|Year : 2020 | Volume
| Issue : 1 | Page : 9-11
Hemodialysis in COVID pandemic: How well patients are doing?
Sunil Prakash1, Bhanu Misra2
1 Director, Department of Nephrology, BLK Hospital, New Delhi, India
2 Senior Registrar, Department of Nephrology, BLK Hospital, New Delhi, India
|Date of Submission||10-Jun-2020|
|Date of Decision||25-Jun-2020|
|Date of Acceptance||14-Jun-2020|
|Date of Web Publication||20-Jul-2020|
Dr. Sunil Prakash
Department of Nephrology, BLK Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Covid pandemic has irreversibly affected the practice of medicine. Hemodialysis population has borne the brunt of this disease by virtue of being immunocompromised, having multiple co-morbidities like heart disease, anemia, acidosis, renal osteodystrophy, protein energy malnutrition and state of persistent inflammation. To cap it they are exposed to risk of highly contagious covid 19 infection due to their repeated hospital visits. In this article we have described the initial experiences of covid 19 CKD patients in china and Italy along with our own experience. The measures taken to minimize infectivity among patients and dialysis personnel have been enumerated. Their nutrition is oft ignored so we have emphasized on their nutritional aspects also.
Keywords: COVID pandemic, disinfection, hemodialysis, nutrition, personal protective equipment
|How to cite this article:|
Prakash S, Misra B. Hemodialysis in COVID pandemic: How well patients are doing?. J Renal Nutr Metab 2020;6:9-11
|How to cite this URL:|
Prakash S, Misra B. Hemodialysis in COVID pandemic: How well patients are doing?. J Renal Nutr Metab [serial online] 2020 [cited 2020 Sep 23];6:9-11. Available from: http://www.jrnm.in/text.asp?2020/6/1/9/290277
| Introduction|| |
In Wuhan, China, a novel and alarmingly contagious primary atypical (viral) pneumonia broke out in December 2019. It has since been identified as a zoonotic coronavirus, similar to SARS coronavirus and Middle East respiratory syndrome coronavirus, and named COVID-19. It was declared a pandemic by the WHO on March 11, 2020. This is a very infective virus with reproduction number (R0), an indication of the transmissibility of a virus, of around 3.28, with a median of 2.79 and interquartile range of 1.16, which is considerably higher than the WHO estimate at 1.95.
People of extremes of age or suffering from chronic diseases, such as chronic kidney disease (CKD), especially patients on dialysis, are particularly vulnerable. The challenge of COVID-19 is very unique as the disease spreads in a community; many patients on dialysis are likely to become infected and require continued dialysis treatments. Thrice-weekly dialysis poses the risk of infection spread among patients and staff.
| Following Are Few Steps That We Took at Our Center to Decrease the Risk of Spread|| |
All patients were counseled about disease symptoms and they were asked for the same at each visit. Thermal screening, strict hand hygiene, compulsory use of face mask for patient and caregiver, and social distancing were practiced. Patients with progressive dyspnea, fever, signs of organ dysfunction, or evidence for adult respiratory distress syndrome were directed to an appropriate area designated as “FLU CORNER.”
Efforts were made to isolate patients with suspected or confirmed COVID-19. As no separate room was available, patients suspected to have COVID-19 were clubbed in a designated isolation shift. At times, patients with COVID-19 had to be treated at the same time with patients who were asymptomatic; in this situation, they were isolated in a corner and at the end-of-row station.
Patients were regularly counseled about the proper use of face masks. Tissues were provided, and patients were instructed to cover the nose and mouth when coughing or sneezing. Educational posters and schematics were placed throughout the facility.
Personal protective equipment
Dialysis staff were trained and reinforced on following standard contact and droplet precautions, including isolation gowns, gloves, masks, and eye protection (shields or goggles). Policies were made for the optimal usage of personal protective equipment (PPE) as its valuable resource, especially in a resource-limited setting.
Routine disinfection practice, comprising disinfection wipes for the dialysis machine, chair, and all dialysis station surfaces and equipment, including blood pressure (BP) cuffs and stethoscopes, was used. Care was taken to carefully wipe all surfaces, including all parts of the dialysis chairs after opening their arms and allowing them to air-dry. Disinfection personnel were using the same PPE as caregivers for patients infected with COVID-19 as we realized that these are actual so-called frontline corona warriors.
Communication with the hospital authority and health department
This was done on a regular basis to organize this herculean and unforeseen task in conjunction with the appropriate authorities. Guidelines from the International Society of Nephrology, Centre for Disease Control, and the Indian Society of Nephrology were utilized to give our patients and staff the best, evidence-based, scientific approach to fight this pandemic.
At our center, three of our patients got converted from thrice-weekly to twice-weekly hemodialysis (HD). The conversion can help facilities in two things. First, it decreases the load on the already-stressed facility. Second, patients were less exposed to the hospital environment. However, this could be dangerous in some situations, especially with patients prone to hyperkalemia and high interdialytic weight gain.
To quote Timothy Meyer of Stanford University, “A shift of patients to less frequent hemodialysis schedules will not relieve all of the pressures that dialysis units face during this pandemic, but it should be considered as one option and would likely provide adequate control of uremia, at least over a matter of weeks.”
| Nutrition and Covid-19|| |
An important question for the nutrition community is whether there are certain nutrients and food patterns that can prevent the viral infection or mitigate its severity. It is well known that the risk of contracting the infection is high under inadequate sleep, psychosocial or physical stress including exposure to cold temperatures, inadequate nutrition, and any condition that compromises the body's immune system. Dr. Linus Pauling, the only person who had ever won two unshared Nobel Prizes, believed that higher intake of ascorbic acid, also known as Vitamin C, is an effective way to prevent and treat the common cold.
Meta-analyses suggest a consistent and statistically significant benefit of Vitamin C to prevent the common cold or to reduce its duration and severity and support respiratory defense mechanisms, not to mention the potential role of Vitamin C in the management of anemia in early stages of CKD.
It is reasonable to ensure adequate consumption of citrus fruits (oranges, nectarine, tangerines, grapefruit, lemons, and limes) as well as tomatoes, broccoli, cauliflower, cantaloupe, kale, kiwi, sweet potato, strawberries, papaya, and all those fruits and vegetables rich in Vitamin C. However, dialysis patients are prone to hyperkalemia and that has to be monitored when suggesting these food items to them.
Fava beans contain chemical compounds similar to quinine-based antimalarial medications, some of which are being used in COVID-19-infected persons, such as hydroxychloroquine. Persons with favism should avoid fava beans, given the risk of hemolytic anemia.
CKD-specific risk factors as protein-energy wasting (PEW) are linked to worse COVID-19 outcomes. It is prudent that during an active COVID-19, we ensure the mitigation of PEW risk and immediate correction of PEW in all patients with kidney diseases including transplant recipients.
We encourage adequate protein and calorie intake, be it enterally or parenterally, so that any occurrence of hypokalemia or hypophosphatemia can be avoided, and that PEW, sarcopenia, and cachexia can be prevented or immediately corrected.
The need to supervise the nutrition regimens of patients with kidney diseases may be enhanced during this period and should not be ignored while focusing on other, seemingly more urgent, matters.
| Hemodialysis and Covid-19|| |
Early during the pandemic, reports by Yiqiong Ma, from the Department of Nephrology, Renmin Hospital of Wuhan University, showed 37 COVID-19 positive among 230 HD patients and four cases among 33 staff members (16% of the patients and 12% among the personnel, respectively). In the 37 COVID-19-positive patients, 6 (16.2%) died. Computed tomography images of the chest showed the ground-glass-like changes, but symptoms were mild, and nobody was admitted to the intensive care unit. The authors underline that none of them died because of COVID-19.
Later, in a bigger cohort, Cheng Li, from the Department of Blood Purification Center, Wuhan, No. 1 Hospital, Wuhan China, in a preprint report documents a wider experience from the same region where the pandemic started. The report records that 66 out of 627 HD patients were certainly infected (10.5%), and 24 cases “suspected” (i.e., the diagnosis was made just on clinical grounds). The authors treat the “suspected” cases as if they were real positives; thus, based on this assumption, the infection prevalence rate was 14.3% (90/627). The authors do not report if the mortality rate between the two subgroups (proven infected and suspected ones) was different; however, putting it all together, the mortality rate was 13.3% (12 patients out of 90 with confirmed or suspected infection).
Latest publication in April 2020 took data from 65 centers across Wuhan. Out of 7154 patients on HD, 154 (2.15%) had laboratory-proven COVID infection. The mean age of the patients was 63.2 years, 57.3% of patients were men, and 68.7% of patients had cardiovascular comorbidity (including hypertension). About 26.6% of patients died during the studied period.
The data reported by the two reports mentioned above are very close to those observed in a very preliminary survey in Lombardy, Italy, (unpublished). In this series, about 650/6000 (11%) HD patients with symptoms resembling those of COVID-19 infection were tested, and among them, only 301 were positive (5%). In this subset, the mortality was 22.3% (67 deaths out of 301 COVID-19-positive patients).
American data (New York experience)
In a report by Valeri et al., 59 patients of dialysis (57 HD and 2 peritoneal) were COVID-19 positive. Hypertension was seen in 98%, and diabetes in 69%. Mortality was higher in patients who were older (median age 75 vs. 62). Eighteen patients (31%) died after hospitalization.
B. L. Kapur Superspeciality Hospital, Delhi, experience
In our center, out of 210 patients on HD, till May 31, 2020, we had 10 (4.7%) laboratory-proven COVID-19 patients. Out of which, three patients (30%) expired and rest improved. Hypertension was present in all the COVID-19 positives. Hypertension and diabetes were there in 50% of positive patients. The mean age was 53.2 years, and males were 70%. As the pandemic is roaring ahead, we expect these numbers to rise exponentially. Our experience is consistent with data coming out from Wuhan, Italy, and the USA.
In a resource-strapped country like ours, this pandemic has created tremendous emotional and financial strain on patients and the society at large. There has been omnipresent fear psychosis at amidst changing and confusing guidelines. Many patients had to undergo COVID-19 testing before hospitalization and surgical intervention. This has led to inordinate delays and unacceptable outcomes. The world is reconciled and is learning ways of containing this pandemic. It is only with the discovery of newer SARS-CoV-2-specific drugs and vaccines will the humankind come out on top again.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ying L, Albert AG, Annelies WS, Rocklöv J. The reproductive number of COVID-19 is higher compared to SARS coronavirus. Journal of Travel Medicine, 2020,1-4.
Meyer TW, Hostetter TH, Watnick S; Twice-weekly hemodialysis is an option for many patients in times of dialysis unit stress. Editorial. J Am Soc Nephrol. 2020;31:1141-2.
Douglas RM, Hemila H, D'Souza R, Chalker EB, Treacy B. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev 2004:CD000980.
Handelman GJ. New insight on vitamin C in patients with chronic kidney disease. J Ren Nutr 2011;21:110-2.
Ferrey AJ, Choi G, Hanna RM, Chang Y, Tantisattamo E, Ivaturi K, et al
. A case of novel coronavirus disease 19 in a chronic hemodialysis patient presenting with gastroenteritis and developing severe pulmonary disease. Am J Nephrol 2020;51:337-42.
Kalantar-Zadeh K, Moore LW. Improving muscle strength and preventing sarcopenia and cachexia in chronic kidney disease and transplanted patients by physical activity and exercise; J Ren Nutr 2019;29:465-6.
Kalantar-Zadeh K, Moore LW. Impact of nutrition and diet on COVID-19 infection and implications for kidney health and kidney disease management. J Ren Nutr 2020;30:179-81.
Ma Y, Diao B, Lv X, Zhu J, Liang W, Liu L, et al
. COVID-19 in hemodialysis (HD) patients: Report from one HD center in Wuhan, China. MedRxiv june 2020. doi.org/10.1101/2020.02.24.20027201.
Cheng L, Ming Y, Tu C, Mao D, Wan S, Liu H, et al
. An analysis on the clinical features of MHD patients with coronavirus disease 2019: A single center study. (in print ) [research square journal, Infectiuos disease section, doi : 10.21203/rs.3.rs- 18043/r1].
Giuseppe R, Francesca B. COVID-19 and dialysis: Why we should be worried. J Nephrol 2020:1-3.
Anthony MV, Robbins-Juarez S, Jacob SS, Wooin A, Maya KR, et al.
Presentation and Outcomes of Patients with ESKD and COVID-19. JASN July 2020;31:1409-15.