In a new study, researchers give the first comprehensive review of COVID-19’s effects outside the lungs.
They found a substantial proportion of patients suffer kidney, heart, and brain damage, and suggested physicians need to treat those conditions along with the respiratory disease.
Their review is the first extensive review of COVID-19’s effects on all affected organs outside the lungs.
The research was conducted by a team at Columbia University Irving Medical Center.
In early March, there wasn’t much clinical guidance on the non-respiratory effects of COVID-19, so the team decided to coalesce findings from studies that were just beginning to appear in the literature with what the physicians were learning from experience.
They reviewed the latest findings on COVID-19’s effect on organ systems outside the lungs and provide clinical guidance for physicians.
One group of problems caused by COVID-19 includes blood Clots, inflammation, and an immune system in overdrive.
The scientists think these clotting complications may stem from the virus’s attack on cells that line the blood vessels.
When the virus attacks blood vessel cells, inflammation increases, and blood begins to form clots, big and small.
These blood clots can travel all over the body and wreak havoc on organs, perpetuating a vicious cycle of thrombo-inflammation.
To combat clotting and its damaging effects, clinicians at Columbia, many of whom are co-authors on this review, are conducting a randomized clinical trial to investigate the optimal dose and timing of anticoagulation drugs in critically ill patients with COVID-19.
The untempered inflammation can also overstimulate the immune system, and though doctors initially shied away from using steroids to globally suppress the immune system, a recent clinical trial has found that at least one steroid, dexamethasone, reduced deaths in ventilated patients by one-third.
Randomized clinical trials are underway to target specific components of thromboinflammation and the immune system, such as interleukin-6 signaling.
The second type of problem is heart damage.
Clots can cause heart attacks, but the virus attacks the heart in other ways, the team says.
The mechanism of heart damage is currently unclear, as the virus has not been frequently isolated from the heart tissue in autopsy cases.
The heart muscle may be damaged by systemic inflammation and the accompanying cytokine release, a flood of immune cells that normally clears up infected cells but can spiral out of control in severe COVID-19 cases.
Despite the degree of heart damage, physicians were not able to utilize the diagnostic and therapeutic strategies, including heart biopsies and cardiac catheterizations, that they would normally use during the early stages of the pandemic given the need to protect personnel and patients from the viral transmission.
Another surprising finding was the high proportion of COVID-19 patients in the ICU with acute kidney damage.
The ACE2 receptor used by the virus to gain entry into the cells is found in high concentrations in the kidney and could likely be responsible for the renal damage.
Studies in China reported renal complications, but in New York City, clinicians saw renal failure in up to 50% of patients in the ICU.
About 5 to 10% of patients needed dialysis. That’s a very high number, the team says.
Data regarding long-term renal damage are currently lacking, but a significant proportion of patients will likely go on to require permanent dialysis.
The team also found that neurological symptoms, including headache, dizziness, fatigue, and loss of smell, may occur in about a third of patients.
More concerning, strokes caused by blood clots occur in up to 6% of severe cases and delirium in 8% to 9%.
COVID-19 patients can be intubated for two to three weeks; a quarter requires ventilators for 30 or more days.
These are very prolonged intubations, and patients need a lot of sedation.
The team says ‘ICU delirium’ was a well-known condition before COVID, and the hallucinations may be less an effect of the virus and more an effect of the prolonged sedation.
They hope that the review, observations, and recommendations can help other clinicians where cases are now surging.
Doctors need to keep all organ systems in mind when caring for patients with COVID-19.
One author of the study is Aakriti Gupta, M.D.
The study is published in Nature Medicine.
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