COVID-19-associated hemodialysis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mydah Sajid, MD[2]
Overview
The 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 infection is the increased age of the patients. Adequate measures should be taken to prevent the spread of COVID-19 infection in dialysis patients.
Pathophysiology
- Patients on hemodialysis have a mild clinical course of COVID 19 infection. It could be due to multiple reasons.
- Patients with chronic kidney disease or end-stage renal disease have low immunity. The low immunity results in low-intensity cytokine storm in response to viral antigens. The patients on maintenance hemodialysis rarely present with a full-blown clinical picture of pneumonia.[1]
- 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 infection. Anticoagulants administered during hemodialysis inhibit coagulation cascade preventing hypercoagulation and DIC.[2]
- In a study done at a hemodialysis center at Renmin Hospital in Wuhan, 37 out of a total of 230 patients were infected with covid-19 infections in one month. Four members of the health care staff were also infected. The peripheral blood examination of the covid 19 infected hemodialysis patients had reduced levels of killer T cells, helper T cells, Natural killer cells, and lower level of inflammatory cytokines as compared to non-dialysis infected patients.[3]
Epidemiology and Demographics
Prevalence
- Patients on maintenance hemodialysis and end-stage kidney disease have low immunity and multiple co-morbidities including hypertension, diabetes, pulmonary and cardiovascular diseases.[4] They are at an increased risk of contracting the covid-19 infection. A case series of 5,700 patients with covid-19 infection was done in 12 hospitals under the Northwell Health system in New York. It showed a prevalence of 5% chronic kidney disease and 3.5% end-stage renal disease in hospitalized covid-19 patients.[5]
- A study was done in 208 acute care hospitals in the UK. The total patients studied were 20,133. It showed chronic kidney disease was one of the most common co-morbidity in hospitalized covid-19 patients present in 16% of patients.[6]
Mortality Rate
- Clinical research was done by Alberici et al. at four outpatient dialysis facilities in Italy showed high overall mortality of 29% in dialysis patients.[7]
Age
A research study done in Japan showed a higher mortality 16.2% (16/99) in dialysis patients as compared to the general population 5.3% (874/16,532). The average age of patients on dialysis was 70 to 90 years while of the general population was 20 to 60 years.[8]
Treatment
Continuous Renal replacement therapy (CRRT) in Acute kidney injury
- In hemodynamically unstable covid-19 patients continuous venovenous hemodialysis is the modality of choice.
- The vascular access of choice is right jugular vein with greater than 12.5 French. [9] Approximately 27 % of covid-19 patients in ICU required prone positioning.[10] 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.[11]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 %.[9]
Measures to prevent COVID 19 infection in hemodialysis patients
Strict measures should be taken to prevent covid 19 infections in hemodialysis patients and health care workers. The measures include:
Screening of the patients
- Appropriate screening of patients should be done before dialysis. The best approach is to call patients and inquire about 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 hospitals.[12] 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.[13]
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.[14] This will reduce air droplet transmission of the virus.
- Suspected covid-19 patients should have at least 6 feet (2 meters) apart from each other in all directions. [14]
Personnel protective equipment
- A selected group of healthcare personnel should be assigned for suspected covid-19 patients. Personal protective equipment should be given to patients and healthcare personnel.
- 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. 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.[15]
- 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. [14]
- Eyeshields and goggles can be used to prevent droplet spread via eyes.
Disinfection
Disinfecting personnel should also wear personal protective equipment while disinfecting the dialysis surface. 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.[14]
Optimum utilization of resources
- As pandemic will be for a long duration, hence resources should be utilized optimally. The gown should ideally be worn by both the health care workers and the patients.
- 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. [14]
- 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. [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.
- 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. [12]
References
- ↑ 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). - ↑ 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). - ↑ 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). - ↑ 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). - ↑ 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). - ↑ 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). - ↑ 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). - ↑ 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). - ↑ 9.0 9.1 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). - ↑ 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). - ↑ "Work Group Membership". Kidney Int Suppl (2011). 2 (1): 2. 2012. doi:10.1038/kisup.2012.2. PMC 4089660. PMID 25028631.
- ↑ 12.0 12.1 12.2 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). - ↑ 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). - ↑ 14.0 14.1 14.2 14.3 14.4 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). - ↑ 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).