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).
REFERENCES
- Wu C, Chen
X, Cai Y, et al. Risk Factors Associated With Acute Respiratory Distress
Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in
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- Alberici F,
Delbarba E, Manenti C, et al. 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 2020; 98:20.
- Goicoechea M,
Sánchez Cámara LA, Macías N, et al. COVID-19: clinical course and outcomes
of 36 hemodialysis patients in Spain. Kidney Int 2020; 98:27.
- Valeri AM,
Robbins-Juarez SY, Stevens JS, et al. Presentation and Outcomes of
Patients with ESKD and COVID-19. J Am Soc Nephrol 2020; 31:1409.
- Flythe JE,
Assimon MM, Tugman MJ, et al. Characteristics and Outcomes of Individuals
With Pre-existing Kidney Disease and COVID-19 Admitted to Intensive Care
Units in the United States. Am J Kidney Dis 2020.
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Zhu G, et al. Clinical Features of Maintenance Hemodialysis Patients with
2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. Clin J Am Soc
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Infection in Hemodialysis Patients Detected Using Serologic Screening. J
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- Corbett RW,
Blakey S, Nitsch D, et al. Epidemiology of COVID-19 in an Urban Dialysis
Center. J Am Soc Nephrol 2020; 31:1815.
- Kliger AS,
Silberzweig J. Mitigating Risk of COVID-19 in Dialysis Facilities. Clin J
Am Soc Nephrol 2020; 15:707.
- Centers for Disease Control and Prevention. Interim Additional
Guidance for Infection Prevention and Control Recommendations for Patients
with Suspected or Confirmed COVID-19 in Outpatient Hemodialysis
Facilities. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dialysis.html
(Accessed on April 08, 2020).
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