Early Ventilator Driving Pressure Linked to Kidney Injury in COVID-19 ARDS Patients

A recent study published in The Journal of Clinical Medicine has identified a significant association between early mechanical ventilator settings and the development of major adverse kidney events (MAKEs) in patients with acute respiratory distress syndrome (ARDS) due to SARS-CoV-2.

Conducted at the National Institute of Respiratory Diseases in Mexico, the prospective cohort study followed 45 critically ill adults who required invasive mechanical ventilation (IMV) within six hours of hospital admission. The researchers found that a higher driving pressure (∆P)—a measure of lung stress calculated as the difference between plateau pressure and PEEP—was independently linked to an increased risk of MAKEs at 30 days.

Higher ∆P May Signal Elevated Renal Risk

Among the 45 patients studied, 71% developed MAKEs and nearly half (49%) developed persistent acute kidney injury (pAKI) within 48 hours. In multivariate analysis, both older age and elevated ∆P were identified as independent risk factors for MAKEs. Specifically, patients with a ∆P greater than 14 cmH₂O had worse outcomes, including higher mortality and prolonged mechanical ventilation.

These findings align with previous research indicating that ∆P may offer a more comprehensive picture of ventilator-induced lung stress compared to tidal volume or PEEP alone. In this study, patients who developed MAKEs had persistently higher ∆P and lower static compliance (Cstat) over the first five days of mechanical ventilation, suggesting a stiffer, less recruitable lung phenotype.

Biomarkers Point to Early Kidney Injury

In addition to ventilatory metrics, the study examined urinary biomarkers to evaluate early kidney stress. Elevated urinary neutrophil gelatinase-associated lipocalin (uNGal) levels (>40 ng/mL), measured shortly after ventilator initiation, were significantly associated with the development of pAKI. This supports the potential utility of uNGal in early identification of renal injury, particularly when traditional markers such as serum creatinine may lag behind clinical changes.

Although urinary IL-6 was higher in patients who developed MAKEs, other biomarkers such as TIMP-2 and IGFBP7 did not show a statistically significant difference between groups.

No Significant Link Between PEEP and MAKEs

Interestingly, the study did not find an association between PEEP levels and kidney outcomes, contrasting with some earlier reports in COVID-19 patients. The authors suggest this could be due to the low-recruitability lung phenotype observed in their cohort, where higher PEEP may not provide physiological benefit and could increase the risk of overdistension and hemodynamic compromise.

Emphasis on Early Monitoring and Tailored Ventilation

The researchers highlight the value of individualized ventilatory strategies that consider lung mechanics early in the course of mechanical ventilation. Given the observed association between ∆P and renal complications, monitoring this parameter may offer insight into systemic stress responses and help guide treatment to reduce multiorgan risk.

While the findings are compelling, the authors caution that the study’s small sample size and focus on severely ill patients admitted during a peak pandemic period may limit generalizability. Larger, multicenter studies are needed to confirm these associations and evaluate whether ∆P-guided ventilation can mitigate kidney injury in ARDS patients.

Source

Casas-Aparicio, Gustavo, Adrián E. Caballero-Islas, Antonio León-Ortiz, et al. "Early Driving Pressure Is Associated with Major Adverse Kidney Events at 30 Days in ARDS Patients with SARS-CoV-2." Journal of Clinical Medicine 14, no. 8 (2025): 2783. https://doi.org/10.3390/jcm14082783.