Dialysis Frequency Can Be Safely Reduced During Pandemic Under Certain Conditions

By Megan Brooks

December 18, 2020

NEW YORK (Reuters Health) - To reduce the risk of COVID-19 exposure and transmission between patients, a large renal service in the U.K. safely converted some of their hemodialysis patients from three to two weekly dialysis sessions.

"Dialysis-frequency reduction is only safe if the decision to reduce dialysis frequency is a shared decision made with the patient (and) there should be no delays or barriers in the re-institution of thrice-weekly dialysis," Dr. James Tollitt of Salford Royal NHS Trust told Reuters Health by email.

"This process," he added, "can only occur if there is real-time monitoring of patients' dialysis parameters and biochemistry blood tests."

Just before the peak of the COVID-19 pandemic, nephrologists at the dialysis unit identified 166 suitable patients (38.4% of the total hemodialysis population) to temporarily convert from thrice- to twice-weekly hemodialysis.

Throughout the month-long project, providers recorded changes in pre-dialysis weight, systolic blood pressure (SBP) and biochemistry on a weekly basis.

In a report in BMC Nephrology, the clinicians report that, as the weeks progressed, there was a significant increase in median SBP and potassium for those who remained on the twice weekly dialysis regime.

However, at the end of the four weeks, 113 (68.1%) patients were still receiving twice-weekly hemodialysis. "This resulted in 452 fewer dialysis sessions potentially minimizing 452 potential exposures to COVID-19 both during dialysis and on transport to and from the units," they note.

They elected to transfer 28 patients back to thrice-weekly dialysis during the four weeks. Indications for transfer back to thrice-weekly dialysis were fluid overload (19 patients), persistent hyperkalemia despite use of binders (four), patient request (four) and compliance (one).

There were 12 deaths in the entire hemodialysis population during the study period including six on twice-weekly hemodialysis. However, no deaths were directly related to twice-weekly dialysis.

"This analysis found that the majority of patients who are deemed suitable to temporarily convert to twice weekly dialysis were able to safely dialyze twice weekly for at least one month during the COVID-19 pandemic, enabling safer grouping of patients to reduce potential viral exposure and transmission and ease service demands which may have been exacerbated by staff sickness," Dr. Tollitt and colleagues write in their paper.

"The best candidates for temporary conversion to twice weekly dialysis include patients who require lower amounts for fluid removal on each dialysis session (highlighting that their own kidneys are removing some fluid and toxins in between dialysis sessions)," Dr. Tollitt told Reuters Health by email.

"Similarly, we know that high potassium is dangerous for dialysis patients. Patients whose predialysis potassium is consistently within the normal range may be suitable for twice weekly dialysis. Thirdly we highlighted that patients who are older may be more suitable for twice weekly dialysis therapy," he said.

Dr. Ankur Shah with the Division of Kidney Diseases and Hypertension at Warren Alpert Medical School of Brown University, in Providence, Rhode Island, said the authors demonstrate that the current "one-size fits all approach of thrice-weekly dialysis may not be necessary for all patients."

"The authors selected a group of patients in whom dialysis twice a week was considered likely to be successful," he told Reuters Health by email. "Unsurprisingly, the group receiving twice-weekly dialysis looked very different from the group that continued to receive thrice-weekly dialysis. Notably this group already had a small number of patients dialyzing twice weekly, they had experience with this format of dialysis. They monitored patients closely for elevations in blood pressure, fluid overload, and increases in solutes typically cleared by dialysis."

"Patients receiving dialysis twice a week largely still had some function from their native kidneys, required less fluid removal on dialysis, and had very well-controlled labs. This group would be the most likely to successfully transition to twice-weekly dialysis. They did notice that the group receiving dialysis twice a week did see increases in blood pressure and potassium levels in blood, close monitoring would be advised if decreasing dialysis intensity," Dr. Shah said.

"Most importantly, there was no difference in mortality," he noted.

"As the pandemic progresses and dialysis resources become more and more scarce, alternate dialysis strategies are more and more likely to be needed. Be it twice weekly hemodialysis, more-frequent short hemodialysis sessions at home, or peritoneal dialysis; it is great to see innovation and guidance," Dr. Shah said.

The study had no specific funding and the authors have indicated no conflicts of interest.

SOURCE: http://bit.ly/38cNwht BMC Nephrology, online December 7, 2020.