Coronavirus and Dialysis Patients: Where is the Contingency Plan?
There are more than 650,000 Americans with kidney failure, of which over 460,000 are on dialysis. By any measure, this is an extraordinarily vulnerable population. The coronavirus will likely not spare this population. Why?
The potential susceptibility of dialysis patients to COVID-19 includes multiple comorbidities such as diabetes, hypertension, and cardiovascular disease, as well as older age (about one-third of patients are more than 60 years of age) and lower socioeconomic settings than average Americans. Still, the real risk is that most dialysis patients undergo treatment in one of more than 5000 dialysis units where they spend 3 days each week often for 3 to 4 hours for each treatment. These centers could become focal points for both exposure and spread.
The challenge is not in just managing a dialysis patient who is discovered to be sick from the coronavirus; that patient would be hospitalized and isolated. Of course, if the burden of patients were very high, hospitals could struggle, because of limitations to the number of ICU beds. The critical problem is what to do with patients and staff in the dialysis unit who have been exposed. The dialysis unit could be an unfortunate incubator of infection among both staff and the remaining patients. For sure, under ordinary circumstances, the dialysis staff—nurses, technicians, and doctors—and the other dialysis patients would ordinarily be told to self-quarantine for 2 weeks until they test negative. But then how and where would dialysis be provided? The coronavirus epidemic is poised to test every aspect of care in our dialysis unit.
There is a very “Nero fiddled while Rome burned” feel to the planning that has (or not) happened. What’s needed is for Medicare to take the initiative and bring together the leaders of dialysis care from DaVita, Fresenius, US Renal Care, Dialysis Clinic Inc., and American Renal Associates who represent the vast majority of dialysis facilities in order to develop an action plan. Physicians, technicians, and nurses who provide dialysis care should also be represented. Medicare could force this planning because it largely funds dialysis in the United States and provides oversight from a regulatory perspective. A contingency plan needs to be formulated, and it needs to be done urgently.
One possibility that Medicare could consider is to identify coronavirus dialysis units where exposed patients would be treated. Patients would come from home to these dialysis units and then go back home and remain quarantined. The staff taking care of these patients would only manage coronavirus patients and no one else. After the epidemic has subsided, patients could go back to dialysis units free of coronavirus (clean units). Staff would need to test for coronavirus and depending on the result, two weeks of quarantine might be necessary before they rejoin the workforce. To accomplish this reorganization of dialysis care will require urgent conversations and action across provider networks, insurance providers, and physician coverage.
I have talked with colleagues and, at least so far [as of early March], no plan is in place. Accessing the websites of ESRD networks in the United States, the specialty societies, and the dialysis providers yields very little information. I am aware that the major dialysis providers have had internal meetings, but contact across providers has not happened. Medicare could force these conversations. The time to do this is now.