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As the coronavirus disease 2019 (COVID-19) pandemic swept through American hospitals in the early part of 2020, the multisystem nature of the disease quickly became apparent, with AKI featuring as a prominent complication of severe acute respiratory syndrome coronavirus 2 infection.1 Severe infection likely drives an immunologic storm, leading to tubular, vascular, and in some cases, glomerular injury. A direct viral cytopathic effect on the kidney is a subject of debate.2,3 In this issue of JASN, two investigative groups provide a comprehensive description of their experience with COVID-19–associated AKI.4,5 Chan et al.4 report on the epidemiology of COVID-19–associated AKI among nearly 4000 patients admitted at a five-hospital health system in New York City. As part of the Study of the Treatment and Outcomes in Critically Ill Patients With COVID-19 project that recruited patients from 67 United States hospitals, Gupta et al.5 followed 3099 critically ill patients with COVID-19 and focused on those who received RRT in the context of AKI. Collectively, these timely studies deliver three crucial messages: (1) AKI afflicted nearly half of all patients hospitalized with COVID-19 and the majority of those admitted to the intensive care unit (ICU), (2) 20% of critically ill patients with COVID-19 received RRT, and (3) survivors of COVID19–associated AKI often have incomplete recovery of kidney function at hospital discharge, with one-third of patients who received acute RRT having a persistent requirement for dialysis at the time of hospital discharge. The high frequency of AKI among patients hospitalized with COVID-19 in United States hospitals contrasts with reports from China, where AKI tended to be less frequent.6,7 It is unclear if this relates to differences in ascertainment, thresholds for hospitalization, ICU care (e.g., concomitant use of mechanical ventilation and fluid management), or the prevalence of AKI risk factors. The proportion of critically ill patients initiating RRTwas especially high, which is consistent with reports from patients with COVID-19 in the United Kingdom8 but higher than what was observed in patients with influenza A subtype H1N1.9,10 The receipt of RRT correlates with both severity of AKI and overall illness acuity, but the ultimate decision to commence RRT is complex and guided by a variety of clinical and logistic factors as well as clinician judgement. Neither of the two papers described the specific triggers for RRT. Recent trials have shown that the preemptive initiation of RRT, specifically before a metabolic or fluid-related emergency of AKI supervenes, does not confer improved survival but may portend a higher risk of persistent dialysis dependence and iatrogenic complications.11 With the procurement of ventilators dominating pandemic preparedness efforts in early 2020, dialysis capacity emerged as a “blind spot” as patients with COVID-19–associated AKI overwhelmed health care systems in New York City and other regions.12Well-established acute RRT programs struggled due to a lack of machines, supplies, and personnel. Scarcity prompted centers to rapidly alter their usual RRT strategies; novel approaches included “sharing” continuous RRT (CRRT)machines between two patients, each receiving a daily 10to 12-hour session, and the utilization of peritoneal dialysis,13 which is not traditionally used inNorthAmerican ICUs for the treatment of AKI. The unexpected deluge of patients with AKI forced rapid adaptation and creative problem-solving. Kidney programs preparing for future COVID-19 surges must proactively prepare for scenarios in which their RRTresources may again become stressed, necessitating the development of wellconceived backup plans. It is also hoped that future surges will see enhanced coordination between health systems and manufacturers to ensure an adequate supply of dialysis hardware and disposables across modalities, with flexible plans to rapidly shift supplies and staff to sites facing the greatest needs. The dialysis prescription in COVID-19–associated AKI presents unique considerations. Irrespective of RRTmodality, the optimal ultrafiltration target for patients with COVID-19 is uncertain. Hypoxemic respiratory failure and acute respiratory distress syndrome, central features of severe COVID-19, may be exacerbated by fluid accumulation, which is worsened by AKI. Whether and how fast to remove fluid with ultrafiltration are uncertain. On one hand,more rapid fluid removal may improve oxygenation and accelerate liberation from mechanical ventilation. However, ultrafiltration may predispose patients to hypotension and secondary organ injury. COVID-19 is associated with a syndrome of hypercoagulability with implications for RRT-related anticoagulation.14 Clinicians should consider using anticoagulation for all Published online ahead of print. Publication date available at www.jasn.org.

COVID-19–Associated Acute Kidney Injury: Learning from the First Wave