COVID-19: Issues related to kidney disease & hypertension Ptns with ESKD are particularly amenable to severe COVID-19...
COVID-19: Issues related to kidney disease & hypertension
Ptns with ESKD are particularly amenable to severe COVID-19 disease due to old age and increased frequency of the associated co-morbidities, e.g. DM & HT, in this cohort. The Centers for Disease Control (CDC), American Society of Nephrology (ASN), and International Society of Nephrology (ISN) hv provided interim guidelines and a list of resources to guide nephrologists to provide life-maintaining DX care. These resources are continuously updated and including the related guidance to: early identification & isolation of subjects presented with respiratory Sms; ptn separation and cohorting within waiting rooms and within DX unit; use of personal protective equipment in DX unit; and additional measures for ptns with confirmed/suspected COVID-19.
Generally, during COVID-19 outbreak, ptns on home HDX or PD should hv their follow-up visit proceeded via telemedicine rather than through in-person, OPD visits. Moreover, home visit by a health care professional should be limited or even hold. Ptns should have at least two wks of DX supply & sufficient medications in case they’re in need to self-isolation, or there’s a break in the supplies. If an in-person visit is clinically warranted, the proper infection control measures for an outpatient unit should be performed, an attempt should be made to limit the daily number of examined ptns, and non-urgent procedures should be postponed
The American Society of Nephrology has provided guidelines for the nephrologists caring hospitalized ptns requiring DX for ESKD & AKI. These guidelines are continuously updated. Although local policies may be enforced, whenever possible, adherent behaviour to these guidelines is currently advised:
1) COVID-19 Ptn should be co-localized on a floor or ICU, whenever possible. Co-localization within adjacent locations may enable one DX nurse to simultaneously deliver DX for > one PTN. If a ptn is in a negative-pressure isolation room, then one HDX nurse will be required for the care of that ptn in a 1:1 nurse-to-ptn ratio.
2) Whenever possible, ptns with suspected/confirmed COVID-19 infection and not critically ill should be dialyzed in their own isolation room rather than being transported to the in-ptn DX unit.
3) Wherever possible, video & audio propaganda should be provided to troubleshoot alarm from outside the room to limit the need for a DX nurse or the nephrologist to contact the ptns on isolation room.
4) CRRT is advised for critically ill ptns in the ICU who hv ESKD or AKI. Even among ptns who are hemodynamically stable & who could tolerate intermittent HDX (IHD), CRRT or prolonged intermittent CRRT (PIRRT), also called sustained low-efficiency DX (SLED), should be provided instead, depending upon machine & staffing facilities. This’s because CRRT or PIRRT can be managed without 1:1 HDX support. This my permit minimizing the wastage of personal protective facilities and limit exposure among HDX staff.
5) If CRRT capacity is overwhelmed, CRRT machine can be used to deliver prolonged intermittent ttt (e.g., 10 hs rather than continuous) with a higher flow rate (eg, 40-50 mL/kg/h). This will enable the CRRT machine to be readily available sooner for another ptn after terminal disinfection.
6) Whenever available HDX or CRRT machines are limited, physicians may need to consider ttt of AKI on a PD basis.
In ptns with suspected/confirmed COVID-19 disease and developed AKI, an emphasis should be placed on optimization of volume status to exclude & ttt pre-renal (functional) AKI to avoid hypervolemia, which may worsen ptn's respiratory condition. Ptns who hv AKI that’s not DX-requiring should be managed on a limited contact basis. Clinical examination & US testing should be co-ordinated with the primary/consulting team to limit contact, whenever possible. Ptns receiving ACEi or ARBs should continue ttt with these medications (unless there’s contra-indication e.g. hyperkalemia or hypotension). There’s no evidence that holding ACEi/ARBs decreases the intensity of COVID-19 disease. Ptns on stage 4-5 CKD who’re referred for DX access placement should proceed on these procedure as currently planned (i.e. haven’t their planned procedures deferred by anymean).
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