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Rapidly progressive critical COVID-19 with acute kidney injury — ABIM Board MCQ

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HardCOVID-19Rapidly progressive critical COVID-19 with acute kidney injuryABIM Board

A 68-year-old man with obesity and hypertension is hospitalized 10 days after the onset of fever, cough, and dyspnea due to polymerase chain reaction–confirmed COVID-19. Dexamethasone, 6 mg daily, was started on admission 2 days ago. During the past 18 hours, his oxygen requirement has increased from 4 L/min by nasal cannula to high-flow nasal cannula at 50 L/min with an FIO2 of 0.70. Oxygen saturation is 92%, respiratory rate is 30/min, and blood pressure is 118/68 mm Hg. Chest radiography shows progressive bilateral airspace opacities. C-reactive protein is 186 mg/L. Serum creatinine has increased from 1.0 to 4.9 mg/dL, urine output is 200 mL over 12 hours, and estimated glomerular filtration rate is 11 mL/min/1.73 m². The absolute neutrophil count is 5200/mm³, platelet count is 168,000/mm³, and AST and ALT are each less than 3 times the upper limit of normal. Blood cultures remain negative, and there is no clinical evidence of bacterial or fungal coinfection. Which of the following is the most appropriate adjunctive pharmacologic treatment?

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Correct answer: C — Add intravenous tocilizumab, 8 mg/kg once

This patient has rapidly progressive critical COVID-19: despite systemic glucocorticoids, he has progressed to high-flow nasal-cannula support and has marked systemic inflammation. IDSA guidance supports adding either baricitinib or tocilizumab to glucocorticoids in this setting. His severe oliguric acute kidney injury determines the choice. FDA prescribing information states that baricitinib is not recommended in patients with COVID-19 who have acute kidney injury or an eGFR below 15 mL/min/1.73 m². Tocilizumab is therefore the appropriate additional immunomodulator; his neutrophil count, platelet count, aminotransferases, and absence of a concurrent uncontrolled infection do not preclude its use. Remdesivir is most useful earlier and in patients requiring less intensive oxygen support; it does not address the immediate need for additional immunomodulation in a patient worsening on high-flow oxygen. Pulse-dose methylprednisolone has no established advantage over standard-dose dexamethasone for COVID-19 and increases toxicity. Baricitinib 1 mg daily is the renal-adjusted dose for a stable eGFR of 15-29 mL/min/1.73 m², not for this patient's acute kidney injury with an eGFR of 11. Combining baricitinib with tocilizumab is not recommended routinely because evidence supports selecting one additional immunomodulator rather than exposing the patient to dual immunosuppression.

Reference: IDSA Guidelines on the Treatment and Management of Patients with COVID-19 (October 14, 2025) — https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/ OLUMIANT (baricitinib) US Prescribing Information (June 2026) — https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/207924s011lbl.pdf TYENNE (tocilizumab-aazg) US Prescribing Information (May 2026) — https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/761275s022lbl.pdf