Geographical Updates on Management of COVID-19 Patients with Kidney Disease

Report authors Dr Anna Francis, Dr Sethu Madhavan, Professor T Alp Ikizler, Associate Professor Germaine Wong, Professor Pierre Ronco, Professor Vivek Jha

Introduction
Since the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Wuhan in December 2019, there has been rapid global spread culminating in the World Health Organisation declaring a global pandemic on March 11, 2020. As of April 16, 2020, over 2 million confirmed cases have occurred in 210 countries and territories, with 137,000 deaths. After the initial epicentre of Wuhan, Italy, Spain, France, the United Kingdom and the United States have been heavily affected with grave concerns held for the impending impact of COVID-19 in developing countries.

The nephrology community recognises their (mostly older) end stage kidney disease patient population are particularly vulnerable, as older people with chronic disease face increased risks of mortality and the necessity of regular hospital visits increases the risk of contracting the virus. In regions where vast numbers of cases have been recorded, health systems are strained to, and beyond, capacity.

The International Society of Nephrology and Kidney International, the ISN Journal, undertook a survey of nephrologists around the globe as represented by the ten ISN Regions, inquiring about the impact of COVID-19 on dialysis patients and staff and health system responses to the pandemic specific to dialysis.

COVID-19 poses an unprecedented threat to the modern world. Every region of the globe is affected, and dialysis services are particularly hit, with an unwell older population at increased risk of infection and mortality. Most haemodialysis patients are dialysed in centre and hence these patients are unable to self isolate, substantially increasing their risk of infection. Peritoneal dialysis patients may be less affected as they are better placed to practice social isolation.

The nephrology workforce is stretched, with an increased workload in both outpatient dialysis and inpatient consults for acute kidney injury secondary to COVID-19 infection. Healthcare workers are also falling ill or needing to be quarantined, further depleting the workforce at this time of increased need. Despite the significant psychological burden, centres around the world celebrate the resilience of their staff and their determination to care for their patients as best as possible.

Globally, mitigation strategies in dialysis units include:

  • Temperature checking and health screening of staff and patients prior to entering units
  • Cohorting (spatially and temporally) patients with suspected and proven COVID-19
  • Maintaining social distancing within units, where possible
  • PPE for staff when dealing with COVID-19+ or suspected patients
  • Differing rules about the wearing of face masks for asymptomatic in-centre dialysis patients
  • Educating patients on signs of COVID-19, social isolation and handwashing
  • The use of telehealth in place of physical reviews

Major challenges reported include:

  • Vastly increased workload with decreased staffing capacity
  • Lack of test kits
  • Lack of widespread testing, especially in outpatient facilities
  • Initial false negatives with earlier test kits
  • Lack of PPE
  • Difficulties in transporting patients to and from dialysis when there is a lockdown
  • Increased demand on dialysis services mean some centres have decreased number of sessions or number of hours per session for chronic haemodialysis patients

The rapidly evolving crisis of COVID-19 continues to imperil our vulnerable dialysis population. The ISN thanks all contributors for providing insights on current regional situations and responses the pandemic.

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