COVID-19-associated hemodialysis

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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

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.

Historical perspective

The first reported case of Covid-19 infection in hemodialysis patient in Japan, was a 69 years old diabetic man on maintenance hemodialysis since last 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 had a successful recovery and was discharged on the 19th day of hospitalization.

Classification

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

Pathophysiology

• The pathogenesis of patients on hemodialysis is characterized by low immunity, low-intensity cytokine storm, and inhibition of coagulation cascade.
• Patients with chronic kidney disease or end-stage renal disease have low immunity. The patients on dialysis have a mild clinical course of COVID-19 infection.The 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.
• 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.
• 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.

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.
• 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 study done in 208 acute care hospitals in the UK. It showed chronic kidney disease was one of the most common co-morbidity in hospitalized covid-19 patients.
• 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 case series of 5,700 patients with covid-19 infection performed in 12 hospitals under the Northwell Health system in New York.

Gender

Covid-19 infection affects men and women equally.

Age

• The covid-19 infection among dialysis patients is more commonly observed among patients aged 70 to 90 years old.

Risk Factors

Patients on maintenance hemodialysis and end-stage kidney disease are at an increased risk of contracting the covid-19 infection due to multiple risk factors. These include:

• low immunity
• hypertension
• diabetes
• pulmonary diseases
• cardiovascular diseases

Natural History, Complications and Prognosis

• The prognosis is unclear and the mortality rate is variable ranging from 16 to 29 % in covid-19 infected hemodialysis patients. The prognosis is generally better in hemodialysis patients treated as outpatient compared to hospitalized patients.
• Clinical research was done by Alberici et al. at four outpatient dialysis facilities in Italy showed high overall mortality of 29% (27/94) in dialysis patients.
• 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).

Diagnosis

Diagnosis of Choice

• Hemodialysis patients present with similar chest CT and chest X-ray findings as the general population.
• Patients have radiological findings consistent with pneumonia including peripheral ground-glass consolidation at both lungs.
• Hemodialysis patients present with similar results on reverse transcriptase-polymerase chain reactions.

Symptoms

Presenting symptoms in hemodialysis patients are similar to those of the general population. The hemodialysis patients have a milder clinical course of symptoms. The classic triad of fever, cough and dyspnea may be absent in majority of hemodialysis patients. The symptoms include:

• Fever
• Cough
• Breathlessness
• Fatigue
• Hypoxia: Low oxygen saturation at the time of presentation was associated with worse prognosis and higher mortality.
• Nausea
• Diarrhea
• Abdominal pain

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. Approximately 27 % of covid-19 patients in ICU required prone positioning.
• 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.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 %.

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. 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.

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.
• Suspected covid-19 patients should have at least 6 feet (2 meters) apart from each other in all directions.

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.
• 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.
• 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.
• 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 chairside stand should be cleaned with disinfecting wipes and allowed to be air dry. 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.

Optimum utilization of resources

• As pandemic will be for a long duration, hence resources should be utilized optimally.
• 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.
• 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.
• 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.