Post–COVID-19 Dialysis Poses Challenges for Dialysis Providers and Patients

As the first wave of survivors of severe COVID-19 begin to leave hospitals, many face a new challenge—dialysis.

Acute kidney injury (AKI) is recognized as a common complication in patients who develop severe COVID-19 infections requiring intensive care. Among those who recover enough to be discharged from the hospital, between 20% and 90% may require dialysis, according to reports from around the country, said Jeffrey Silberzweig, MD, co-chair of the ASN COVID-19 Response team, during a recent ASN webinar (1).

“We need to anticipate a surge of these patients,” Silberzweig said.

The Dialysis After Discharge: Transitions of Care For COVID-19–Positive Patients webinar brought together experts from around the country to discuss the challenges facing these patients and the steps dialysis providers should take to help them.

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Post-recovery transitions

Care transitions under normal circumstances can be “fraught with disaster,” noted Thomas Watson, MD. For example, confusion about medications or missed doses or transportation problems can lead to serious problems, he said. But these transitions may be even more challenging for patients who are recovering from COVID-19.

“One of the bewildering issues we currently face, is that we just don’t know a lot [about the disease],” Watson said. For example, there are questions about how long a patient who has been COVID-19 positive remains infectious and whether they are immune to the SARS-CoV-2 virus after infection. The CDC has created guidelines (2) for dialysis facilities on isolation for COVID-19 patients and staff, as well as recommendations for screening, mask use, and disinfection policies during the pandemic. These precautions have also been addressed in previous ASN webinars (3).

Many COVID-19 patients leave the hospital debilitated after prolonged hospitalization, Watson noted. They may need staff assistance to get to their chair in an outpatient dialysis facility. They may require more frequent check-ins or follow-up testing for hypoxia or blood clots. They may need dietitian support to treat protein or calorie malnutrition or administration of oral nutritional supplements onsite, which may be difficult in dialysis facilities where masks are required. Many will be admitted to rehabilitation or skilled nursing facilities requiring additional transitions in care.

“Each of these transitions we have to worry about making sure their medications are appropriate, we have to worry about making sure they are appropriately set up for transportation to get their life-sustaining dialysis treatments,” Watson said.

Transportation to dialysis is a major concern for patients who are COVID-19 positive because they cannot take public transportation or use a van service or ambulette, Watson noted. They can take an ambulance. But it may only be covered by Medicare for patients who are non-ambulatory. Ambulance availability also may be limited in COVID-19 hotspots.

Financial stress for newly discharged COVID-19 patients, as well as all dialysis patients, is a concern now and in coming months, Watson noted. They may be unable to work or have family members laid off during the pandemic. “This will affect their ability to get their prescriptions, to get transportation to and from dialysis, and even [meet] very basic needs of food and shelter,” he said. Uninsured patients who developed AKI as a complication of COVID-19 also do not qualify for Medicare coverage for outpatient dialysis.

Nephrologists also face the challenge of deciding when it is appropriate to certify these patients with end stage renal disease and begin planning for vascular access or a potential home dialysis modality. Watson explained it is not yet clear how many patients with COVID-19–related AKI will recover normal kidney function, although he expected more data will be available soon.

“It’s probable that they won’t recover as frequently as someone who had AKI related to a different type of infection,” he said.

In fact, nephrologists from hard hit Louisiana and New York City estimated during the web briefing that only 10% to 15% of patients with COVID-related AKI will recover kidney function based on their experience so far. Mihran Naljayan, MD, acting chief of nephrology and hypertension and associate professor of clinical medicine at the Louisiana State University School of Medicine in New Orleans explained that patients who require intensive care for COVID-19 are extremely ill; in fact 70% to 80% do not survive. Among those who do survive, those who had fewer health problems prior to COVID-19 are the most likely to recover kidney function, said Vesh Srivatana, MD, director of peritoneal dialysis at the Rogosin Institute in New York City.

Peritoneal dialysis in demand

Peritoneal dialysis (PD) is emerging as an appealing option for COVID-19 survivors requiring dialysis after discharge. Acute PD has been associated with improved rates of kidney recovery (4), and it preserves residual kidney function better than hemodialysis (5), noted Naljayan. It can also allow patients to avoid complications associated with a hemodialysis catheter and allow home dialysis.

“In COVID-19 hotspots in the US, traditional dialysis resources have been stretched thin and that’s caused a recent surge in interest and use of acute PD,” Srivatana said.

There are some barriers, Srivatana noted. For example, currently the Centers for Medicare & Medicaid Services (CMS) does not reimburse for telehealth PD training. But the Special Purpose Renal Dialysis Facility designation from CMS has expanded dialysis options for COVID-19 patients. For example, it can be used by dialysis centers with PD programs to simultaneously treat and train patients before transitioning them home, he said.

Few skilled nursing facilities have the capacity to offer PD. A CMS waiver will allow home PD nurses to provide care in these settings, Srivatana said, though they would have to find coverage for their regular home patients.

“We must do better across the United States to have PD capability in our skilled nursing facilities and long-term care facilities and provide safe and quality care in these facilities,” Naljayan said.

Another concern is that PD is associated with higher rates of readmission (6), Naljayan noted, which may be of particular concern among COVID-19 patients who may experience both weakness and cognitive difficulties after discharge. It is important these patients be assessed prior to discharge to determine if they are a good candidate for home dialysis. He also recommended a virtual home visit to assess their home environment.

“These patients are at a very high risk for readmission and they’re extremely frail, so close monitoring with frequent assessments and communication with the team and the physician will be needed to keep these patients from going back into the hospital,” he said. Periodic assessments by a social worker may also be necessary to ensure that it is safe for the patient or their caregiver to continue home PD.

Telehealth has proved to be a critical tool for facilitating home PD during the pandemic, Srivatana said. This has been particularly important in hotspots like New York City where patients would likely have to brave public transportation for inpatient visits.

“My own patients have found this option very, very satisfying as they’re extremely reluctant to leave their homes and come to clinics or offices,” Srivatana said.

Naljayan said telehealth may also facilitate the frequent check-ins necessary to ensure patients remain safe doing home PD. Srivatana predicted that increased use of telehealth to reduce unnecessary visits may be here for some time given the uncertainty about how long the pandemic and associated precautions will last.

“This is a challenge, but also an opportunity to rethink the way we do things,” Srivatana said.

June 2020 (Vol. 12, Number 6)

References

1. ASN. Dialysis After Discharge: Transitions of Care for COVID-19 Positive Patients. https://www.asn-online.org/ntds/resources/Webcast_2020_05_07_COVID-19.mp4

2. CDC. Coronavirus Disease 2019 (COVID-19): Dialysis Facilities. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dialysis.html

3. ASN Resources and Recommendations https://www.asn-online.org/covid-19/ASN#Webinars

4. Gabriel DP, et al. High volume peritoneal dialysis vs. daily hemodialysis: A randomized, controlled trial in patients with acute kidney injury. Kidney Int Suppl 2008; 108:S87–93.

5. Lysaght MJ, et al. The influence of dialysis treatment modality on the decline of remaining renal function. ASAIO Trans 1991; 37:598–604.

6. Perl J, et al. Dialysis modality and readmission following hospital discharge: A population-based cohort study. Am J Kidney Dis 2017; 70:11– 20.