Microvascular Thrombosis and Acute Kidney Injury in COVID-19: A Systematic Review and Quantitative Analysis
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Objective
To synthesize the available evidence on the association between SARS-CoV-2-related microvascular thrombosis and acute kidney injury (AKI), with emphasis on renal outcomes, mortality, and renal replacement therapy requirements.
Methods
This systematic review followed the PRISMA 2020 statement and was prospectively registered in PROSPERO (CRD420251132701). PubMed/MEDLINE, Scopus, and Embase were searched for systematic reviews, including meta-analyses, and umbrella reviews investigating the association between SARS-CoV-2-related microvascular thrombosis and acute kidney injury. Two reviewers independently performed study selection, data extraction, and methodological quality assessment using AMSTAR-2 and ROBIS. Evidence was synthesized through a structured narrative synthesis supported by quantitative data extracted from the included reviews.
Results
Six evidence syntheses evaluating kidney involvement, thrombotic events, and microvascular mechanisms in COVID-19 were included. AKI incidence was 9.2% (95%CI 4.6–13.9) among hospitalized patients and 32.6% (95%CI 8.5–56.6) among critically ill patients. In children with multisystem inflammatory syndrome associated with SARS-CoV-2, AKI incidence was 20% (95%CI 14–28). Microvascular or thrombotic events were associated with adverse renal outcomes (OR 2.14; 95%CI 1.32– 3.48). AKI was associated with increased mortality (OR 4.68; 95%CI 1.06–20.70) and greater likelihood of renal replacement therapy requirement (OR 2.87; 95%CI 1.45– 5.68). The certainty of evidence ranged from moderate to high for the principal outcomes.
Conclusion
Current evidence supports an important association between microvascular thrombotic injury and COVID-19-associated AKI. These findings reinforce the relevance of endothelial dysfunction and thromboinflammatory pathways in kidney involvement during COVID-19 and highlight the need for early renal monitoring, risk stratification, and kidney-protective strategies in high-risk patients.
