Kidney News Editorial Board member Edgar Lerma, MD, interviewed Joel Topf, MD, about his experience on the front lines of the COVID-19 pandemic. Topf is a private practice nephrologist who works primarily at St. John Ascension in Detroit. He is also on the faculty of the St. John Nephrology Fellowship program, where he teaches residents and medical students, using his academic energy to engage them through social media. He is co-creator of NephJC and NephMadness and hosts a nephrology-focused podcast called Freely Filtered.
How did you get to be on the COVID-19 front lines? Did you volunteer?
I never signed up for this. I was rotating on the Nephrology Consult service during the second half of March. During that time, we saw our first COVID patient and 10 days later our 300th COVID patient. It came very quickly.
Please tell us about your experience.
This is the most challenging medical problem I have ever faced. Because of the avalanche of patients, our normal systems are overwhelmed, so tremendous creativity and innovation are required to adapt to a situation no one has seen before. The way hospitals have responded has been incredible. Our hospital normally has 40 ICU beds. They were able to balloon that up to 100 ICU beds by adapting the cardiac cath labs, the PICU, the PACU, and many other appropriate spaces. It is amazing to witness people shed egos and work together to adapt to some of the most trying times medicine has ever seen.
One of the early things my fellow and I noted was that if we got a patient from positive to negative balance, we would see an improvement in the chest x-ray, oxygenation, and vent settings. This may be just coincidence, but in the absence of clear evidence-based medical guidelines, we fell back on Loeb’s Law of Medicine Number One: If what you are doing is working, keep doing it.
We saw success with this strategy in both patients with dialysis-dependent AKI as well as non-dialysis–dependent AKI, where we pushed high-dose loop diuretics to produce and extend negative balance. We stopped being creatinine police and focused on lower oxygen requirements while tolerating modest (or not so modest) rises in creatinine.
We also tried to tailor our orders to keep nurses out of the rooms. So instead of furosemide 80 mg IV q8h, we would start a drip at 10 mg per hour. This was a place where we really appreciated the flexibility of the nursing staff. A lot of the hospital normally restricts where furosemide drips can be run. Many of these regulations make sense where nurses specialize in a single specialty like oncology or orthopedic surgery. But, wisely, nurse managers are realizing that we need to be flexible in implementing regulations designed for an entirely different hospital environment, and we have had little trouble getting these drips approved during the crisis.
The biggest problem I am seeing now is the extended nature of the disease. I am starting to see a lot of patients who emerge from the acute aspect of the disease and are about to go home. And patients ask about elderly family members, is it safe for them to go home? How can I prevent this from affecting more of my family? It feels like an extension of the shelter in place orders we have already implemented. We need places where patients can go after the hospital but while they are still shedding virus. The home may not be ideal.
How does your family feel about you volunteering? What do you do differently when you come home—decontaminate, etc.
This has been very hard on my family. They are very nervous that I could bring SARS-CoV-2 into our house. I always wash before leaving the hospital. I leave all my PPE in the car, and I change clothes as soon as I get home. I then wash my hands and face. I have seen firsthand how this disease just rips through families. This is definitely a concern. We are doing the best we can.
What have you observed about the COVID patients you have encountered with regard to COVID + AKI?
The COVID AKI story is multipronged. One population should be very familiar to anyone who takes care of ICU patients. These patients act like they are septic. They have decreased blood pressure, multi-organ failure, and they develop ATN. But there is another population where a patient’s COVID-19 is not that bad, but they have profound AKI. We are seeing patients come in with creatinine of 8 to 18 mg/dL along with hyperkalemia who need to be started on dialysis right away. Usually when we hear about patients arriving with bad AKI we go down to the ER and find a patient who is profoundly volume depleted, but these COVID-19 patients look volume resuscitated, and when you give them fluids they don’t get better. It looks to me like there is direct viral damage to the kidney not dependent on multi-organ failure and sepsis. I am not alone with this observation. A lot of people are talking about this. Additionally, the early biopsy and autopsy studies on patients with COVID-19 and AKI are finding evidence of direct viral infection.
What about COVID + ESKD?
We are seeing more and more of our dialysis patients turn positive. And, sadly, I have lost a longtime patient to COVID-19. My dialysis patients all go to DaVita units. DaVita has organized three tiers of dialysis units, one for people with no suspicion for COVID-19, another for people under investigation for possible infection, and a third level for patients with confirmed COVID. I have patients at all three levels. I am impressed with how DaVita has adapted to the challenge of a highly communicable disease and with how they are doing what they need to do to protect our patients. So far (fingers crossed), we have not seen an outbreak in any of the units I go to. They have done a great job of building the airplane while we are flying at 35,000 feet.
What about COVID + transplant?
A number of our transplant patients have been infected with COVID-19 or have become patients under investigation. I am not doing anything too creative. I am stopping the antimetabolite, cutting the CNI in half, and doubling up the steroids to compensate. This seems to be pretty successful. I am seeing transplant patients doing reasonably well without rejection. This protocol came right from the pages of NephJC, which surfaced several early case reports of transplant patients who have developed and recovered from COVID-19. (http://www.nephjc.com/news/covidtx)
As a physician on the front lines, what is your take on the shortage of personal protective equipment (PPE), ventilators, etc.?
This is one of the big problems with the COVID-19 pandemic. I wish there wasn’t a shortage. Tragically, the shortage of PPE will mean that doctors and nurses are going to unnecessarily get infected and likely will spread the disease to their families.
I am also concerned about all the emphasis on decontaminating N95 masks. I recognize the need to prevent infections from contact with a mask, but these masks were designed to be used one time. I have found that as I use the masks for a second and third day they lose their shape and no longer seal to my face. I can tell this because on the first day I can wear a mask all day without fogging my glasses, but on the second day I get repeated fogging, and that means the mask isn’t sealing to my nose, and that means I’m not being protected by the mask. I worry that attempts to decontaminate a mask by heating it will break down the glue holding it together and make it lose its integrity even faster.
There is a lot of misinformation about COVID-19 out there. What is your take on that?
The rate at which information is coming out about COVID-19 is unprecedented. As of April 8, 2020, there were just over 3000 articles about COVID-19, with 900 of them published just during the previous week. This amazing productivity is being paired with unending public interest, so articles and even pre-prints are finding their way onto CNN, into the New York Times, and even the speeches of the president. This means that premature conclusions and sloppy clickbait logic are getting amplified way beyond what we normally see with the traditional publication chain.
One of the early rumors relevant to nephrology was the idea that ARBs and ACEis were harmful in SARS-CoV-2 infection. This was one of the first myth-busting projects that the team at NephJC took on. They analyzed all the relevent publications, going beyond the abstracts and digging into the methods to determine the soundness of the analyses, which turned out to not be so sound. NephJC, along with all the major scientific and professional societies, instructed patients to remain on their RAASi unless instructed by a doctor to stop. There is no compelling data that these drugs are harmful or protective from COVID-19 as of April 9, 2020. This was an example of a group of doctors and scientists coming together in the spirit of cooperation and working to vet the literature of an emerging threat in order to help doctors and patients around the world.
What is your advice to colleagues who are on the front lines and to those who are not?
Be safe out there and do your best. This is the greatest challenge medicine has ever faced, and getting through it will take grit, creativity, flexibility, and all the talents you have developed in your career. This is not a time to close yourself off and try to solve everything yourself. Listen to your peers. Join a physician group, whether it is on Facebook, ASN Communities, or #MedTwitter, because together we know more and can go further than any of us alone. https://twitter.com/kidney_boy/status/1245717240097443840?s=20
