Dialysis Should Continue Despite COVID-19; CDC Gives Guidance

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Updated guidance from the US Centers for Disease Control and Prevention (CDC) details key strategies for managing patients who have COVID-19 on renal dialysis — a population whose unique vulnerability is underscored by the fact that the first two patients in the United States known to have died from COVID-19 were in fact outpatients at dialysis centers in the Seattle area.

"The first reported death (from COVID-19) in the United States occurred in one of our dialysis patients," said Suzanne Watnick, MD, chief medical officer of Northwest Kidney Centers, in Seattle, Washington, speaking about the latest CDC guidance during a webinar by the American Society of Nephrology.

The second identified death of a COVID-19-positive patient in the United States had also been treated at a kidney dialysis center.

Elizabeth McNamara, RN, chief nursing officer of Northwest Kidney Centers, who also presented during the webinar, noted the patient had ties to the nursing home in Kirkland, Washington, that has been the epicenter of a larger COVID-19 outbreak — the first in the United States.

Shannon Novosad, MD, MPH, acting team lead for the CDC's Dialysis Safety Team, told Medscape Medical News that, as of Wednesday this week, no larger reports of dialysis center outbreaks have been reported.

"In the United States, we have seen some scattered reports and we know...a handful of people who have become COVID-19 positive are dialysis patients, but we haven't had any reports of any widespread transmissions among dialysis patients in any specific area — but we're staying alert," she observed.

Amid the ever-increasing alarm, however, is the key message to dialysis centers of the need to balance strict precautions while making sure patients are able to continue dialysis treatment.

"Our guiding principle is first and foremost to make sure patients are coming to dialysis," Watnick emphasized.

"Message out to your group — make sure that not just the patients and their families but all of your staff know that patients should continue coming in to get their treatment," she stressed.

Additional Guidance From the CDC

The new CDC guidance for dialysis centers provides additional updates that are meant to complement but not replace the general CDC guidelines on interim infection prevention and control.

Recommendations on the recognition and isolation of individual staff members with respiratory infections include that centers should implement sick leave policies that are flexible, nonpunitive, and allow ill healthcare personnel to stay home.

For patients, efforts should be made to identify those with signs and symptoms of respiratory infection, such as fever and/or cough, before they even enter the treatment area, the guidelines recommend. Measures should include:

Instructing patients to call ahead to report fever or respiratory symptoms so the center can be prepared for their arrival or to triage to a more appropriate setting, such as an acute care hospital.
Patients should be asked to inform staff of fever or respiratory problems immediately upon arrival at the facility.
Those with symptoms of a respiratory infection should be provided with a facemask at check-in and instructed to wear it until their departure.

In addition, all patients and healthcare personnel should be instructed, in appropriate languages, about hand hygiene, respiratory hygiene, and cough etiquette, including instruction on how to use facemasks and tissues to cover nose and mouth when coughing, and proper disposal of tissues and contaminated items, the guidance states.

And signs should be posted throughout dialysis facilities reminding patients to inform staff of fever or symptoms of respiratory infection.

Supplies for hand and respiratory hygiene and information about cough etiquette should be placed in close proximity to dialysis chairs and nursing stations.

Patient Placement — Wait in the Car?

The CDC guidance recommends that for medically stable patients facilities give the option of waiting in a personal vehicle or outside the facility and to be contacted by mobile phone when they are ready to be seen.

Dialysis facilities should have space allocated to allow patients who are ill to sit separately from other patients by at least 6 feet.
Patients experiencing respiratory symptoms should promptly be taken to appropriate treatment areas to reduce time in waiting areas.
For those with symptoms, ideally, dialysis treatment should be provided in a separate room from other patients, with the door closed.
If a separate room is not available, the masked patient should be treated at a corner or end-of-row station not near the main traffic flow. A separation of at least 6 feet should be maintained between masked, symptomatic patients and other patients during treatment.
Use of hepatitis B isolation rooms should only be considered for patients with respiratory symptoms if the patient has hepatitis B or if no patients treated at the facility have hepatitis B.

Healthcare personnel caring for patients with undiagnosed respiratory infections should further observe standard contact and droplet precautions with eye protection unless a suspected diagnosis such as tuberculosis requires airborne precautions, according to the guidance.

Precautions should include using gloves, facemasks, eye protection, and isolation gowns.

When COVID-19 Is Suspected or Confirmed in a Hemodialysis Patient

When a patient receiving hemodialysis at the center is suspected or confirmed to be positive for COVID-19, health department officials should be notified and healthcare personnel should follow CDC recommendations for those patients in healthcare settings.

Should a facility have more than one patient with suspected or confirmed COVID-19, the center should consider cohorting or grouping these patients and the healthcare personnel caring for them together in the same section of the unit and/or on the same shift, such as the last shift of the day, according to the CDC guidance.

However, if patients with respiratory symptoms have different etiologies, cohorting is not recommended.

Routine Cleaning Is Appropriate as Situation Rapidly Evolves

The guidance notes that routine cleaning and disinfection for COVID-19 are appropriate in dialysis settings. All surfaces, supplies, or equipment located within 6 feet of symptomatic patients should be disinfected or discarded.

The list of disinfectants qualified under the emerging viral pathogens program of the Environmental Protection Agency (EPA) for use against SARS-CoV-2 is available on the EPA website.

The CDC also issued updates this week to guidance on recommendations for patients with suspected or confirmed COVID-19 in all healthcare settings, including updates to personal protective equipment recommendations and considerations for designing entire units within a care facility for known or suspected COVID-19 patients.

Alan Kliger, MD, clinical professor of medicine at the Yale School of Medicine, in New Haven, Connecticut, who also presented during the American Society of Nephrology webinar, underscored the key caveat in all recommendations is the rapid fluidity of the response to COVID-19.

"This is a quickly evolving situation that we're all living through. The [recommendations] have evolved in the past week and a half, and surely will continue to evolve as the next days and weeks go by," he said.

Currently Cited Mortality Rate for COVID-19 "Likely Higher Than Is Real"

Kliger noted that, in addition to those who are elderly and with chronic diseases such as diabetes and heart disease, patients with chronic kidney disease are also suspected to be at higher risk of succumbing to COVID-19.

But on an encouraging note, Kliger added that the current mortality rate cited for COVID-19, estimated to be 2%-3%, is “likely higher than is real.”

"The reason for this is we know about people who have died with this infection, but the denominator — the number of people infected — is probably an underestimate since in China, the United States, and other places the test kits have not been widely used, largely because many of these infections are mild or asymptomatic."

In comparison, he noted mortality rates for other recent pandemics include SARS at 9.6%, MERS at 34%, recent influenza pandemics at 0.1%, and Swine flu at 0.02%.

CDC. Interim Additional Guidance for Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed COVID-19 in Outpatient Hemodialysis Facilities. Guidance

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