COVID-19-associated hemodialysis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mydah Sajid, MD[2]
Overview
The Covid-19 infection has high mortality among dialysis patients as compared to normal individuals. One of the factors for increased mortality for dialysis patients as compared to the general population due to COVID-19 infection is the increased age of the patients. Adequate measures should be taken to prevent the spread of COVID-19 infection in dialysis patients.
Historical perspective
The first reported case of Covid-19 infection in hemodialysis patient in Japan, was a 69 years old diabetic man on maintenance hemodialysis since last 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 had a successful recovery and was discharged on the 19th day of hospitalization.[1]
Classification
There is no established system for the classification of hemodialysis in Covid-19.
Pathophysiology
- It is thought that covid-19 infection in hemodialysis patients is mediated by low immunity, low-intensity cytokine storm, and inhibition of coagulation cascade.[2][3]
- Patients with chronic kidney disease or end-stage renal disease have low immunity. The patients on dialysis have a mild clinical course of COVID-19 infection.The patients on maintenance hemodialysis rarely present with a full-blown clinical picture of pneumonia.[2] This can be attributed to low-intensity cytokine storm in response to viral antigens due to low immunity.[2]
- 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.[3]
- 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.[4]
Causes
- Covid-19 in hemodialysis patients is caused by Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[5]
- SARS-Cov-2 is a novel beta coronavirus that share genetic sequence homology with SARS-CoV and bat SARS-like coronavirus (SL-CoV).[6]
- It has a high rate of transmission by the human spread.[7]
- 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 and there is an increased expression of ACE-2 receptors on proximal tubular cells due to uremia. This can result in increase susceptibility of covid-19 infection in hemodialysis patients.[8]
Epidemiology and Demographics
Prevalence
- The prevalence of chronic kidney disease ranges from 4,702 to 16,166 per 100,000 individuals in hospitalized covid-19 patients.[9][10]
- 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 study done in 208 acute care hospitals in the UK. It showed chronic kidney disease was one of the most common co-morbidity in hospitalized covid-19 patients.[10]
- 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 case series of 5,700 patients with covid-19 infection performed in 12 hospitals under the Northwell Health system in New York.[9]
Gender
Covid-19 infection affects men and women equally.[10]
Age
- The covid-19 infection among dialysis patients is more commonly observed among patients aged 70 to 90 years old. [11]
Risk Factors
Common risk factors in the development of covid-19 in patients on maintenance hemodialysis include:[12]
- low immunity
- hypertension
- diabetes
- pulmonary diseases
- cardiovascular diseases
Screening
- According to the CDC, screening for covid-19 by triage protocol is recommended before dialysis among patients on maintenance hemodialysis.[13]
- The best approach is to call patients and inquire about covid-19 symptoms. [13]The body temperature and clinical symptoms of covid-19 should be inquired when patient arrives at the dialysis facility.[14]
- Patients reporting illness or covid-19 symptoms should be placed in the screening area. Hand sanitizers and face masks should be provided to patients.[13]
- Symptomatic patients should be taken to testing clinics, hospitals or tested in dialysis facility as per the triage protocol instituted in dialysis facilities.[13]
- Patients with suspected coronavirus illness are preferred to have dialysis in hospitals as compared to dialysis facilities. The dialyzing facilities can accommodate patients with coronavirus illness if it can comply with CDC guidelines.[15]
Natural History, Complications and Prognosis
- Common complications of covid-19 in hemodialysis patients include shock, acute respiratory distress syndrome, acute cardiac injury, and arrhythmia.[16]
- The prognosis is unclear and the mortality rate is variable ranging from 16 to 29 % in covid-19 infected hemodialysis patients.[17][11]
- The prognosis is generally better in hemodialysis patients treated as outpatient compared to hospitalized patients.
- Clinical research was done by Alberici et al. at four outpatient dialysis facilities in Italy showed high overall mortality of 29% (27/94) in dialysis patients.[17]
- 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).[11]
Diagnosis
Diagnosis of Choice
- Hemodialysis patients present with similar chest CT and chest X-ray findings as the general population.[18][19]
- Patients have radiological findings consistent with pneumonia including peripheral ground-glass consolidation at both lungs.[18][19]
- Hemodialysis patients present with similar results on reverse transcriptase-polymerase chain reactions.[18]
History & Symptoms
- Common symptoms of covid-19 in hemodialysis patients include:[20][21]
- Fever
- Cough
- Breathlessness
- Fatigue
- Hypoxia: Low oxygen saturation at the time of presentation was associated with worse prognosis and higher mortality.
- Nausea
- Diarrhea
- Abdominal pain
- The hemodialysis patients have a milder clinical course of symptoms.[20] The classic triad of fever, cough and dyspnea may be absent in majority of hemodialysis patients. [22]
- Hemodialysis patients have an increased prevalence of co-existing morbid diseases. These include diabetes, hypertension, lung and cardiac disease.[12]
Laboratory Findings
The laboratory findings in hemodialysis patients with covid-19 are consistent with the general population.[20] [23]
- Lymphocyte count
- Lymphopenia has been reported in hemodialysis patients with covid-19.
- The lymphocyte count continues to decrease during the early course of illness. In a study done on hemodialysis patients with covid-19 infection by Goicoechea et al., the lymphocyte count was lowest 7 days after the onset of symptoms in patients who died during the course of illness.[20]
- Anemia
- Elevated Ferritin level
- Elevated D-dimers level
- Elevated ESR level
- Elevated Lactate dehydrogenase level
- CRP
- Elevated levels of CRP and LDH are associated with severe disease and increase mortality in hemodialysis patients.[20]
Electrocardiogram
There are no ECG findings associated with covid-19 associated hemodialysis.
Chest X-ray
Chest X-ray findings in the hemodialysis patients were similar to the findings seen in the general population.[18][19]
Chest CT-scan
Chest CT-scan findings in the hemodialysis patients were similar to the findings seen in the general population.[18][19]
Treatment
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.[24][25]
- 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.[26]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 %.[24]
Surgical Therapy
Surgical intervention is not recommended for the management of covid 19 infections in hemodialysis patients.
Primary prevention
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.[27]
- Suspected covid-19 patients should have at least 6 feet (2 meters) apart from each other in all directions. [27]
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.[28]
- 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.[28] 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.[29]
- 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. [27]
- Eyeshields and goggles can be used to prevent droplet spread via eyes.
Disinfection
- Disinfecting personnel should also wear personal protective equipment.
- The dialysis machine, chair, dialysis surface station including BP cuff, stethoscope, the chairside stand should be cleaned with disinfecting wipes and allowed to be air dry.[27] 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.[27]
Optimum utilization of resources
- As pandemic will be for a long duration, hence resources should be utilized optimally.[27]
- 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. [27]
- The 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. [13]
- 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.[27]
- In this pandemic, the health care workers can become sick and shortage of health care staff can arise. To encounter it a back up list should be created to fill up the positions. Training courses should be conducted for the health care staff. [13]
Secondary Prevention
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.[14]
- 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.[14]
- 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.[14]
- 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.[14]
References
- ↑ Kuroki Y, Hiyama K, Minami J, Takeuchi M, Shojima M, Matsueda S; et al. (2020). "The first case of COVID-19 pneumonia in a hemodialysis patient in Japan". CEN Case Rep. doi:10.1007/s13730-020-00495-5. PMC 7300373 Check
|pmc=value (help). PMID 32557209 Check|pmid=value (help). - ↑ 2.0 2.1 2.2 Zhang X, Tan Y, Ling Y, Lu G, Liu F, Yi Z; et al. (2020). "Viral and host factors related to the clinical outcome of COVID-19". Nature. doi:10.1038/s41586-020-2355-0. PMID 32434211 Check
|pmid=value (help). - ↑ 3.0 3.1 Tang N, Li D, Wang X, Sun Z (2020). "Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia". J Thromb Haemost. 18 (4): 844–847. doi:10.1111/jth.14768. PMC 7166509 Check
|pmc=value (help). PMID 32073213 Check|pmid=value (help). - ↑ Bose KS, Sarma RH (1975). "Delineation of the intimate details of the backbone conformation of pyridine nucleotide coenzymes in aqueous solution". Biochem Biophys Res Commun. 66 (4): 1173–9. doi:10.1016/0006-291x(75)90482-9. PMID 02.24.20027201 Check
|pmid=value (help). - ↑ Zhu N, Zhang D, Wang W, Li X, Yang B, Song J; et al. (2020). "A Novel Coronavirus from Patients with Pneumonia in China, 2019". N Engl J Med. 382 (8): 727–733. doi:10.1056/NEJMoa2001017. PMC 7092803 Check
|pmc=value (help). PMID 31978945. - ↑ Tian X, Li C, Huang A, Xia S, Lu S, Shi Z; et al. (2020). "Potent binding of 2019 novel coronavirus spike protein by a SARS coronavirus-specific human monoclonal antibody". Emerg Microbes Infect. 9 (1): 382–385. doi:10.1080/22221751.2020.1729069. PMC 7048180 Check
|pmc=value (help). PMID 32065055 Check|pmid=value (help). - ↑ Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y; et al. (2020). "Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia". N Engl J Med. 382 (13): 1199–1207. doi:10.1056/NEJMoa2001316. PMC 7121484 Check
|pmc=value (help). PMID 31995857. - ↑ Zou X, Chen K, Zou J, Han P, Hao J, Han Z (2020). "Single-cell RNA-seq data analysis on the receptor ACE2 expression reveals the potential risk of different human organs vulnerable to 2019-nCoV infection". Front Med. 14 (2): 185–192. doi:10.1007/s11684-020-0754-0. PMC 7088738 Check
|pmc=value (help). PMID 32170560 Check|pmid=value (help). - ↑ 9.0 9.1 Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW; et al. (2020). "Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area". JAMA. doi:10.1001/jama.2020.6775. PMC 7177629 Check
|pmc=value (help). PMID 32320003 Check|pmid=value (help). - ↑ 10.0 10.1 10.2 Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L; et al. (2020). "Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study". BMJ. 369: m1985. doi:10.1136/bmj.m1985. PMC 7243036 Check
|pmc=value (help). PMID 32444460 Check|pmid=value (help). - ↑ 11.0 11.1 11.2 Kikuchi K, Nangaku M, Ryuzaki M, Yamakawa T, Hanafusa N, Sakai K; et al. (2020). "COVID-19 in dialysis patients in Japan: Current status and guidance on preventive measures". Ther Apher Dial. doi:10.1111/1744-9987.13531. PMC 7301044 Check
|pmc=value (help). PMID 32506762 Check|pmid=value (help). - ↑ 12.0 12.1 Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX; et al. (2020). "Clinical Characteristics of Coronavirus Disease 2019 in China". N Engl J Med. 382 (18): 1708–1720. doi:10.1056/NEJMoa2002032. PMC 7092819 Check
|pmc=value (help). PMID 32109013 Check|pmid=value (help). - ↑ 13.0 13.1 13.2 13.3 13.4 13.5 Ikizler TA, Kliger AS (2020). "Minimizing the risk of COVID-19 among patients on dialysis". Nat Rev Nephrol. 16 (6): 311–313. doi:10.1038/s41581-020-0280-y. PMC 7132217 Check
|pmc=value (help). PMID 32249840 Check|pmid=value (help). - ↑ 14.0 14.1 14.2 14.3 14.4 Esposito P, Russo R, Conti N, Falqui V, Massarino F, Moriero E; et al. (2020). "Management of COVID-19 in hemodialysis patients: The Genoa experience". Hemodial Int. doi:10.1111/hdi.12837. PMC 7267634 Check
|pmc=value (help). PMID 32365278 Check|pmid=value (help). - ↑ Ikizler TA (2020). "COVID-19 and Dialysis Units: What Do We Know Now and What Should We Do?". Am J Kidney Dis. 76 (1): 1–3. doi:10.1053/j.ajkd.2020.03.008. PMC 7146661 Check
|pmc=value (help). PMID 32217082 Check|pmid=value (help). - ↑ Wu J, Li J, Zhu G, Zhang Y, Bi Z, Yu Y; et al. (2020). "Clinical Features of Maintenance Hemodialysis Patients with 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China". Clin J Am Soc Nephrol. doi:10.2215/CJN.04160320. PMID 32444393 Check
|pmid=value (help). - ↑ 17.0 17.1 Alberici F, Delbarba E, Manenti C, Econimo L, Valerio F, Pola A; et al. (2020). "A report from the Brescia Renal COVID Task Force on the clinical characteristics and short-term outcome of hemodialysis patients with SARS-CoV-2 infection". Kidney Int. 98 (1): 20–26. doi:10.1016/j.kint.2020.04.030. PMC 7206428 Check
|pmc=value (help). PMID 32437768 Check|pmid=value (help). - ↑ 18.0 18.1 18.2 18.3 18.4 Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W; et al. (2020). "Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases". Radiology: 200642. doi:10.1148/radiol.2020200642. PMC 7233399 Check
|pmc=value (help). PMID 32101510 Check|pmid=value (help). - ↑ 19.0 19.1 19.2 19.3 Belfiore MP, Urraro F, Grassi R, Giacobbe G, Patelli G, Cappabianca S; et al. (2020). "Artificial intelligence to codify lung CT in Covid-19 patients". Radiol Med. 125 (5): 500–504. doi:10.1007/s11547-020-01195-x. PMC 7197034 Check
|pmc=value (help). PMID 32367319 Check|pmid=value (help). - ↑ 20.0 20.1 20.2 20.3 20.4 Goicoechea M, Sánchez Cámara LA, Macías N, Muñoz de Morales A, Rojas ÁG, Bascuñana A; et al. (2020). "COVID-19: clinical course and outcomes of 36 hemodialysis patients in Spain". Kidney Int. 98 (1): 27–34. doi:10.1016/j.kint.2020.04.031. PMC 7211728 Check
|pmc=value (help). PMID 32437770 Check|pmid=value (help). - ↑ Wang R, Liao C, He H, Hu C, Wei Z, Hong Z; et al. (2020). "COVID-19 in Hemodialysis Patients: A Report of 5 Cases". Am J Kidney Dis. 76 (1): 141–143. doi:10.1053/j.ajkd.2020.03.009. PMC 7118604 Check
|pmc=value (help). PMID 32240718 Check|pmid=value (help). - ↑ Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J; et al. (2020). "Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China". JAMA. doi:10.1001/jama.2020.1585. PMC 7042881 Check
|pmc=value (help). PMID 32031570 Check|pmid=value (help). - ↑ Alalwan AA, Taher A, Alaradi AH (2020). "A Hemodialysis Patient with Severe COVID-19 Pneumonia". Cureus. 12 (5): e7995. doi:10.7759/cureus.7995. PMC 7205364 Check
|pmc=value (help). PMID 32391234 Check|pmid=value (help). - ↑ 24.0 24.1 Ronco C, Reis T, Husain-Syed F (2020). "Management of acute kidney injury in patients with COVID-19". Lancet Respir Med. doi:10.1016/S2213-2600(20)30229-0. PMC 7255232 Check
|pmc=value (help). PMID 32416769 Check|pmid=value (help). - ↑ Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A; et al. (2020). "Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy". JAMA. doi:10.1001/jama.2020.5394. PMC 7136855 Check
|pmc=value (help). PMID 32250385 Check|pmid=value (help). - ↑ "Work Group Membership". Kidney Int Suppl (2011). 2 (1): 2. 2012. doi:10.1038/kisup.2012.2. PMC 4089660. PMID 25028631.
- ↑ 27.0 27.1 27.2 27.3 27.4 27.5 27.6 27.7 Kliger AS, Silberzweig J (2020). "Mitigating Risk of COVID-19 in Dialysis Facilities". Clin J Am Soc Nephrol. 15 (5): 707–709. doi:10.2215/CJN.03340320. PMC 7269225 Check
|pmc=value (help). PMID 32198130 Check|pmid=value (help). - ↑ 28.0 28.1 Peters MDJ, Marnie C, Butler A (2020). "Policies and procedures for personal protective equipment: Does inconsistency increase risk of contamination and infection?". Int J Nurs Stud: 103653. doi:10.1016/j.ijnurstu.2020.103653. PMC 7273160 Check
|pmc=value (help). PMID 32564886 Check|pmid=value (help). - ↑ Cheng VCC, Wong SC, Chen JHK, Yip CCY, Chuang VWM, Tsang OTY; et al. (2020). "Escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 in Hong Kong". Infect Control Hosp Epidemiol. 41 (5): 493–498. doi:10.1017/ice.2020.58. PMC 7137535 Check
|pmc=value (help). PMID 32131908 Check|pmid=value (help).