Renal Replacement Therapy (RRT) Used Successfully in Ebola Case
Physicians provided details of the first successful delivery of RRT to a patient with Ebola.
PHILADELPHIA—At the annual Kidney Week meeting, physicians provided details of the first successful delivery of renal replacement therapy (RRT) to a patient with Ebola virus disease (EVD) and offered advice on how to administer RRT safely in such cases.
The patient acquired EVD while working at an Ebola treatment unit in the West African nation of Sierra Leone and was transported to Emory University in Atlanta. Speaking before meeting attendees, Michael J. Connor, Jr., MD, and Harold A. Franch, MD, both of Emory, described the case and the protocol used for the patient's care. Dr. Connor and Dr. Franch, as well as other clinicians, described their experience in a paper published online ahead of print in the Journal of the American Society of Nephrology (JASN) to coincide with the Ebola session.
“In our opinion,” Dr. Connor said, “this report confirms that with adequate training, preparation, and adherence to safety protocols, renal replacement therapies can be provided safely and should be considered a viable option to provide advanced supportive care in patients with Ebola.”
Dr. Franch, a nephrologist who oversaw the delivery of RRT to the patient, noted that extra training of volunteer intensive care unit nurses made success possible. “We thank them for their bravery and commitment,” he said. “Our case also shows that dialysis is not a death sentence for patients suffering from Ebola virus disease and recovery of kidney function is possible.”
According to the JASN report, despite aggressive supportive care with intravenous fluids and experimental antiviral treatments, the patient developed hypoxic acute respiratory failure and acute kidney injury (AKI) secondary to acute tubular necrosis on day 8 of illness. On day 11, continuous RRT (CRRT) via a non-tunneled temporary right internal jugular dialysis catheter was initiated.
As the patient's overall clinical condition improved, he was transitioned to prolonged intermittent RRT performed for 6–12 hours daily using the CRRT device. Renal function recovered, allowing for RRT discontinuation after 24 days, with a steadily improving estimated glomerular filtration rate to 33 mL/min/1.73 m2 7 days after RRT discontinuation.
Dr. Connor told listeners that he and his colleagues recommend CRRT for initial treatment because it minimizes exposure of additional staff and equipment to the isolation environment. The right internal jugular vein is the preferred access site based on KDIGO recommendations, as it tends to have superior performance and the internal jugular sites typically have the lowest bleeding risk.
CRRT effluent presents a very low infection risk, Dr. Connor said, but, given that it is handled in an Ebola positive environment, it was treated at Emory as hazardous and disposed of in a similar manner.
Another speaker, Sarah Faubel, MD, professor of medicine at the University of Colorado School of Medicine at the Anschutz Medical Campus, and chair of the American Society of Nephrology's AKI Advisory Group, summarized recommendations for developing an EVD protocol, emphasizing that the best protocol is one that incorporates center-specific expertise.
“The right protocol at one center is not going to be the same as the right protocol at another center,” Dr. Faubel stressed. “Trust what your understanding [is] about how this disease is transmitted, trust your expertise about providing renal replacement therapy, and come up with the best plan at your institution.”
Before doctors can start thinking about dialysis, she noted, their institutions have to be prepared. Among other measures, hospitals need to have a biocontainment unit and protocols for protecting healthcare workers, deciding who is going to care for EVD patients, and disposing of waste materials.
She emphasized that nephrologists must be involved early in the development of an Ebola treatment protocol, and introduction of new procedures should be kept to a minimum. “If you haven't done regional citrate, the Ebola patient is not the first place to try it,” she said.
Developing an Ebola Protocol
Sarah Faubel, MD, professor of medicine at the University of Colorado Denver, and chair of the American Society of Nephrology's Acute Kidney Injury Advisory Group, summarized 5 main considerations for developing a renal replacement therapy protocol for handling Ebola cases.
- Dialysis Modality - The best modality probably is continuous renal replacement therapy (CRRT), and hospitals should have a CRRT machine dedicated to the care of Ebola patients.
- Line Placement - The optimal place for line placement is probably the right internal jugular vein, Dr. Faubel said. Placement of a line in that vein must be checked with an x-ray, so if no dedicated x-ray machine is available, the right internal jugular vein may not be a good choice, and a femoral approach may be a better option, she said.
- Dialysis Effluent - Effluent is highly unlikely to contain Ebola virus, she said. Although the Centers for Disease Control and Prevention said effluent does not need to be disinfected, hospitals should check with the local wastewater department and public health officials.
- Anticoagulation - Clinicians should use the anticoagulation approach with which they are comfortable at their facility, but modifications may need to be made based on the laboratory tests that are available.
- Laboratory tests - Ebola patients will require point-of-care testing, so not all laboratory tests will be available, especially phosphorus testing. “You're also going to have to think about how frequently you check those labs,” Dr. Faubel said. “In CRRT, we usually check a lot of labs, but you don't want your healthcare workers to be doing too many blood draws because that's blood exposure. So you're probably going to reduce the number of lab checks, and you may have to do empiric electrolyte replacement.”