Nirmatrelvir-ritonavir for COVID-19 works in patients with advanced kidney dysfunction

Treatment with nirmatrelvir-ritonavir yields reductions in the risk of acute respiratory failure and pneumonia in COVID-19 patients with advanced kidney function, according to a retrospective matched cohort study.

The study included 4,020 COVID-19 patients with eGFR of 15–30 mL/min/1.73m² cared for in Veterans Health Administration facilities. Logistic and conditional logistic regression models were used to examine the incidence of cardiac events, stroke, acute kidney injury, liver injury, hypertension, and infection-related death, respiratory failure, pneumonia, severe infection, and hospitalization within 30–60 days of COVID-19 diagnosis.

A total of 117 (mean age 75.6 years, mean eGFR 24.9 mL/min/1.73m²) were treated with nirmatrelvir-ritonavir. Of these patients, 33 received the full dose (300 mg nirmatrelvir/100 mg ritonavir twice daily for 5 days), while 84 received the dose recommended for patients with eGFR 30-60 ml/min/1.73m² (150 mg nirmatrelvir-100 mg ritonavir twice daily for 5 days).

Compared with treatment with neither nirmatrelvir-ritonavir nor molnupiravir, treatment with nirmatrelvir-ritonavir showed no effect on the different risks of cardiovascular events (heart failure: risk ratio [RR], 1.0, 95 percent confidence interval [CI], 0.7–1.2), liver injury (RR, 1.2, 95 percent CI, 0.7–1.7), or acute kidney injury (RR, 1.0, 95 percent CI, 0.8–1.2). However, nirmatrelvir-ritonavir treatment was associated with a reduced risk of acute respiratory failure (RR, 0.5, 95 percent [CI], 0.2–0.7) and pneumonia (RR, 0.6, 95 percent CI, 0.3–0.8).

When compared with treatment with molnupiravir, nirmatrelvir-ritonavir likewise showed a null effect on the different risks of cardiovascular events, acute respiratory failure, or pneumonia. However, nirmatrelvir-ritonavir was associated with a higher risk of acute kidney injury.

Sensitivity analyses limited to patients with eGFR 15–35 ml/min/1.73m² yielded similar findings.