Umbrella Approach to Protect Kidney Patients, Clinicians in COVID-19

Maureen Salamon

July 15, 2020

Although no clear guidelines yet exist to manage patients with advanced kidney disease and COVID-19, nephrologists should watch for atypical presentation of the illness in dialysis and transplant recipients, and should discuss home dialysis as an option with appropriate individuals, among other measures, according to a new editorial published online July 7 in CJASN.

"It's very important to realize we are taking care of a very high risk population that, just by the very nature of dialysis and transplant patients, and their treatments, puts them at very high risk of getting COVID-19 and at worse risk for outcomes because of immunosuppression," said Michal Melamed, MD, MHS, an associate professor of medicine, and of epidemiology population health, at Albert Einstein College of Medicine at Montefiore Medical Center in Bronx, New York City.  

"As their physicians we have to try to do everything in our power to keep them as safe as possible, including universal masking and good hand hygiene," Melamed told Medscape Medical News.

"In an ideal world, we would have rapid COVID-19 testing before people walked into clinics," she urged.

But nephrologists can still address some "bigger issues," she said, such as, "Can we change some of our in-center hemodialysis patients to home therapies, where they don't have to leave their house three times a week and be near other patients?"

And in a Patient Voice article accompanying Melamed's editorial, Nieltje Gedney of West Virginia, says: "The world has become terrifying" for those with chronic kidney disease, on dialysis, or with a transplanted kidney in light of COVID-19.

Gedney said she learns a great deal from reading scientific journal articles about COVID-19 that helps her manage her disease and dialysis treatment.

Atypical Symptoms in Dialysis Patients

Melamed cites two new reports published alongside her editorial in CJASN that examine the health and outcomes of patients with COVID-19 who have received kidney transplants or are on dialysis.

In one study, authors Xiangyou Li, PhD, of Tongren Hospital, Wuhan, China, and colleagues compared 49 hospitalized patients with COVID-19 on dialysis to 52 patients with COVID-19 but without kidney failure.

They found that the most common virus symptoms in patients on dialysis were fatigue and anorexia, while fever, fatigue, and dry cough were the dominant symptoms in the control group. 

Additionally, 14% of patients on dialysis died, compared with 4% of controls. "That study sort of confirmed what we thought — that people with kidney disease are at higher risk of getting more severe disease with COVID-19," Melamed said.

Gedney, a patient, said she hadn't been aware that patients on dialysis hospitalized for the novel coronavirus "didn't necessarily present with the same clinical symptoms as patients not on dialysis."

"As a patient advocate, I would use the data in this and other studies to campaign for regular mandatory [COVID-19] testing of all patients on dialysis presenting for in-center treatments," she writes.

"This study demonstrates that merely testing for fever in the dialysis population is inadequate."

Some Patients Can Manage at Home, Protocols Needed

The other study, by S. Ali Husain, MD, MPH, of Columbia University and New York-Presbyterian Hospital in New York City, and colleagues looked at the outcomes of 41 outpatients with established or suspected COVID-19 who had undergone a kidney transplant.

This group most commonly reported fever, cough, and shortness of breath, but most patients' symptoms resolved without hospitalization, while 32% required hospital care.

The authors said their report "underscores the fact that a comprehensive outpatient monitoring protocol could provide adequate clinical care and excellent outcomes for outpatient kidney transplant recipients with COVID-19 by allowing identification of those individuals who would benefit from inpatient care."

Melamed said nephrologists should discuss with patients the possibility of switching from in-center to home dialysis as a way of lowering these patients' risks of contracting the novel coronavirus.

"Doing dialysis at home puts a lot of responsibility on patients, but also, there are a lot of physicians who may also be more comfortable with in-center hemodialysis," she said. "So I think it's potentially an obstacle for both the patient and physician."

"I don't know the capacity of major dialysis providers to ramp up their home dialysis capabilities, and I don't foresee everybody switching from in-center to home therapies," Melamed noted.

"But there are definitely people who may have been thinking of it in the past, are new to dialysis, or are really scared of getting COVID-19, and this is an option to decrease their risk."

Patients with COVID-19 who are already receiving home dialysis and do not require hospitalization should have certain monitoring equipment on hand to promote proactive care while they have the virus, Melamed said.

This includes a pulse oximeter, a thermometer, a blood pressure cuff, and a glucometer if they also have diabetes.

"I think the main thing is a pulse oximeter to make sure their oxygen level is okay," she said.

"We know not everyone with COVID-19 needs to be in the hospital, but COVID disease starts getting bad about a week into it, with shortness of breath and possible trouble breathing. Those are the things people have to be watching for if they're at home."

Hospitals Should Take Measures to Prepare for Patients

Meanwhile, hospitals are trying to determine how kidney transplants might be resumed safely during the pandemic and how immunosuppression can be adjusted accordingly in transplant patients to minimize their COVID-19 risks, Melamed told Medscape Medical News.

"I think one path forward is trying to do very low risk transplants, where we don't need to use a lot of immunosuppression," she explained.

"I think in addition to home dialysis therapies, getting someone a transplant also gets them out of thrice-weekly center visits. So transplants are important to do if they can be done safely."

Other COVID-related proactive measures hospitals can take to benefit patients with advanced kidney disease include stocking up on potassium binders and other related supplies, she noted.

"In case dialysis becomes scarce, hyperkalemia may need to be managed medically," Melamed said.

Don't Forget Acute Kidney Injury; More Now Known About COVID-19

Melamed also notes that during the pandemic's surge in April and May in New York City, her hospital treated many patients not only on chronic dialysis, but ICU patients who experienced acute kidney injury as a complication of COVID-19.

Hospitals "need to increase their stash of peritoneal dialysis fluids if they need to do emergent peritoneal dialysis and take extreme precautions with staff to keep them safe," she recommended.

"We used baby monitors to keep the nurse out of the room [of COVID-19 patients] as much as possible, because dialysis treatment is 3 hours and you're in a close room with a COVID patient who is breathing," she said.

"So even if you're wearing a mask and an N95, it's still a lot of risk. We tried to minimize the risk of exposure."

Melamed said nephrologists "know a lot more than we did 3 or 4 months ago" about best practices for treating patients with COVID-19 and advanced kidney disease.

But she's not sure how long it may take to develop a formal treatment protocol.

"We know more about when to intubate patients and the need for anticoagulation for patients, because — especially with continuous renal replacement therapy — we found a lot were clotting the circuits and so almost everyone needs to be anticoagulated for continuous dialysis."

But more formal advice is needed. "As time passes, a treatment protocol on the basis of patient characteristics, phase of illness, and disease severity using antivirals, anticoagulation, immunomodulators, and immunosuppressive agents will be formulated," she concludes.

Melamed has declared no relevant financial relationships.

CJASN. Published online July 7, 2020. EditorialPatient Voice

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