key: cord-278971-tb2he1cb
authors: Valeri, Anthony
title: COVID-19 and ESRD: Entering a New Era of Uncertainty
date: 2020-07-25
journal: Kidney Int Rep
DOI: 10.1016/j.ekir.2020.07.020
sha: 
doc_id: 278971
cord_uid: tb2he1cb

nan

The SARS-CoV-2 (COVID-19) pandemic has raised our awareness of the susceptibility to certain members of the population to this serious and often fatal infection. Across the globe, over 5.8 million cases have been confirmed and over 360,000 death reported as of the end of May 2020. Some areas have been particularly hard hit (the so-called epi-centers of the pandemic) and certain populations within these epi-centers have been particularly affected. Witness to this is those living in skilled nursing facilities (SNF). A report from King County, WA, found that as of mid-March 2020 in one SNF, over 100 residents became infected with 55% requiring hospitalization with a case fatality of about 34% (1). Forbes magazine recently reported that 42% of the deaths from COVID-19 in the U.S.A. were in SNF despite the fact they represent only 0.6% of the total U.S. population. And in some states in the U.S., they account for about 70-80% of all the deaths attributed to COVID-19 and about 70-95 deaths per 1,000 SNF residents. This has been attributed to risk factors that include an older population often with multiple co-morbid medical conditions, including diabetes, hypertension and cardiovascular disease. It is also attributed to the need for close cohorting of patients to receive needed care and supervision and, thus, the inability to practice social distancing. These concerns apply to the end stage renal disease (ESRD) population around the world as well. In the U.S. alone, over 62,000 healthcare workers have also become infected with a death rate of 0.5%. In Wuhan, China, 12% of the dialysis center staff at Renmin Hospital contracted COVID-19, while in Lombardy, Italy a 33% infection rate was reported among the hospital dialysis staff (2) (3) .

To that end, we have four reports published in Kidney International Reports from Wuhan, China, the Lombardy region of northern Italy, London, England and Paris, France (2-5) detailing their early experience with COVID-19 outbreaks affecting ESRD patients at outpatient dialysis facilities and leading to a large number resulting in hospitalization and, often, death, similar to our experience in New York City (6) .

Based on the aggressiveness of testing, these reports show an infection rate of 11-26% among ESRD patients. Three of these reports found that about 24-27% of ESRD patient who tested positive had expired, except for one report (from London, England) that found only a 9% death rate (but an approximately additional 20% of their cohort were still hospitalized at the time of the report). This is compared to the global death rate of about 4% as of the mid-July 2020. In comparison, upon routine screening of all patients regardless of symptoms, a study in over 1,500 ESKD patients in the epicenter of the outbreak in Wuhan and the nearby Guandong province in China reported only a 0.32% rate of active infection by RT-PCR of nasopharyngeal swabs and only a 3.3% rate of recent infection by serologic antibody testing (7) .

A recently published study in N.E.J.M. by Arons et al found that in a SNF in King County, WA, (one of the first "hot spots" and epicenters of the pandemic in the USA), widespread testing demonstrated that about half of the infected residents were asymptomatic at the time of testing and likely contributed to the outbreak at that facility (8) . Taking this and the lessons from hospital facilities, the use of personal protective equipment (for both patients and staff) and the cohorting of patients has helped to lessen the spread of the virus among susceptible individuals as demonstrated in the reports and others from London, England, the Lombardy region, Italy and Wuhan, China (9, S1).

An additional area of concern is the high incidence of AKI in COVID-19 infected patients requiring hospital resources that strain not only ICU and ventilator capacity, but also renal replacement resources, including both conventional hemodialysis and continuous renal replacement resources. One study found AKIN, stage 3 to develop in 31% of hospitalized COVID-19 patients with 14.3% requiring renal replacement therapy (RRT), of which 96.8% were also in the ICU requiring ventilator support, while another study in a survey of nearby hospitals in NYC found 20-40% of ventilated ICU patients with COVID-19 to require RRT (S2-S5). This can exhaust a hospital's capacity to provide either form of RRT. One temporizing measure is reported in this issue of KI Reports by the use of acute peritoneal dialysis in patients with AKI (S6).

Since we do not know what the future holds for our race as a whole in terms of repeated outbreaks or annual resurgence of this or a mutated virus, the success of vaccinations or future pandemics, we may have entered into a new norm of infection control measures to help stem any outbreaks among the most fragile of us and to have the resources in reserve to handle such outbreaks.

Supplemental material can be found on the KI Reports' web site.

for the Public Health-Seattle and King County, EvergreenHealth, and CDC COVID-19 Investigation Team. Epidemiology of COIVD-19 in a Long-term Care Facility in King County

Epidemiological, Clinical, and Immunologic Features of a Cluster of COVID-19 Contracted Hemodialysis Patients

COVID-19 Outbreak in a Large Hemodialysis Centre in Lombardy

Delivering Dialysis During the COVID-19 Outbreak Strategies and Outcomes

COVID-19 in Patients on Maintenance Dialysis in the Paris Region: A Single-center Experience

Presentation and Outcomes of patients with ESRD and COVID-19

The Cumulative Rate of SARS-CoV-2 Infection in Chinese Hemodialysis Patients

for the Public-Heath-Seattle and King County and CDC COVID-1-Investigation Team. Pressymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility

Mitigating Risk of COVID-19 in Dialysis Facilities