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 novel coronavirus (COVID-19) epidemic that is increasingly gripping the United States will not spare this population.
The potential susceptibility of dialysis patients to coronavirus includes multiple comorbidities like diabetes, hypertension and cardiovascular disease, older age—about one-third of patients are over 60 years of age, and lower socio-economic 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 Centers for Disease Control and Prevention (CDC) issued recent guidelines on how to manage a dialysis patient suspected of coronavirus1. Quoting from the guideline: “Facilities should maintain at least 6 feet of separation between masked, symptomatic patients and other patients during dialysis treatment. Ideally, symptomatic patients would be dialyzed in a separate room (if available) with the door closed.” Dr. Shannon Novodad from the CDC similarly discussed these guidelines in a webinar organized by the ASN2. The guidelines suggest that every effort should be made to keep dialyzing patients within the dialysis unit not send them to the hospital. Yet if an infected symptomatic dialysis patient was sent to the hospital, most facilities would place an infected patient in an airborne infection isolation room (AIIRs) if one were available.
Managing a symptomatic highly contagious patient with COVID-19 is fraught with risk to other non-infected patients and to staff—not too dissimilar to being on a cruise boat. The dialysis unit could be an unfortunate incubator of infection. As well, under ordinary circumstances, the dialysis staff would ordinarily be told to self-quarantine for 2 weeks if they were exposed, because they could spread the disease in the community. But how and where would dialysis be provided if the staff is furloughed? The coronavirus epidemic is poised to test every aspect of care in our dialysis unit.
What’s needed is cohorting of patients in “coronavirus only” units. Coronavirus positive patients who are ill, especially if they are at high risk (older, diabetics, immunocompromised), would be sent to the hospital. The remainder, with milder disease, would dialyze in dedicated units coming to the unit in dedicated “for-coronavirus-only” transportation and then going back home where they would remain quarantined. The staff taking care of these patients would only manage coronavirus patients and no-one else. Staff in coronavirus dedicated units would also quarantine at home. After the epidemic has subsided, staff would need to test for coronavirus, and depending on the result, could return to the workforce.
To accomplish this reorganization of dialysis care will require urgent conversations and action across provider networks, insurance providers and physician coverage. Medicare and the CDC should 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 majority of dialysis facilities in the US so that an action plan can be developed. Physicians, technicians and nurses who provide dialysis care should also be represented. Medicare could force this planning because it largely funds and regulates dialysis in the US. Some might say this is making a mountain of a molehill, but I would argue that uncontrolled infection by the novel coronavirus could be devastating to our dialysis population. A contingency plan needs to be formulated, and it needs to be done urgently.
Read More from Dr. Singh in his most recent DocWire Nephrology Times Article below.
Should patients stop ACE inhibitors (ACEi) and Angiotensin blockers (ARBs) to reduce their risk of COVID-19 infection?
- Interim Additional Guidance for Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed COVID-19 in Outpatient Hemodialysis Facilities. https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/dialysis.ht
- https://www.asn-online.org/g/blast/files/ASN_COVID-19_webinar_combined_slides_03.11.2020_Final.pdf Slide 14-46