacientes con COVID-19: revisión integrativa

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

to assess scientific evidence on SARS-CoV-2 Acute Kidney Injury in patients with COVID-19.

Methods:

an integrative review, with adoption of PICO strategy and classification of the level of evidence, carried out on April 10, 2020 in the PubMed database, of articles available between December 2019 and April 2020.

Results:

the sample consisted of six original, five observational and one experimental articles. Observational studies addressed the clinical findings of patients with COVID-19 and association between kidney damage, infection, and morbidity-mortality.

Conclusion:

the studies addressed the mechanism of intracellular infection of SARS-CoV-2, its cytopathic effects on kidney cells and incidence of acute kidney injury in patients infected with SARS-CoV-2. Acute kidney injury is associated with increased mortality and morbidity in these patients. This review realizes the need for new research that can mention kidney care to patients with COVID-19.

Descriptors:
Coronavirus Infections; Acute Kidney Injury; Review; Infection; Morbidity; Mortality

Search strategy	"Acute Kidney Injury" AND "COVID-19"
PubMed	Results: 13 Full text: 13 Filter application of the last 5 months: 13 Selected: 8

N	Title	Authors	Year	Place	Journal
⁽ ¹1 Lana R M, Coelho FC, Gomes MFC, Cruz OG, Bastos LS, Villela DAM, et al. Emergência do novo coronavírus (SARS-CoV-2) e o papel de uma vigilância nacional em saúde oportuna e efetiva. Cad Saúde Pública. 2020;36(3):e00019620. doi: 10.1590/0102-311x00019620 https://doi.org/10.1590/0102-311x0001962... ⁾	Identification of a potential mechanism of acute kidney injury during the COVID-19 outbreak: a study based on single-cell transcriptome analysis⁽²⁰20 Xu D, Zhang H, Gong H, Chen J, Ye J, Meng T, et al. Identification of a potential mechanism of acute kidney injury during the Covid-19 outbreak: a study based on single-cell transcriptome analysis. Intensive Care Med [internet]. 2020 [cited 2020 Apr 12]. Available From: https://link.springer.com/article/10.1007/s00134-020-06026-1#citeas https://link.springer.com/article/10.100... ⁾.	Pan XW, Xu D, Zhang H, Zhou W, Wang LH, Cui XG.	March 31, 2020	Shanghai-China	Intensive Care Medicine
⁽ ²2 Xu J, Zhao S, Teng T, Abdalla AE, Zhu W, Xie L, et al. Systematic comparison of two animal-to-human transmitted human coronaviruses: SARS-CoV-2 and SARS-CoV. Viruses. 2020;12(2):244. doi: 10.3390/v12020244 https://doi.org/10.3390/v12020244... ⁾	Coronavirus Disease 19 Infection Does Not Result in Acute Kidney Injury: An Analysis of 116 Hospitalized Patients from Wuhan, China⁽²¹21 Wang L, Li X, Chen H, Yan S, Li D, Li Y, et al. Coronavirus Disease 19 infection does not result in acute kidney injury: an analysis of 116 hospitalized patients from Wuhan, China. Am J Nephrol [Internet]. 2020 [cited 2020 Apr 12];1-6. Available From: https://www.karger.com/Article/FullText/507471 https://www.karger.com/Article/FullText/... ⁾.	Wang L, Li X, Chen H, Yan S, Li D, Li Y, Gong Z.	March 31, 2020	Wuhan-China	American Journal of Nephrology
⁽ ³3 Sun P, Lu X, Xu C, Sun W, Pan B. Understanding of COVID-19 based on current evidence. J Med Virol. 2020;92:548-51. doi: 10.1002/jmv.25722 https://doi.org/10.1002/jmv.25722... ⁾	Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study⁽²⁶26 Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ [Internet]. 2020 [cited 2020 Apr 12];368m1091. Available From: https://www.bmj.com/content/368/bmj.m1091 https://www.bmj.com/content/368/bmj.m109... ⁾.	Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, Ma K, Xu D, Yu H, Wang H, Wang T, Guo W, Chen J, Ding C, Zhang X, Huang J, Han M, Li S, Luo X, Zhao J, Ning Q.	March 26, 2020	Wuhan-China	The BMJ
⁽ ⁴4 Fan Y, Zhao K, Shi Z-L, Zhou P. Bat Coronaviruses in China. Viruses [Internet]. 2019 [cited 2020 Apr 11];11(3):210. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6466186/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾	Clinical characteristics of fatal and recovered cases of coronavirus disease 2019 (COVID-19) in Wuhan, China: a retrospective study⁽²⁷27 Deng Y, Liu W, Liu K, Fang Y-Y, Shang J, Zhou L, et al. Clinical characteristics of fatal and recovered cases of coronavirus disease 2019 (COVID-19) in Wuhan, China: a retrospective study. Chin Med J (Engl). 2020;133(11):1261-7 doi: 10.1097/CM9.0000000000000824 https://doi.org/10.1097/CM9.000000000000... ⁾.	Deng Y, Liu W, Liu K, Fang YY, Shang J, Zhou L, Wang K, Leng F, Wei S, Chen L, Liu HG.	March 20, 2020	Wuhan-China	Chinese Medical Journal
⁽ ⁵5 Cheng VCC, Lau SKP, Woo PCY, Yuen KY. Severe Acute Respiratory Syndrome Coronavirus as an agent of emerging and reemerging infection. Clin Microbiol Rev [Internet]. 2007 [cited 2020 Apr 11];20(4):660-94. Available From: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2176051/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾	Kidney disease is associated with in-hospital death of patients with COVID-19⁽¹⁹19 Cheng Y, Luo R, Wang K, Zhang M, Wang Z, Dong L, Li J, Yao Y, Ge S, Xu G. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int [Internet]. 2020 [Cited 2020 Apr 12];97(5);829-838. Available From: https://www.kidney-international.org/article/S0085-2538(20)30255-6/fulltext https://www.kidney-international.org/art... ⁾.	Cheng Y, Luo R, Wang K, Zhang M, Wang Z, Dong L, Li J, Yao Y, Ge S, Xu G.	March 20, 2020	Wuhan-China	Kidney International
⁽ ⁶6 Bastos L. OPAS/OMS Brasil - Folha Informativa - COVID-19 (Doença Causada Pelo Novo Coronavírus) \| OPAS/OMS. [Internet]. 2020. Pan American Health Organization/World Health Organization. [cited 2020 Apr 11]. Available from: https://www.paho.org/bra/index.php?option=com_content&view=article&id=6101:covid19&Itemid=875 ⁾	Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study⁽²⁸28 Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, 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[Internet] 2020[cited 2020 Apr 12];S2213-2600(20)30079-5. Available From: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30079-5/fulltext https://www.thelancet.com/journals/lanre... ⁾.	Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, Wu Y, Zhang L, Yu Z, Fang M, Yu T, Wang Y, Pan S, Zou X, Yuan S, Shang Y	February 24, 2020	Wuhan-China	The Lancet Respiratory Medicine

Outlining/Level of Evidence/number of patients	Objective	Main results	Conclusion
(1) Experimental, descriptive study/ Level 5/n=not applicable⁽²⁰20 Xu D, Zhang H, Gong H, Chen J, Ye J, Meng T, et al. Identification of a potential mechanism of acute kidney injury during the Covid-19 outbreak: a study based on single-cell transcriptome analysis. Intensive Care Med [internet]. 2020 [cited 2020 Apr 12]. Available From: https://link.springer.com/article/10.1007/s00134-020-06026-1#citeas https://link.springer.com/article/10.100... ⁾.	To identify the potential mechanism of AKI by COVID-19 by analysis of unicellular transcriptome in human kidney cells⁽²⁰20 Xu D, Zhang H, Gong H, Chen J, Ye J, Meng T, et al. Identification of a potential mechanism of acute kidney injury during the Covid-19 outbreak: a study based on single-cell transcriptome analysis. Intensive Care Med [internet]. 2020 [cited 2020 Apr 12]. Available From: https://link.springer.com/article/10.1007/s00134-020-06026-1#citeas https://link.springer.com/article/10.100... ⁾.	The location of the genes angiotensin-converting enzyme 2 (ACE2) and transmembrane serine proteases (TMPRSS) showed relatively high co-expression in podocytes and proximal straight tubule cells. Candidate host cells for SARS-CoV-2 have been showed. TMPRSS2 enters host cells and is co-expressed with ACE2 in podocytes. There was no significant difference in the expression of TMPRSS and the ACE2 receptor in podocytes and cells in proximal straight tubules. Comparative analysis showed that co-expression of genes in renal cells was not inferior to that of the lung, esophagus, small intestine and colon, suggesting that the kidney may be an important target for this virus⁽²⁰20 Xu D, Zhang H, Gong H, Chen J, Ye J, Meng T, et al. Identification of a potential mechanism of acute kidney injury during the Covid-19 outbreak: a study based on single-cell transcriptome analysis. Intensive Care Med [internet]. 2020 [cited 2020 Apr 12]. Available From: https://link.springer.com/article/10.1007/s00134-020-06026-1#citeas https://link.springer.com/article/10.100... ⁾.	Viral (SARS-CoV-2) cytopathic effect on podocytes and proximal straight tubules can cause AKI. The proposed mechanism for the pathophysiology of AKI during COVID-19 has yet to be validated in autopsies and in experiments on animals and cells⁽²⁰20 Xu D, Zhang H, Gong H, Chen J, Ye J, Meng T, et al. Identification of a potential mechanism of acute kidney injury during the Covid-19 outbreak: a study based on single-cell transcriptome analysis. Intensive Care Med [internet]. 2020 [cited 2020 Apr 12]. Available From: https://link.springer.com/article/10.1007/s00134-020-06026-1#citeas https://link.springer.com/article/10.100... ⁾.
(2) Descriptive study/ Level 5/n=116⁽²¹21 Wang L, Li X, Chen H, Yan S, Li D, Li Y, et al. Coronavirus Disease 19 infection does not result in acute kidney injury: an analysis of 116 hospitalized patients from Wuhan, China. Am J Nephrol [Internet]. 2020 [cited 2020 Apr 12];1-6. Available From: https://www.karger.com/Article/FullText/507471 https://www.karger.com/Article/FullText/... ⁾.	To explore the effects of SARS-CoV-2 infection on renal function by analyzing the clinical data of 116 hospitalized COVID-19 confirmed patients⁽²¹21 Wang L, Li X, Chen H, Yan S, Li D, Li Y, et al. Coronavirus Disease 19 infection does not result in acute kidney injury: an analysis of 116 hospitalized patients from Wuhan, China. Am J Nephrol [Internet]. 2020 [cited 2020 Apr 12];1-6. Available From: https://www.karger.com/Article/FullText/507471 https://www.karger.com/Article/FullText/... ⁾.	Twelve (10.8%) showed a slight increase in blood urea nitrogen or SCr. Eight (7.2%) patients had a trace or 1+ albuminuria in patients without chronic kidney disease (CKD). All of these patients did not meet the AKI diagnostic criteria. During treatment, renal function indicators showed stable status in patients with CKD, without exacerbation of CKD, and pulmonary inflammation was gradually absorbed. SARS-CoV-2 RNA in the urine sediment was positive only in 4 patients out of 53 cases and 1 patient had a positive result in the SARS-CoV-2 open reading frame⁽²¹21 Wang L, Li X, Chen H, Yan S, Li D, Li Y, et al. Coronavirus Disease 19 infection does not result in acute kidney injury: an analysis of 116 hospitalized patients from Wuhan, China. Am J Nephrol [Internet]. 2020 [cited 2020 Apr 12];1-6. Available From: https://www.karger.com/Article/FullText/507471 https://www.karger.com/Article/FullText/... ⁾.	AKI was unusual in COVID-19. SARS-CoV-2 infection does not result in AKI or worsens CKD in patients with COVID-19⁽²¹21 Wang L, Li X, Chen H, Yan S, Li D, Li Y, et al. Coronavirus Disease 19 infection does not result in acute kidney injury: an analysis of 116 hospitalized patients from Wuhan, China. Am J Nephrol [Internet]. 2020 [cited 2020 Apr 12];1-6. Available From: https://www.karger.com/Article/FullText/507471 https://www.karger.com/Article/FullText/... ⁾.
(3) Retrospective cohort study/ Level 4/ n=113⁽²⁶26 Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ [Internet]. 2020 [cited 2020 Apr 12];368m1091. Available From: https://www.bmj.com/content/368/bmj.m1091 https://www.bmj.com/content/368/bmj.m109... ⁾.	To outline the clinical characteristics of patients with COVID-19 who died⁽²⁶26 Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ [Internet]. 2020 [cited 2020 Apr 12];368m1091. Available From: https://www.bmj.com/content/368/bmj.m1091 https://www.bmj.com/content/368/bmj.m109... ⁾.	Deceased patients, compared to recovered ones, were older (68 and 51 years old, respectively), male, with chronic hypertension and other cardiovascular comorbidities (54 [48%] and 16 [14%]). They had dyspnea, chest tightness and consciousness disorder (70 [62%], 55 [49%] and 25 [22%]). Leukocytosis was present in 56 (50%) of deceased patients and in 6 (4%) of those who recovered, and lymphopenia was present in 103 (91%) and 76 (47%) patients. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatinine, creatine kinase, lactate dehydrogenase, cardiac troponin I, N-terminal pro-brain natriuretic peptide and D-dimer levels were higher. The most common complications were acute respiratory distress syndrome (ARDS) (113; [100%]), type I respiratory failure (18/35; [51%]), sepsis (113 [100%]), acute cardiac injury (72/94; [77%]), alkalosis (14/35 [40%]) and AKI (28 [25%])⁽²⁶26 Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ [Internet]. 2020 [cited 2020 Apr 12];368m1091. Available From: https://www.bmj.com/content/368/bmj.m1091 https://www.bmj.com/content/368/bmj.m109... ⁾.	SARS-CoV-2 infection can cause pulmonary and systemic inflammation, leading to multiple organ dysfunction in high-risk patients. ARDS and respiratory failure, sepsis, acute cardiac injury and heart failure were the most common critical complications of COVID-19⁽²⁶26 Chen T, Wu D, Chen H, Yan W, Yang D, Chen G, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ [Internet]. 2020 [cited 2020 Apr 12];368m1091. Available From: https://www.bmj.com/content/368/bmj.m1091 https://www.bmj.com/content/368/bmj.m109... ⁾.
(4) Retrospective control group study/Level 4/ n=964⁽²⁷27 Deng Y, Liu W, Liu K, Fang Y-Y, Shang J, Zhou L, et al. Clinical characteristics of fatal and recovered cases of coronavirus disease 2019 (COVID-19) in Wuhan, China: a retrospective study. Chin Med J (Engl). 2020;133(11):1261-7 doi: 10.1097/CM9.0000000000000824 https://doi.org/10.1097/CM9.000000000000... ⁾.	To investigate the characteristics of dead patients and provide some ideas on COVID-19 treatment⁽²⁷27 Deng Y, Liu W, Liu K, Fang Y-Y, Shang J, Zhou L, et al. Clinical characteristics of fatal and recovered cases of coronavirus disease 2019 (COVID-19) in Wuhan, China: a retrospective study. Chin Med J (Engl). 2020;133(11):1261-7 doi: 10.1097/CM9.0000000000000824 https://doi.org/10.1097/CM9.000000000000... ⁾.	The mean age was higher in the deceased group compared to recovered (P <0.001), underlying diseases (P <0.001), longer time from disease onset to hospitalization (Z = 3.216, P = 0.001). Upon admission, there was a greater proportion of dyspnea (χ = 60.905, P/<0.001) and sputum (χ = 13.250, P <0.001). The deceased group exhibited a lymphocyte count (Z = 8.037, P <0.00a1) and a lymphocyte/leukocyte proportion (Z = 10.315, P <0.001) that was lower at admission and hospitalization (Z = 5.242, P <0.001). ALT (Z = 2.592, P = 0.010), AST (Z = 7.308, P <0.001) and creatinine levels (Z = 6.478, P <0.001) were higher in the deceased group. C-reactive protein (CRP) were also higher (Z = 10.206, P <0.001). The deceased group had more ARDS (χ = 148.105, P <0.001), acute cardiac injury (χ = 93.222, P <0.001), AKI (χ = 23.257, P <0.001), and shock (χ = 14.618, P <0.001)⁽²⁷27 Deng Y, Liu W, Liu K, Fang Y-Y, Shang J, Zhou L, et al. Clinical characteristics of fatal and recovered cases of coronavirus disease 2019 (COVID-19) in Wuhan, China: a retrospective study. Chin Med J (Engl). 2020;133(11):1261-7 doi: 10.1097/CM9.0000000000000824 https://doi.org/10.1097/CM9.000000000000... ⁾.	Compared to the recovered group, more patients in the deceased group exhibited characteristics of advanced age, pre-existing comorbidities, dyspnea, low oxygen saturation, increased leukocytes, decreased lymphocytes and elevated CRP levels. In addition, they presented ARDS, acute cardiac injury, AKI, shock, and IHD⁽²⁷27 Deng Y, Liu W, Liu K, Fang Y-Y, Shang J, Zhou L, et al. Clinical characteristics of fatal and recovered cases of coronavirus disease 2019 (COVID-19) in Wuhan, China: a retrospective study. Chin Med J (Engl). 2020;133(11):1261-7 doi: 10.1097/CM9.0000000000000824 https://doi.org/10.1097/CM9.000000000000... ⁾.
(5) – Prospective cohort study, Level 4/n=701⁽¹⁹19 Cheng Y, Luo R, Wang K, Zhang M, Wang Z, Dong L, Li J, Yao Y, Ge S, Xu G. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int [Internet]. 2020 [Cited 2020 Apr 12];97(5);829-838. Available From: https://www.kidney-international.org/article/S0085-2538(20)30255-6/fulltext https://www.kidney-international.org/art... ⁾.	To assess the association between abnormal renal function markers and death in patients with COVID-19⁽¹⁹19 Cheng Y, Luo R, Wang K, Zhang M, Wang Z, Dong L, Li J, Yao Y, Ge S, Xu G. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int [Internet]. 2020 [Cited 2020 Apr 12];97(5);829-838. Available From: https://www.kidney-international.org/article/S0085-2538(20)30255-6/fulltext https://www.kidney-international.org/art... ⁾.	Upon admission, 43.9% of the 701 patients had proteinuria and 26.7% had hematuria. High SCr prevalence was 14.4%, high blood urea nitrogen was 13.1% and low glomerular filtration rate was 13.1%. AKI occurred in 5.1% of patients. High basal SCr (risk rate: 2.10, 1.36-3.26), high basal urea nitrogen (3.97, 2.57-6.14), AKI stage 1 (1.90, 0 , 76-4.76), stage 2 (3.51, 1.49-8.26), stage 3 (4.38, 2.31-8.31), proteinuria 1+ (1.80, 0, 81-4.00), 2 + ~3 + (4.84, 2.00-11.70) and hematuria 1+ (2.99, 1.39-6.42), 2 + ~3 + (5.56 , 2.58-12.01) were independent risk factors for death⁽¹⁹19 Cheng Y, Luo R, Wang K, Zhang M, Wang Z, Dong L, Li J, Yao Y, Ge S, Xu G. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int [Internet]. 2020 [Cited 2020 Apr 12];97(5);829-838. Available From: https://www.kidney-international.org/article/S0085-2538(20)30255-6/fulltext https://www.kidney-international.org/art... ⁾.	Prevalence of kidney disease upon admission and development of AKI during hospitalization in patients with COVID-19 was high and is associated with hospital mortality⁽¹⁹19 Cheng Y, Luo R, Wang K, Zhang M, Wang Z, Dong L, Li J, Yao Y, Ge S, Xu G. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int [Internet]. 2020 [Cited 2020 Apr 12];97(5);829-838. Available From: https://www.kidney-international.org/article/S0085-2538(20)30255-6/fulltext https://www.kidney-international.org/art... ⁾.
(6) Retrospective epidemiological study, Level 4/ n=52⁽²⁸28 Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, 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[Internet] 2020[cited 2020 Apr 12];S2213-2600(20)30079-5. Available From: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30079-5/fulltext https://www.thelancet.com/journals/lanre... ⁾.	To describe the clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia⁽²⁸28 Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, 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[Internet] 2020[cited 2020 Apr 12];S2213-2600(20)30079-5. Available From: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30079-5/fulltext https://www.thelancet.com/journals/lanre... ⁾.	The mean age of the 52 patients was 59.7 years old (SD 13.3), the majority 35 (67%) were men, 21 (40%) had chronic diseases and 51 (98%) had fever. Thirty-two (61.5%) patients died after 28 days of hospitalization and the median duration of admission to the intensive care unit (ICU) until death was 7 days (IQR 3-11). Compared to survivors, non-survivors were older (64.6 years old [11.2] vs 51.9 years old [12.9]). Twenty-six (81%) patients vs nine (45%) patients were more likely to develop ARDS and to receive mechanical ventilation (30 [94%] vs 7 [35%]). From clinical evolution, (35 [67%]) with ARDS, (15 [29%]) with AKI and (12 [23%]) with cardiac injury⁽²⁸28 Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, 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[Internet] 2020[cited 2020 Apr 12];S2213-2600(20)30079-5. Available From: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30079-5/fulltext https://www.thelancet.com/journals/lanre... ⁾.	The survival time of non-survivors is likely to be 1 to 2 weeks after admission to the ICU. Elderly patients (> 65 years) with comorbidities and ARDS are at increased risk of death⁽²⁸28 Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, 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[Internet] 2020[cited 2020 Apr 12];S2213-2600(20)30079-5. Available From: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30079-5/fulltext https://www.thelancet.com/journals/lanre... ⁾.

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[1] Corresponding author: Cassiane Dezoti da Fonseca. E-mail: cassiane.dezoti@unifesp.br