key: cord-335838-n1184x8g
authors: Hsu, Caroline M.; Weiner, Daniel E.
title: COVID-19 in Dialysis Patients: Outlasting and Outsmarting a Pandemic
date: 2020-10-13
journal: Kidney Int
DOI: 10.1016/j.kint.2020.10.005
sha: 
doc_id: 335838
cord_uid: n1184x8g

COVID-19 has affected dialysis patients and dialysis patient care worldwide. In this issue of Kidney International, three reports highlight the disproportionately severe impact of COVID-19 on dialysis patients, noting its high prevalence, particularly among in-center dialysis patients. This likely reflects patients’ limited ability to physically distance as well as community exposures, including residence in areas with high rates of infection. Dialysis patients are at extremely high risk should they develop COVID-19, with short-term mortality of 20% or higher. Accordingly, it is imperative that the kidney community intervene to reduce the threat of COVID-19 in the vulnerable population by focusing on modifiable factors, including universal masking of patients and staff and enhanced screening, including testing asymptomatic patients for COVID-19 in times of high local prevalence.

Ten months after the emergence of coronavirus disease 2019 , it continues to devastate health and livelihood worldwide. September 28, 2020 witnessed the bleak milestone of one million deaths worldwide. 1 While COVID-19 has ebbed in some regions, it has surged in others. Within the kidney community, we continue to seek better understanding of how to protect the patients at greatest risk, those who depend on dialysis.

For most of the 2 to 3 million dialysis patients worldwide, 2 kidney failure is their defining chronic illness, their nephrologist is their principal care provider, and the dialysis facility is the site of the majority of their medical care; we in the kidney community therefore have a responsibility to our dialysis patients during this pandemic. In March 2020, as cases surged in Northern Italy, New York City, and elsewhere, rapidly published editorials and guidelines advised on how best to keep dialysis patients safe. [3] [4] [5] These statements rightfully presumed a predisposition for infection due to inability to maintain physical distancing, particularly among those receiving in-center hemodialysis, and predicted worse outcomes due to comorbid conditions and, potentially, kidney failure-associated immunocompromise.

In this issue of Kidney International, three reports highlight the impact of COVID-19 on kidney failure patients in Europe and the United States. Couchoud and colleagues, reporting data from the French REIN registry of maintenance dialysis patients, show that, among dialysis facilities with at least one patient with COVID-19, the COVID-19 prevalence was 6% during the initial 7 week surge in France.

Compared to COVID-19 incidence estimates of 0.2% in the general population, 3.3% of dialysis patients nationwide developed COVID-19, with a nearly two-fold greater risk among in-center hemodialysis patients as compared to home dialysis patients. Critically, the regional incidence of COVID-19 among dialysis patients mirrored the regional incidence in the general population, suggesting a major role for the impact of community spread on infection in dialysis patients. Mortality among dialysis patients with COVID-19 was approximately 20%. 6 This mortality figure is confirmed by Jager and colleagues, who, reporting from the ERA-EDTA Registry, note an approximately 20% mortality rate due to COVID-19 among both dialysis patients and kidney transplant recipients, 7 dramatically higher than the estimated 4% mortality rate overall in Europe among people diagnosed with COVID-19. 1 The third study, by Ng and colleagues, describes the experience of a health system in New York at the height of the first COVID-19 surge, noting that, among 419 dialysis patients hospitalized with COVID-19, 32% died, with a 37% higher adjusted risk of death among hospitalized dialysis patients than other hospitalized patients with COVID-19. 8 Taken together, these studies demonstrate the high COVID-19 risk for dialysis patients, both for acquiring infection and, especially, for poor outcomes once infected, with short-term mortality likely 20% or higher.

In Europe and much of Asia, aggressive steps were taken to control the spread of COVID-19 in the general population, with institution of mandatory physical distancing policies in times of high community spread, implementation of mandatory masking policies, and broad availability of contact tracing and testing, including among asymptomatic individuals, with resultant substantial reductions in mortality. In the United States, implementation of and adherence to public health measures have been inconsistent, with the result that the US still averaged more than 40,000 new cases per day and 750 deaths per day due to COVID-19 in September 2020, 6 months after the initial surge in New York. 1 The US experience, with ongoing regional surges and highly variable adoption of precautions against COVID-19 transmission, highlights that the threat posed by COVID-19 persists and that ongoing sensible steps to limit transmission are critical to protect all people, particularly vulnerable dialysis patients. Therefore, the kidney community must consider how to manage our patients through potentially overlapping J o u r n a l P r e -p r o o f scenarios: prolonged, sustained presence of the virus in the community for months to come and additional surges that again test the limits of existing health systems.

The kidney community, particularly dialysis providers and patients, must remain vigilant. Interventions to mitigate the impact of COVID-19 among the dialysis population apply to three key settings: the dialysis center, transportation to and from the dialysis center, and the communities in which dialysis patients live (Table) . 9 Within dialysis facilities, reasonable precautions can decrease the risk of transmission and facilitate care of dialysis patients with COVID-19, thereby reducing the need for hospitalization and the burden on hospital systems. 10 These include universal mask use among patients and dialysis staff, screening and triage to help identify and rapidly cohort patients with symptoms of or exposure to COVID-19, reduced crowding in hemodialysis facilities including in waiting rooms and staff break rooms, specified treatment areas and protocols for providing hemodialysis to patients under investigation for or with COVID-19, and, in times of higher community prevalence, testing asymptomatic dialysis patients and staff for COVID-19. Critically, dialysis facilities should anticipate a continued need for increased physical space and staffing capacity while the pandemic persists, particularly in areas of ongoing community transmission. Patients need education that they remain at high risk, and that the easing of physical distancing guidelines poses greater risk to them. Transportation to and from dialysis varies greatly around the world; nevertheless, reducing shared rides and mandating sanitation protocols can reduce infection. Lastly, many dialysis patients reside in high-risk communities, such as densely populated urban areas or congregate residences like nursing facilities; 11,12 awareness of the risk posed in these settings and expanded testing of individuals residing in high risk settings can reduce the threat of COVID-19 both to these patients and to the broader dialysis population.

Given the poor outcomes among dialysis patients with COVID-19, prevention is our best weapon.

Critically, the kidney community needs to advocate for inclusion of dialysis and kidney transplant patients in trials of COVID-19 vaccines. The pandemic also has reinforced the critical need to increase treatment of kidney failure with home dialysis and kidney transplantation, modalities that substantially enhance the ability of kidney patients to physically distance.

Improving outcomes among dialysis patients with COVID-19 remains difficult, with management largely supportive. We witnessed the critical need for resource management in April 2020 when the surge in New York City led to shortages of dialysis machines, consumables, and staff. 13 Similar experiences occurred in Italy and elsewhere. In hospitalized COVID-19 patients, the high rate of acute kidney injury requiring dialysis superimposed on the already-high hospitalization rate of maintenance dialysis patients with COVID-19 can strain healthcare systems beyond capacity. In the United States, this has been magnified by the high prevalence of COVID-19 in nursing homes and rehabilitation facilities, resulting in prolonged hospitalizations and greater inpatient demands for dialysis. Even beyond a surge, dialysis providers must ensure sufficient availability of resources and vigilance regarding COVID-19 risk as dialysis patients transition across healthcare settings.

In conclusion, the studies published in this issue of Kidney International highlight not only the high risk of developing COVID-19 among in-center hemodialysis patients but also the severe consequences of COVID-19 in this population, with 20% mortality among dialysis patients with COVID-19. Until the pandemic is controlled, the kidney community needs to aggressively pursue infection control and appropriate resource management to optimize outcomes in this vulnerable population.

J o u r n a l P r e -p r o o f

GBD Chronic Kidney Disease Collaboration. Global, regional, and national burden of chronic kidney disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study

Recommendations for the prevention, mitigation and containment of the emerging SARS-CoV-2 (COVID-19) pandemic in haemodialysis centres

Practical indications for the prevention and management of SARS-CoV-2 in ambulatory dialysis patients: lessons from the first phase of the epidemics in Lombardy

Mitigating Risk of COVID-19 in Dialysis Facilities

Low incidence of SARS-CoV-2, risk factors of mortality and the course of illness in the French national cohort of dialysis patients

Results from the ERA-EDTA Registry indicate a high mortality due to COVID-19 in dialysis patients and kideny transplant recipients across Europe

Outcomes of patients with end-stage kidney disease hospitalized with COVID-19

Interim Additional Guidance for Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed COVID-19 in Outpatient Hemodialysis Facilities

COVID-19 Infection Risk Among Hemodialysis Patients in Long-term Care Facilities

Shortage of Dialysis Equipment Leads to Difficult Decisions in New York ICUs. National Public Radio