View source for Patients on Hemodialysis before Covid 19 pandemic

==Overview==
The [[COVID-19|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|COVID-19 infection]] is the increased age of the [[Patient|patients]]. Adequate measures should be taken to prevent the spread of [[COVID-19|COVID-19 infection]] in [[dialysis]] patients.
==Pathophysiology==
Patients on hemodialysis have a mild clinical course of COVID 19 infection. It could be due to multiple reasons.
*[[Patient|Patients]] with [[chronic kidney disease]] or [[Chronic renal failure|end-stage renal disease]] have low [[Immunity (medical)|immunity]]. The low [[Immunity (medical)|immunity]] results in low-intensity [[cytokine storm]] in response to viral antigens. The [[Patient|patients]] on maintenance hemodialysis rarely present with a full-blown clinical picture of pneumonia.<ref name="pmid32434211">{{cite journal| author=Zhang X, Tan Y, Ling Y, Lu G, Liu F, Yi Z | display-authors=etal| title=Viral and host factors related to the clinical outcome of COVID-19. | journal=Nature | year= 2020 | volume=  | issue=  | pages=  | pmid=32434211 | doi=10.1038/s41586-020-2355-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32434211  }} </ref>
*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|COVID 19 infection]]. [[Anticoagulant|Anticoagulants]] administered during hemodialysis inhibit coagulation cascade preventing hypercoagulation and [[Disseminated intravascular coagulation|DIC]].<ref name="pmid32073213">{{cite journal| author=Tang N, Li D, Wang X, Sun Z| title=Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. | journal=J Thromb Haemost | year= 2020 | volume= 18 | issue= 4 | pages= 844-847 | pmid=32073213 | doi=10.1111/jth.14768 | pmc=7166509 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32073213  }} </ref>
*In a study done at a hemodialysis center at Renmin Hospital in Wuhan, 37 out of a total of 230 [[patient]]<nowiki/>s were infected with [[COVID-19|covid-19]] infections in one month. Four members of the health care staff were also infected. The [[Peripheral blood smear|peripheral blood]] examination of the covid 19 infected hemodialysis patients had reduced levels of killer T cells, [[T helper cell|helper T cells]], [[Natural killer cell|Natural killer cells]], and lower level of [[Cytokines|inflammatory cytokines]] as compared to non-dialysis infected [[Patient|patients]].<ref name="pmid02.24.20027201">{{cite journal| author=Bose KS, Sarma RH| title=Delineation of the intimate details of the backbone conformation of pyridine nucleotide coenzymes in aqueous solution. | journal=Biochem Biophys Res Commun | year= 1975 | volume= 66 | issue= 4 | pages= 1173-9 | pmid=02.24.20027201 | doi=10.1016/0006-291x(75)90482-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2  }} </ref>
==Epidemiology and Demographics==
*[[Patient|Patients]] on maintenance hemodialysis and end-stage kidney disease have low immunity and multiple co-morbidities. They are at an increased risk of contracting the [[Covid-19|covid-19 i]]<nowiki/>nfection.  A case series of 5,700 patients with [[COVID-19|covid-19]] infection was done in 12 hospitals under the Northwell Health system in New York. It showed a prevalence of 5% [[Chronic renal failure|chronic kidney disease]] and 3.5% end-stage renal disease in hospitalized covid-19 patients.<ref name="pmid32320003">{{cite journal| author=Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW | display-authors=etal| title=Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. | journal=JAMA | year= 2020 | volume=  | issue=  | pages=  | pmid=32320003 | doi=10.1001/jama.2020.6775 | pmc=7177629 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32320003  }} </ref>
* A research study done in Japan showed a higher mortality 16.2% (16/99) in [[dialysis]] [[Patient|patients]] as compared to the general population 5.3% (874/16,532). The average age of [[Patient|patients]] on [[dialysis]] was 70 to 90 years while of the general population was 20 to 60 years.<ref name="pmid32506762">{{cite journal| author=Kikuchi K, Nangaku M, Ryuzaki M, Yamakawa T, Hanafusa N, Sakai K | display-authors=etal| title=COVID-19 in dialysis patients in Japan: Current status and guidance on preventive measures. | journal=Ther Apher Dial | year= 2020 | volume=  | issue=  | pages=  | pmid=32506762 | doi=10.1111/1744-9987.13531 | pmc=7301044 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32506762  }} </ref>
*A study was done in 208 acute care hospitals in the UK. The total patients studied were 20,133. It showed [[Chronic renal failure|chronic kidney disease]] was one of the most common co-morbidity in hospitalized [[COVID-19|covid-19]] patients present in 16% of patients.<ref name="pmid32444460">{{cite journal| author=Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L | display-authors=etal| title=Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. | journal=BMJ | year= 2020 | volume= 369 | issue=  | pages= m1985 | pmid=32444460 | doi=10.1136/bmj.m1985 | pmc=7243036 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32444460  }} </ref>
*Clinical research was done by Alberici et al. at four outpatient [[dialysis]] facilities in Italy showed high overall mortality of 29% in [[dialysis]] [[patients]].<ref name="pmid32437768">{{cite journal| author=Alberici F, Delbarba E, Manenti C, Econimo L, Valerio F, Pola A | display-authors=etal| title=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. | journal=Kidney Int | year= 2020 | volume= 98 | issue= 1 | pages= 20-26 | pmid=32437768 | doi=10.1016/j.kint.2020.04.030 | pmc=7206428 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32437768  }} </ref>
==Treatment==
===Measures to prevent COVID 19 infection in hemodialysis patients===
Strict measures should be taken to prevent [[COVID-19|covid]] 19 infections in hemodialysis patients and health care workers. The measures include:
====Screening of the patients====
*Appropriate screening of patients should be done before dialysis. The best approach is to call patients and inquire about [[COVID-19|covid-19]] symptoms.
*Patients reporting illness or covid-19 symptoms should be placed in the screening area. Hand sanitizers and face masks should be provided to patients.
*A triage protocol should be instituted in [[dialysis]] facilities to take patients to testing clinics, particular [[dialysis]] facilities, and [[hospital]]<nowiki/>s.<ref name="pmid32249840">{{cite journal| author=Ikizler TA, Kliger AS| title=Minimizing the risk of COVID-19 among patients on dialysis. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 311-313 | pmid=32249840 | doi=10.1038/s41581-020-0280-y | pmc=7132217 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32249840  }} </ref>
====Managing patients with suspected illness====
*If there are adequate resources in the [[hospital]], [[Patient|patients]] should have [[dialysis]] at a specific shift, or a separate isolation dialysis ward should be made.
*[[Patient]]<nowiki/>s should be instructed to wear masks and cover mouth and nose while [[cough]]<nowiki/>ing and [[Sneeze|sneezing]]. This will reduce air droplet transmission of the [[virus]].
*Suspected [[COVID-19|covid]]-19 patients should have at least 6 feet (2 meters) apart from each other in all directions. <ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc=7269225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
====Personnel protective equipment====
*A selected group of healthcare personnel should be assigned for suspected [[COVID-19|covid-19]] [[patient]]<nowiki/>s. [[Personal protective equipment]] should be given to patients and healthcare personnel.
*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. <ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
*Eyeshields and goggles can be used to prevent droplet spread via [[Eye|eyes]].
====Disinfection====
Disinfecting personnel should also wear [[personal protective equipment]] while disinfecting the [[dialysis]] surface. 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.<ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
====Optimum utilization of resources====
*As pandemic will be for a long duration, hence resources should be utilized optimally. The gown should ideally be worn by both the health care workers and the [[patient]]<nowiki/>s.
*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. <ref name="pmid32198130">{{cite journal| author=Kliger AS, Silberzweig J| title=Mitigating Risk of COVID-19 in Dialysis Facilities. | journal=Clin J Am Soc Nephrol | year= 2020 | volume= 15 | issue= 5 | pages= 707-709 | pmid=32198130 | doi=10.2215/CJN.03340320 | pmc=7269225 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32198130  }} </ref>
*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. <ref name="pmid32249840">{{cite journal| author=Ikizler TA, Kliger AS| title=Minimizing the risk of COVID-19 among patients on dialysis. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 311-313 | pmid=32249840 | doi=10.1038/s41581-020-0280-y | pmc=7132217 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32249840  }} </ref>
*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|covid-19]] due to exposure. The exposure of health care workers can be minimized by working in shifts.
*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. <ref name="pmid32249840">{{cite journal| author=Ikizler TA, Kliger AS| title=Minimizing the risk of COVID-19 among patients on dialysis. | journal=Nat Rev Nephrol | year= 2020 | volume= 16 | issue= 6 | pages= 311-313 | pmid=32249840 | doi=10.1038/s41581-020-0280-y | pmc=7132217 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32249840  }} </ref>
==References==
{{Reflist}}