WikiDoc Resources for COVID-19-associated hemodialysis
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COVID-19 infection has a higher mortality among dialysis patients as compared to normal individuals. The factors for increased mortality for dialysis patients as compared to the general population due to COVID-19 infection are low immunity, co-existence of multiple co-morbid conditions, and the increased age of the patients. The lab and imaging findings in COVID-19 infection in dialysis patients are similar to general population. Adequate measures should be taken to prevent the spread of COVID-19 infection in dialysis patients.
The first reported case of COVID-19 infection of a hemodialysis patient in Japan, was a 69 years old diabetic man on maintenance hemodialysis for three years due to end-stage kidney disease. He presented with cough, fever, and breathlessness. His CT-scan chest showed bilateral multiple pulmonary consolidation and pleural effusion. He successfully recovered and was discharged on the 19th day of hospitalization.
- It is understood that COVID-19 infection in hemodialysis patients is mediated by low immunity, low-intensity cytokine storm, and inhibition of coagulation cascade.
- Patients with chronic kidney disease or end-stage renal disease have low immunity. Patients on dialysis have a mild clinical course of COVID-19 infection.Patients on maintenance hemodialysis rarely present with a full-blown clinical picture of pneumonia.This can be attributed to low-intensity cytokine storm in response to viral antigens due to low immunity.
- Hypercoagulation plays an important role in aggravating the disease. Hypercoagulation initiates the coagulation cascade resulting in disseminated intravascular coagulation (DIC). DIC results in organ dysfunction and high mortality in COVID-19 infection. Anticoagulants administered during hemodialysis inhibit coagulation cascade preventing hypercoagulation and DIC.
- In a study done at a hemodialysis center at Renmin Hospital in Wuhan, 37 out of a total of 230 patients were infected with COVID-19 infections in one month. Four members of the health care staff were also infected. The peripheral blood examination of the COVID-19 infected hemodialysis patients had reduced levels of killer T cells, helper T cells, Natural killer cells, and lower level of inflammatory cytokines as compared to non-dialysis infected patients.
- COVID-19 in hemodialysis patients is caused by Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
- SARS-CoV-2 is a novel beta coronavirus that shares genetic sequence homology with SARS-CoV and SARS-like coronavirus (SL-CoV).
- SARS-CoV-2 can invade the cells in the body by binding with Angiotensin-converting enzyme 2 receptors. A large percentage of hemodialysis patients have chronic or end-stage renal failure and there is an increased expression of ACE-2 receptors on proximal tubular cells due to uremia. This can result in increased susceptibility of COVID-19 infection in hemodialysis patients.
- To view causes of COVID-19, click here.
Epidemiology and Demographics
- The prevalence of chronic kidney disease ranges from 4,702 to 16,166 per 100,000 individuals in hospitalized COVID-19 patients.
- The prevalence of COVID-19 infection in chronic kidney disease and end-stage renal disease patients varies at different geographical areas. The prevalence of chronic kidney disease is approximately 16,166 per 100,000 individuals as per a study done in 208 acute care hospitals in the UK. It showed chronic kidney disease was one of the most common co-morbidities in hospitalized COVID-19 patients.
- The prevalence of chronic kidney disease is approximately 4,702 per 100,000 individuals and end-stage renal disease is approximately 3,263 per 100,000 individuals in hospitalized COVID-19 patients according to a case series of 5,700 patients with COVID-19 infection performed in 12 hospitals under the Northwell Health system in New York.
- The COVID-19 infection among dialysis patients is more commonly observed among patients aged 70 to 90 years old. 
- According to the CDC, screening for COVID-19 by triage protocol is recommended before dialysis among patients on maintenance hemodialysis.
- The suggested approach is to call patients and inquire about COVID-19 symptoms.  Body temperature and clinical symptoms of COVID-19 should be assessed when patient arrives at the dialysis facility.
- Patients reporting illness or COVID-19 symptoms should be placed in the screening area. Hand sanitizers and face masks should be provided to patients.
- Symptomatic patients should be taken to testing clinics, hospitals or tested in dialysis facility as per the triage protocol instituted in dialysis facilities.
- Patients with suspected COVID-19 illness are preferred to have dialysis in hospitals as compared to dialysis facilities. The dialysis facilities can accommodate patients with COVID-19 illness if it can comply with CDC guidelines.
Natural History, Complications and Prognosis
- Common complications of COVID-19 in hemodialysis patients include shock, acute respiratory distress syndrome, acute cardiac injury, and arrhythmia.
- The prognosis is unclear and the mortality rate is variable ranging from 16% to 29% in COVID-19 infected hemodialysis patients.
- The prognosis is generally better in hemodialysis patients treated as outpatient compared to hospitalized patients.
- Clinical research done by Alberici et al. at four outpatient dialysis facilities in Italy showed high overall mortality of 29% (27/94) in dialysis patients.
- A research study done in Japan showed a higher mortality 16.2% (16/99) in dialysis patients as compared to the general population 5.3% (874/16,532).
Diagnosis of Choice
- The diagnostic test of choice in COVID-19 in hemodialysis patients is positive nucleic acid amplification test by reverse transcriptase-polymerase chain reaction on respiratory samples.
- Hemodialysis patients present with similar chest CT and chest X-ray findings as the general population.
- Patients have radiological findings consistent with pneumonia including peripheral ground-glass consolidation at both lungs.
History & Symptoms
- Common symptoms of covid-19 in hemodialysis patients include:
- Hemodialysis patients have a milder clinical course of symptoms. The classic triad of fever, cough and dyspnea may be absent in majority of hemodialysis patients. 
- Hemodialysis patients have an increased prevalence of co-existing morbid diseases. These include diabetes, hypertension, lung and cardiac disease.
- Elevated Ferritin level
- Elevated D-dimers level
- Elevated ESR level
- Elevated Lactate dehydrogenase level
- Elevated CRP
- There are no ECG findings associated with COVID-19 associated hemodialysis.
- To view the electrocardiogram findings on COVID-19, click here.
- A Chest X-ray may be helpful in the diagnosis of COVID-19 in the hemodialysis patients. Findings on a Chest X-ray suggestive of COVID-19 include bilateral peripheral ground glass consolidation mostly in lower or middle lobes along with blunting of costophrenic angle.
Echocardiography or Ultrasound
- There are no typical echocardiographic findings for COVID-19-associated hemodialysis.
- To view the echocardiographic findings on COVID-19, click here.
Chest CT-scan may be helpful in the diagnosis of COVID-19 in hemodialysis patients. Findings on CT scan that may suggest COVID-19 include ground glass opacification in periphery of both lungs.
- To view the CT scan findings on COVID-19, click here.
- There are no typical MRI findings for COVID-19-associated hemodialysis.
- To view the MRI findings on COVID-19, click here.
Other Imaging Findings
- To view other imaging findings on COVID-19, click here.
Other Diagnostic Studies
- To view other diagnostic studies for COVID-19, click here.
Continuous Renal replacement therapy (CRRT) in Acute kidney injury
- The dialysis of choice in hemodynamically unstable COVID-19 patients is continuous venovenous hemodialysis.
- The preferred vascular access is right jugular vein with greater than 12.5 French. Approximately 27% of COVID-19 patients in ICU required prone positioning.
- The anchor of the vascular access is visible at the catheter exit site at the right jugular vein even in the prone position.
- The minimum dose of CRRT delivery should be adjusted at 20-25 ml/kg/hour. The patient’s fluid status and hemodynamic balance determine the daily fluid balance and net ultrafiltration rate of CRRT. The physician should calculate treatment downtime. Ultrafiltration should be less than 20%.
Surgical intervention is not recommended for the management of covid 19 infections in hemodialysis patients.
Effective measures for the primary prevention of covid 19 infections in hemodialysis patients and health care workers include:
Managing patients with suspected illness
- If there are adequate resources in the hospital, patients should have dialysis at a specific shift, or a separate isolation dialysis ward should be made.
- Patients should be instructed to wear masks and cover mouth and nose while coughing and sneezing. This will reduce air droplet transmission of the virus.
- Suspected COVID-19 patients should have at least 6 feet (2 meters) apart from each other in all directions. 
Personnel protective equipment
- A selected group of healthcare personnel should be assigned for suspected COVID-19 patients. Personal protective equipment should be provided to healthcare personnel.
- There should be an emphasis on compliance with proper infection control techniques. Health care personnel should be educated about types of PPE and proper procedures and the protocol of putting on, using, and taking off the PPE. Proper infection control in the hospital in Hong Kong resulted in zero nosocomial transmission in 413 health care personnel taking care of 42 confirmed coronavirus patients.
- Healthcare workers should follow droplet and contact precautions. The workers should wear masks, gowns, goggles, shields, and gloves. Surgical face masks and N95 masks can be used. 
- Eyeshields and goggles can be used to prevent droplet spread via eyes.
- Disinfecting personnel should also wear personal protective equipment.
- The dialysis machine, chair, dialysis surface station including BP cuff, stethoscope, the chair side stand should be cleaned with disinfecting wipes and allowed to be air dry. All the surfaces of the dialysis station and equipment need to be disinfected with the wipes.
- The benefit of dialyzing COVID-19 patients at a particular shift is reduced time pressure and effective disinfection of the stations at the end of the shift.
Optimum utilization of resources
- The pandemic is assumed to be of long duration, hence resources should be utilized optimally.
- If there are a limited number of gowns, then health care workers should wear it at the time of initiating and terminating dialysis, manipulating catheters and access sites, disinfecting dialysis station, and assisting to and from the dialysis station. 
- Goggles and eye shields can be reused after proper disinfection procedure. The eye shields and face masks should be used for an extended time period. 
- A track of the personal protective equipment stock should be made.
Work labor Management
- The healthcare workers are at risk for infection with COVID-19 due to exposure. The exposure of health care workers can be minimized by working in shifts.
- During this pandemic, health care workers can become sick and shortage of health care staff can arise. To counter this, a back up list should be created to fill up the vacated positions of sick staff. Training courses should be conducted for the health care staff. 
Effective measures for the secondary prevention of COVID-19 include:
- Clinical stability and saturation of oxygen should be assessed in patients with fever and symptoms suggestive of covid-19 illness including cough, fatigue, myalgia, breathlessness, diarrhea, and loss of smell.
- The nasopharyngeal or oropharyngeal sample can be taken in the dialysis facility by healthcare workers under strict precautionary guidelines of patients with normal oxygen saturation and stable vital signs.
- The requirement for urgent hemodialysis should be assessed in clinically stable patients. The hemodialysis session should be postponed while awaiting results and instructions should be given to the patient regarding social distancing. Dialysis should be done in a separate isolation room in patients requiring urgent hemodialysis.
- Patients with falling levels of oxygen saturation and unstable vital signs should be immediately transferred to the Emergency department of the hospital. The patient nasopharyngeal swab, other evaluation tests, and infectious disease specialist consultation regarding care and treatment should be done.
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