COVID-19 Changed Kidney Care Will Those Changes Stick?

In-center dialysis

Brigitte Schiller, MD, FACP, FASN, chief medical officer at Satellite Healthcare based in San Jose, California, says in-center dialysis is normally a very predictable model of care, but with the arrival of COVID-19, she and her colleagues had to improvise. In a matter of days, they learned what they could about the novel coronavirus, set up a screening protocol, acquired additional personal protective equipment (PPE), enlisted nonclinical personnel to help in the clinics with screening and cleaning procedures, and adjusted workflows, introducing an extra shift at the end of the day to accommodate infected patients without exposing others. They also implemented telehealth options for physicians to continue to visit their patients at least once a month during dialysis in center or at home without worries about possible virus transmission.

In some urban areas, dialysis providers were able to dedicate entire centers to dialyzing people whose test results for COVID-19 were positive, but even that solution had its limitations. “Transportation companies weren’t necessarily ready and equipped to transport infectious patients,” Schiller says. “They didn’t have masks for their own employees, and it was not clear how much they needed to deep-clean after each transfer, so we faced logistic obstacles in simply getting the patient to the treatment because of these additional risks.”

Dialysis centers also found themselves navigating a changing regulatory environment. “The public health response varied from county to county,” says Schiller, whose company operates in three states. “I can’t imagine what the nationwide dialysis organizations had to go through with every state doing things differently. That causes a lot of additional logistical administrative work to implement something that required a really swift response.”

Schiller would like to see coordination of policy and healthcare delivery increase before the next crisis occurs. “My real hope is that we learn to build a healthcare system that addresses the current fragmentation. We need solid, high-quality population health management, an underlying safety net, and agreement on how one approaches a threat. Then during a crisis, the incident command center needs to develop evidence-based and standardized policies and procedures, which providers can then execute in a locally adapted way.”

Inpatient kidney care

The high incidence of acute kidney injury (AKI) among COVID-19 patients in intensive care units put enormous strain on hospital nephrology departments in New York City and other hotspots. The availability of hemodialysis machines and supplies was insufficient to meet the demand for kidney replacement therapy (RRT), relatively few clinicians on staff had experience with peritoneal dialysis, and skilled dialysis personnel were unable to work when they themselves became infected with SARS-CoV-2 (1).

“In St. Louis, we were fortunate,” says Anitha Vijayan, MD, FASN, professor of medicine in the division of nephrology at Washington University School of Medicine. “Our case numbers were not as high as hard-hit areas. We were able to learn from reports out of Italy, New York, and elsewhere and take a strong approach to predicting dialysis requirements for inpatients with acute kidney injury.”

Vijayan directs the Acute Dialysis Services at Barnes-Jewish Hospital, Missouri’s largest hospital. As SARS-CoV-2 made its way inland from the coasts, Barnes-Jewish took many of the same steps used at other healthcare systems. The hospital suspended elective procedures and transitioned its intensive care units for COVID-19 care. In the nephrology unit, the hospital relied on its attending physicians so as not to expose trainees to the virus. The unit ordered and borrowed dialysis machines to prepare for a surge in AKI. Anesthesiologists and critical care physicians pitched in with hemodialysis catheter placement, and nurses were cross-trained to assist with dialysis care. The department instituted in-room dialysis rather than transporting infectious patients through the hospital and put them in rooms with video connections or glass doors to reduce the exposure of nurses monitoring their care.

BJC HealthCare, the hospital’s parent organization, established a central command center, which could shift supplies in case of shortages. Vijayan, who served as the center’s nephrology expert, worked with her colleagues to conserve essential dialysis fluids and supplies for continuous RRT for critically ill patients with AKI. They decreased the flow rate of continuous RRT and reduced the duration of intermittent hemodialysis treatment times, among other measures. Vijayan chairs the ASN COVID-19 Response Team In-Patient Kidney Care Subcommittee.

She attributes part of Barnes-Jewish’s success in treating patients with COVID-19 to unprecedented collaboration within BJC and among all St. Louis healthcare organizations. “That sharing and coordination needs to remain in place,” she says.

Transplantation

For kidney transplantation physicians, the experience of COVID-19 fell at two extremes. In coastal cities hard hit by COVID-19, these specialists found themselves sidelined as deceased- and living-donor transplantations were put on hold because of a lack of available hospital beds. The result was a boon for their counterparts at transplantation centers less affected by the pandemic.

“Contrary to what our expectations were, we started getting a lot of deceased-donor kidneys from centers that weren’t doing transplants anymore,” says Uday Nori, MD, FASN, transplantation nephrologist at The Ohio State University Wexner Medical Center. “We did more deceased-donor kidney transplants in 3 months than ever before. In 2019, we did 310 transplants, and [were] poised to surpass this number in 2020. This despite putting living-donor kidney transplantations on hold for more than 2 months.”

While accommodating the increased volume of procedures, Nori and other transplantation physicians made adjustments to reduce their patients’ risk of SARS-CoV-2 infection. They tailored their transplantation patients’ immunosuppression regimens to give their bodies a fighting chance should they encounter the coronavirus (2).

“We stratified people as high and medium risk. We gave those at high risk of organ rejection the same induction treatment as before, involving antithymocyte globulin infusions. We gave the medium-risk patients a lower intensity of induction with basiliximab, a non–lymphocyte-depleting drug. There was a concern that this new approach would cause more rejections,” Nori says, “but it turned out the patients did fine, and that’s an important lesson. Maybe immunosuppression should be individualized rather than based on a one-size-fits-all protocol,” he surmises, suggesting that stratification be used routinely to plan induction treatment in the future.

At the start of the pandemic, the transplantation center put a COVID-19 screening and testing plan in place for both kidney donors and recipients with the help of the National Kidney Registry. Scrupulous care was taken to isolate transplantation patients from staff treating patients with COVID-19 elsewhere at the medical center, and all post-transplantation patients were housed in a designated area. Follow-up care also had to change. Typically, transplant recipients return to clinical sites for wound care, stent and staple removal, and other consultations as many as nine times in 90 days after their procedures. The medical center limited the number of in-person encounters to a minimum and, like other providers, relied heavily on telehealth to monitor patients’ recovery.

Screening, testing, isolation, and telehealth are all practices that have stood the test of time, in Nori’s view. “These things are easy to do and don’t require a lot of extra resources,” he says. “They are common-sense practices to carry into the future.”

Home dialysis

Might the COVID-19 pandemic be a catalyst for expanding the use of home dialysis? That question has been on the minds of many observers who would like to see this modality gain traction in the United States (3). Jeffrey Perl, who practices nephrology in Canada, where home dialysis is far more widely used, is a firm believer in its value. The pandemic provides another argument in favor of home therapies in his view, but, he adds, “There is much work to be done before COVID-19 alone can become a catalyst for change.”

Perl says nephrologists are not sufficiently exposed to home dialysis during residency, and most feel uncomfortable managing it. Not every patient can self-dialyze at home without assistance. (That help is available in Europe and Canada, but assisted home dialysis is not typically covered in the United States.) And there simply are not enough nurses who can get folks started on dialysis at home.

Such home-training nurses need a full year of registered nursing under their belts plus at least 3 months of experience in the dialysis modality they will be teaching. This experience is especially difficult to obtain for peritoneal dialysis, according to Glenda Payne, MS, RN, CNN, cofounder and chief compliance officer at the National Dialysis Accreditation Commission and past president of the American Nephrology Nurses Association. “We have to grow that workforce,” she says.

At the same time, she adds, a key opportunity for expanding home dialysis emerged when the US Centers for Medicare and Medicaid Services (CMS) clarified that dialysis centers may use the same machine for multiple patients. “This is a big deal. I think we will see nursing home programs bring in a small number of machines to treat a larger number of patients rather than transporting all their residents needing dialysis to a center,” she predicts.

Telehealth

To support kidney care patients during the pandemic, providers have relied heavily on telehealth, and at least in the case of home dialysis, they’ve discovered that video visits have some unexpected advantages over in-person care. Perl recalls one case where “a glimpse into a patient’s home during a virtual visit gave me insight into the challenges they faced dialyzing in their home environment.” He was also able to meet patients’ families and loop in other healthcare providers with greater ease. “We can now communicate with the patient as a unified health team,” he says.

Perl would like the option of telehealth visits to continue for all nephrologists, but he has concerns about relying on telehealth in its current form. Many providers are scrolling through medical records and interacting with patients and others on a single screen; connectivity is poor in some patients’ homes; others lack the technological know-how to reliably participate; and patients may be poorly prepared to make full use of virtual visits. Most importantly, Perl says, “For telemedicine to be successful, it requires a heightened level of self-management among patients. I worry about health literacy, and, in particular, socially isolated groups who may find telemedicine more of a challenge.”

Payne also sees limits to the use of telehealth. “It would be very difficult for most patients beginning home dialysis to achieve competency through virtual training alone,” she says. “There are a lot of technical, hands-on skills that you have to show and then watch the patient demonstrate.”

Perl would like to see new tools developed and processes refined to make telehealth an effective delivery mechanism for all types of kidney care and all types of patients. “We have to step up our game and make sure that we come up with something that engages patients and is universally available,” he says.

Preparing for whatever comes next

To be eligible for Medicare coverage, facilities must have an emergency preparedness plan, says Payne, but recent events have shown that many existing plans contained a major flaw. “They focused on things like hurricanes, tornadoes, earthquakes, flooding. It’s become painfully clear that every emergency preparedness plan needs to focus on the risk of pandemic as well, particularly on having sufficient PPE.”

Payne worked for the Center for Medicare & Medi-caid Services (CMS) when Hurricane Katrina hit the Gulf Coast. She says the kidney community was viewed as a leader at the time because its members knew how to cooperate. They formed the Kidney Community Emergency Response (KCER) program to provide technical assistance during ensuing crises. Regular KCER and CMS calls during the pandemic have been “a life-saver” for the dialysis community, she says, as have calls and webinars organized by ASN.

The pandemic has also underscored the value of portable professional licensing. Payne would like more states to join the Enhanced Nurse Licensure Compact, which currently allows nurses in any of the 34 compact states to work where they are needed without obtaining additional licenses (4).

Research can also better prepare nephrologists for the resurgence of COVID-19 and other novel infectious diseases. According to Uday Nori, the Centers for Disease Control and Prevention and many other funding agencies are eager to underwrite projects so long as they relate to COVID-19 or SARS-CoV-2. He is cautious in evaluating the information that has flooded publications in recent months, but he believes that ongoing data collection will ultimately yield valuable knowledge. He is especially eager to see what emerges from an effort by Olivia Kates, MD, an infectious disease physician at the University of Washington in Seattle, who has established a registry to collect data on transplant recipients whose test results for COVID-19 were positive. “Hopefully that will be a goldmine that everybody can access and analyze to do their own research,” Nori says.

Perl anticipates that recent experience will encourage a more patient-centered approach to care. “COVID-19 has been a catalyst for us to reevaluate what really are the requirements for such frequent kidney care visits. What really are we trying to accomplish?” Perl asks, citing a recent study of 7454 patients receiving hemodialysis in Ontario. “Led by Alison Thomas, our group found more frequent blood work was not necessarily associated with better health outcomes (5). I would love to see more personalized care plans to consider different lengths of time between blood work, between clinic visits,” he says. “We can potentially save money, reduce burden, improve patient-reported outcomes, and intensify our efforts on behalf of patients that need more care.”

What else can be done to better prepare for the next crisis? “The disproportionate impact of the pandemic on Black people raises the broader question of how we fix health disparities,” Vijayan says. She would like to see healthcare systems, researchers, and physicians address the social determinants of health and inequities that currently exist in their communities. Schiller also stresses the need to tackle the fundamental issues that leave people vulnerable in times like the present. “The socioeconomic inequality in healthcare has been exposed painfully in this crisis,” she says. “As a physician, this inequality is utterly unacceptable. Every life is precious.”