Creativity and Safety Paramount in Caring for Kidney Failure Patients with COVID-19

Karen Blum
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Good communication, creative use of resources, and protecting dialysis and other hospital staff are all keys to success in caring for COVID-19-positive patients with end-stage kidney disease and acute kidney injury in the hospital, according to Michele H. Mokrzycki, MD, MS, professor of medicine at Montefiore Medical Center and Albert Einstein College of Medicine in the Bronx,.

The pandemic developed in New York very quickly, Mokrzycki said, from a few international travelers to hotspots to many communities. As of late spring, her hospital had admitted 829 patients with COVID-19. The nephrology service cared for 47 hemodialysis patients with COVID, 8.5% of whom died; 109 AKI patients with COVID, of whom 31% died; and 24 kidney transplant patients with COVID, of whom 17% died.

At Montefiore, an outdoor tent is set up to triage emergency department patients, including kidney failure patients with fever, respiratory symptoms, or known COVID exposure. Those with confirmed COVID are masked and evaluated. If they need to be admitted, they are placed on a COVID floor and receive bedside hemodialysis or continuous renal replacement therapy (CRRT). Those considered persons under investigation (PUI) are masked and isolated for testing; if admitted, they’re placed on a PUI floor.

COVID-19 and PUI patients with a fever, hepatitis B, or who are intubated receive bedside hemodialysis in their room using a portable machine with reverse osmosis hooked up to the wall plumbing. Nurses managing them wear full personal protective equipment (PPE). Machines are cleaned and disinfected but not dedicated to particular patients. Tubing and dialyzers are discarded in hazardous waste bins. COVID-19 and PUI patients who are no longer coughing, are seven days out from the onset of symptoms, or are 72 hours fever-free can be safely transported to the inpatient dialysis unit, where COVID-19 patients are cohorted on the last shift.

COVID-19 and PUI patients in the intensive care unit receive either CRRT, continuous venovenous hemodiafiltration (CVVHD) or sustained low efficiency dialysis (SLED), or intermittent hemodialysis, depending on their acuity level, Mokrzycki said. Staff use extra-long tubing so they can sit outside the room. Again, machines are cleaned and disinfected but not dedicated to particular patients, and tubing and dialyzers are discarded. To optimize the use of CVVHD for two to three patients a day, she said, treatment times may be shortened to eight hours and high dialysate flow of 30-40 mL/kg/hour may be used.

To protect healthcare providers, patients remain masked during RRT procedures, and droplet precautions are maintained. Dialysis staff use full PPE and extra-long tubing, and direct exposure with patients is limited. Some use baby monitors to observe patients during hemodialysis treatments from the doorways. Limited nephrology staff who are rounding enter patient rooms for physical exams, use full PPE in patient rooms, and wear masks the entire time in the hospital.

Staff shortages a challenge

One of the biggest challenges, Mokrzycki said, is providing dialysis treatments with ongoing staff shortages owing to illness or quarantine. Pre-COVID, the team was doing about 8–12 sessions per day. “That has increased two- to threefold and has really put a strain on our nursing staff,” she said.

The medical center has made several adaptations in response to the growing number of COVID patients requiring RRT, Mokrzycki said. These adaptations include reducing hemodialysis frequency to twice a week, shortening treatment times, initiating more AKI patients on urgent or acute peritoneal dialysis and creating a peritoneal dialysis rounding service, as well as using palliative care consultants where appropriate. Key to their success has been establishing several COVID task forces among the nephrology division, ICU teams, and hospital administration, with frequent communication, she said.

Mokrzycki spoke about her experiences during an ASN webinar about hospital care and treatment options for COVID-19–positive patients.