COVID-19-associated hemodialysis: Difference between revisions

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__NOTOC__
__NOTOC__
{{COVID-19}}
{{SI}}
{{Main|COVID-19}}
{{Main|COVID-19}}


{{CMG}}; {{AE}} {{MSJ}}
{{CMG}}; {{AE}} {{MSJ}}
==Overview==
==Overview==
The [[COVID-19|Covid-19]] infection has high mortality among dialysis [[patients]] as compared to normal individuals. One of the factors for increased mortality for [[dialysis]] patients as compared to the general population due to [[COVID-19|COVID-19 infection]] is the increased age of the [[Patient|patients]]. Adequate measures should be taken to prevent the spread of [[COVID-19|COVID-19 infection]] in [[dialysis]] patients.
[[COVID-19]] infection has a higher mortality among [[dialysis]] [[patients]] as compared to normal individuals. The factors for increased mortality for [[dialysis]] patients as compared to the general population due to [[COVID-19|COVID-19 infection]] are low [[immunity]], co-existence of multiple co-morbid conditions, and the increased age of the [[Patient|patients]]. The lab and imaging findings in [[COVID-19]] infection in [[dialysis]] [[Patient|patients]] are similar to general population. Adequate measures should be taken to prevent the spread of [[COVID-19|COVID-19 infection]] in [[dialysis]] [[patient|patients]].
 
 
==Historical perspective==
==Historical perspective==
There is limited information about the historical perspective of [[COVID-19|Covid-19]] associated [[hemodialysis]].
The first reported case of [[COVID-19]] infection of a [[hemodialysis]] [[patient]] in Japan, was a 69 years old [[Diabetes|diabetic]] man on maintenance [[hemodialysis]] for three years due to end-stage kidney disease. He presented with cough, fever, and breathlessness. His CT-scan chest showed bilateral multiple pulmonary consolidation and [[pleural effusion]]. He successfully recovered and was discharged on the 19th day of hospitalization.<ref name="pmid32557209">{{cite journal| author=Kuroki Y, Hiyama K, Minami J, Takeuchi M, Shojima M, Matsueda S | display-authors=etal| title=The first case of COVID-19 pneumonia in a hemodialysis patient in Japan. | journal=CEN Case Rep | year= 2020 | volume=  | issue=  | pages=  | pmid=32557209 | doi=10.1007/s13730-020-00495-5 | pmc=7300373 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32557209  }} </ref>
 
==Classification==
==Classification==
There is no established system for the classification of [[hemodialysis]] in [[COVID-19|Covid-19]].
There is no established system for the classification of [[hemodialysis]] in [[COVID-19]].
==Pathophysiology==
==Pathophysiology==
*The pathogenesis of patients on [[hemodialysis]] is characterized by low immunity, low-intensity cytokine storm, and inhibition of coagulation cascade.
*It is understood that [[COVID-19|COVID-19 infection]] in [[hemodialysis]] [[patients]] is mediated by low [[immunity]], low-intensity [[cytokine]] storm, and inhibition of [[coagulation]] cascade.<ref name="pmid32434211">{{cite journal| author=Zhang X, Tan Y, Ling Y, Lu G, Liu F, Yi Z | display-authors=etal| title=Viral and host factors related to the clinical outcome of COVID-19. | journal=Nature | year= 2020 | volume=  | issue=  | pages=  | pmid=32434211 | doi=10.1038/s41586-020-2355-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32434211  }} </ref><ref name="pmid32073213">{{cite journal| author=Tang N, Li D, Wang X, Sun Z| title=Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. | journal=J Thromb Haemost | year= 2020 | volume= 18 | issue= 4 | pages= 844-847 | pmid=32073213 | doi=10.1111/jth.14768 | pmc=7166509 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32073213  }} </ref>
*[[Patient|Patients]] with [[chronic kidney disease]] or [[Chronic renal failure|end-stage renal disease]] have low [[Immunity (medical)|immunity]]. The patients on [[dialysis]] have a mild clinical course of [[COVID-19]] infection.The [[Patient|patients]] on maintenance hemodialysis rarely present with a full-blown clinical picture of [[pneumonia]].<ref name="pmid32434211">{{cite journal| author=Zhang X, Tan Y, Ling Y, Lu G, Liu F, Yi Z | display-authors=etal| title=Viral and host factors related to the clinical outcome of COVID-19. | journal=Nature | year= 2020 | volume=  | issue=  | pages=  | pmid=32434211 | doi=10.1038/s41586-020-2355-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32434211  }} </ref> This can be attributed to low-intensity [[cytokine storm]] in response to viral antigens due to low [[Immunity (medical)|immunity]].
*[[Patient|Patients]] with [[chronic kidney disease]] or [[Chronic renal failure|end-stage renal disease]] have low [[Immunity (medical)|immunity]]. Patients on [[dialysis]] have a mild clinical course of [[COVID-19]] infection.[[Patient|Patients]] on maintenance hemodialysis rarely present with a full-blown clinical picture of [[pneumonia]].This can be attributed to low-intensity [[cytokine storm]] in response to viral antigens due to low [[Immunity (medical)|immunity]].<ref name="pmid32434211">{{cite journal| author=Zhang X, Tan Y, Ling Y, Lu G, Liu F, Yi Z | display-authors=etal| title=Viral and host factors related to the clinical outcome of COVID-19. | journal=Nature | year= 2020 | volume=  | issue=  | pages=  | pmid=32434211 | doi=10.1038/s41586-020-2355-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32434211  }} </ref>
*Hypercoagulation plays an important role in aggravating the disease. Hypercoagulation initiates the coagulation cascade resulting in [[disseminated intravascular coagulation]] (DIC). DIC results in organ dysfunction and high mortality in [[COVID-19|COVID 19 infection]]. [[Anticoagulant|Anticoagulants]] administered during hemodialysis inhibit coagulation cascade preventing hypercoagulation and [[Disseminated intravascular coagulation|DIC]].<ref name="pmid32073213">{{cite journal| author=Tang N, Li D, Wang X, Sun Z| title=Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. | journal=J Thromb Haemost | year= 2020 | volume= 18 | issue= 4 | pages= 844-847 | pmid=32073213 | doi=10.1111/jth.14768 | pmc=7166509 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32073213  }} </ref>
*Hypercoagulation plays an important role in aggravating the disease. Hypercoagulation initiates the coagulation cascade resulting in [[disseminated intravascular coagulation]] (DIC). DIC results in organ dysfunction and high mortality in [[COVID-19|COVID-19 infection]]. [[Anticoagulant|Anticoagulants]] administered during hemodialysis inhibit coagulation cascade preventing hypercoagulation and [[Disseminated intravascular coagulation|DIC]].<ref name="pmid32073213">{{cite journal| author=Tang N, Li D, Wang X, Sun Z| title=Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. | journal=J Thromb Haemost | year= 2020 | volume= 18 | issue= 4 | pages= 844-847 | pmid=32073213 | doi=10.1111/jth.14768 | pmc=7166509 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32073213  }} </ref>
*In a study done at a hemodialysis center at Renmin Hospital in Wuhan, 37 out of a total of 230 [[patient]]<nowiki/>s were infected with [[COVID-19|covid-19]] infections in one month. Four members of the health care staff were also infected. The [[Peripheral blood smear|peripheral blood]] examination of the covid 19 infected hemodialysis patients had reduced levels of killer T cells, [[T helper cell|helper T cells]], [[Natural killer cell|Natural killer cells]], and lower level of [[Cytokines|inflammatory cytokines]] as compared to non-dialysis infected [[Patient|patients]].<ref name="pmid02.24.20027201">{{cite journal| author=Bose KS, Sarma RH| title=Delineation of the intimate details of the backbone conformation of pyridine nucleotide coenzymes in aqueous solution. | journal=Biochem Biophys Res Commun | year= 1975 | volume= 66 | issue= 4 | pages= 1173-9 | pmid=02.24.20027201 | doi=10.1016/0006-291x(75)90482-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2  }} </ref>
*In a study done at a hemodialysis center at Renmin Hospital in Wuhan, 37 out of a total of 230 [[patient]]<nowiki/>[[patient|s]] were infected with [[COVID-19]] infections in one month. Four members of the health care staff were also infected. The [[Peripheral blood smear|peripheral blood]] examination of the COVID-19 infected hemodialysis patients had reduced levels of killer T cells, [[T helper cell|helper T cells]], [[Natural killer cell|Natural killer cells]], and lower level of [[Cytokines|inflammatory cytokines]] as compared to non-dialysis infected [[Patient|patients]].<ref name="pmid02.24.20027201">{{cite journal| author=Bose KS, Sarma RH| title=Delineation of the intimate details of the backbone conformation of pyridine nucleotide coenzymes in aqueous solution. | journal=Biochem Biophys Res Commun | year= 1975 | volume= 66 | issue= 4 | pages= 1173-9 | pmid=02.24.20027201 | doi=10.1016/0006-291x(75)90482-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2  }} </ref>
 
==Causes==
*[[COVID-19]] in [[hemodialysis]] [[patient]]<nowiki/>[[patient|s]] is caused by Severe acute respiratory syndrome [[coronavirus]] 2 (SARS-CoV-2).<ref name="pmid31978945">{{cite journal| author=Zhu N, Zhang D, Wang W, Li X, Yang B, Song J | display-authors=etal| title=A Novel Coronavirus from Patients with Pneumonia in China, 2019. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 8 | pages= 727-733 | pmid=31978945 | doi=10.1056/NEJMoa2001017 | pmc=7092803 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31978945  }} </ref>
*SARS-CoV-2 is a novel beta [[coronavirus]] that shares genetic sequence homology with SARS-CoV and SARS-like coronavirus (SL-CoV).<ref name="pmid32065055">{{cite journal| author=Tian X, Li C, Huang A, Xia S, Lu S, Shi Z | display-authors=etal| title=Potent binding of 2019 novel coronavirus spike protein by a SARS coronavirus-specific human monoclonal antibody. | journal=Emerg Microbes Infect | year= 2020 | volume= 9 | issue= 1 | pages= 382-385 | pmid=32065055 | doi=10.1080/22221751.2020.1729069 | pmc=7048180 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32065055  }} </ref>
*SARS-CoV-2 can invade the cells in the body by binding with [[Angiotensin-converting enzyme]] 2 receptors. A large percentage of [[hemodialysis]] [[patient]]<nowiki/>[[patient|s]] have chronic or end-stage renal failure and there is an increased expression of ACE-2 receptors on proximal tubular cells due to uremia. This can result in increased susceptibility of [[COVID-19]] infection in [[hemodialysis]] patients.<ref name="pmid32170560">{{cite journal| author=Zou X, Chen K, Zou J, Han P, Hao J, Han Z| title=Single-cell RNA-seq data analysis on the receptor ACE2 expression reveals the potential risk of different human organs vulnerable to 2019-nCoV infection. | journal=Front Med | year= 2020 | volume= 14 | issue= 2 | pages= 185-192 | pmid=32170560 | doi=10.1007/s11684-020-0754-0 | pmc=7088738 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32170560  }} </ref>
*To view causes of COVID-19, [[COVID-19 causes|click here]].
 
==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Prevalence===
===Prevalence===
*<nowiki/>A case series of 5,700 patients with [[COVID-19|covid-19]] infection was done in 12 hospitals under the Northwell Health system in New York. It showed a prevalence of 5% [[Chronic renal failure|chronic]] <nowiki/>[[Chronic renal failure|kidney disease]] and 3.5% end-stage renal disease in hospitalized <nowiki/>covid-19 patients.<ref name="pmid32320003">{{cite journal| author=Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW | display-authors=etal| title=Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=32320003 | doi=10.1001/jama.2020.6775 | pmc=7177629 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32320003  }} </ref>
*The prevalence of [[Chronic renal failure|chronic]] <nowiki/>[[Chronic renal failure|kidney disease]] ranges from 4,702 to 16,166 per 100,000 individuals in hospitalized [[COVID-19]] patients.<ref name="pmid32320003">{{cite journal| author=Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW | display-authors=etal| title=Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=32320003 | doi=10.1001/jama.2020.6775 | pmc=7177629 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32320003 }} </ref><ref name="pmid32444460">{{cite journal| author=Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L | display-authors=etal| title=Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. | journal=BMJ | year= 2020 | volume= 369 | issue=  | pages= m1985 | pmid=32444460 | doi=10.1136/bmj.m1985 | pmc=7243036 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32444460 }} </ref>
*A study was done in 208 acute care hospitals in the UK. The total patients studied were 20,133. It showed [[Chronic renal failure|chronic kidney disease]] was one of the most common co-morbidity in hospitalized [[COVID-19|covid-19]] patients present in 16% of patients.<ref name="pmid32444460">{{cite journal| author=Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L | display-authors=etal| title=Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. | journal=BMJ | year= 2020 | volume= 369 | issue=  | pages= m1985 | pmid=32444460 | doi=10.1136/bmj.m1985 | pmc=7243036 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32444460  }} </ref>
*The prevalence of [[COVID-19]] infection in [[Chronic renal failure|chronic kidney disease]] and end-stage renal disease patients varies at different geographical areas. The prevalence of [[Chronic renal failure|chronic]] [[Chronic renal failure|kidney disease]] is approximately 16,166 per 100,000 individuals as per a study done in 208 acute care hospitals in the UK. It showed [[Chronic renal failure|chronic kidney disease]] was one of the most common co-morbidities in hospitalized [[COVID-19]] patients.<ref name="pmid32444460">{{cite journal| author=Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L | display-authors=etal| title=Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. | journal=BMJ | year= 2020 | volume= 369 | issue=  | pages= m1985 | pmid=32444460 | doi=10.1136/bmj.m1985 | pmc=7243036 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32444460  }} </ref>
===Mortality Rate===
*The prevalence of [[Chronic renal failure|chronic]]<nowiki/> [[Chronic renal failure|kidney disease]] is approximately 4,702 per 100,000 individuals and end-stage renal disease is approximately 3,263 per 100,000 individuals in hospitalized [[COVID-19]] patient<nowiki/>s according to a case series of 5,700 patie<nowiki/>nts with [[COVID-19]] infection performed in 12 hospitals under the Northwell Health system in New York.<ref name="pmid32320003">{{cite journal| author=Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW | display-authors=etal| title=Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. | journal=JAMA | year= 2020 | volume= | issue= | pages= | pmid=32320003 | doi=10.1001/jama.2020.6775 | pmc=7177629 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32320003  }} </ref>
*Clinical research was done by Alberici et al. at four outpatient [[dialysis]] facilities in Italy showed high overall mortality of 29% in [[dialysis]] [[patients]].<ref name="pmid32437768">{{cite journal| author=Alberici F, Delbarba E, Manenti C, Econimo L, Valerio F, Pola A | display-authors=etal| title=A report from the Brescia Renal COVID Task Force on the clinical characteristics and short-term outcome of hemodialysis patients with SARS-CoV-2 infection. | journal=Kidney Int | year= 2020 | volume= 98 | issue= 1 | pages= 20-26 | pmid=32437768 | doi=10.1016/j.kint.2020.04.030 | pmc=7206428 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32437768 }} </ref>
===Gender===
[[COVID-19]] infection affects men and women equally.<ref name="pmid32444460">{{cite journal| author=Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L | display-authors=etal| title=Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. | journal=BMJ | year= 2020 | volume= 369 | issue=  | pages= m1985 | pmid=32444460 | doi=10.1136/bmj.m1985 | pmc=7243036 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32444460 }} </ref>
===Age===
===Age===
A research study done in Japan showed a higher mortality 16.2% (16/99) in [[dialysis]] [[Patient|patients]] as compared to the general population 5.3% (874/16,532). The average age of [[Patient|pati]]<nowiki/>[[Patient|ents]] on [[dialysis]] was 70 to 90 years while of the general population was 20 to 60 years.<ref name="pmid32506762">{{cite journal| author=Kikuchi K, Nangaku M, Ryuzaki M, Yamakawa T, Hanafusa N, Sakai K | display-authors=etal| title=COVID-19 in dialysis patients in Japan: Current status and guidance on preventive measures. | journal=Ther Apher Dial | year= 2020 | volume=  | issue=  | pages=  | pmid=32506762 | doi=10.1111/1744-9987.13531 | pmc=7301044 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32506762  }} </ref>
*The [[COVID-19]] infection <nowiki/>among [[dialysis]] patients is more commonly observed among patients aged 70 to 90 years old. <ref name="pmid32506762">{{cite journal| author=Kikuchi K, Nangaku M, Ryuzaki M, Yamakawa T, Hanafusa N, Sakai K | display-authors=etal| title=COVID-19 in dialysis patients in Japan: Current status and guidance on preventive measures. | journal=Ther Apher Dial | year= 2020 | volume=  | issue=  | pages=  | pmid=32506762 | doi=10.1111/1744-9987.13531 | pmc=7301044 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32506762  }} </ref>
==Risk Factors==
==Risk Factors==
Patients on maintenance [[hemodialysis]] and [[Chronic renal failure|end-stage kidney disease]] are at an increased risk of contracting the [[COVID-19|covid-19]] infection due to multiple risk factors. These include:<ref name="pmid32109013">{{cite journal| author=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX | display-authors=etal| title=Clinical Characteristics of Coronavirus Disease 2019 in China. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 18 | pages= 1708-1720 | pmid=32109013 | doi=10.1056/NEJMoa2002032 | pmc=7092819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32109013  }} </ref>
Common risk factors in the development of [[COVID-19]] in patients on maintenance [[hemodialysis]] include:<ref name="pmid32109013">{{cite journal| author=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX | display-authors=etal| title=Clinical Characteristics of Coronavirus Disease 2019 in China. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 18 | pages= 1708-1720 | pmid=32109013 | doi=10.1056/NEJMoa2002032 | pmc=7092819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32109013  }} </ref>
*low [[Immunity (medical)|immunity]]
*low [[Immunity (medical)|immunity]]
*[[hypertension]]
*[[hypertension]]
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*pulmonary diseases
*pulmonary diseases
*[[cardiovascular diseases]]
*[[cardiovascular diseases]]
==Screening==
*According to the CDC, screening for [[COVID-19]] by triage protocol is recommended before [[dialysis]] among patients on maintenance [[hemodialysis]].<ref name="pmid32249840">{{cite journal| author=Ikizler TA, Kliger AS| title=Minimizing the risk of COVID-19 among patients on dialysis. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 311-313 | pmid=32249840 | doi=10.1038/s41581-020-0280-y | pmc=7132217 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32249840  }} </ref>
*The suggested approach is to call patients and inquire about [[COVID-19]] symptoms. <ref name="pmid32249840">{{cite journal| author=Ikizler TA, Kliger AS| title=Minimizing the risk of COVID-19 among patients on dialysis. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 311-313 | pmid=32249840 | doi=10.1038/s41581-020-0280-y | pmc=7132217 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32249840  }} </ref> Body temperature and clinical symptoms of COVID-19 should be assessed when patient arrives at the dialysis facility.<ref name="pmid32365278">{{cite journal| author=Esposito P, Russo R, Conti N, Falqui V, Massarino F, Moriero E | display-authors=etal| title=Management of COVID-19 in hemodialysis patients: The Genoa experience. | journal=Hemodial Int | year= 2020 | volume=  | issue=  | pages=  | pmid=32365278 | doi=10.1111/hdi.12837 | pmc=7267634 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32365278  }} </ref>
*Patients reporting illness or [[COVID-19]] symptoms should be placed in the screening area. Hand sanitizers and face masks should be provided to patients.<ref name="pmid32249840">{{cite journal| author=Ikizler TA, Kliger AS| title=Minimizing the risk of COVID-19 among patients on dialysis. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 311-313 | pmid=32249840 | doi=10.1038/s41581-020-0280-y | pmc=7132217 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32249840  }} </ref>
*Symptomatic patients should be taken to testing clinics, hospitals or tested in dialysis facility as per the triage protocol instituted in [[dialysis]] facilities.<nowiki/><ref name="pmid32249840">{{cite journal| author=Ikizler TA, Kliger AS| title=Minimizing the risk of COVID-19 among patients on dialysis. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 311-313 | pmid=32249840 | doi=10.1038/s41581-020-0280-y | pmc=7132217 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32249840  }} </ref>
*Patients with suspected COVID-19 illness are preferred to have dialysis in hospitals as compared to dialysis facilities. The dialysis facilities can accommodate patients with [[COVID-19]] illness if it can comply with CDC guidelines.<ref name="pmid32217082">{{cite journal| author=Ikizler TA| title=COVID-19 and Dialysis Units: What Do We Know Now and What Should We Do? | journal=Am J Kidney Dis | year= 2020 | volume= 76 | issue= 1 | pages= 1-3 | pmid=32217082 | doi=10.1053/j.ajkd.2020.03.008 | pmc=7146661 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32217082  }} </ref>
==Natural History, Complications and Prognosis==
*Common complications of [[COVID-19]] in [[hemodialysis]] patients include [[shock]], [[acute respiratory distress syndrome]], acute cardiac injury, and [[Cardiac arrhythmia|arrhythmia]].<ref name="pmid32444393">{{cite journal| author=Wu J, Li J, Zhu G, Zhang Y, Bi Z, Yu Y | display-authors=etal| title=Clinical Features of Maintenance Hemodialysis Patients with 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. | journal=Clin J Am Soc Nephrol | year= 2020 | volume=  | issue=  | pages=  | pmid=32444393 | doi=10.2215/CJN.04160320 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32444393  }} </ref>
*The prognosis is unclear and the mortality rate is variable ranging from 16% to 29% in [[COVID-19]] infected hemodialysis patients.<ref name="pmid32437768">{{cite journal| author=Alberici F, Delbarba E, Manenti C, Econimo L, Valerio F, Pola A | display-authors=etal| title=A report from the Brescia Renal COVID Task Force on the clinical characteristics and short-term outcome of hemodialysis patients with SARS-CoV-2 infection. | journal=Kidney Int | year= 2020 | volume= 98 | issue= 1 | pages= 20-26 | pmid=32437768 | doi=10.1016/j.kint.2020.04.030 | pmc=7206428 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32437768  }} </ref><ref name="pmid32506762">{{cite journal| author=Kikuchi K, Nangaku M, Ryuzaki M, Yamakawa T, Hanafusa N, Sakai K | display-authors=etal| title=COVID-19 in dialysis patients in Japan: Current status and guidance on preventive measures. | journal=Ther Apher Dial | year= 2020 | volume=  | issue=  | pages=  | pmid=32506762 | doi=10.1111/1744-9987.13531 | pmc=7301044 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32506762  }} </ref>
*The prognosis is generally better in [[hemodialysis]] patients treated as outpatient compared to hospitalized patients.
*Clinical research done by Alberici et al. at four outpatient [[dialysis]] facilities in Italy showed high overall mortality of 29% (27/94) in [[dialysis]] [[patients]].<ref name="pmid32437768">{{cite journal| author=Alberici F, Delbarba E, Manenti C, Econimo L, Valerio F, Pola A | display-authors=etal| title=A report from the Brescia Renal COVID Task Force on the clinical characteristics and short-term outcome of hemodialysis patients with SARS-CoV-2 infection. | journal=Kidney Int | year= 2020 | volume= 98 | issue= 1 | pages= 20-26 | pmid=32437768 | doi=10.1016/j.kint.2020.04.030 | pmc=7206428 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32437768  }} </ref>
*A research study done in Japan showed a higher mortality 16.2% (16/99) in [[dialysis]] [[Patient|patients]] as compared to the general population 5.3% (874/16,532).<ref name="pmid32506762">{{cite journal| author=Kikuchi K, Nangaku M, Ryuzaki M, Yamakawa T, Hanafusa N, Sakai K | display-authors=etal| title=COVID-19 in dialysis patients in Japan: Current status and guidance on preventive measures. | journal=Ther Apher Dial | year= 2020 | volume=  | issue=  | pages=  | pmid=32506762 | doi=10.1111/1744-9987.13531 | pmc=7301044 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32506762  }} </ref>
==Diagnosis==
===Diagnosis of Choice===
*The diagnostic test of choice in [[COVID-19]] in [[hemodialysis]] p<nowiki/>atients is positive nucleic acid amplification test by reverse transcriptase-[[polymerase chain reaction]] on respiratory samples.<ref name="pmid32101510">{{cite journal| author=Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W | display-authors=etal| title=Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. | journal=Radiology | year= 2020 | volume=  | issue=  | pages= 200642 | pmid=32101510 | doi=10.1148/radiol.2020200642 | pmc=7233399 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32101510  }} </ref>
*[[Hemodialysis]] [[patient]]<nowiki/>s present with similar chest CT and [[chest X-ray]] findings as the general population.<ref name="pmid32582309">{{cite journal| author=Durrani M, Haq IU, Kalsoom U, Yousaf A| title=Chest X-rays findings in COVID 19 patients at a University Teaching Hospital - A descriptive study. | journal=Pak J Med Sci | year= 2020 | volume= 36 | issue= COVID19-S4 | pages= S22-S26 | pmid=32582309 | doi=10.12669/pjms.36.COVID19-S4.2778 | pmc=7306947 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32582309  }} </ref><ref name="pmid32101510">{{cite journal| author=Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W | display-authors=etal| title=Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. | journal=Radiology | year= 2020 | volume=  | issue=  | pages= 200642 | pmid=32101510 | doi=10.1148/radiol.2020200642 | pmc=7233399 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32101510  }} </ref><ref name="pmid32367319">{{cite journal| author=Belfiore MP, Urraro F, Grassi R, Giacobbe G, Patelli G, Cappabianca S | display-authors=etal| title=Artificial intelligence to codify lung CT in Covid-19 patients. | journal=Radiol Med | year= 2020 | volume= 125 | issue= 5 | pages= 500-504 | pmid=32367319 | doi=10.1007/s11547-020-01195-x | pmc=7197034 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32367319  }} </ref>
*Patients have radiological findings consistent with [[pneumonia]] including peripheral ground-glass consolidation at both [[Lung|lungs]].<ref name="pmid32101510">{{cite journal| author=Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W | display-authors=etal| title=Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. | journal=Radiology | year= 2020 | volume=  | issue=  | pages= 200642 | pmid=32101510 | doi=10.1148/radiol.2020200642 | pmc=7233399 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32101510  }} </ref><ref name="pmid32367319">{{cite journal| author=Belfiore MP, Urraro F, Grassi R, Giacobbe G, Patelli G, Cappabianca S | display-authors=etal| title=Artificial intelligence to codify lung CT in Covid-19 patients. | journal=Radiol Med | year= 2020 | volume= 125 | issue= 5 | pages= 500-504 | pmid=32367319 | doi=10.1007/s11547-020-01195-x | pmc=7197034 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32367319  }} </ref>
===History & Symptoms===
*Common symptoms of covid-19 in [[hemodialysis]] patient<nowiki/>s include:<ref name="pmid32437770">{{cite journal| author=Goicoechea M, Sánchez Cámara LA, Macías N, Muñoz de Morales A, Rojas ÁG, Bascuñana A | display-authors=etal| title=COVID-19: clinical course and outcomes of 36 hemodialysis patients in Spain. | journal=Kidney Int | year= 2020 | volume= 98 | issue= 1 | pages= 27-34 | pmid=32437770 | doi=10.1016/j.kint.2020.04.031 | pmc=7211728 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32437770  }} </ref><ref name="pmid32240718">{{cite journal| author=Wang R, Liao C, He H, Hu C, Wei Z, Hong Z | display-authors=etal| title=COVID-19 in Hemodialysis Patients: A Report of 5 Cases. | journal=Am J Kidney Dis | year= 2020 | volume= 76 | issue= 1 | pages= 141-143 | pmid=32240718 | doi=10.1053/j.ajkd.2020.03.009 | pmc=7118604 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32240718  }} </ref>
**[[Fever]]
**[[Cough]]
**[[Dyspnea|Breathlessness]]
**[[Fatigue]]
**[[Hypoxia (medical)|Hypoxia]]: Low oxygen saturation at the time of presentation was associated with worse prognosis and higher mortality.
**[[Nausea and vomiting|Nausea]]
**[[Diarrhea]]
**[[Abdominal pain]]
*[[Hemodialysis]] patients ha<nowiki/>ve a milder clinical course of symptoms.<ref name="pmid32437770">{{cite journal| author=Goicoechea M, Sánchez Cámara LA, Macías N, Muñoz de Morales A, Rojas ÁG, Bascuñana A | display-authors=etal| title=COVID-19: clinical course and outcomes of 36 hemodialysis patients in Spain. | journal=Kidney Int | year= 2020 | volume= 98 | issue= 1 | pages= 27-34 | pmid=32437770 | doi=10.1016/j.kint.2020.04.031 | pmc=7211728 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32437770  }} </ref> The classic triad of [[fever]], [[cough]] and [[dyspnea]] may be absent in majority of [[hemodialysis]] patients. <ref name="pmid32031570">{{cite journal| author=Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J | display-authors=etal| title=Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=32031570 | doi=10.1001/jama.2020.1585 | pmc=7042881 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32031570  }} </ref>
*[[Hemodialysis]] [[Patient|patients]] have an increased prevalence of co-existing morbid diseases. These include [[diabetes|diabetes]], [[hypertension|hypertension]], lung and [[heart disease|cardiac disease]].<ref name="pmid32109013">{{cite journal| author=Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX | display-authors=etal| title=Clinical Characteristics of Coronavirus Disease 2019 in China. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 18 | pages= 1708-1720 | pmid=32109013 | doi=10.1056/NEJMoa2002032 | pmc=7092819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32109013  }} </ref>
===Laboratory Findings===
Laboratory findings consistent with the diagnosis of [[COVID-19]] in [[hemodialysis]] patients include:<ref name="pmid32437770">{{cite journal| author=Goicoechea M, Sánchez Cámara LA, Macías N, Muñoz de Morales A, Rojas ÁG, Bascuñana A | display-authors=etal| title=COVID-19: clinical course and outcomes of 36 hemodialysis patients in Spain. | journal=Kidney Int | year= 2020 | volume= 98 | issue= 1 | pages= 27-34 | pmid=32437770 | doi=10.1016/j.kint.2020.04.031 | pmc=7211728 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32437770  }} </ref> <ref name="pmid32391234">{{cite journal| author=Alalwan AA, Taher A, Alaradi AH| title=A Hemodialysis Patient with Severe COVID-19 Pneumonia. | journal=Cureus | year= 2020 | volume= 12 | issue= 5 | pages= e7995 | pmid=32391234 | doi=10.7759/cureus.7995 | pmc=7205364 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32391234  }} </ref>
*[[Lymphocytopenia|Lymphopenia]]
**The [[lymphocyte]] count continues to decrease during the early course of illness. In a study done on [[hemodialysis]] patients with [[COVID-19|covid-19]] infection by Goicoechea et al., the [[lymphocyte]] count was lowest 7 days after the onset of symptoms in patients who died during the course of illness.<ref name="pmid32437770">{{cite journal| author=Goicoechea M, Sánchez Cámara LA, Macías N, Muñoz de Morales A, Rojas ÁG, Bascuñana A | display-authors=etal| title=COVID-19: clinical course and outcomes of 36 hemodialysis patients in Spain. | journal=Kidney Int | year= 2020 | volume= 98 | issue= 1 | pages= 27-34 | pmid=32437770 | doi=10.1016/j.kint.2020.04.031 | pmc=7211728 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32437770  }} </ref>
*[[Anemia]]
*Elevated [[Ferritin]] level
*Elevated [[D-dimer|D-dimers]] level
*Elevated [[Erythrocyte sedimentation rate|ESR]] level
*Elevated [[Lactate dehydrogenase]] level
*Elevated [[C-reactive protein|CRP]]
**Elevated levels of [[C-reactive protein|CRP]] and [[Lactate dehydrogenase|LDH]] are associated with severe disease and increase mortality in [[hemodialysis]] [[patient]]<nowiki/>s.<ref name="pmid32437770">{{cite journal| author=Goicoechea M, Sánchez Cámara LA, Macías N, Muñoz de Morales A, Rojas ÁG, Bascuñana A | display-authors=etal| title=COVID-19: clinical course and outcomes of 36 hemodialysis patients in Spain. | journal=Kidney Int | year= 2020 | volume= 98 | issue= 1 | pages= 27-34 | pmid=32437770 | doi=10.1016/j.kint.2020.04.031 | pmc=7211728 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32437770  }} </ref>
====Electrocardiogram====
* There are no ECG findings associated with COVID-19 associated hemodialysis.
* To view the electrocardiogram findings on COVID-19, [[COVID-19 electrocardiogram|click here]].<br />
====X-ray====
* A [[Chest X-ray]] may be helpful in the diagnosis of COVID-19 in the [[hemodialysis]] patients. Findings on a [[Chest X-ray]] suggestive of COVID-19 include bilateral peripheral ground glass consolidation mostly in lower or middle lobes along with blunting of costophrenic angle.<ref name="pmid32582309">{{cite journal| author=Durrani M, Haq IU, Kalsoom U, Yousaf A| title=Chest X-rays findings in COVID 19 patients at a University Teaching Hospital - A descriptive study. | journal=Pak J Med Sci | year= 2020 | volume= 36 | issue= COVID19-S4 | pages= S22-S26 | pmid=32582309 | doi=10.12669/pjms.36.COVID19-S4.2778 | pmc=7306947 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32582309  }} </ref>
===Echocardiography or Ultrasound===
* There are no typical [[Echocardiography|echocardiographic]] findings for [[COVID-19]]-associated hemodialysis.
* To view the echocardiographic findings on COVID-19, [[COVID-19 echocardiography and ultrasound|click here]].<br />
====CT-scan====
[[Chest]] CT-scan may be helpful in the diagnosis of [[COVID-19]] in [[hemodialysis]] patients.  Findings on CT scan that may suggest [[COVID-19]] include ground glass opacification in periphery of both lungs.<ref name="pmid32101510">{{cite journal| author=Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W | display-authors=etal| title=Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. | journal=Radiology | year= 2020 | volume=  | issue=  | pages= 200642 | pmid=32101510 | doi=10.1148/radiol.2020200642 | pmc=7233399 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32101510  }} </ref><ref name="pmid32367319">{{cite journal| author=Belfiore MP, Urraro F, Grassi R, Giacobbe G, Patelli G, Cappabianca S | display-authors=etal| title=Artificial intelligence to codify lung CT in Covid-19 patients. | journal=Radiol Med | year= 2020 | volume= 125 | issue= 5 | pages= 500-504 | pmid=32367319 | doi=10.1007/s11547-020-01195-x | pmc=7197034 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32367319  }} </ref>
*To view the CT scan findings on COVID-19, [[COVID-19 CT scan|click here]].
===MRI===
* There are no typical [[MRI]] findings for [[COVID-19]]-associated hemodialysis.
* To view the MRI findings on COVID-19, [[COVID-19 MRI|click here]].<br />
===Other Imaging Findings===
* To view other imaging findings on COVID-19, [[COVID-19 other imaging findings|click here]].<br />
===Other Diagnostic Studies===
* To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]].<br />


==Treatment==
==Treatment==
===Continuous Renal replacement therapy (CRRT) in Acute kidney injury===
===Continuous Renal replacement therapy (CRRT) in Acute kidney injury===
*In hemodynamically unstable [[COVID-19|covid-19]] patients continuous venovenous hemodialysis is the modality of choice.
*The dialysis of choice in hemodynamically unstable [[COVID-19]] patients is continuous venovenous hemodialysis.
*The vascular access of choice is right [[jugular vein]] with greater than 12.5 French. Approximately 27 % of [[COVID-19|covid-19]] patients in [[Intensive care unit|ICU]] required [[Prone position|prone]] positioning.<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume=  | issue=  | pages=  | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769  }} </ref><ref name="pmid32250385">{{cite journal| author=Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A | display-authors=etal| title=Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=32250385 | doi=10.1001/jama.2020.5394 | pmc=7136855 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32250385  }} </ref>
*The preferred vascular access is right [[jugular vein]] with greater than 12.5 French. Approximately 27% of [[COVID-19]] patients in [[Intensive care unit|ICU]] required [[Prone position|prone]] positioning.<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume=  | issue=  | pages=  | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769  }} </ref><ref name="pmid32250385">{{cite journal| author=Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A | display-authors=etal| title=Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=32250385 | doi=10.1001/jama.2020.5394 | pmc=7136855 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32250385  }} </ref>
*The anchor of the vascular access is visible at the catheter exit site at the right [[jugular vein]] even in the [[Prone position|prone position.]]
*The anchor of the vascular access is visible at the catheter exit site at the right [[jugular vein]] even in the [[Prone position|prone position.]]
*The minimum dose of CRRT delivery should be adjusted at 20-25 ml/kg/hour.<ref name="pmid25028631">{{cite journal| author=| title=Work Group Membership. | journal=Kidney Int Suppl (2011) | year= 2012 | volume= 2 | issue= 1 | pages= 2 | pmid=25028631 | doi=10.1038/kisup.2012.2 | pmc=4089660 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25028631  }} </ref>The patient’s fluid status and hemodynamic balance determine the daily fluid balance and net ultrafiltration rate of CRRT. The physician should calculate treatment downtime. Ultrafiltration should be less than 20 %.<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume=  | issue=  | pages=  | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769  }} </ref>
*The minimum dose of CRRT delivery should be adjusted at 20-25 ml/kg/hour.<ref name="pmid25028631">{{cite journal| author=| title=Work Group Membership. | journal=Kidney Int Suppl (2011) | year= 2012 | volume= 2 | issue= 1 | pages= 2 | pmid=25028631 | doi=10.1038/kisup.2012.2 | pmc=4089660 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25028631  }} </ref> The patient’s fluid status and hemodynamic balance determine the daily fluid balance and net ultrafiltration rate of CRRT. The physician should calculate treatment downtime. Ultrafiltration should be less than 20%.<ref name="pmid32416769">{{cite journal| author=Ronco C, Reis T, Husain-Syed F| title=Management of acute kidney injury in patients with COVID-19. | journal=Lancet Respir Med | year= 2020 | volume=  | issue=  | pages=  | pmid=32416769 | doi=10.1016/S2213-2600(20)30229-0 | pmc=7255232 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32416769  }} </ref>
 
===Surgical Therapy===
===Measures to prevent COVID 19 infection in hemodialysis patients===
Surgical intervention is not recommended for the management of [[COVID-19|covid]] 19 infections in hemodialysis patients.
Strict measures should be taken to prevent [[COVID-19|covid]] 19 infections in hemodialysis patients and health care workers. The measures include:
===Primary prevention===
====Screening of the patients====
Effective measures for the primary prevention of [[COVID-19|covid]] 19 infections in hemodialysis patients and health care workers include:
*Appropriate screening of patients should be done before dialysis. The best approach is to call patients and inquire about [[COVID-19|covid-19]] symptoms.
*Patients reporting illness or covid-19 symptoms should be placed in the screening area. Hand sanitizers and face masks should be provided to patients.
*A triage protocol should be instituted in [[dialysis]] facilities to take patients to testing clinics, particular [[dialysis]] facilities, and [[hospital]]<nowiki/>s.<ref name="pmid32249840">{{cite journal| author=Ikizler TA, Kliger AS| title=Minimizing the risk of COVID-19 among patients on dialysis. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 311-313 | pmid=32249840 | doi=10.1038/s41581-020-0280-y | pmc=7132217 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32249840  }} </ref> Patients with suspected coronavirus illness are preferred to have dialysis in hospitals as compared to dialysis facilities. The dialyzing facilities can accommodate patients with coronavirus illness if it can comply with CDC guidelines.<ref name="pmid32217082">{{cite journal| author=Ikizler TA| title=COVID-19 and Dialysis Units: What Do We Know Now and What Should We Do? | journal=Am J Kidney Dis | year= 2020 | volume= 76 | issue= 1 | pages= 1-3 | pmid=32217082 | doi=10.1053/j.ajkd.2020.03.008 | pmc=7146661 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32217082  }} </ref>
 
====Managing patients with suspected illness====
====Managing patients with suspected illness====
*If there are adequate resources in the [[hospital]], [[Patient|patients]] should have [[dialysis]] at a specific shift, or a separate isolation dialysis ward should be made.
*If there are adequate resources in the [[hospital]], [[Patient|patients]] should have [[dialysis]] at a specific shift, or a separate isolation dialysis ward should be made.
*<nowiki/><nowiki/>[[Patient]]<nowiki/>s should be instructed to wear masks and cover mouth and nose while [[cough]]<nowiki/>ing and [[Sneeze|sneezing]]. This will reduce air droplet transmission of the [[virus]].<ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc=7269225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
*<nowiki/><nowiki/>Patient<nowiki/>s should be instructed to wear masks and cover mouth and nose while [[cough]]<nowiki/>[[cough|ing]] and [[Sneeze|sneezing]]. This will reduce air droplet transmission of the [[virus]].<ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc=7269225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
*Suspect<nowiki/>ed [[COVID-19|covid]]-19 patients should have at least 6 feet (2 meters) apart from ea<nowiki/>ch other in all directions. <ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc=7269225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
*Suspect<nowiki/>ed [[COVID-19|COVID]]-19 patients should have at least 6 feet (2 meters) apart from ea<nowiki/>ch other in all directions. <ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc=7269225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
 
====Personnel protective equipment====
====Personnel protective equipment====
*A selected group of healthcare personnel should be assigned for suspected [[COVID-19|covid-19]] [[patient]]<nowiki/>s. [[Personal protective equipment]] should be provided to healthcare personnel.<ref name="pmid32564886">{{cite journal| author=Peters MDJ, Marnie C, Butler A| title=Policies and procedures for personal protective equipment: Does inconsistency increase risk of contamination and infection? | journal=Int J Nurs Stud | year= 2020 | volume=  | issue=  | pages= 103653 | pmid=32564886 | doi=10.1016/j.ijnurstu.2020.103653 | pmc=7273160 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32564886  }} </ref>
*A selected group of healthcare personnel should be assigned for suspected [[COVID-19]] patient<nowiki/>s. [[Personal protective equipment]] should be provided to healthcare personnel.<ref name="pmid32564886">{{cite journal| author=Peters MDJ, Marnie C, Butler A| title=Policies and procedures for personal protective equipment: Does inconsistency increase risk of contamination and infection? | journal=Int J Nurs Stud | year= 2020 | volume=  | issue=  | pages= 103653 | pmid=32564886 | doi=10.1016/j.ijnurstu.2020.103653 | pmc=7273160 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32564886  }} </ref>
*There should be an emphasis on compliance with proper infection control techniques. Health care personnel should be educated about types of [[Personal protective equipment|PPE]] and proper procedures and the protocol of putting on, using, and taking off the [[Personal protective equipment|PPE]].<ref name="pmid32564886">{{cite journal| author=Peters MDJ, Marnie C, Butler A| title=Policies and procedures for personal protective equipment: Does inconsistency increase risk of contamination and infection? | journal=Int J Nurs Stud | year= 2020 | volume=  | issue=  | pages= 103653 | pmid=32564886 | doi=10.1016/j.ijnurstu.2020.103653 | pmc=7273160 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32564886  }} </ref> Proper infection control in the hospital in Hong Kong resulted in zero nosocomial transmission in 413 health care personnel taking care of 42 confirmed coronavirus patients.<ref name="pmid32131908">{{cite journal| author=Cheng VCC, Wong SC, Chen JHK, Yip CCY, Chuang VWM, Tsang OTY | display-authors=etal| title=Escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 in Hong Kong. | journal=Infect Control Hosp Epidemiol | year= 2020 | volume= 41 | issue= 5 | pages= 493-498 | pmid=32131908 | doi=10.1017/ice.2020.58 | pmc=7137535 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32131908  }} </ref>
*There should be an emphasis on compliance with proper infection control techniques. Health care personnel should be educated about types of [[Personal protective equipment|PPE]] and proper procedures and the protocol of putting on, using, and taking off the [[Personal protective equipment|PPE]].<ref name="pmid32564886">{{cite journal| author=Peters MDJ, Marnie C, Butler A| title=Policies and procedures for personal protective equipment: Does inconsistency increase risk of contamination and infection? | journal=Int J Nurs Stud | year= 2020 | volume=  | issue=  | pages= 103653 | pmid=32564886 | doi=10.1016/j.ijnurstu.2020.103653 | pmc=7273160 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32564886  }} </ref> Proper infection control in the hospital in Hong Kong resulted in zero nosocomial transmission in 413 health care personnel taking care of 42 confirmed coronavirus patients.<ref name="pmid32131908">{{cite journal| author=Cheng VCC, Wong SC, Chen JHK, Yip CCY, Chuang VWM, Tsang OTY | display-authors=etal| title=Escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 in Hong Kong. | journal=Infect Control Hosp Epidemiol | year= 2020 | volume= 41 | issue= 5 | pages= 493-498 | pmid=32131908 | doi=10.1017/ice.2020.58 | pmc=7137535 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32131908  }} </ref>
*Healthcare workers should follow droplet and contact precautions. The workers should wear masks, gowns, goggles, shields, and gloves. Surgical face masks and N95 masks can be used. <ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
*Healthcare workers should follow droplet and contact precautions. The workers should wear masks, gowns, goggles, shields, and gloves. Surgical face masks and N95 masks can be used. <ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
*Eyeshields and goggles can be used to prevent droplet spread via [[Eye|eyes]].
*Eyeshields and goggles can be used to prevent droplet spread via [[Eye|eyes]].
====Disinfection====
====Disinfection====
*Disinfecting personnel should also wear [[personal protective equipment]].  
*Disinfecting personnel should also wear [[personal protective equipment]].  
*The [[dialysis]] machine, chair, [[dialysis]] surface station including BP cuff, stethoscope, the chairside stand should be cleaned with disinfecting wipes and allowed to be air dry.<ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref> All the surfaces of the dialysis station and equipment need to be disinfected with the wipes.
*The [[dialysis]] machine, chair, [[dialysis]] surface station including BP cuff, stethoscope, the chair side stand should be cleaned with disinfecting wipes and allowed to be air dry.<ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref> All the surfaces of the dialysis station and equipment need to be disinfected with the wipes.
*The benefit of dialyzing covid-19 patients at a particular shift is reduced time pressure and effective disinfection of the stations at the end of the shift.<ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
*The benefit of dialyzing COVID-19 patients at a particular shift is reduced time pressure and effective disinfection of the stations at the end of the shift.<ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
 
====Optimum utilization of resources====
====Optimum utilization of resources====
*As pandemic will be for a long duration, hence resources should be utilized optimally.<ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc=7269225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
*The pandemic is assumed to be of long duration, hence resources should be utilized optimally.<ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc=7269225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
*If there are a limited number of gowns, then health care workers should we<nowiki/>ar it at the time of initiating and terminating [[dialysis]], manipulating catheters and access sites, disinfecting [[dialysis]] station, and assisting to and from the [[dialysis]] station. <ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc=7269225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
*If there are a limited number of gowns, then health care workers should we<nowiki/>ar it at the time of initiating and terminating [[dialysis]], manipulating catheters and access sites, disinfecting [[dialysis]] station, and assisting to and from the [[dialysis]] station. <ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc=7269225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
*The goggles and eye shields can be reused after proper disinfection procedure. The eye shields and face masks should be used for an extended time period. <ref name="pmid32249840">{{cite journal| author=Ikizler TA, Kliger AS| title=Minimizing the risk of COVID-19 among patients on dialysis. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 311-313 | pmid=32249840 | doi=10.1038/s41581-020-0280-y | pmc=7132217 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32249840  }} </ref>
*Goggles and eye shields can be reused after proper disinfection procedure. The eye shields and face masks should be used for an extended time period. <ref name="pmid32249840">{{cite journal| author=Ikizler TA, Kliger AS| title=Minimizing the risk of COVID-19 among patients on dialysis. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 311-313 | pmid=32249840 | doi=10.1038/s41581-020-0280-y | pmc=7132217 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32249840  }} </ref>
*A track of the [[personal protective equipment]] stock should be made.
*A track of the [[personal protective equipment]] stock should be made.
====Work labor Management====
====Work labor Management====
*The healthcare workers are at risk for infection with [[COVID-19|covid-19]] due to exposure. The exposure of health care workers can be minimized by working in shifts.<ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc=7269225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
*The healthcare workers are at risk for infection with [[COVID-19]] due to exposure. The exposure of health care workers can be minimized by working in shifts.<ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc=7269225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
*In this pandemic, the health care workers can become sick and shortage of health care staff can arise. To encounter it a back up list should be created to fill up the positions. Training courses should be conducted for the health care staff. <ref name="pmid32249840">{{cite journal| author=Ikizler TA, Kliger AS| title=Minimizing the risk of COVID-19 among patients on dialysis. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 311-313 | pmid=32249840 | doi=10.1038/s41581-020-0280-y | pmc=7132217 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32249840  }} </ref>
*During this pandemic, health care workers can become sick and shortage of health care staff can arise. To counter this, a back up list should be created to fill up the vacated positions of sick staff. Training courses should be conducted for the health care staff. <ref name="pmid32249840">{{cite journal| author=Ikizler TA, Kliger AS| title=Minimizing the risk of COVID-19 among patients on dialysis. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 311-313 | pmid=32249840 | doi=10.1038/s41581-020-0280-y | pmc=7132217 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32249840 }} </ref>
===Secondary Prevention===
Effective measures for the secondary prevention of [[COVID-19]] include:
*Clinical stability and saturation of oxygen should be assessed in patients with [[fever]] and symptoms suggestive of covid-19 illness including [[cough]], [[fatigue]], [[myalgia]], [[Dyspnea|breathlessness]], [[diarrhea]], and [[Anosmia|loss of smell]].<ref name="pmid32365278">{{cite journal| author=Esposito P, Russo R, Conti N, Falqui V, Massarino F, Moriero E | display-authors=etal| title=Management of COVID-19 in hemodialysis patients: The Genoa experience. | journal=Hemodial Int | year= 2020 | volume=  | issue=  | pages=  | pmid=32365278 | doi=10.1111/hdi.12837 | pmc=7267634 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32365278  }} </ref>
*The nasopharyngeal or oropharyngeal sample can be taken in the dialysis facility by healthcare workers under strict precautionary guidelines of patients with normal oxygen saturation and stable vital signs.<ref name="pmid32365278">{{cite journal| author=Esposito P, Russo R, Conti N, Falqui V, Massarino F, Moriero E | display-authors=etal| title=Management of COVID-19 in hemodialysis patients: The Genoa experience. | journal=Hemodial Int | year= 2020 | volume=  | issue=  | pages=  | pmid=32365278 | doi=10.1111/hdi.12837 | pmc=7267634 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32365278  }} </ref>
*The requirement for urgent [[hemodialysis]] should be assessed in clinically stable patients. The [[hemodialysis]] session should be postponed while awaiting results and instructions should be given to the patient regarding social distancing. [[Dialysis]] should be done in a separate isolation room in patients requiring urgent hemodialysis.<ref name="pmid32365278">{{cite journal| author=Esposito P, Russo R, Conti N, Falqui V, Massarino F, Moriero E | display-authors=etal| title=Management of COVID-19 in hemodialysis patients: The Genoa experience. | journal=Hemodial Int | year= 2020 | volume=  | issue=  | pages=  | pmid=32365278 | doi=10.1111/hdi.12837 | pmc=7267634 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32365278  }} </ref>
*[[Patient|Patients]] with falling levels of oxygen saturation and unstable vital signs should be immediately transferred to the Emergency department of the hospital. The patient nasopharyngeal swab, other evaluation tests, and infectious disease specialist consultation regarding care and treatment should be done.<ref name="pmid32365278">{{cite journal| author=Esposito P, Russo R, Conti N, Falqui V, Massarino F, Moriero E | display-authors=etal| title=Management of COVID-19 in hemodialysis patients: The Genoa experience. | journal=Hemodial Int | year= 2020 | volume=  | issue=  | pages=  | pmid=32365278 | doi=10.1111/hdi.12837 | pmc=7267634 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32365278 }} </ref>


==References==
==References==
{{Reflist}}
{{Reflist|2}}
[[Category:Up-To-Date]]

Latest revision as of 19:35, 27 July 2020

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Main article: COVID-19

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mydah Sajid, MD[2]

Overview

COVID-19 infection has a higher mortality among dialysis patients as compared to normal individuals. The factors for increased mortality for dialysis patients as compared to the general population due to COVID-19 infection are low immunity, co-existence of multiple co-morbid conditions, and the increased age of the patients. The lab and imaging findings in COVID-19 infection in dialysis patients are similar to general population. Adequate measures should be taken to prevent the spread of COVID-19 infection in dialysis patients.


Historical perspective

The first reported case of COVID-19 infection of a hemodialysis patient in Japan, was a 69 years old diabetic man on maintenance hemodialysis for three years due to end-stage kidney disease. He presented with cough, fever, and breathlessness. His CT-scan chest showed bilateral multiple pulmonary consolidation and pleural effusion. He successfully recovered and was discharged on the 19th day of hospitalization.[1]

Classification

There is no established system for the classification of hemodialysis in COVID-19.

Pathophysiology

Causes

Epidemiology and Demographics

Prevalence

  • The prevalence of chronic kidney disease ranges from 4,702 to 16,166 per 100,000 individuals in hospitalized COVID-19 patients.[8][9]
  • The prevalence of COVID-19 infection in chronic kidney disease and end-stage renal disease patients varies at different geographical areas. The prevalence of chronic kidney disease is approximately 16,166 per 100,000 individuals as per a study done in 208 acute care hospitals in the UK. It showed chronic kidney disease was one of the most common co-morbidities in hospitalized COVID-19 patients.[9]
  • The prevalence of chronic kidney disease is approximately 4,702 per 100,000 individuals and end-stage renal disease is approximately 3,263 per 100,000 individuals in hospitalized COVID-19 patients according to a case series of 5,700 patients with COVID-19 infection performed in 12 hospitals under the Northwell Health system in New York.[8]

Gender

COVID-19 infection affects men and women equally.[9]

Age

  • The COVID-19 infection among dialysis patients is more commonly observed among patients aged 70 to 90 years old. [10]

Risk Factors

Common risk factors in the development of COVID-19 in patients on maintenance hemodialysis include:[11]

Screening

  • According to the CDC, screening for COVID-19 by triage protocol is recommended before dialysis among patients on maintenance hemodialysis.[12]
  • The suggested approach is to call patients and inquire about COVID-19 symptoms. [12] Body temperature and clinical symptoms of COVID-19 should be assessed when patient arrives at the dialysis facility.[13]
  • Patients reporting illness or COVID-19 symptoms should be placed in the screening area. Hand sanitizers and face masks should be provided to patients.[12]
  • Symptomatic patients should be taken to testing clinics, hospitals or tested in dialysis facility as per the triage protocol instituted in dialysis facilities.[12]
  • Patients with suspected COVID-19 illness are preferred to have dialysis in hospitals as compared to dialysis facilities. The dialysis facilities can accommodate patients with COVID-19 illness if it can comply with CDC guidelines.[14]

Natural History, Complications and Prognosis

Diagnosis

Diagnosis of Choice

History & Symptoms

Laboratory Findings

Laboratory findings consistent with the diagnosis of COVID-19 in hemodialysis patients include:[20] [23]

Electrocardiogram

  • There are no ECG findings associated with COVID-19 associated hemodialysis.
  • To view the electrocardiogram findings on COVID-19, click here.

X-ray

  • A Chest X-ray may be helpful in the diagnosis of COVID-19 in the hemodialysis patients. Findings on a Chest X-ray suggestive of COVID-19 include bilateral peripheral ground glass consolidation mostly in lower or middle lobes along with blunting of costophrenic angle.[18]

Echocardiography or Ultrasound

CT-scan

Chest CT-scan may be helpful in the diagnosis of COVID-19 in hemodialysis patients. Findings on CT scan that may suggest COVID-19 include ground glass opacification in periphery of both lungs.[17][19]


  • To view the CT scan findings on COVID-19, click here.

MRI

  • There are no typical MRI findings for COVID-19-associated hemodialysis.
  • To view the MRI findings on COVID-19, click here.

Other Imaging Findings

  • To view other imaging findings on COVID-19, click here.

Other Diagnostic Studies

  • To view other diagnostic studies for COVID-19, click here.

Treatment

Continuous Renal replacement therapy (CRRT) in Acute kidney injury

  • The dialysis of choice in hemodynamically unstable COVID-19 patients is continuous venovenous hemodialysis.
  • The preferred vascular access is right jugular vein with greater than 12.5 French. Approximately 27% of COVID-19 patients in ICU required prone positioning.[24][25]
  • The anchor of the vascular access is visible at the catheter exit site at the right jugular vein even in the prone position.
  • The minimum dose of CRRT delivery should be adjusted at 20-25 ml/kg/hour.[26] The patient’s fluid status and hemodynamic balance determine the daily fluid balance and net ultrafiltration rate of CRRT. The physician should calculate treatment downtime. Ultrafiltration should be less than 20%.[24]

Surgical Therapy

Surgical intervention is not recommended for the management of covid 19 infections in hemodialysis patients.

Primary prevention

Effective measures for the primary prevention of covid 19 infections in hemodialysis patients and health care workers include:

Managing patients with suspected illness

  • If there are adequate resources in the hospital, patients should have dialysis at a specific shift, or a separate isolation dialysis ward should be made.
  • Patients should be instructed to wear masks and cover mouth and nose while coughing and sneezing. This will reduce air droplet transmission of the virus.[27]
  • Suspected COVID-19 patients should have at least 6 feet (2 meters) apart from each other in all directions. [27]

Personnel protective equipment

  • A selected group of healthcare personnel should be assigned for suspected COVID-19 patients. Personal protective equipment should be provided to healthcare personnel.[28]
  • There should be an emphasis on compliance with proper infection control techniques. Health care personnel should be educated about types of PPE and proper procedures and the protocol of putting on, using, and taking off the PPE.[28] Proper infection control in the hospital in Hong Kong resulted in zero nosocomial transmission in 413 health care personnel taking care of 42 confirmed coronavirus patients.[29]
  • Healthcare workers should follow droplet and contact precautions. The workers should wear masks, gowns, goggles, shields, and gloves. Surgical face masks and N95 masks can be used. [27]
  • Eyeshields and goggles can be used to prevent droplet spread via eyes.

Disinfection

  • Disinfecting personnel should also wear personal protective equipment.
  • The dialysis machine, chair, dialysis surface station including BP cuff, stethoscope, the chair side stand should be cleaned with disinfecting wipes and allowed to be air dry.[27] All the surfaces of the dialysis station and equipment need to be disinfected with the wipes.
  • The benefit of dialyzing COVID-19 patients at a particular shift is reduced time pressure and effective disinfection of the stations at the end of the shift.[27]

Optimum utilization of resources

  • The pandemic is assumed to be of long duration, hence resources should be utilized optimally.[27]
  • If there are a limited number of gowns, then health care workers should wear it at the time of initiating and terminating dialysis, manipulating catheters and access sites, disinfecting dialysis station, and assisting to and from the dialysis station. [27]
  • Goggles and eye shields can be reused after proper disinfection procedure. The eye shields and face masks should be used for an extended time period. [12]
  • A track of the personal protective equipment stock should be made.

Work labor Management

  • The healthcare workers are at risk for infection with COVID-19 due to exposure. The exposure of health care workers can be minimized by working in shifts.[27]
  • During this pandemic, health care workers can become sick and shortage of health care staff can arise. To counter this, a back up list should be created to fill up the vacated positions of sick staff. Training courses should be conducted for the health care staff. [12]

Secondary Prevention

Effective measures for the secondary prevention of COVID-19 include:

  • Clinical stability and saturation of oxygen should be assessed in patients with fever and symptoms suggestive of covid-19 illness including cough, fatigue, myalgia, breathlessness, diarrhea, and loss of smell.[13]
  • The nasopharyngeal or oropharyngeal sample can be taken in the dialysis facility by healthcare workers under strict precautionary guidelines of patients with normal oxygen saturation and stable vital signs.[13]
  • The requirement for urgent hemodialysis should be assessed in clinically stable patients. The hemodialysis session should be postponed while awaiting results and instructions should be given to the patient regarding social distancing. Dialysis should be done in a separate isolation room in patients requiring urgent hemodialysis.[13]
  • Patients with falling levels of oxygen saturation and unstable vital signs should be immediately transferred to the Emergency department of the hospital. The patient nasopharyngeal swab, other evaluation tests, and infectious disease specialist consultation regarding care and treatment should be done.[13]

References

  1. ↑ Kuroki Y, Hiyama K, Minami J, Takeuchi M, Shojima M, Matsueda S; et al. (2020). "The first case of COVID-19 pneumonia in a hemodialysis patient in Japan". CEN Case Rep. doi:10.1007/s13730-020-00495-5. PMC 7300373 Check |pmc= value (help). PMID 32557209 Check |pmid= value (help).
  2. ↑ 2.0 2.1 Zhang X, Tan Y, Ling Y, Lu G, Liu F, Yi Z; et al. (2020). "Viral and host factors related to the clinical outcome of COVID-19". Nature. doi:10.1038/s41586-020-2355-0. PMID 32434211 Check |pmid= value (help).
  3. ↑ 3.0 3.1 Tang N, Li D, Wang X, Sun Z (2020). "Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia". J Thromb Haemost. 18 (4): 844–847. doi:10.1111/jth.14768. PMC 7166509 Check |pmc= value (help). PMID 32073213 Check |pmid= value (help).
  4. ↑ Bose KS, Sarma RH (1975). "Delineation of the intimate details of the backbone conformation of pyridine nucleotide coenzymes in aqueous solution". Biochem Biophys Res Commun. 66 (4): 1173–9. doi:10.1016/0006-291x(75)90482-9. PMID 02.24.20027201 Check |pmid= value (help).
  5. ↑ Zhu N, Zhang D, Wang W, Li X, Yang B, Song J; et al. (2020). "A Novel Coronavirus from Patients with Pneumonia in China, 2019". N Engl J Med. 382 (8): 727–733. doi:10.1056/NEJMoa2001017. PMC 7092803 Check |pmc= value (help). PMID 31978945.
  6. ↑ Tian X, Li C, Huang A, Xia S, Lu S, Shi Z; et al. (2020). "Potent binding of 2019 novel coronavirus spike protein by a SARS coronavirus-specific human monoclonal antibody". Emerg Microbes Infect. 9 (1): 382–385. doi:10.1080/22221751.2020.1729069. PMC 7048180 Check |pmc= value (help). PMID 32065055 Check |pmid= value (help).
  7. ↑ Zou X, Chen K, Zou J, Han P, Hao J, Han Z (2020). "Single-cell RNA-seq data analysis on the receptor ACE2 expression reveals the potential risk of different human organs vulnerable to 2019-nCoV infection". Front Med. 14 (2): 185–192. doi:10.1007/s11684-020-0754-0. PMC 7088738 Check |pmc= value (help). PMID 32170560 Check |pmid= value (help).
  8. ↑ 8.0 8.1 Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW; et al. (2020). "Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area". JAMA. doi:10.1001/jama.2020.6775. PMC 7177629 Check |pmc= value (help). PMID 32320003 Check |pmid= value (help).
  9. ↑ 9.0 9.1 9.2 Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L; et al. (2020). "Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study". BMJ. 369: m1985. doi:10.1136/bmj.m1985. PMC 7243036 Check |pmc= value (help). PMID 32444460 Check |pmid= value (help).
  10. ↑ 10.0 10.1 10.2 Kikuchi K, Nangaku M, Ryuzaki M, Yamakawa T, Hanafusa N, Sakai K; et al. (2020). "COVID-19 in dialysis patients in Japan: Current status and guidance on preventive measures". Ther Apher Dial. doi:10.1111/1744-9987.13531. PMC 7301044 Check |pmc= value (help). PMID 32506762 Check |pmid= value (help).
  11. ↑ 11.0 11.1 Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX; et al. (2020). "Clinical Characteristics of Coronavirus Disease 2019 in China". N Engl J Med. 382 (18): 1708–1720. doi:10.1056/NEJMoa2002032. PMC 7092819 Check |pmc= value (help). PMID 32109013 Check |pmid= value (help).
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 Ikizler TA, Kliger AS (2020). "Minimizing the risk of COVID-19 among patients on dialysis". Nat Rev Nephrol. 16 (6): 311–313. doi:10.1038/s41581-020-0280-y. PMC 7132217 Check |pmc= value (help). PMID 32249840 Check |pmid= value (help).
  13. ↑ 13.0 13.1 13.2 13.3 13.4 Esposito P, Russo R, Conti N, Falqui V, Massarino F, Moriero E; et al. (2020). "Management of COVID-19 in hemodialysis patients: The Genoa experience". Hemodial Int. doi:10.1111/hdi.12837. PMC 7267634 Check |pmc= value (help). PMID 32365278 Check |pmid= value (help).
  14. ↑ Ikizler TA (2020). "COVID-19 and Dialysis Units: What Do We Know Now and What Should We Do?". Am J Kidney Dis. 76 (1): 1–3. doi:10.1053/j.ajkd.2020.03.008. PMC 7146661 Check |pmc= value (help). PMID 32217082 Check |pmid= value (help).
  15. ↑ Wu J, Li J, Zhu G, Zhang Y, Bi Z, Yu Y; et al. (2020). "Clinical Features of Maintenance Hemodialysis Patients with 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China". Clin J Am Soc Nephrol. doi:10.2215/CJN.04160320. PMID 32444393 Check |pmid= value (help).
  16. ↑ 16.0 16.1 Alberici F, Delbarba E, Manenti C, Econimo L, Valerio F, Pola A; et al. (2020). "A report from the Brescia Renal COVID Task Force on the clinical characteristics and short-term outcome of hemodialysis patients with SARS-CoV-2 infection". Kidney Int. 98 (1): 20–26. doi:10.1016/j.kint.2020.04.030. PMC 7206428 Check |pmc= value (help). PMID 32437768 Check |pmid= value (help).
  17. ↑ 17.0 17.1 17.2 17.3 Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W; et al. (2020). "Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases". Radiology: 200642. doi:10.1148/radiol.2020200642. PMC 7233399 Check |pmc= value (help). PMID 32101510 Check |pmid= value (help).
  18. ↑ 18.0 18.1 Durrani M, Haq IU, Kalsoom U, Yousaf A (2020). "Chest X-rays findings in COVID 19 patients at a University Teaching Hospital - A descriptive study". Pak J Med Sci. 36 (COVID19–S4): S22–S26. doi:10.12669/pjms.36.COVID19-S4.2778. PMC 7306947 Check |pmc= value (help). PMID 32582309 Check |pmid= value (help).
  19. ↑ 19.0 19.1 19.2 Belfiore MP, Urraro F, Grassi R, Giacobbe G, Patelli G, Cappabianca S; et al. (2020). "Artificial intelligence to codify lung CT in Covid-19 patients". Radiol Med. 125 (5): 500–504. doi:10.1007/s11547-020-01195-x. PMC 7197034 Check |pmc= value (help). PMID 32367319 Check |pmid= value (help).
  20. ↑ 20.0 20.1 20.2 20.3 20.4 Goicoechea M, Sánchez Cámara LA, Macías N, Muñoz de Morales A, Rojas ÁG, Bascuñana A; et al. (2020). "COVID-19: clinical course and outcomes of 36 hemodialysis patients in Spain". Kidney Int. 98 (1): 27–34. doi:10.1016/j.kint.2020.04.031. PMC 7211728 Check |pmc= value (help). PMID 32437770 Check |pmid= value (help).
  21. ↑ Wang R, Liao C, He H, Hu C, Wei Z, Hong Z; et al. (2020). "COVID-19 in Hemodialysis Patients: A Report of 5 Cases". Am J Kidney Dis. 76 (1): 141–143. doi:10.1053/j.ajkd.2020.03.009. PMC 7118604 Check |pmc= value (help). PMID 32240718 Check |pmid= value (help).
  22. ↑ Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J; et al. (2020). "Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China". JAMA. doi:10.1001/jama.2020.1585. PMC 7042881 Check |pmc= value (help). PMID 32031570 Check |pmid= value (help).
  23. ↑ Alalwan AA, Taher A, Alaradi AH (2020). "A Hemodialysis Patient with Severe COVID-19 Pneumonia". Cureus. 12 (5): e7995. doi:10.7759/cureus.7995. PMC 7205364 Check |pmc= value (help). PMID 32391234 Check |pmid= value (help).
  24. ↑ 24.0 24.1 Ronco C, Reis T, Husain-Syed F (2020). "Management of acute kidney injury in patients with COVID-19". Lancet Respir Med. doi:10.1016/S2213-2600(20)30229-0. PMC 7255232 Check |pmc= value (help). PMID 32416769 Check |pmid= value (help).
  25. ↑ Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A; et al. (2020). "Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy". JAMA. doi:10.1001/jama.2020.5394. PMC 7136855 Check |pmc= value (help). PMID 32250385 Check |pmid= value (help).
  26. ↑ "Work Group Membership". Kidney Int Suppl (2011). 2 (1): 2. 2012. doi:10.1038/kisup.2012.2. PMC 4089660. PMID 25028631.
  27. ↑ 27.0 27.1 27.2 27.3 27.4 27.5 27.6 27.7 Kliger AS, Silberzweig J (2020). "Mitigating Risk of COVID-19 in Dialysis Facilities". Clin J Am Soc Nephrol. 15 (5): 707–709. doi:10.2215/CJN.03340320. PMC 7269225 Check |pmc= value (help). PMID 32198130 Check |pmid= value (help).
  28. ↑ 28.0 28.1 Peters MDJ, Marnie C, Butler A (2020). "Policies and procedures for personal protective equipment: Does inconsistency increase risk of contamination and infection?". Int J Nurs Stud: 103653. doi:10.1016/j.ijnurstu.2020.103653. PMC 7273160 Check |pmc= value (help). PMID 32564886 Check |pmid= value (help).
  29. ↑ Cheng VCC, Wong SC, Chen JHK, Yip CCY, Chuang VWM, Tsang OTY; et al. (2020). "Escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 in Hong Kong". Infect Control Hosp Epidemiol. 41 (5): 493–498. doi:10.1017/ice.2020.58. PMC 7137535 Check |pmc= value (help). PMID 32131908 Check |pmid= value (help).
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