Moser, Jill

van Meurs, Matijs

Zijlstra, Jan G.

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Meurs, Matijs van

Dissertations of the University of Groningen

   University of GroningenPost-Mortem Diagnostics in COVID-19 AKI, More Often but TimelyZijlstra, Jan G.; Meurs, Matijs van; Moser, JillPublished in:Journal of the American Society of NephrologyDOI:10.1681/ASN.2020091263IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Zijlstra, J. G., Meurs, M. V., & Moser, J. (2021). Post-Mortem Diagnostics in COVID-19 AKI, More Often butTimely. Journal of the American Society of Nephrology, 32(1), 255.https://doi.org/10.1681/ASN.2020091263CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 12-10-2022LETTERS TO THE EDITOR www.jasn.orgPost-Mortem Diagnostics in COVID-19 AKI, More Often but TimelyCoronavirus disease 2019 (COVID-19) is a new and devastat-ing disease with renal involvement that deserves an intenseand collaborative research effort. Golmai et al.1 make use ofclassic autopsy with the modern modification of postmortem,fine-needle kidney biopsy. Autopsy was originally developedto investigate macroscopic, light-microscopic, postmortem,anatomic and histologic changes associated with disease. Stan-dard autopsy is mildly time sensitive, with autolysis develop-ing several hours after death. However, new developments inpathophysiologic diagnostics—protein, RNA, and DNA anal-yses—require faster sample handling and careful samplestorage to prevent postmortem effects. Golmai et al.1 do notdescribe how long after death biopsies were performed, butstate the majority of samples show signs of autolysis. Thisprecludes protein, RNA, and most DNA analyses because wewould be observing mostly postmortem effects. Similar tosepsis, COVID-19 microscopic changes in the kidney are lim-ited, with most studies showing some acute tubular necrosis,which cannot fully explain AKI. A large proportion of renalfailure in patients with COVID-19 and those with sepsis seemsto be attributed to functional defects without major histologicchanges. Therefore, modern protein and nucleic-acid techni-ques might shed some light on the underlying mechanismsdriving renal failure. We have shown that kidney biopsies canbe performed at the bedside within 1 hour after death, and thatgene expression analyses are feasible.2,3 Mortality of patientswith COVID-19 was shown to be higher in patients with AKI.4Yet, the mechanisms driving renal failure in patients withCOVID-19 still remain largely unknown. Therefore, we pleadformore studies to investigate postmortem renal biopsy speci-mens taken rapidly after death to enable the use of modernmolecular diagnostics, together with classic autopsy, to inves-tigate mechanisms of AKI induced by COVID-19.DISCLOSURESAll authors have nothing to disclose.FUNDINGNone.REFERENCES1. Golmai P, Larsen CP, DeVita MV, Wahl SJ, Weins A, Rennke HG, et al.:Histopathologic and ultrastructural findings in postmortem kidney bi-opsy material in 12 patients with AKI and COVID-19. J Am Soc Nephrol31: 1944–1947, 20202. Aslan A, Jongman RM, Moser J, Stegeman CA, van Goor H, Diepstra A,et al.: The renal angiopoietin/Tie2 system in lethal human sepsis. CritCare 18: 423, 20143. Jou-Valencia D, Koeze J, Popa ER, Aslan A, Zwiers PJ, Molema G, et al.:Heterogenous renal injury biomarker production reveals human sepsis-associated acute kidney injury subtypes.Crit Care Explor 1: e0047, 20194. Pei G, Zhang Z, Peng J, Liu L, Zhang C, Yu C, et al.: Renal involvementand early prognosis in patients with COVID-19 pneumonia. J Am SocNephrol 31: 1157–1165, 2020See related Letters to the Editor, “Authors’ Reply,” on pages xxx–xxx.Jan G. Zijlstra1,2, Matijs van Meurs1,2, andJill Moser 1,21Department of Pathology and Medical Biology, Medical BiologySection, University Medical Center Groningen, University ofGroningen, Groningen, The Netherlands2Department of Critical Care, University Medical CenterGroningen, University of Groningen, Groningen, The NetherlandsJASN 32: ccc–ccc, 2021.doi: https://doi.org/10.1681/ASN.2020091263Published online ahead of print. Publication date available at www.jasn.org.Correspondence: Prof. Jan G. Zijlstra, Department of Critical Care, UniversityMedical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB,Groningen, The Netherlands. Email: j.g.zijlstra@umcg.nlCopyright © 2021 by the American Society of NephrologyJASN 32: ccc–ccc, 2021 ISSN : 1046-6673/3201-ccc 1

Post-Mortem Diagnostics in COVID-19 AKI, More Often but Timely

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University of Groningen

   University of GroningenPost-Mortem Diagnostics in COVID-19 AKI, More Often but Timely ReplyZijlstra, Jan G.; van Meurs, Matijs; Moser, JillPublished in:Journal of the American Society of NephrologyDOI:10.1681/ASN.2020101479IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Zijlstra, J. G., van Meurs, M., & Moser, J. (2021). Post-Mortem Diagnostics in COVID-19 AKI, More Oftenbut Timely Reply. Journal of the American Society of Nephrology, 32(1), 255-256.https://doi.org/10.1681/ASN.2020101479CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 29-04-2023LETTERS TO THE EDITOR www.jasn.orgPost-Mortem Diagnostics in COVID-19 AKI, More Often but TimelyCoronavirus disease 2019 (COVID-19) is a new and devastat-ing disease with renal involvement that deserves an intenseand collaborative research effort. Golmai et al.1 make use ofclassic autopsy with the modern modification of postmortem,fine-needle kidney biopsy. Autopsy was originally developedto investigate macroscopic, light-microscopic, postmortem,anatomic and histologic changes associated with disease. Stan-dard autopsy is mildly time sensitive, with autolysis develop-ing several hours after death. However, new developments inpathophysiologic diagnostics—protein, RNA, and DNA anal-yses—require faster sample handling and careful samplestorage to prevent postmortem effects. Golmai et al.1 do notdescribe how long after death biopsies were performed, butstate the majority of samples show signs of autolysis. Thisprecludes protein, RNA, and most DNA analyses because wewould be observing mostly postmortem effects. Similar tosepsis, COVID-19 microscopic changes in the kidney are lim-ited, with most studies showing some acute tubular necrosis,which cannot fully explain AKI. A large proportion of renalfailure in patients with COVID-19 and those with sepsis seemsto be attributed to functional defects without major histologicchanges. Therefore, modern protein and nucleic-acid tech-niques might shed some light on the underlying mechanismsdriving renal failure. We have shown that kidney biopsies canbe performed at the bedside within 1 hour after death, and thatgene expression analyses are feasible.2,3 Mortality of patientswith COVID-19 was shown to be higher in patients with AKI.4Yet, the mechanisms driving renal failure in patients withCOVID-19 still remain largely unknown. Therefore, we pleadfor more studies to investigate postmortem renal biopsy spec-imens taken rapidly after death to enable the use of modernmolecular diagnostics, together with classic autopsy, to inves-tigate mechanisms of AKI induced by COVID-19.DISCLOSURESAll authors have nothing to disclose.FUNDINGNone.REFERENCES1. Golmai P, Larsen CP, DeVita MV, Wahl SJ, Weins A, Rennke HG, et al.:Histopathologic and ultrastructural findings in postmortem kidney bi-opsy material in 12 patients with AKI and COVID-19. J Am Soc Nephrol31: 1944–1947, 20202. Aslan A, Jongman RM, Moser J, Stegeman CA, van Goor H, Diepstra A,et al.: The renal angiopoietin/Tie2 system in lethal human sepsis. CritCare 18: 423, 20143. Jou-Valencia D, Koeze J, Popa ER, Aslan A, Zwiers PJ, Molema G, et al.:Heterogenous renal injury biomarker production reveals human sepsis-associated acute kidney injury subtypes.Crit Care Explor 1: e0047, 20194. Pei G, Zhang Z, Peng J, Liu L, Zhang C, Yu C, et al.: Renal involvementand early prognosis in patients with COVID-19 pneumonia. J Am SocNephrol 31: 1157–1165, 2020See related reply, “Authors’ Reply,” on pages 255–256, and original article“Histopathologic and Ultrastructural Findings in Postmortem Kidney BiopsyMaterial in 12 Patients with AKI and COVID-19,” in Vol. 31, Iss. 9, 1944–1947.Jan G. Zijlstra1,2, Matijs van Meurs1,2, andJill Moser 1,21Department of Pathology and Medical Biology, Medical BiologySection, University Medical Center Groningen, University ofGroningen, Groningen, The Netherlands2Department of Critical Care, University Medical CenterGroningen, University of Groningen, Groningen, The NetherlandsJASN 32: 255, 2021.doi: https://doi.org/10.1681/ASN.2020091263Authors’ ReplyZijlstra et al.1 question whether delay to postmortem biopsyand ensuing tissue autolysis could have interfered with ourmolecular diagnostics. They ask how long after death werebiopsies done in our study, and suggest that studies usingmore rapid postmortem biopsy might be more productive.Supplemental Table 1, included in our paper,2 provided thetimes between death and biopsy. Out of 12 cases, 11 werebiopsied within 24 hours postmortem; three were performedPublished online ahead of print. Publication date available at www.jasn.org.Correspondence: Prof. Jan G. Zijlstra, Department of Critical Care, UniversityMedical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB,Groningen, The Netherlands. Email: j.g.zijlstra@umcg.nlCopyright © 2021 by the American Society of NephrologyPublished online ahead of print. Publication date available at www.jasn.org.Correspondence: Dr. Jordan L. Rosenstock, Lenox Hill Hospital, Donald andBarbara Zucker School of Medicine, 130 East 77th St., New York, NY 10075-1850. Email: jrosenstock@northwell.eduCopyright © 2021 by the American Society of NephrologyJASN 32: 255–258, 2021 ISSN : 1046-6673/3201-255 255LETTERSTOTHEEDITORwithin 2.5 hours. The fastest time to biopsy was 1.5 hours. Anumber of the cases had mild or no autolysis, as seen inTable 1. Similarly, Santoriello et al.3 did not find any clearevidence of viral infection of kidney in a postmortem series of42 patients, many of whom had mild or absent autolysis. Weacknowledge there remains the possibility that postmortemautolysis could interfere with the detection of the virus, al-though it must be emphasized that, in both of these afore-mentioned studies, lung specimens from autopsies used ascontrols were clearly positive for the virus. Corroboratingour findings are two series of renal biopsy specimens in livingpatients with coronavirus disease 2019 included in the sameissue of JASN.4,5 In these series (the majority in patients whohad severe AKI), they also found no clear evidence of viralinfection of the kidney, by ultrastructural examination inaddition to immunohistochemical staining for viral spikeand nucleocapsid proteins, and in situ hybridization for se-vere acute respiratory syndrome coronavirus 2 viral RNA.The conclusions of these four reports, two in living andtwo in postmortem kidneys, are consistent: it does not appearlikely that direct viral infection is a primary contributor torenal dysfunction in patients with coronavirus disease 2019.DISCLOSURESJ. Rosenstock is an editorial board member of International Urology andNephrology. V. Bijol reports honoraria from International Society ofNephrology.FUNDINGNone.REFERENCES1. Zijlstra J, van Meurs M, Moser J: Post-mortem diagnostics in COVID-19,more often but timely. J Am Soc Nephrol 32: 255, 20212. Golmai P, Larsen CP, DeVita MV, Wahl SJ, Weins A, Rennke HG, et al.:Histopathologic and ultrastructural findings in postmortem kidney bi-opsy material in 12 patients with AKI and COVID-19. J Am Soc Nephrol31: 1944–1947, 20203. Santoriello D, Khairallah P, Bomback AS, Xu K, Kudose S, Batal I, et al.:Postmortem kidney pathology findings in patients with COVID-19. J AmSoc Nephrol 31: 2158–2167, 20204. Sharma P, Uppal NN, Wanchoo R, Shah HH, Yang Y, Parikh R, et al.;Northwell Nephrology COVID-19 Research Consortium: COVID-19 as-sociated kidney injury: A case series of kidney biopsy findings. J Am SocNephrol 31: 1948–1958, 20205. Kudose S, Batal I, Santoriello D, Xu K, Barasch J, Peleg Y, et al.: Kidneybiopsy findings in patients with COVID-19. J Am Soc Nephrol 31:1959–1968, 2020See related letter to the editor, “Post-Mortem Diagnostics in COVID-19 AKI,More Often but Timely,” on page 255, and original article “Histopathologicand Ultrastructural Findings in Postmortem Kidney Biopsy Material in 12 Pa-tients with AKI and COVID-19,” in Vol. 31, Iss. 9, 1944–1947.Jordan L. Rosenstock1 and Vanesa Bijol21Divison of Nephrology, Lenox Hill Hospital, Donald and BarbaraZucker School of Medicine at Hofstra/Northwell, Hofstra University,New York, New York2Department of Pathology, Donald and Barbara Zucker School ofMedicine at Hofstra/Northwell, Hofstra University, Hempstead,New YorkJASN 32: 255–256, 2021.doi: https://doi.org/10.1681/ASN.2020101479Complexities of eGFRs in aStudy of Glomerular PhysiologyIn a recent article in JASN, Collard et al.1 used a new methodto indirectly determine glomerular pressures (Pglom) fromrenal artery pressures and flows that were measured in 28patients undergoing angiography. Kidney function was ex-pressed as a patient’s eGFR by the Chronic Kidney DiseaseEpidemiology Collaboration (CKD-EPI) equation.2 Afteranalysis, higher renal perfusion pressure, higher body massindex (BMI), and the presence of diabetes were associatedwith higher Pglom.The use of eGFRs in this study may have introduced cer-tain complexities. An eGFR is a size-indexed GFR, in milli-liters per minute per 1.73 m2. The ratio of GFR to bodysurface area (BSA) is indexed to a standard BSA of1.73 m2.2 Normally, with the same eGFR, larger peoplehave higher BSAs, BMIs, and measured GFRs (in millilitersper minute), and smaller people have the opposite. Anadvantage of screening with eGFRs in this study was to besure that reasonably healthy kidneys were studied, i.e., withfunction appropriate to body size. But when kidney functionwas expressed as eGFR and BMI was used as an independentvariable, higher BMIs selected for higher nonindexed GFRs(in milliliters per minute). Therefore, the more fundamentalassociation might have been between (higher) nonindexedGFR and (higher) Pglom, not (higher) BMI and Pglom. Itmay be relevant that, in the early days of continuous ambu-latory peritoneal dialysis, we found misleading correlationswhen multiple size-related terms were studied in the samepatient. This happened, for example, when both protein cat-abolic rate and dialytic clearance were normalized to bodysize.3 In this study, multiplying the eGFRs by each individual’sBSA/1.73 to “unindex” them might help clarify the results.Published online ahead of print. Publication date available at www.jasn.org.Correspondence: Dr. Robert W. Steiner, University of California San DiegoCenter for Transplantation, 9300 Campus Point Drive #7745, San Diego, CA92037-9745. Email: rsteiner@health.ucsd.eduCopyright © 2021 by the American Society of Nephrology256 JASN JASN 32: 255–258, 2021LETTERS TO THE EDITOR www.jasn.org

Post-Mortem Diagnostics in COVID-19 AKI, More Often but Timely Reply

   University of GroningenPost-Mortem Diagnostics in COVID-19 AKI, More Often but TimelyZijlstra, Jan G.; Meurs, Matijs van; Moser, JillPublished in:Journal of the American Society of NephrologyDOI:10.1681/ASN.2020091263IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Zijlstra, J. G., Meurs, M. V., & Moser, J. (2021). Post-Mortem Diagnostics in COVID-19 AKI, More Often butTimely. Journal of the American Society of Nephrology, 32(1), 255. Advance online publication.https://doi.org/10.1681/ASN.2020091263CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 10-09-2023LETTERS TO THE EDITOR www.jasn.orgPost-Mortem Diagnostics in COVID-19 AKI, More Often but TimelyCoronavirus disease 2019 (COVID-19) is a new and devastat-ing disease with renal involvement that deserves an intenseand collaborative research effort. Golmai et al.1 make use ofclassic autopsy with the modern modification of postmortem,fine-needle kidney biopsy. Autopsy was originally developedto investigate macroscopic, light-microscopic, postmortem,anatomic and histologic changes associated with disease. Stan-dard autopsy is mildly time sensitive, with autolysis develop-ing several hours after death. However, new developments inpathophysiologic diagnostics—protein, RNA, and DNA anal-yses—require faster sample handling and careful samplestorage to prevent postmortem effects. Golmai et al.1 do notdescribe how long after death biopsies were performed, butstate the majority of samples show signs of autolysis. Thisprecludes protein, RNA, and most DNA analyses because wewould be observing mostly postmortem effects. Similar tosepsis, COVID-19 microscopic changes in the kidney are lim-ited, with most studies showing some acute tubular necrosis,which cannot fully explain AKI. A large proportion of renalfailure in patients with COVID-19 and those with sepsis seemsto be attributed to functional defects without major histologicchanges. Therefore, modern protein and nucleic-acid techni-ques might shed some light on the underlying mechanismsdriving renal failure. We have shown that kidney biopsies canbe performed at the bedside within 1 hour after death, and thatgene expression analyses are feasible.2,3 Mortality of patientswith COVID-19 was shown to be higher in patients with AKI.4Yet, the mechanisms driving renal failure in patients withCOVID-19 still remain largely unknown. Therefore, we pleadformore studies to investigate postmortem renal biopsy speci-mens taken rapidly after death to enable the use of modernmolecular diagnostics, together with classic autopsy, to inves-tigate mechanisms of AKI induced by COVID-19.DISCLOSURESAll authors have nothing to disclose.FUNDINGNone.REFERENCES1. Golmai P, Larsen CP, DeVita MV, Wahl SJ, Weins A, Rennke HG, et al.:Histopathologic and ultrastructural findings in postmortem kidney bi-opsy material in 12 patients with AKI and COVID-19. J Am Soc Nephrol31: 1944–1947, 20202. Aslan A, Jongman RM, Moser J, Stegeman CA, van Goor H, Diepstra A,et al.: The renal angiopoietin/Tie2 system in lethal human sepsis. CritCare 18: 423, 20143. Jou-Valencia D, Koeze J, Popa ER, Aslan A, Zwiers PJ, Molema G, et al.:Heterogenous renal injury biomarker production reveals human sepsis-associated acute kidney injury subtypes.Crit Care Explor 1: e0047, 20194. Pei G, Zhang Z, Peng J, Liu L, Zhang C, Yu C, et al.: Renal involvementand early prognosis in patients with COVID-19 pneumonia. J Am SocNephrol 31: 1157–1165, 2020See related Letters to the Editor, “Authors’ Reply,” on pages xxx–xxx.Jan G. Zijlstra1,2, Matijs van Meurs1,2, andJill Moser 1,21Department of Pathology and Medical Biology, Medical BiologySection, University Medical Center Groningen, University ofGroningen, Groningen, The Netherlands2Department of Critical Care, University Medical CenterGroningen, University of Groningen, Groningen, The NetherlandsJASN 32: ccc–ccc, 2021.doi: https://doi.org/10.1681/ASN.2020091263Published online ahead of print. Publication date available at www.jasn.org.Correspondence: Prof. Jan G. Zijlstra, Department of Critical Care, UniversityMedical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB,Groningen, The Netherlands. Email: j.g.zijlstra@umcg.nlCopyright © 2021 by the American Society of NephrologyJASN 32: ccc–ccc, 2021 ISSN : 1046-6673/3201-ccc 1

   University of GroningenPost-Mortem Diagnostics in COVID-19 AKI, More Often but Timely ReplyZijlstra, Jan G.; van Meurs, Matijs; Moser, JillPublished in:Journal of the American Society of NephrologyDOI:10.1681/ASN.2020101479IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Zijlstra, J. G., van Meurs, M., & Moser, J. (2021). Post-Mortem Diagnostics in COVID-19 AKI, More Oftenbut Timely Reply. Journal of the American Society of Nephrology, 32(1), 255-256.https://doi.org/10.1681/ASN.2020101479CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 31-10-2023LETTERS TO THE EDITOR www.jasn.orgPost-Mortem Diagnostics in COVID-19 AKI, More Often but TimelyCoronavirus disease 2019 (COVID-19) is a new and devastat-ing disease with renal involvement that deserves an intenseand collaborative research effort. Golmai et al.1 make use ofclassic autopsy with the modern modification of postmortem,fine-needle kidney biopsy. Autopsy was originally developedto investigate macroscopic, light-microscopic, postmortem,anatomic and histologic changes associated with disease. Stan-dard autopsy is mildly time sensitive, with autolysis develop-ing several hours after death. However, new developments inpathophysiologic diagnostics—protein, RNA, and DNA anal-yses—require faster sample handling and careful samplestorage to prevent postmortem effects. Golmai et al.1 do notdescribe how long after death biopsies were performed, butstate the majority of samples show signs of autolysis. Thisprecludes protein, RNA, and most DNA analyses because wewould be observing mostly postmortem effects. Similar tosepsis, COVID-19 microscopic changes in the kidney are lim-ited, with most studies showing some acute tubular necrosis,which cannot fully explain AKI. A large proportion of renalfailure in patients with COVID-19 and those with sepsis seemsto be attributed to functional defects without major histologicchanges. Therefore, modern protein and nucleic-acid tech-niques might shed some light on the underlying mechanismsdriving renal failure. We have shown that kidney biopsies canbe performed at the bedside within 1 hour after death, and thatgene expression analyses are feasible.2,3 Mortality of patientswith COVID-19 was shown to be higher in patients with AKI.4Yet, the mechanisms driving renal failure in patients withCOVID-19 still remain largely unknown. Therefore, we pleadfor more studies to investigate postmortem renal biopsy spec-imens taken rapidly after death to enable the use of modernmolecular diagnostics, together with classic autopsy, to inves-tigate mechanisms of AKI induced by COVID-19.DISCLOSURESAll authors have nothing to disclose.FUNDINGNone.REFERENCES1. Golmai P, Larsen CP, DeVita MV, Wahl SJ, Weins A, Rennke HG, et al.:Histopathologic and ultrastructural findings in postmortem kidney bi-opsy material in 12 patients with AKI and COVID-19. J Am Soc Nephrol31: 1944–1947, 20202. Aslan A, Jongman RM, Moser J, Stegeman CA, van Goor H, Diepstra A,et al.: The renal angiopoietin/Tie2 system in lethal human sepsis. CritCare 18: 423, 20143. Jou-Valencia D, Koeze J, Popa ER, Aslan A, Zwiers PJ, Molema G, et al.:Heterogenous renal injury biomarker production reveals human sepsis-associated acute kidney injury subtypes.Crit Care Explor 1: e0047, 20194. Pei G, Zhang Z, Peng J, Liu L, Zhang C, Yu C, et al.: Renal involvementand early prognosis in patients with COVID-19 pneumonia. J Am SocNephrol 31: 1157–1165, 2020See related reply, “Authors’ Reply,” on pages 255–256, and original article“Histopathologic and Ultrastructural Findings in Postmortem Kidney BiopsyMaterial in 12 Patients with AKI and COVID-19,” in Vol. 31, Iss. 9, 1944–1947.Jan G. Zijlstra1,2, Matijs van Meurs1,2, andJill Moser 1,21Department of Pathology and Medical Biology, Medical BiologySection, University Medical Center Groningen, University ofGroningen, Groningen, The Netherlands2Department of Critical Care, University Medical CenterGroningen, University of Groningen, Groningen, The NetherlandsJASN 32: 255, 2021.doi: https://doi.org/10.1681/ASN.2020091263Authors’ ReplyZijlstra et al.1 question whether delay to postmortem biopsyand ensuing tissue autolysis could have interfered with ourmolecular diagnostics. They ask how long after death werebiopsies done in our study, and suggest that studies usingmore rapid postmortem biopsy might be more productive.Supplemental Table 1, included in our paper,2 provided thetimes between death and biopsy. Out of 12 cases, 11 werebiopsied within 24 hours postmortem; three were performedPublished online ahead of print. Publication date available at www.jasn.org.Correspondence: Prof. Jan G. Zijlstra, Department of Critical Care, UniversityMedical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB,Groningen, The Netherlands. Email: j.g.zijlstra@umcg.nlCopyright © 2021 by the American Society of NephrologyPublished online ahead of print. Publication date available at www.jasn.org.Correspondence: Dr. Jordan L. Rosenstock, Lenox Hill Hospital, Donald andBarbara Zucker School of Medicine, 130 East 77th St., New York, NY 10075-1850. Email: jrosenstock@northwell.eduCopyright © 2021 by the American Society of NephrologyJASN 32: 255–258, 2021 ISSN : 1046-6673/3201-255 255LETTERSTOTHEEDITORwithin 2.5 hours. The fastest time to biopsy was 1.5 hours. Anumber of the cases had mild or no autolysis, as seen inTable 1. Similarly, Santoriello et al.3 did not find any clearevidence of viral infection of kidney in a postmortem series of42 patients, many of whom had mild or absent autolysis. Weacknowledge there remains the possibility that postmortemautolysis could interfere with the detection of the virus, al-though it must be emphasized that, in both of these afore-mentioned studies, lung specimens from autopsies used ascontrols were clearly positive for the virus. Corroboratingour findings are two series of renal biopsy specimens in livingpatients with coronavirus disease 2019 included in the sameissue of JASN.4,5 In these series (the majority in patients whohad severe AKI), they also found no clear evidence of viralinfection of the kidney, by ultrastructural examination inaddition to immunohistochemical staining for viral spikeand nucleocapsid proteins, and in situ hybridization for se-vere acute respiratory syndrome coronavirus 2 viral RNA.The conclusions of these four reports, two in living andtwo in postmortem kidneys, are consistent: it does not appearlikely that direct viral infection is a primary contributor torenal dysfunction in patients with coronavirus disease 2019.DISCLOSURESJ. Rosenstock is an editorial board member of International Urology andNephrology. V. Bijol reports honoraria from International Society ofNephrology.FUNDINGNone.REFERENCES1. Zijlstra J, van Meurs M, Moser J: Post-mortem diagnostics in COVID-19,more often but timely. J Am Soc Nephrol 32: 255, 20212. Golmai P, Larsen CP, DeVita MV, Wahl SJ, Weins A, Rennke HG, et al.:Histopathologic and ultrastructural findings in postmortem kidney bi-opsy material in 12 patients with AKI and COVID-19. J Am Soc Nephrol31: 1944–1947, 20203. Santoriello D, Khairallah P, Bomback AS, Xu K, Kudose S, Batal I, et al.:Postmortem kidney pathology findings in patients with COVID-19. J AmSoc Nephrol 31: 2158–2167, 20204. Sharma P, Uppal NN, Wanchoo R, Shah HH, Yang Y, Parikh R, et al.;Northwell Nephrology COVID-19 Research Consortium: COVID-19 as-sociated kidney injury: A case series of kidney biopsy findings. J Am SocNephrol 31: 1948–1958, 20205. Kudose S, Batal I, Santoriello D, Xu K, Barasch J, Peleg Y, et al.: Kidneybiopsy findings in patients with COVID-19. J Am Soc Nephrol 31:1959–1968, 2020See related letter to the editor, “Post-Mortem Diagnostics in COVID-19 AKI,More Often but Timely,” on page 255, and original article “Histopathologicand Ultrastructural Findings in Postmortem Kidney Biopsy Material in 12 Pa-tients with AKI and COVID-19,” in Vol. 31, Iss. 9, 1944–1947.Jordan L. Rosenstock1 and Vanesa Bijol21Divison of Nephrology, Lenox Hill Hospital, Donald and BarbaraZucker School of Medicine at Hofstra/Northwell, Hofstra University,New York, New York2Department of Pathology, Donald and Barbara Zucker School ofMedicine at Hofstra/Northwell, Hofstra University, Hempstead,New YorkJASN 32: 255–256, 2021.doi: https://doi.org/10.1681/ASN.2020101479Complexities of eGFRs in aStudy of Glomerular PhysiologyIn a recent article in JASN, Collard et al.1 used a new methodto indirectly determine glomerular pressures (Pglom) fromrenal artery pressures and flows that were measured in 28patients undergoing angiography. Kidney function was ex-pressed as a patient’s eGFR by the Chronic Kidney DiseaseEpidemiology Collaboration (CKD-EPI) equation.2 Afteranalysis, higher renal perfusion pressure, higher body massindex (BMI), and the presence of diabetes were associatedwith higher Pglom.The use of eGFRs in this study may have introduced cer-tain complexities. An eGFR is a size-indexed GFR, in milli-liters per minute per 1.73 m2. The ratio of GFR to bodysurface area (BSA) is indexed to a standard BSA of1.73 m2.2 Normally, with the same eGFR, larger peoplehave higher BSAs, BMIs, and measured GFRs (in millilitersper minute), and smaller people have the opposite. Anadvantage of screening with eGFRs in this study was to besure that reasonably healthy kidneys were studied, i.e., withfunction appropriate to body size. But when kidney functionwas expressed as eGFR and BMI was used as an independentvariable, higher BMIs selected for higher nonindexed GFRs(in milliliters per minute). Therefore, the more fundamentalassociation might have been between (higher) nonindexedGFR and (higher) Pglom, not (higher) BMI and Pglom. Itmay be relevant that, in the early days of continuous ambu-latory peritoneal dialysis, we found misleading correlationswhen multiple size-related terms were studied in the samepatient. This happened, for example, when both protein cat-abolic rate and dialytic clearance were normalized to bodysize.3 In this study, multiplying the eGFRs by each individual’sBSA/1.73 to “unindex” them might help clarify the results.Published online ahead of print. Publication date available at www.jasn.org.Correspondence: Dr. Robert W. Steiner, University of California San DiegoCenter for Transplantation, 9300 Campus Point Drive #7745, San Diego, CA92037-9745. Email: rsteiner@health.ucsd.eduCopyright © 2021 by the American Society of Nephrology256 JASN JASN 32: 255–258, 2021LETTERS TO THE EDITOR www.jasn.org

ARTS repository - University of Groningen

   University of GroningenPost-Mortem Diagnostics in COVID-19 AKI, More Often but Timely ReplyZijlstra, Jan G.; van Meurs, Matijs; Moser, JillPublished in:Journal of the American Society of NephrologyDOI:10.1681/ASN.2020101479IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Zijlstra, J. G., van Meurs, M., & Moser, J. (2021). Post-Mortem Diagnostics in COVID-19 AKI, More Oftenbut Timely Reply. Journal of the American Society of Nephrology, 32(1), 255-256.https://doi.org/10.1681/ASN.2020101479CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 10-09-2023LETTERS TO THE EDITOR www.jasn.orgPost-Mortem Diagnostics in COVID-19 AKI, More Often but TimelyCoronavirus disease 2019 (COVID-19) is a new and devastat-ing disease with renal involvement that deserves an intenseand collaborative research effort. Golmai et al.1 make use ofclassic autopsy with the modern modification of postmortem,fine-needle kidney biopsy. Autopsy was originally developedto investigate macroscopic, light-microscopic, postmortem,anatomic and histologic changes associated with disease. Stan-dard autopsy is mildly time sensitive, with autolysis develop-ing several hours after death. However, new developments inpathophysiologic diagnostics—protein, RNA, and DNA anal-yses—require faster sample handling and careful samplestorage to prevent postmortem effects. Golmai et al.1 do notdescribe how long after death biopsies were performed, butstate the majority of samples show signs of autolysis. Thisprecludes protein, RNA, and most DNA analyses because wewould be observing mostly postmortem effects. Similar tosepsis, COVID-19 microscopic changes in the kidney are lim-ited, with most studies showing some acute tubular necrosis,which cannot fully explain AKI. A large proportion of renalfailure in patients with COVID-19 and those with sepsis seemsto be attributed to functional defects without major histologicchanges. Therefore, modern protein and nucleic-acid tech-niques might shed some light on the underlying mechanismsdriving renal failure. We have shown that kidney biopsies canbe performed at the bedside within 1 hour after death, and thatgene expression analyses are feasible.2,3 Mortality of patientswith COVID-19 was shown to be higher in patients with AKI.4Yet, the mechanisms driving renal failure in patients withCOVID-19 still remain largely unknown. Therefore, we pleadfor more studies to investigate postmortem renal biopsy spec-imens taken rapidly after death to enable the use of modernmolecular diagnostics, together with classic autopsy, to inves-tigate mechanisms of AKI induced by COVID-19.DISCLOSURESAll authors have nothing to disclose.FUNDINGNone.REFERENCES1. Golmai P, Larsen CP, DeVita MV, Wahl SJ, Weins A, Rennke HG, et al.:Histopathologic and ultrastructural findings in postmortem kidney bi-opsy material in 12 patients with AKI and COVID-19. J Am Soc Nephrol31: 1944–1947, 20202. Aslan A, Jongman RM, Moser J, Stegeman CA, van Goor H, Diepstra A,et al.: The renal angiopoietin/Tie2 system in lethal human sepsis. CritCare 18: 423, 20143. Jou-Valencia D, Koeze J, Popa ER, Aslan A, Zwiers PJ, Molema G, et al.:Heterogenous renal injury biomarker production reveals human sepsis-associated acute kidney injury subtypes.Crit Care Explor 1: e0047, 20194. Pei G, Zhang Z, Peng J, Liu L, Zhang C, Yu C, et al.: Renal involvementand early prognosis in patients with COVID-19 pneumonia. J Am SocNephrol 31: 1157–1165, 2020See related reply, “Authors’ Reply,” on pages 255–256, and original article“Histopathologic and Ultrastructural Findings in Postmortem Kidney BiopsyMaterial in 12 Patients with AKI and COVID-19,” in Vol. 31, Iss. 9, 1944–1947.Jan G. Zijlstra1,2, Matijs van Meurs1,2, andJill Moser 1,21Department of Pathology and Medical Biology, Medical BiologySection, University Medical Center Groningen, University ofGroningen, Groningen, The Netherlands2Department of Critical Care, University Medical CenterGroningen, University of Groningen, Groningen, The NetherlandsJASN 32: 255, 2021.doi: https://doi.org/10.1681/ASN.2020091263Authors’ ReplyZijlstra et al.1 question whether delay to postmortem biopsyand ensuing tissue autolysis could have interfered with ourmolecular diagnostics. They ask how long after death werebiopsies done in our study, and suggest that studies usingmore rapid postmortem biopsy might be more productive.Supplemental Table 1, included in our paper,2 provided thetimes between death and biopsy. Out of 12 cases, 11 werebiopsied within 24 hours postmortem; three were performedPublished online ahead of print. Publication date available at www.jasn.org.Correspondence: Prof. Jan G. Zijlstra, Department of Critical Care, UniversityMedical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB,Groningen, The Netherlands. Email: j.g.zijlstra@umcg.nlCopyright © 2021 by the American Society of NephrologyPublished online ahead of print. Publication date available at www.jasn.org.Correspondence: Dr. Jordan L. Rosenstock, Lenox Hill Hospital, Donald andBarbara Zucker School of Medicine, 130 East 77th St., New York, NY 10075-1850. Email: jrosenstock@northwell.eduCopyright © 2021 by the American Society of NephrologyJASN 32: 255–258, 2021 ISSN : 1046-6673/3201-255 255LETTERSTOTHEEDITORwithin 2.5 hours. The fastest time to biopsy was 1.5 hours. Anumber of the cases had mild or no autolysis, as seen inTable 1. Similarly, Santoriello et al.3 did not find any clearevidence of viral infection of kidney in a postmortem series of42 patients, many of whom had mild or absent autolysis. Weacknowledge there remains the possibility that postmortemautolysis could interfere with the detection of the virus, al-though it must be emphasized that, in both of these afore-mentioned studies, lung specimens from autopsies used ascontrols were clearly positive for the virus. Corroboratingour findings are two series of renal biopsy specimens in livingpatients with coronavirus disease 2019 included in the sameissue of JASN.4,5 In these series (the majority in patients whohad severe AKI), they also found no clear evidence of viralinfection of the kidney, by ultrastructural examination inaddition to immunohistochemical staining for viral spikeand nucleocapsid proteins, and in situ hybridization for se-vere acute respiratory syndrome coronavirus 2 viral RNA.The conclusions of these four reports, two in living andtwo in postmortem kidneys, are consistent: it does not appearlikely that direct viral infection is a primary contributor torenal dysfunction in patients with coronavirus disease 2019.DISCLOSURESJ. Rosenstock is an editorial board member of International Urology andNephrology. V. Bijol reports honoraria from International Society ofNephrology.FUNDINGNone.REFERENCES1. Zijlstra J, van Meurs M, Moser J: Post-mortem diagnostics in COVID-19,more often but timely. J Am Soc Nephrol 32: 255, 20212. Golmai P, Larsen CP, DeVita MV, Wahl SJ, Weins A, Rennke HG, et al.:Histopathologic and ultrastructural findings in postmortem kidney bi-opsy material in 12 patients with AKI and COVID-19. J Am Soc Nephrol31: 1944–1947, 20203. Santoriello D, Khairallah P, Bomback AS, Xu K, Kudose S, Batal I, et al.:Postmortem kidney pathology findings in patients with COVID-19. J AmSoc Nephrol 31: 2158–2167, 20204. Sharma P, Uppal NN, Wanchoo R, Shah HH, Yang Y, Parikh R, et al.;Northwell Nephrology COVID-19 Research Consortium: COVID-19 as-sociated kidney injury: A case series of kidney biopsy findings. J Am SocNephrol 31: 1948–1958, 20205. Kudose S, Batal I, Santoriello D, Xu K, Barasch J, Peleg Y, et al.: Kidneybiopsy findings in patients with COVID-19. J Am Soc Nephrol 31:1959–1968, 2020See related letter to the editor, “Post-Mortem Diagnostics in COVID-19 AKI,More Often but Timely,” on page 255, and original article “Histopathologicand Ultrastructural Findings in Postmortem Kidney Biopsy Material in 12 Pa-tients with AKI and COVID-19,” in Vol. 31, Iss. 9, 1944–1947.Jordan L. Rosenstock1 and Vanesa Bijol21Divison of Nephrology, Lenox Hill Hospital, Donald and BarbaraZucker School of Medicine at Hofstra/Northwell, Hofstra University,New York, New York2Department of Pathology, Donald and Barbara Zucker School ofMedicine at Hofstra/Northwell, Hofstra University, Hempstead,New YorkJASN 32: 255–256, 2021.doi: https://doi.org/10.1681/ASN.2020101479Complexities of eGFRs in aStudy of Glomerular PhysiologyIn a recent article in JASN, Collard et al.1 used a new methodto indirectly determine glomerular pressures (Pglom) fromrenal artery pressures and flows that were measured in 28patients undergoing angiography. Kidney function was ex-pressed as a patient’s eGFR by the Chronic Kidney DiseaseEpidemiology Collaboration (CKD-EPI) equation.2 Afteranalysis, higher renal perfusion pressure, higher body massindex (BMI), and the presence of diabetes were associatedwith higher Pglom.The use of eGFRs in this study may have introduced cer-tain complexities. An eGFR is a size-indexed GFR, in milli-liters per minute per 1.73 m2. The ratio of GFR to bodysurface area (BSA) is indexed to a standard BSA of1.73 m2.2 Normally, with the same eGFR, larger peoplehave higher BSAs, BMIs, and measured GFRs (in millilitersper minute), and smaller people have the opposite. Anadvantage of screening with eGFRs in this study was to besure that reasonably healthy kidneys were studied, i.e., withfunction appropriate to body size. But when kidney functionwas expressed as eGFR and BMI was used as an independentvariable, higher BMIs selected for higher nonindexed GFRs(in milliliters per minute). Therefore, the more fundamentalassociation might have been between (higher) nonindexedGFR and (higher) Pglom, not (higher) BMI and Pglom. Itmay be relevant that, in the early days of continuous ambu-latory peritoneal dialysis, we found misleading correlationswhen multiple size-related terms were studied in the samepatient. This happened, for example, when both protein cat-abolic rate and dialytic clearance were normalized to bodysize.3 In this study, multiplying the eGFRs by each individual’sBSA/1.73 to “unindex” them might help clarify the results.Published online ahead of print. Publication date available at www.jasn.org.Correspondence: Dr. Robert W. Steiner, University of California San DiegoCenter for Transplantation, 9300 Campus Point Drive #7745, San Diego, CA92037-9745. Email: rsteiner@health.ucsd.eduCopyright © 2021 by the American Society of Nephrology256 JASN JASN 32: 255–258, 2021LETTERS TO THE EDITOR www.jasn.org

   University of GroningenPost-Mortem Diagnostics in COVID-19 AKI, More Often but TimelyZijlstra, Jan G.; Meurs, Matijs van; Moser, JillPublished in:Journal of the American Society of NephrologyDOI:10.1681/ASN.2020091263IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2021Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Zijlstra, J. G., Meurs, M. V., & Moser, J. (2021). Post-Mortem Diagnostics in COVID-19 AKI, More Often butTimely. Journal of the American Society of Nephrology, 32(1), 255.https://doi.org/10.1681/ASN.2020091263CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 29-04-2023LETTERS TO THE EDITOR www.jasn.orgPost-Mortem Diagnostics in COVID-19 AKI, More Often but TimelyCoronavirus disease 2019 (COVID-19) is a new and devastat-ing disease with renal involvement that deserves an intenseand collaborative research effort. Golmai et al.1 make use ofclassic autopsy with the modern modification of postmortem,fine-needle kidney biopsy. Autopsy was originally developedto investigate macroscopic, light-microscopic, postmortem,anatomic and histologic changes associated with disease. Stan-dard autopsy is mildly time sensitive, with autolysis develop-ing several hours after death. However, new developments inpathophysiologic diagnostics—protein, RNA, and DNA anal-yses—require faster sample handling and careful samplestorage to prevent postmortem effects. Golmai et al.1 do notdescribe how long after death biopsies were performed, butstate the majority of samples show signs of autolysis. Thisprecludes protein, RNA, and most DNA analyses because wewould be observing mostly postmortem effects. Similar tosepsis, COVID-19 microscopic changes in the kidney are lim-ited, with most studies showing some acute tubular necrosis,which cannot fully explain AKI. A large proportion of renalfailure in patients with COVID-19 and those with sepsis seemsto be attributed to functional defects without major histologicchanges. Therefore, modern protein and nucleic-acid techni-ques might shed some light on the underlying mechanismsdriving renal failure. We have shown that kidney biopsies canbe performed at the bedside within 1 hour after death, and thatgene expression analyses are feasible.2,3 Mortality of patientswith COVID-19 was shown to be higher in patients with AKI.4Yet, the mechanisms driving renal failure in patients withCOVID-19 still remain largely unknown. Therefore, we pleadformore studies to investigate postmortem renal biopsy speci-mens taken rapidly after death to enable the use of modernmolecular diagnostics, together with classic autopsy, to inves-tigate mechanisms of AKI induced by COVID-19.DISCLOSURESAll authors have nothing to disclose.FUNDINGNone.REFERENCES1. Golmai P, Larsen CP, DeVita MV, Wahl SJ, Weins A, Rennke HG, et al.:Histopathologic and ultrastructural findings in postmortem kidney bi-opsy material in 12 patients with AKI and COVID-19. J Am Soc Nephrol31: 1944–1947, 20202. Aslan A, Jongman RM, Moser J, Stegeman CA, van Goor H, Diepstra A,et al.: The renal angiopoietin/Tie2 system in lethal human sepsis. CritCare 18: 423, 20143. Jou-Valencia D, Koeze J, Popa ER, Aslan A, Zwiers PJ, Molema G, et al.:Heterogenous renal injury biomarker production reveals human sepsis-associated acute kidney injury subtypes.Crit Care Explor 1: e0047, 20194. Pei G, Zhang Z, Peng J, Liu L, Zhang C, Yu C, et al.: Renal involvementand early prognosis in patients with COVID-19 pneumonia. J Am SocNephrol 31: 1157–1165, 2020See related Letters to the Editor, “Authors’ Reply,” on pages xxx–xxx.Jan G. Zijlstra1,2, Matijs van Meurs1,2, andJill Moser 1,21Department of Pathology and Medical Biology, Medical BiologySection, University Medical Center Groningen, University ofGroningen, Groningen, The Netherlands2Department of Critical Care, University Medical CenterGroningen, University of Groningen, Groningen, The NetherlandsJASN 32: ccc–ccc, 2021.doi: https://doi.org/10.1681/ASN.2020091263Published online ahead of print. Publication date available at www.jasn.org.Correspondence: Prof. Jan G. Zijlstra, Department of Critical Care, UniversityMedical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB,Groningen, The Netherlands. Email: j.g.zijlstra@umcg.nlCopyright © 2021 by the American Society of NephrologyJASN 32: ccc–ccc, 2021 ISSN : 1046-6673/3201-ccc 1

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