As a pandemic of a novel coronavirus illness called COVID-19 continues to widen globally, including in the United States, dialysis facilities have stepped up precautions to protect patients with kidney failure from the pathogen, which can cause severe respiratory illness and death.

Dialysis patients could be particularly hard hit by COVID-19 because of their high prevalence of underlying and debilitating health problems.

The Centers for Disease Control and Prevention (CDC) and the American Society of Nephrology (ASN) have issued recommendations to prevent transmission of the virus in dialysis facilities. The National Kidney Foundation, which converted its 2020 Spring Clinical Meetings in New Orleans into a live-virtual conference because of the virus, issued a press statement urging patients on dialysis not to skip treatments.

Of the 743,624 individuals in the United States with kidney failure as of December 31, 2017, 468,086 (62.9%) received hemodialysis, with 98% of them undergoing the treatment inside dialysis facilities, according to the US Renal Data System. Physicians at the University of California Irvine reported one of the first US cases of COVID-19 in a hemodialysis patient. Although the extent to which dialysis patients have been impacted was unclear as this issue went to press, Jeffrey Giullian, MD, Chief Medical Officer at DaVita Inc., one of the largest providers of dialysis treatment in the United States, told Renal & Urology News that, as of the week of March 16, “we have less than 15 patients who have tested positive for the virus.”


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Underlying kidney disease common

Kidney disease has emerged as a common underlying chronic condition in individuals stricken with the virus. For example, among 81 residents of a long-term care facility in Washington State diagnosed with COVID-19, kidney disease was the third most common underlying chronic condition (present in 43.2% of residents) after hypertension (69.1%) and cardiac disease (56.8%), according a report from the CDC. In addition, a recent study by investigators in Wuhan, China, source of the first COVID-19 reports, suggests that the coronavirus may attack the kidneys. The study included 710 hospitalized COVID-19 patients with a median age of 63 years. Of these, 89 (12.3%) died in the hospital, the investigators reported in medRxiv. On admission, 44% of patients had proteinuria and hematuria, 26.9% had hematuria, and 15.5% and 14.1% had elevated serum creatinine and blood urea nitrogen, respectively. Acute kidney injury developed in 3.2% of patients. “Clinicians should increase their awareness of kidney impairment in hospitalized COVID-19 patients,” the authors concluded.

COVID-19 is short for coronavirus disease 2019, the name the World Health Organization (WHO) gave to the illness caused by the virus. Symptoms include fever, cough, and shortness of breath. The virus has spread to many countries outside of China, with Iran, South Korea, and Italy particularly hard hit.

DaVita and Fresenius Medical Care North America, the companies that provide dialysis services for the vast majority of patients with kidney failure in the United States, started preparing for COVID-19 soon after reports of the illness surfaced.

“DaVita has been closely monitoring the COVID-19 situation since January,” Dr Giullian said. “At that time, we launched dual task forces, one for our US operations and the other for international. On the domestic front, we have been working with the CDC, ASN, and KCER [Kidney Community Emergency Response program] to ensure proper prevention efforts as well as contingency plans in the event of a larger scale outbreak.”

DaVita provides outpatient care to in-center and home dialysis patients across the United States as well as to in-patients at more than 900 hospitals, Dr Giullian said. For this reason, the US task force has focused on securing ample supplies, including personal protective equipment such as gloves and masks.

DaVita also is working proactively with its pharmaceutical distributor to ensure ongoing access to critical medications, he said.

“DaVita has been proactive in educating our teammates and patients regarding the COVID-19 situation, including efforts around prevention and response,” said Dr Giullian. “We do expect to see an uptick in vocalized concerns by our patients and their family members.”

Fresenius also reports taking vigorous efforts to protect patients and staff from the virus. “We are acutely aware of the danger of COVID-19 to our patient population, as well as the importance of protecting the health of our staff if the virus continues to spread,” said Jeffrey Hymes, MD, Chief Medical Officer for Fresenius Kidney Care. “In an abundance of caution, we have taken many steps over the past 2 months to prepare.

In January, we instructed all our clinics to begin preparation, including the ordering of protective masks, and had [staff] conduct pandemic exercises overseen by our disaster response team. As the COVID-19 outbreak continues to spread, we have implemented additional detailed guidance and procedures in our clinics to protect patients and staff.” Most importantly, he said, Fresenius has re-issued detailed guidance to its clinical staff on the continued importance of strict adherence to infection control policies and procedures.

Safety recommendations

The CDC recommends that patients and visitors be screened for symptoms of acute respiratory illness (eg, fever cough, difficulty breathing) prior to entering healthcare facilities. CKD also recommends that dialysis facilities maintain at least 6 feet of separation between masked, symptomatic patients and other patients during dialysis treatment.

The CDC also advises facilities to have supplies positioned close to dialysis chairs and nursing stations to ensure adherence to hand and respiratory hygiene and “cough etiquette.” These include tissues and no-touch receptacles for disposal of tissues and hand hygiene supplies such as alcohol-based hand sanitizer. ASN recommends that outpatient dialysis facilities ensure rapid triage and isolation of patients with symptoms of suspected COVID-19 or other respiratory infection, such as cough or fever. Patients with symptoms of suspected COVID-19 should not be allowed to wait among other patients seeking care.