Gretchen Brandt MD, FASN - Washington, DC
 

We had an amazing “emergency edition” Twitter Chat on COVID-19 and the kidneys. This was a joint project between ASN and #NephJC. The special guests were Drs. Alan Kliger (@AlanKliger) and Jeffrey Silberzweig (@SilberjRogosin) from Nephrologists Transforming Dialysis Safety (NTDS) and the ASN Emergency Partnership Initiative (EPI), respectively. The chat was hosted by the dynamic social media duo and co-founders of #NephJC, Drs. Joel Topf and Matt Sparks.

This Twitter chat was a whirlwind of fascinating and exciting data exchange and information on the global pandemic of COVID-19 and how it is affecting the kidney community.

There were 1,239 tweets, 255 participants, and 4,329,409 impressions, making it a whirlwind!

The discussion tackled five core topics:

1. Are you seeing COVID-19 infections where you work?

2. What are you changing and how are you adapting hemodialysis for the pandemic?

3. What do we know about COVID-19 and AKI and CRRT?

4. COVID-19 and Kidney Transplants: What should you do? What are you doing?

5. The ACEi and ARB conundrum: What do we know? What should we do?

1. Are you seeing COVID-19 in your work?

Folks report not seeing much yet (sans Washington State) as likely we are in early incubation phases and have not done extensive testing. Focus is on preparing for onset, practicing social distancing and hygiene effective immediately. Some areas are seeing cases and focus on testing is key, too.

@VelezNephHepato noted that they had 3 cases of confirmed COVID-19 patients  whom they dialyzed in their rooms using CRRT. He noted the these were standard, vented ICU patients and not as challenging as the outpatient ESRD patients.

@hswapnil noted they have 13 patients in Ottawa, one of whom is hospitalized, and NYC has patients in their ICUs.
 

2. What are you changing and how are you adapting hemodialysis for the pandemic?

Dr. Silberzweig noted hemodialysis centers are being asked to manage patients with COVID-19 by separating all patients by at least 6 feet and using full PPE for staff caring for those patients. He also noted that CRRT has no greater risk or benefit that is yet known and it does alter staffing ratios which is an important factor in choosing CRRT vs intermittent HD.

Dr. Kliger did a comprehensive webinar and slide set (March 13) regarding dialysis center preparation and experience with COVID-19.

First advice for the dialysis units who have a dialysis patient with NEW fever, cough, or shortness of breath is to see if there is a private room in the dialysis center with a door that ideally can close. If this patient must be dialyzed together with a non-infected patient, then have the patient at the end of the line or the corner position with 6 feet of separation. This is practicing a modified contact droplet transmission utilizing the 6 feet of distance precaution.

There is talk of organizing COVID-19 dialysis units depending on the numbers infected. One unit in Ottawa is already a designated unit for suspected COVID-19 cases. And another dialysis unit converted their 6 separate rooms for training home hemodialysis patients into a COVID-19 unit. Another outpatient dialysis unit is creating a new shift for COVID-19 patients. Some are creating the third shift or TTS lighter shifts for COVID-19. And ASN is advocating for waiver of certification requirements to help facilitate these endeavors, according to @ASNAdvocacy .

Many units are using PPE for patients and health care professionals.

The question was raised if we should be proactively testing and isolating outpatients on HD to flatten the curve given most patients in the Wuhan HD cohort were asymptomatic.

Note was made of the WHO considering "airborne precautions" for medical staff after study shows coronavirus can survive in air. We know that the Wuhan strategy for protecting healthcare workers involved full gear.

And note was made of shortage of PPE with need to preserve PPE and using N95 masks for aerosolized procedures only. Note was also made of reuse of N95 masks.  Question of how to sterilize?  Microwave? There is little data on this. Dr. Kliger noted that he agrees with the CDC to use surgical masks as N95 supplies are very limited.

Dr. Silberzweig noted the supply chain is of real concern – PPE, home dialysis supplies, transplant medications, and CVVHD supplies.

@ASNAdvocacy is requesting federal government to prioritize access to testing kits for dialysis and transplant patients and donors. And ASN is also advocating for telemedicine as an option for ALL kidney patients!

3. What do we know about COVID-19 and AKI and CRRT?

With regards to AKI, one study found 44% proteinuria and hematuria; 26.7% hematuria on admission.  Elevation of BUN and creatinine were 15.5% and 14.1%. AKI was an independent risk factor for mortality: https://www.medrxiv.org/content/10.1101/2020.02.18.20023242v1

Risk for AKI is perhaps lower (0.5% in this NEJM article) with a more general mix of cases:
https://www.nejm.org/doi/full/10.1056/NEJMoa2002032?query=featured_home

A case series of 6 showed AKI with lymphocytic infiltrate:
https://www.medrxiv.org/content/10.1101/2020.03.04.20031120v3

Note was made that ICU teams are asking folks not to go into the rooms so as to minimize contact and spare PPE. Assessment of patients is per usual, though “examination” is through the window. Questions for whether discussions with coders and hospital administration has occurred regarding this.

One nephrology group was limiting COVID-19 consults to one (of three) consults teams to minimize exposure and to assure ongoing provider availability if there are many who are exposed or test positive. Other groups were doing it similarly, with note being made that in one group for volunteers for their inpatient experience there were “more volunteers (MD + RN) than needed so far” ( @keepingitrenal ). As Dr. Silberzweig notes, “incredibly proud of my colleagues!”

Comments also centered around not exposing medical trainees. And comments suggested trainees need to embrace the profession they signed up for and lighten the work load of older care givers.

4. COVID-19 and Kidney Transplant.  What should you do? What are you doing?

Transplant surgeries are mostly being placed on hold given infection risks, ICU resources and staffing.

Samira Farouk (@ssfarouk) mentioned that we should remind our transplant patients that social distance and hygiene are key as well as cutting back on routine post-transplant care visits while trying to ensure necessary lab work is done.

There was a beautiful visual for transplant patients: https://twitter.com/nephjc/status/1240091262499336193?s=21

5. The ACEi and ARB conundrum.  What do we know? What should we do?

Are ACE/ARB the doorway to COVID-9 infection? This is an incredibly hot topic now.

Current guidelines do not recommend discontinuation of ACEi/ARB.

There is variability in expression of ACE2 in genes, disease states, and organs (@elezNephHepato). And with ACEi/ARB use there is IL6 and cytokine storm, leading to upregulation of tissues factors and initiation of coagulation.

A recent piece in Kidney News Online, written by Matt Sparks on behalf of the NephJC working group, explored this topic:
/policy-advocacy/leading-edge/coronavirus-and-ace2-what-is-the-evidence-regarding-aceis-and-arbs

So what is the good news?  And were do we go from here?

Medicare announced March 17 that effective March 6 it will temporarily reimburse for telehealth inpatient and outpatient services at the same rate as in person visits and without the system-based telehealth apparatus.

We need to work smartly, efficiently, pace ourselves, and work together to maximize our health care workers!

And we need to fill out FMLA forms and delay routine labs and in-person visits to help our patients.

Remember social distancing and hygiene – for our mobile devices, too! It was Dr. Kliger who reminded everyone that “CDC recommends surface decontamination of iphones!”