Caring for Dialysis Patients in a Time of COVID-19

Abstract

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a pandemic and a public health emergency. The overwhelming increase in the number of cases has brought significant challenges to health care systems worldwide. Patients with end-stage kidney disease are highly vulnerable with the multiple comorbid conditions that make them susceptible to adverse outcomes with COVID-19. More than 2 million people worldwide receive maintenance hemodialysis at outpatient centers. Effectively preventing the spread of infection among hemodialysis centers, health care personnel, and patients is essential to ensure the continued delivery of dialysis to patients with end-stage kidney disease. This article discusses dialysis patients’ care during COVID-19, addressing measures for patient and health care personnel protection and care of dialysis patients with suspected or confirmed COVID-19. Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a pandemic and a public health emergency. The overwhelming increase in the number of cases has brought significant challenges to health care systems worldwide. Patients with end-stage kidney disease are highly vulnerable with the multiple comorbid conditions that make them susceptible to adverse outcomes with COVID-19. More than 2 million people worldwide receive maintenance hemodialysis at outpatient centers. Effectively preventing the spread of infection among hemodialysis centers, health care personnel, and patients is essential to ensure the continued delivery of dialysis to patients with end-stage kidney disease. This article discusses dialysis patients’ care during COVID-19, addressing measures for patient and health care personnel protection and care of dialysis patients with suspected or confirmed COVID-19. Editorial, p. 675 Editorial, p. 675 Coronavirus disease 2019 (COVID-19) is a respiratory illness that started in Wuhan, China, and has now spread to more than 150 countries, including the United States.1US Centers for Disease Control and PreventionCoronavirus disease 2019 (COVID-19): situation summary. Vol 2020.https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/index.htmlDate accessed: October 23, 2020Google Scholar As of July 14, the total number of confirmed COVID-19 cases has reached 13,145,302 worldwide.2Johns Hopkins Coronavirus Resource Center. Vol 20202020.https://coronavirus.jhu.edu/map.htmlDate accessed: October 23, 2020Google Scholar Patients with COVID-19 usually present with fever (44%-98%), cough (68%-76%), myalgia (18%), and fatigue (18%).3Guan W.J. Ni Z.Y. Hu Y. et al.Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (20519) Google Scholar The overwhelming increase in the number of cases has challenged health care systems all over the world. The estimated case fatality risk for COVID-19 ranges from 0.25% to 3%,4Nick W. Amanda K. Lucy Telfar B. Michael G.B. Case-fatality risk estimates for COVID-19 calculated by using a lag time for fatality.Emerg Infect Dis J. 2020; 26: 1339-1441PubMed Google Scholar with risks higher in those with preexisting comorbid conditions: 10.5% for cardiovascular disease, 7.3% for diabetes, 6.3% for chronic respiratory disease, 6.0% for hypertension, and 5.6% for cancer.5Wu Z. McGoogan J.M. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention.JAMA. 2020; 323: 1239-1242Crossref PubMed Scopus (12778) Google Scholar In 2016, nearly 125,000 people in the United States were initiated on kidney replacement therapy (KRT) for end-stage kidney disease, with more than 726,000 receiving dialysis or living with a kidney transplant.6Centers for Disease Control and PreventionChronic Kidney Disease Surveillance System website. Vol 20202019.https://www.cdc.gov/kidneydisease/index.htmlDate accessed: October 23, 2020Google Scholar Dialysis patients receive KRT through various modalities, including in-center hemodialysis (HD), peritoneal dialysis, and home HD. In the United States, 62.7% of patients with end-stage kidney disease receive HD as their KRT modality, with 98% of them receiving treatments in outpatient centers. Patients on KRT have multiple comorbid conditions, such as diabetes, hypertension, and cardiovascular disease, which are risk factors for adverse outcomes in COVID-19. In addition, patients on KRT who are infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) usually present with atypical symptoms, making it a diagnostic challenge.7Tang B. Li S. Xiong Y. et al.COVID-19 pneumonia in a hemodialysis patient.Kidney Med. 2020; 2: 354-358Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar The second patient who died from COVID-19 in the United States was an outpatient HD patient from the Seattle area.8Dialysis should continue despite COVID-19; CDC gives guidance. Vol 20202020.https://www.medscape.com/viewarticle/926720Date accessed: October 23, 2020Google Scholar,9Watnick S. McNamara E. On the frontline of the COVID-19 outbreak.CJASN. 2020; 15: 710-713Crossref PubMed Scopus (40) Google Scholar The experiences of frontline nephrologists caring for dialysis patients in Seattle and New York have been described recently.9Watnick S. McNamara E. On the frontline of the COVID-19 outbreak.CJASN. 2020; 15: 710-713Crossref PubMed Scopus (40) Google Scholar,10Mokrzycki M.H. Coco M. Management of hemodialysis patients with suspected or confirmed COVID-19 infection: perspective of two nephrologists in the United States.Kidney360. 2020; 1: 273-278Crossref Scopus (8) Google Scholar SARS-CoV-2 spreads from person to person through droplets expelled during coughing and sneezing.1US Centers for Disease Control and PreventionCoronavirus disease 2019 (COVID-19): situation summary. Vol 2020.https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/index.htmlDate accessed: October 23, 2020Google Scholar Transmission through direct contact and fecal contamination can also occur.1US Centers for Disease Control and PreventionCoronavirus disease 2019 (COVID-19): situation summary. Vol 2020.https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/index.htmlDate accessed: October 23, 2020Google Scholar Recent reports show that aerosol transmission is also possible.11van Doremalen N. Bushmaker T. Morris D.H. et al.Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1.N Engl J Med. 2020; 382: 1564-1567Crossref PubMed Scopus (6789) Google Scholar Patients receiving HD are a particularly unique and vulnerable population in the COVID-19 pandemic. HD patients cannot practice social distancing because they receive HD treatments routinely at least 3 times a week at outpatient dialysis units. Each session requires traveling to and from the outpatient group and inevitable exposures to health care personnel and all the patients concurrently receiving treatment in a particular session. At any given shift, more than 20 patients can be treated. To continue providing usual care for these patients, a framework to protect patients and health care personnel from contracting and spreading COVID-19 needs to be in place. In response to this, the American Society of Nephrology, together with the Centers for Disease Control and Prevention (CDC), established a COVID-19 response team. This response team has laid out guidelines for all HD facilities to follow, especially in caring for patients under investigation and patients infected with COVID-19. In this review, we discuss the best practices on how to care for patients with known or suspected COVID-19 in the outpatient HD setting, how to protect patients and health care personnel from disease exposure using personal protective equipment (PPE), and how to approach a patient receiving HD with confirmed COVID-19. Patients with COVID-19 can be asymptomatic or symptomatic 2 to 14 days after exposure.1US Centers for Disease Control and PreventionCoronavirus disease 2019 (COVID-19): situation summary. Vol 2020.https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/index.htmlDate accessed: October 23, 2020Google Scholar In the setting of COVID-19, HD facilities need to provide instructions for preventative measures to include proper hygiene and handwashing techniques, coughing and sneezing etiquette, and practice of social distancing to all patients. Each patient should be instructed to inform the HD unit if they had traveled to COVID-19 endemic areas or had contact with persons found to be positive for SARS-CoV-2. On arrival, patients should be screened for signs and symptoms of respiratory infections before entering the outpatient unit. In a recent perspective from Wuhan, China, HD patients were screened for viral pneumonia using computed tomography of the chest to augment the limited sensitivity and relatively slower turnaround time of SARS-CoV-2 polymerase chain reaction testing.12Li J. Xu G. Lessons from the experience in Wuhan to reduce risk of COVID-19 infection in patients undergoing long-term hemodialysis.Clin J Am Soc Nephrol. 2020; 15: 717-719Crossref PubMed Scopus (62) Google Scholar If possible, all patients with suspected or confirmed COVID-19 should travel in private vehicles and not in shared rides. Mandatory signs and directions should be clearly shown in the outpatient dialysis units. Educational pamphlets about CDC dialysis guidelines and COVID-19 should be kept at the front desk for patients and visitors. Patients with symptoms should wear masks while in the dialysis facility and should be seated at least 6 feet away from other patients and health care personnel. If available, a different seating room for patients with suspected or confirmed SARS-CoV-2 infection is preferred. If patients with symptoms are medically stable, they should only present to the dialysis center at the time of their shift to minimize time within the HD facility. All supplies such as alcohol hand rubs, tissue paper, and masks should be available in the triage and waiting areas. Clear communication among the unit health care personnel, medical director, and state health department is vital to stay updated with the evolving guidelines for COVID-19. Figure 1 shows the algorithm for screening patients and delivery of dialysis. Health care personnel are at the front lines caring for HD patients with suspected or confirmed COVID-19. Protecting health care personnel from contracting this infection is of prime importance. Although guidelines for PPE may vary across different institutions, all health care personnel in outpatient HD units should wear a surgical mask for their shifts. All outpatient and inpatient HD facilities should offer nonpunitive and flexible sick leave to their employees, consistent with current public health policies that mandate ill health care personnel to stay home. As with dialysis patients, health care personnel should practice proper hand hygiene techniques. After a known exposure, health care personnel should inform their supervisor and should stop working if symptomatic. If asymptomatic, the next course of action would depend on the type of exposure as determined by CDC or relevant national guidelines.13Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease (COVID-19). Vol 20202020.https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.htmlDate accessed: October 23, 2020Google Scholar High-risk exposure is defined as having prolonged close contact with COVID-19–infected patients with the health care personnel not wearing PPE, with nose and mouth exposed to droplets potentially carrying the virus. Medium-risk exposure is defined as having prolonged close contact with COVID-19–infected patients while wearing a face mask while the nose and mouth were potentially exposed to material that may contain the virus. Low-risk exposure is defined as having brief interactions with patients with COVID-19 or prolonged close contact with patients wearing a face mask for source control while the health care personnel was wearing a face mask or respirator. Health care personnel deemed to be high or medium risk will be instructed to self-quarantine for 14 days. Health care personnel considered to have had low-risk exposure can continue to work and self-monitor for symptoms, including twice-a-day temperature checks, with instructions to stop working if fever or respiratory symptoms develop. The health care personnel should then self-quarantine and subsequently update the dialysis facility about disease course. Figure 2 illustrates an algorithm for health care personnel after a positive exposure. The symptoms-based strategy and test-based strategy should be used for directing discontinuation of home isolation for health care personnel. A person with symptoms and positive COVID-19 should discontinue home isolation after the resolution of fever without the use of fever-reducing medications, improvement in respiratory symptoms, and subsequent negative results of a molecular assay for COVID-19 from at least 2 consecutive nasopharyngeal swab specimens collected 24 or more hours apart.14Discontinuation of Home Isolation for Persons with COVID-19 (Interim Guidance). Vol 20202020.https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.htmlDate accessed: October 23, 2020Google Scholar A person without symptoms and positive COVID-19 should discontinue home isolation when at least 7 days have passed since the date of their first positive COVID-19 diagnostic test and have had no subsequent illness.14Discontinuation of Home Isolation for Persons with COVID-19 (Interim Guidance). Vol 20202020.https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.htmlDate accessed: October 23, 2020Google Scholar PPE conservation and use are integral parts of health care delivery in times of COVID-19. PPE, which includes surgical mask, eye goggles, face shield, N95 respirator mask, and isolation gown, is critical for all health care personnel safety. Guidance for PPE practice varies across countries and specified units within the country. Universally, all guidelines have advised using surgical masks for patients and health care personnel. In the United States, using N95 is advised for care of COVID-19–infected dialysis patients. Variation in PPE practice across units is dependent on the availability of resources and specific guidelines adopted by the units. All dialysis facilities should provide health care personnel required education and training about using PPE and proper technique of donning and doffing of the PPE. All dialysis facilities should keep an updated PPE inventory. The administration should keep track of all PPE use and future needs. The administration should be communicating with local, public, and federal health offices on the need for additional supplies. Standard droplet and contact precautions should be applied when caring for suspected or confirmed COVID-19–infected patients. Isolation gowns, N95 masks or high-level respirator (or facemask, if respirator is not available), and eye protection should be used for direct patient care within 6 feet of COVID-19–positive patients. For procedures mostly on inpatient HD patients, when there is the risk for aerosolization, N95 respirator masks should be used with eye protection and isolation gowns. For nondirect care of patients, only a surgical mask, standard laboratory coat, and eye protection are required. Physician encounters for home dialysis patients should be transitioned to telemedicine if possible to reduce further contact and exposure. Similarly, reducing physical examination during inpatient rounds on COVID-19–infected patients, cohorting patients, and restricting visitors to the patient rooms are essential to minimize exposure and conserve PPE. Patients with suspected or confirmed COVID-19 should be dialyzed in a separate isolation room. Hepatitis B isolation rooms should be used first with patients with positive hepatitis B antigen and then can be used for isolation of patients with COVID-19. If the isolation room is not available, patients should dialyze during the last shift and at the end of a row or in a corner at least 6 feet away from other patients. If there is more than 1 suspected or confirmed COVID-19–infected patient at a dialysis center, all such patients should receive dialysis during the last dialysis shift. The same health care personnel staff should dialyze patients with suspected or confirmed COVID-19 to avoid cross-contamination and infection. In dire circumstances of HD nursing staff shortage, a fast credentialing and accreditation for nurses should be in place. All dialysis machines, dialysis stations, and chairs should be disinfected per protocol. Telemedicine should be used for physicians’ visits when applicable. All dialysis patients, mainly in inpatient sites, should be instructed to have strict potassium and fluid restriction to avoid the need for added treatment sessions.15Meyer T.W. Hostetter T.H. Watnick S. Twice-weekly hemodialysis is an option for many patients in times of dialysis unit stress.J Am Soc Nephrol. 2020; 31: 1141-1142Crossref PubMed Scopus (29) Google Scholar If there is a of outpatient HD patients with COVID-19, a unit for them minimize exposure to the HD population and health care personnel. 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Coco M. hemodialysis patients with outcomes in the New 2020; 1: Scopus Google et al.Clinical characteristics of and medical for COVID-19 in hemodialysis patients in Wuhan, Am Soc Nephrol. 2020; 31: PubMed Scopus Google Scholar shows outcomes of in HD patients with in HD Patients of HD of report for in the Vol accessed: October 23, 2020Google et S. et of COVID-19 in an dialysis Am Soc Nephrol. 2020; 31: PubMed Scopus Google et E. et report from the on the characteristics and of hemodialysis patients with SARS-CoV-2 2020; Full Text Full Text PDF PubMed Scopus Google et M. M. M.H. E. Coco M. hemodialysis patients with outcomes in the New 2020; 1: Scopus Google et et al.Clinical characteristics of and medical for COVID-19 in hemodialysis patients in Wuhan, Am Soc Nephrol. 2020; 31: PubMed Scopus Google COVID-19, coronavirus disease in a COVID-19, coronavirus disease dialysis and home HD patients can also be by COVID-19, there is limited to these of patients can their KRT at this risks of exposure and them to practice social is vital to any with the delivery of supplies to those receiving home dialysis More than have been initiated on KRT since In standard patients for KRT requires of to include education on KRT modalities, outpatient visits for with surgical for for and time to for to outpatient visits are and and procedures are during the it is essential to that patients with chronic kidney disease KRT are an vulnerable On the Centers for that for patients with end-stage kidney disease an essential Disease to COVID-19. 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In this time of a public health it is essential to transmission and use in caring for dialysis patients to avoid any in their usual

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