Global Reports

Contributor
Dr Abdou Niang

Contributor: Professor Sydney Tang, Professor Philip Li

Contributor
Assistant Professor Raja Ramachandran

Contributor
Dr Abduzhappar Gaipov

Contributor
Professor Dibya Singh Shah

Contributor
Prof. Rubina Naqvi

Contributor
Dr Marjorie Foo

Contributor
Dr Gheun-Ho Kim

Contributor
Dr Bassam Saeed

Contributor
Professor Masaomi Nangaku

Impact on patient care

In Japan, the first patient of Covid-19, who came back from Wuhan, was reported on Jan 15. On Feb 3, the famous cruise ship hosting 3711 people with many Covid-19 patients came to Yokohama. Until mid-Feb, most Covid-19 patients were those who came back from foreign countries or had link with other Covid-19 patients. However, the number of patients, especially those without links with other Covid-19 patients, increased dramatically after mid-Mar. On April 1 President of the Japan Medical Association declared “Medical Crisis”. On April 4 the Japanese government finally declared “emergency” at seven prefectures, including Tokyo Metropolis and expanded “emergency” to all the nation on April 16.

The strange characteristic of Japan is the very small number of PCR analyses occurring to diagnose Covid-19 in spite of the large population (40,263 tests in the total population of 126.5 million on April 8). The Japanese prime minister announced that the government secured 28,000 beds for Covid-19 patients on April 6, but this is suspected to be overstatement because the number is more than 2.5 times of the sum of the total number of beds which all the prefectures secured (10,607 beds). Many hospitals are slowing regular healthcare routine down. On April 9, Japanese Association for Acute Medicine and Japanese Society for Emergency Medicine announced that many hospitals have difficulty in accepting patients with severe acute illness because of the outbreak of Covid-19.

By the end of April 16, total number of confirmed cases in Japan was 9,167 and total number of deaths was 148 (mortality 1.6%). On April 17, the number of new Covid-19 infection per day in Tokyo Metropolis became more than 200 for the first time.

Impact on the dialysis workforce

Japan has a huge dialysis population. At the end of 2018, the number of prevalent dialysis patients was 339,841, which corresponds to 2,688 per million population. According to the preliminary report by Japanese Society of Dialysis Physicians, the number of dialysis patients with confirmed COVID-19 infection was 47 with 4 deaths on April 17.

Preventative Strategies

The Japanese society of Nephrology (JSN) made a website about COVID-19 (https://www.jsn.or.jp/covid19/) and introduced the activity of the ISN to the members of JSN. The Japanese Society of Dialysis Physicians released guidance documents for dialysis and renal transplantation patients to be shared with the public, and the latest version (4th edition) was published on April 3
(http://www.touseki-ikai.or.jp/htm/03_info/doc/20200402_corona_virus_15.pdf).

JSN and Japanese Society for Dialysis Therapy help with the distribution of the documents. According to this guidance, all HD patients have temperature measurements every morning. If they have a temperature of more than 37.5C° or symptoms of common cold, they report to dialysis clinics by telephone in advance. Patients with cough should wear masks. Patients with suspected or confirmed COVID-19 infection should arrange personal transportation. Their pass route for entering hospital and dialysis unit should not be shared with other dialysis patients. Patients with suspected or confirmed COVID-19 infection should be dialyzed in a separate room. If the capacity of the isolation dialysis is overloaded, social distance (more than 2m) with curtain or partitioning screen should be employed during dialysis treatment. If spatial isolation is difficult or there are many patients, change of dialysis shifts for temporal isolation may be required. Equipment that may come into contact with patients or potentially contaminated material should be disinfected according to standard protocols after dialysis.

Contributor
Professor Bo Feldt-Rasmussen

Impact on patient care
In Denmark we have been able to control the epidemic during the first month. As of April 15, about 300 have died in Denmark which is about 50 per million inhabitants.  Hospital admissions are declining and the number of patients in intensive care units with need of ventilators is going down.

Patients on ventilators at ICU have in many cases used CRRT. Some have needed hemodialysis for a short period afterwards, but we have had capacity to meet these needs. Unfortunately, some ICU patients get so terribly ill and can´t be saved, even younger patients with no comorbidities.

So far we have had no capacity issues in any of the dialysis centres of the Capital Region. In the Capital Region we are taking care of about 900 dialysis patients (about 700 HD and 200 PD). Very few have been infected, two with many comorbidities have died.

An area of concern is that Patients with many other diseases are now on rapidly growing waiting lists because of the highly needed focus and allocation of resources to COVID.

Impact on the dialysis workforce

Nephrologists and nurses have only to a minor extent been infected. At one hospital, we have had two out of 26 doctors verified infected. Three nurses and one secretary out of a staff of 250 has been documented with COVID 19. We have been able to include staff that have previously been working with dialysis in order to meet demands of increased sick leave.

The staff have been worried, in particular in the beginning. As time has passed the staff are acting very professionally and calm.

Preventative strategies

Denmark is a public health service system with open and free access to all medical treatments to all. It has therefore been possible to plan and implement a national strategy to close down parts of the health service system in order to transfer and train staff to work with all aspects of COVID in new settings. New ICU´s with ventilators have rapidly been established and we have not had any problems with capacity so far.

We managed to build up a high capacity of these ICU beds with ventilators and to train nurses and doctors to handle these patients within the first weeks. We now have an overcapacity and the society is now planning to gradually open. We therefore expect more cases in the near future.

Specific to dialysis, we have planned with separate rooms for isolation of patients suspected of COVID until falsified or verified. We have plans for separate or cluster isolation as the epidemic might escalate. We have been able to include staff  that have previously been working with dialysis in order to meet demands of increased sick leave. The staff has been educated in dealing with these patients.

Contributor
Professor Eric Daugas

Impact on patient care

According to a specific transversal survey performed on March 30th by the Agence de la Biomedecine in charge of the REIN registry -a national prospective registry listing all ESRD patients, who started a renal replacement – almost three weeks after the beginning of pandemic in France, 298 dialysis patients were recorded in France as COVID positive with 37 (12.5%) deaths in this population. These numbers are preliminary and obviously under evaluated due to the incomplete gathering of cases and also considering that mortality will be observed later in some of these ongoing cases.

Subjectively, we must consider that the pandemic in dialysis patients population had quickly expanded considering that currently all dialysis centers in the geographic area have now organized specific dialysis sessions for COVID positive patients. A large proportion, up to one-third of the dialysis patients is now affected by the disease. The initial expansion of the pandemic in patients with ESKD was largely located in the east of France and in Ile-de-France, – which are the most impacted regions in France. This maybe in part due to the delay between the real but imperceptible beginning of the pandemic and the implementation of segregation measures of dialysis patients according to their COVID-19 status in specific dialysis sessions with dedicated care givers.

Impact on the dialysis workforce

In spite of initial apprehension, all members of our staff committed to the new challenge and turned to a positive mind to offer their best to the patients. The solidarity between the dialysis centers in the area allowed an efficient repartition of the patients according to their individual need to be referred to hospitalization. Even, health care professionals with specific skills for dialysis, who were recently retired or who moved to other professional orientations, came back to us as volunteers and proposed their help for dialysis of COVID positive patients. Still, this is clearly helpful considering that some caregivers in dialysis centers are now unable to work due to contamination by the virus. It is too early to measure their proportion, and I can only give the information from our center, where five members of our dialysis staff including one nephrologist contracted the disease, which roughly corresponds to a proportion of 15 %. It should be underlined that the usual financial barriers usually used to control the health expenditure in our hospitals have been quickly lifted allowing the fast recruitment of these volunteers in our centers.

Preventive measures

We now have national and regional guidelines available for patient transportation for caregivers’ protection. Currently, it is more challenging to establish treatment guidelines for COVID-19 and even more for dialysis patients. Each center developed its treatment proposal with a highly empirical approach due to the absence of definitive treatment evaluations. Locally we apply treatment guidelines proposed for all patients to dialysis patients according to the pharmacokinetic specificity and contraindications in ESRD patients (for instance, we considered the ratio benefit over risk of hydroxychloroquine unfavorable in dialysis patients).

Contributor
Prof. Giuseppe Remuzzi, Prof. Fabio Paglialonga

Impact on patient care

The Italian Society of Nephrology conducted a national survey with data provision for 54% of patients treated by HD (17,774 from total 36,433) or PD (2,252 from total 4,143 patients) in the Italy. According to this survey, at the national level 2.8% and 0.6% are COVID-19 positive on HD and PD (521 and 18 patients), respectively. In Lombardy, which is among of the most affected by the epidemic regions, these percentages are 7.4% and 0.7% (333 and 7 patients), respectively.

From the patients having COVID-19 infection, the isolation at the dialysis center was possible to 311 and 5 patients on HD and PD in the Italy in total, and to 249 and 4 patients on HD and PD in the Lombardy region. The clinical conditions of many patients require to hospitalize them to semi-intensive or intensive care units. From the 577 COVID-19 positive patients in Italy, 103 required semi-intensive and 24 intensive care, in Lombardy these numbers were 57 and 3, respectively. Many of them had unfavourable outcome, with 147 patients died in Italy in total (139 receiving HD and 8 PD), and 88 in Lombardy (86 and 2, respectively). These numbers equal to 25.5% mortality rate among dialysis patients in Italy in total and 25.9% in Lombardy.

Impact on dialysis workforce

The medical staff is also affected by the COVID-19 infection, and at April 7 there were 156 dialysis healthcare workers with confirmed positive tests in Italy, among them 103 were in the Lombardy region.

Preventative measures

There are no officially adopted guidelines at the national level, but every dialysis center introduced protective measures to prevent the COVID-19 spread. A total of 154 from 173 centers modified their protocols for transporting patients to and from Professor Giuseppe Remuzzi home to the dialysis treatment. Instructions were issued to patients to follow social distancing, washing hands frequently, wear surgical masks in the presence of others, on public transport and in dialysis units. Patients were contacted prior to dialysis and screened for symptoms. Waiting rooms were refurbished to allow social distancing and patients temperatures were checked on arrival. Symptomatic patients are evaluated by a nephrologist and infectious disease physician and, if possible, dialysis is delayed until swab results are back (4-6 hours). COVID positive patients are assessed at the positive COVID Emergency Unit to decide whether they deserve hospitalization or not. For Covid19 positive patients who do not need hospitalization, they usually return home after dialysis with mandatory recommendations for strict isolation from their family members. COVID+ patients are cohorted in dialysis areas.

All dialysis staff (doctors, nurses, cleaners, transporters etc) are instructed to use surgical masks during their stay at the centre and/or at any time when contacting a dialysis patient. Staff are also requested to report respiratory symptoms or fever to the designated authorities of the hospital to decide whether they can be admitted back to work or not (with or without COVID19 swab).

There are substantial variations in the testing procedures and criteria by centres: 110 performed tested only in symptomatic patients, 47 in patients with history of contacts with infected persons, 14 centres performed tests in all patients. These discrepancies are also observed in Lombardy, Italy.

Contributor
Dr Maria José Soler, Professor Manuel Praga Terente

Impact on patient care

So far, our institution in Madrid has treated 215 active hemodialysis patients and 39 peritoneal dialysis patients. Up to now, 28 dialysis patients (11%) has tested positive for COVID-19. Of them, 25 patients (23 HD patients, 2 PD patients) required hospital admission. The most common symptoms in our patients who required hospital admission (23 HD patients, 2 PD patients) were fever (64%), non-productive cough (64%), dyspnea (40%), gastrointestinal symptoms (20%) and myalgias (24%). The most frequent biochemical findings were a high C-reactive protein, D-dimer elevation, and a moderate decrease in the lymphocyte count. Chest X-ray showed ground glass opacities in 60% of the cases, alveolar consolidations in 30% and bilateral pulmonary involvement in 64%. Most patients were treated with hydroxychloroquine (96%)- see Treatment Algorithm . Other therapeutic regimens were added according to clinical course and severity: lopinavir/ritonavir (48%), a 3-day course of intravenous methylprednisolone (40%), interferon beta (11%), and tocilizumab (4%). All patients received antibiotics, mainly cephalosporines and azithromycin. Seventeen patients (68%) received prophylactic anticoagulation with low-molecular-weight heparin. During a mean follow-up of 13±7 days of in-hospital stay, 10 patients (40%) developed acute respiratory distress syndrome (ARDS) and 7 of them eventually died. Ten patients have been discharged and the 8 remaining show a favorable course. In the last days no new positive cases among dialysis patients have been observed.

We needed to increase our ICU beds to ensure adequate capacity for patients with severe respiratory distress syndrome. In addition, consultation with our infectious disease specialists are crucial in the care of COVID-19 patients. Psychological support for these patients is important to ensure the overall well-being of our patients.

The epidemic posed a dramatic challenge for Madrid’s Hospitals. Our Hospital, with 1,200 hospital beds, admitted more than 1,050 infected patients hospitalized at the highest peak of the outbreak (March, last week). ICU unit was near collapse during several days.

Impact on the dialysis workforce

In Barcelona, around 13-15% of Nephrologists and dialysis healthcare workers are infected. But massive COVID-19 testing has not been performed in all centers.

In Madrid, another serious problem during the first days was the number of health workers infected, due to the scarcity of protection material and the lack of awareness of the seriousness of the disease. In our Division the number of infected nephrologists, nurses and auxiliary persons ranged between 8 and 15%. We rapidly decided to suspend all outpatient visits and non-urgent activities (i.e. kidney transplants) in order to maintain our capacity to attend hospitalized infected patients. However, we keep 2-4 nephrologists attending phone calls of kidney transplant recipients. Of the approximately 2,500 kidney transplants that our Division controls, less than 1% required admission. An important fact is that our Division was required to attend an important proportion of hospitalized patients (more than 80 in the highest peak) considering the recognized nephrologist’s expertise in the management of seriously ill patients.

Policies, practices and guidelines.

In Barcelona, COVID-19 patients who have recovered from the disease may have dialysis in 2 outpatient dialysis centers, that has been re-designed to accommodate the care of these patients. We are following the ERA-EDTA and the Spanish Society of Nephrology recommendations. The Spanish Society of Nephrology have guidelines (in Spanish in the link ) available and these guidelines are derived from ASN and EDTA guidelines.

https://senefro.org/modules.php?name=webstructure&idwebstructure=157

In Madrid, our center has developed treatment protocol for infected patients and is being updated regularly. For the management of peritoneal dialysis patients, we use the guidelines provided by the Spanish Society of Nephrology.

Further acknowledgements: Hernando Trujillo, Fernando Caravaca-Fontán, Ángel Sevillano, Eduardo Gutiérrez, Jara Caro, Elena Gutiérrez, Claudia Yuste, Amado Andrés, Manuel Praga

Contributor
Professor Rumeyza Kazancioglu, Professor Mustafa Arici

Impact on patient care

The first case of Coronavirus has been identified on March 11, 2020 in Istanbul, Turkey. Since then Istanbul has been the mostly affected city in the country. Being an international hub and a densely populated (16 million inhabitants) area Istanbul became the major center of the pandemic. The latest numbers regarding the pandemic in Istanbul are 12,231 confirmed COVID-19 patients consisting 60% of all Turkish cases (23934) on April 4 2020. The latest cumulative number of confirmed COVID-19 patients in Turkey is 42,282 including 908 deaths (April 9, 2020).

According to the latest registry there are 91 dialysis centers with 2,636 hemodialysis machines (15% of all machines in the country) in Istanbul. There are 364 peritoneal dialysis (adult and pediatric) and 10,808 hemodialysis (including 111 home hemodialysis) patients. Most of the patients are dialyzed at private outpatient centers. Nearly all of the costs of dialysis are covered for these patients.

In Turkey, preparations against Covid-19 pandemic has started after the New Year. The Ministry of Health (MoH) set up a “Coronavirus Scientific Advisory Board” on 10 January 2020 in Turkey. Several pandemic plans have been prepared and some precautionary measures have started in this period. However, there was a silent fear and somehow inertia among public and even healthcare workers till the announcement of first case. First case in Turkey was officially confirmed on 11 March 2020 and everything changed suddenly. Strict precautions were announced along with a sharp increase in the number of cases. By the end of 10th April, total number of confirmed cases in Turkey was 40.029 and total number of deaths was 1006. Regular healthcare routine was sharply slowed down by mid March 2020, even it stopped by mid-April. All regular outpatient appointments in the clinics were deferred except emergent or severe cases. These precautions have obviously affected the healthcare in nephrology.

Impact on the dialysis workforce

Since the beginning of the pandemic (March 2020) the Turkish Ministry of Health issued new regulations regarding the refill of the prescription drugs and dialysis solutions and the duration of the health reports enabling our patients to have access to free medications and dialysis to avoid unnecessary visits to the hospitals. All reports have been prolonged till the end of June 2020 and the patients will not require visiting their physicians to get the prescriptions unless there is a change and they can get it directly from the pharmacy based on previous records including dialysis solutions.

A practicing nephrologist at age of 55 had a severe Covid-19 infection. He had ICU care with intubation for 10 days, but luckily he recovered and well now. There are no more known cases among healthcare workers in Nephrology community.

Preventive measures

As the pandemic was approaching our country The Renal Disaster Task Force of Turkish Society of Nephrology (TSN) worked on recommendation documents for our kidney patients and dialysis centers and health care providers. TSN executive board published and distributed these recommendations during March 2020 to all. These suggestions were shared with the health authorities and Turkish Ministry of Health issued the revised version of the suggestions as a guideline on March 26, 2020. In order to run the in-center dialysis operations safely personal protective equipment (PPE) has been distributed to all healthcare providers of dialysis units in hospitals. The outpatient clinics also provided PPE to their staff. According to the personal communications, the dialysis staff has been working in divided shifts in case a potential infection occurs in one then the other team can take over the care of the patients in many of the dialysis centers.

The guidelines of Turkish Ministry of Health have been shared both with the staff and the patients in regards to self-protection and care of the patients. Especially every patient and their caregivers have been informed once more about sanitation and social distancing rules as well as symptoms about COVID-19. In any suspicion of the disease the dialysis patients are also triaged according to the up-to-date suggestions of the health authorities, which is revised regularly (nearly every other day) based on the new information.

In some centres like ours, there has been set a separate dialysis room with portable water systems in the new COVID wards to provide dialysis to the inpatients with the diagnosis. Till now we have dialyzed two confirmed and three suspected cases of COVID-19 patients in our hospital in this new setting.

Moreover the virtual care of home dialysis patients have been used more commonly and the patients have been advised to make use of community labs for immediate analysis and report back to the unit through available communication platforms. The home visits for peritoneal dialysis patients and clinically stable patients’ in center visits have been postponed at least a month for the time being.

Regarding the facilities for health care providers, some of the hospitals have provided nearby accommodation to the staff in case they would not be able to go home because of protective measures.

Policies, practices and guidelines.

The Renal Disaster Task Force of TSN and TSN prepared an online questionnaire to be completed among the nephrologists in the country inquiring about the kidney patients with COVID-19 infection. According to the unpublished data there are at least 26 dialysis patients reported currently with half of them from Istanbul. We are hoping to be able to share our initial experiences with colleagues soon.

TSN has just started a database for documenting Covid-19 infected patients with kidney problems, including CKD stage 4-5, dialysis or renal transplant patients. Almost 60 cases were registered in a week and the numbers are increasing every day. There is no outcome data yet, but it will soon be analysed.

Additionally, TSN Renal Disaster Task Force immediately released guidance documents by 20th March for dialysis and renal transplantation patients
(http://www.nefroloji.org.tr/haber.php?id=283). These documents were continuously updated and shared with the public. MoH has also released a guidance document for dialysis patients on March 26, 2020
(https://dosyaism.saglik.gov.tr/Eklenti/103148,onerilerpdf.pdf?0). Meanwhile, TSN’s social media and literature update platforms were all reserved for current Covid-19 information for healthcare workers and patients (http://www.nefroloji.org.tr/nefroblog/corona.php and https://www.instagram.com/turknefrolojidernegi/?hl=tr).

Contributor
Professor Andrew Davenport

Impact on patient care

The UK has been in “lock down” now for 3 weeks. Our first Covid-19+ve haemodialysis patient was admitted on the 7th March, 2 weeks before the “lock down”. We have had 2 clusters of Covid-19+ve cases in two of our satellite dialysis centres, and sporadic cases in all centres. So far we have had 100 confirmed cases. There are other patients with suspected Covid-19 who either have had negative swabs, or awaiting test results. Depending on the timing of samples taken for testing there may be a 20% false-negative rate. Forty patients are currently hospital inpatients and we have had to increase the number of dialysis machines in the main hospital to accommodate the increased demand. Forty-six patents remain dialysing in our satellite dialysis centres, and unfortunately 14 patients have died.

Our university hospital dialyses some 750 patients in four satellite centres. The average age of the haemodialysis population is > 65 years and more than 40% have hypertension. The National Health Service (NHS) provides transport to and from dialysis centres for older more frail patients who cannot independently make their own way to and from dialysis. To reduce transport costs, 2 or more patients will travel together in taxis. When several patients all arrive at the same time to the dialysis centre, they will typically wait in waiting areas before being called to a dialysis station. Similarly, at the end of their dialysis session, patients have to wait for all members of their travel group to be ready to leave, before they can be picked up and taken home.

The hospital supervises the management of 170 peritoneal dialysis patients. So-far only 5 peritoneal dialysis patients have caught covid-19 and 2 have died. This supports the major effect of social isolation with peritoneal dialysis compared to communal travel and waiting in haemodialysis centres.​

Impact on the dialysis workforce

The UK position is that individuals should self-isolate for 14 days if a family member becomes unwell with a fever and cough, and similarly if they become unwell to remain at home for 7 days after start of symptoms. The Covid-19 epidemic started at a time when a number of other respiratory viruses were circulating, as such a number of staff started self-isolating. Initially the hospital was severely restricted as to the number of tests allowed for covid-19, and only patients admitted to hospital could be tested. As such we were not able to test patients attending the dialysis centres for some weeks, and similarly there was no supply of masks for patients for some weeks. Testing for staff was only introduced last week, but staff could only be tested in a limited time window, so many staff who were ill at home could not be tested. This has led to severe staff shortage with two of our dialysis centres reporting 50-60% nursing staff sickness. To compensate for staff shortages, the department has pulled together with professors and senior consultants volunteering to clean down and make beds for dialysis patients, setting up dialysis machines, and a proportion of patients have had their dialysis schedules changed from thrice weekly to twice weekly, or twice weekly to once weekly.

Contributor
James Tollitt

Impact on patient care and dialysis workforce

Salford Royal NHS Foundation Trust is a large teaching hospital in the North West of England, UK. It provides renal services for 1.55 million people. In March 2020 we encountered “lockdown 1” due to a surge in the number of COVID-19 cases in our community. We lost junior medical and senior specialist nursing staff to support intensive care services, we reshaped our renal service so we were providing only essential medical care. We realigned consultant rotas so more consultants were working on the “front line”. We moved inpatient wards so patients who were COVID-19 negative could be treated separately. We digitally stratified patients within our CKD outpatient service who were most at risk of end stage renal disease based upon historical eGFR decline and prioritised those most in need. We remotely monitored and managed 179 (41.4% of our total prevalent haemodialysis patients) onto a twice weekly dialysis schedule to reduce nosocomial COVID-19 exposure in the dialysis units, allow for the creation of a “hot” COVID-19 positive dialysis unit and attempt to mitigate against unprecedented haemodialysis staff sickness rates. Transplant patients had phlebotomy performed in a setting away from the hospital main site. Face to face transplant patient reviews were kept to a minimum to avoid unnecessary travel and hospital visitation. Immunosuppression regimens for glomerulonephritides were modified to provide the best treatment with fewest hospital visits

Normal renal services were resumed in July and August 2020. Cases of COVID-19 rapidly increased in September and October 2020 within the UK. At this point the North West of England saw the highest rate of COVID-19 in the country. The Prime Minister of England announced a second national lockdown to start on 5th November until 2nd December 2020. As I write we are in the midst of “lockdown 2”. Cases are falling and hopes are high for a vaccine programme to begin in the New Year. Throughout lockdown 2 renal services are running as close to “normal” as possible. All outpatient activity is up and running with over 80% of it being performed remotely using digital technology. Our renal inpatient ward is COVID-19 free. Routine surveillance screening of asymptomatic staff is about to be commenced. We have purchased a van which can perform phlebotomy services in the community and hence avoid unnecessary hospital exposure. Furthermore our renal research nurses and doctors are recruiting participants to a vaccine trial.

Preventative measures

Throughout the COVID-19 pandemic our department has shared knowledge which has helped to inform the national conversation in relation to safe personal protective equipment, safe dialysis frequency reduction and the role of antibody screening in health care workers (Gray et al., 2020; Lodge et al., 2020; Poulikakos et al., 2020). Our medical staff have also played a key national role in patient safety work streams around minimising nosocomial COVID-19 transmission in dialysis units using quality improvement methodology.

Policies, practices and guideline

The impact of COVID-19 on healthcare will be long-lasting. We must remain positive and value what it has taught us. Firstly we have managed to rapidly change and safely deliver an incremental dialysis programme. Secondly we have introduced telephone and video clinic consultations and supported this with the introduction of an acute face to face renal clinic for urgent referrals/acute issues. We have safely reduced the required frequency of haemoglobin testing for erythropoietin monitoring in stable CKD patients. Finally we have seen an improvement in intra and interdepartmental relationships within our hospital and across our neighbourhood hospitals. The spirit of cohesion and collaboration will hopefully last for many years and bear fruit for the mutual benefit of many future renal patients and renal clinicians.

References

Gray, S., Clough, T., Mcgee, Y., Murphy, T., & Poulikakos, D. (2020). Increased risk of COVID-19 in haemodialysis healthcare workers in a tertiary centre in the North West of England. Journal of Hospital Infection, 106(2), 390–391. https://doi.org/10.1016/j.jhin.2020.07.030

Lodge, M., Abeygunaratne, T., Alderson, H., Ali, I., Brown, N., Chrysochou, C., Donne, R., Erekosima, I., Evans, P., Flanagan, E., Gray, S., Green, D., Hegarty, J., Hyde, A., Kalra, P., Lamerton, E., Lewis, D., Middleton, R., New, D., & Tollitt, J. (2020). Safely reducing haemodialysis frequency during the COVID-19 pandemic. https://doi.org/10.21203/rs.3.rs-41399/v1

Poulikakos, D., Sinha, S., & Kalra, P. A. (2020). SARS-CoV-2 antibody screening in healthcare workers in a tertiary centre in North West England. Journal of Clinical Virology, 129, 104545. https://doi.org/10.1016/j.jcv.2020.104545

Contributor
Professor Adeera Levin

Impact on patient care

BC Renal (BCR) and British Columbia’s 5 geographic Health Authority Renal Programs (HARP) mobilized our response to the COVID-19 pandemic in early March. In short order, we developed and implemented strategies and guidelines to ensure continued comprehensive care for BC’s 14000 CKD patients, 3200 dialysis patients (30% home-based) and 3200 persons living with kidney transplants.

At the time of this writing (14/04/2020), 4 HD and 1 PD patient have swabbed positive in 2 different jurisdictions, all of which are presumed to be community acquired. Two of these were in long term care facilities with known outbreaks. One elderly patient (>85 years of age) with multiple co-morbidities has unfortunately died. Two kidney transplant patients are COVID+.

Impact on the dialysis workforce

One PD nurse contracted and recovered from COVID-19, and is back to work. No physicians have been affected. The moral distress felt by nurses, doctors and patients is well recognized during this time, and we have attempted to address it with regular online bulletins, written and virtual nephrology specific communications, to enhance feeling of belonging.

Policies, practices and guidelines.

BCR had a pre-existing Emergency Management Plan, including pandemic guidance, which supported our efforts, which were built on 2 guiding principles:

A. Minimize MD and HCP contact with patients who are by definition not able to isolate, while balancing good care of those patients, and careful consideration of the actions/ reactions that changes to care paradigms bring, and

B. Ensure that the totality of our patient population receives necessary care to avoid either COVID-related or unrelated adverse outcomes (e.g. crash starts and poor outcomes due to non-focus on disease specific needs)

Strategies and initiatives
(http://www.bcrenalagency.ca/health-professionals/clinicalresources/novel-coronavirus-(covid-19)) successfully implemented to date:

• Established the BCR COVID-19 Emergency Operations Committee (the authors), who meet at 5pm daily, M-F, or as needed, to enhance problem solving, best practices sharing and communication
• Established virtual patient care (phone, video, Telehealth) in outpatient clinics – CKD, Home Dialysis, Transplant
• Modelled and confirmed acute dialysis capacity, including use of portable RO and acute PD.
• Created a Guideline for HD care during the COVID-19 pandemic
  • Screening
  • Protected dialysis of COVID+ and Patients Under Investigation
  • Adjustments in HD unit workflow (e.g. patient HD schedule, staggered starts, cohorting)
  • Infection Prevention and Control recommendations including PPE for staff and physicians
  • Adjustments to nurses schedules, breaks and physical distancing
• Created an Ethical framework for allocation of Dialysis Resources
• Ensured stable supply of renal medications, including limited supply of K-binding resins
• Ongoing work with public and private providers to ensure stable transport for COVID19 + and – patients from home to dialysis units and outpatient clinics
• Confirmed continued surgical capacity for PD tube insertions and AV access procedures for CKD patients at high risk for dialysis start in coming months. We hope to reduce unintended HD starts or use of tunneled HD catheters which may increase hospitalization
• Established patient-specific reduced testing frequency for CKD, Transplant and Home Dialysis patients. Worked with public and private medical laboratories to ensure access for necessary CKD, transplant and dialysis testing. Worked with public health and laboratories to ensure guideline-based COVID-19 testing and rapid result turnaround
• Ensuring expert guidance for use of, and adequate supply of immunosuppressive agents for both GN and Tx patients, was available
• Systematic collection of COVID data collection for all HD patients

The authors wish to acknowledge the amazing work of so many who help all our patients living with kidney disease, their families and care providers during this unprecedented time. Without their humanity, skill, and dedication, many more would have been impacted. We continue to support each other as we learn, listen and do the best we can.

Further Acknowledgements: Antonsen, John E.; Brown, Melanie; Copland, Michael, Michaud, Marie; Singh, Anurag, Levin, Adeera, submitted on behalf of the BC Nephrology Community

Contributor
Professor Steven Fishbane, Dr. S. Ali Husain,
Professor John Cijiang He

Impact on patient care

As the epicenter of the COVID-19 outbreak in the United States, New York State has been under a state of emergency declaration for over one month, with widespread practice of social distancing for over three weeks. As of April 6th, New York State has had 140,081 cases. In New York, as the number of cases increased many people were admitted into hospitals critically sick overwhelming the healthcare systems hence causing extreme levels of stress. For nephrology related services (inpatient consults, outpatient CKD COVID-19 complications and ESRD related COVID-19 cases), the demands were greatly increased and remain so at the time of this writing. Outcome data is not available yet but COVID patients with AKI have high mortality (50%) and ESRD patients with COVID seem to be doing better than we thought.

COVID-19 pattern in New York: https://www.nytimes.com/interactive/2020/us/new-york-coronavirus-cases.html

Chronic hemodialysis patients are considered a vulnerable and high risk group. Clinicians and patients also face immense challenges with social distancing because of the complexity it entails. Because of the population density of New York City and a broad reliance on public transit, there has been concern for the vulnerability of patients who receive thrice weekly incenter hemodialysis and are therefore unable to shelter at home.

We recognized early on that intense infection control surveillance, health status monitoring and attention to stress and anxiety were going to be critically important for both patients and staff. On-going communications with frontline staff is crucial to alleviate the concerns, stress and anxiety created by this pandemic.

To ensure adequate patient care as well as the wellness of our workforce, we implemented several measures at the divisional level:

1. All nephrology attendings were assigned no more than 7 days of inpatient coverage at a time. Everyday 4 nephrology attending were available as back-up coverage as needed.

2. A 2nd inpatient service (staffed by 1 fellow and 1 attending) was created to redistribute nephrology patients

3. Weekends are normally staffed by 2 nephrology attendings and 2 nephrology fellows. To meet the demands of a higher volume of patients, 5 nephrology attendings and 2 nephrology fellows staffed weekend coverage.

4. Healthcare workers who developed symptoms were referred to Employee Health Services (EHS) and returned to work once cleared by EHS 5. Antibody testing was offered to those who recovered from symptoms suspicious for COVID-19 infection

6. Healthcare workers were given access to scrubs

7. All intermittent hemodialysis treatments were shortened to 2.5 hours

8. Patients with detected COVID-19 infection were dialyzed on separate shifts or in their patient rooms

9. An acute peritoneal dialysis (PD) was initiated, started with either bedside surgical catheter placement or placement by interventional radiology

10. Physicians were trained on the use of PRRT to optimize the use of CRRT machines

11. Physicians were advised to initiate potassium binding agents to delay dialysis treatments if necessary

12. As these dialysis filters and catheters have been clotting at a higher frequency, we implemented an anticoagulation protocol with heparin for both intermittent hemodialysis, CKDRT, and heparin catheter locks.

Preventive measures

Special measures have been set up to ensure all prevention practices are in place. These include: social distancing, mandating the use of PPE (surgical face masks during direct patient contacts), active screening outside the dialysis units for temperature checks and symptoms before entry to the waiting room. (Figure 2). If patients has a fever or symptoms, they are then escorted in a separate room to be evaluated by a nurse or physician (with all precautions) and a decision is made to either get an evaluation in the emergency room or continue with outpatient dialysis.

Limited testing capacity

A lack of widespread testing makes it difficult to determine if these measures have been successful. As the number of COVID-19 cases increases, individual dialysis units have been dedicated to treating patients with COVID-19 in order to avoid nosocomial spread, and hospitals have reserved specific shifts to dialyze inpatients with COVID-19. While we do not yet have reliable data on outcomes for dialysis patients who develop COVID-19 in our region due to limited testing availability and the large proportion of hospitalizations that are still ongoing.

Figure 1: Screening personnel outside our dialysis unit for symptoms and fever.

Among patients under investigation for the virus due to their history of exposure, we cohorted them in to a separate dialysis unit when possible or a different shift based on the availability. In such cases, we maintained a 15-foot spacing between patients when possible. Similarly, for patients who are COVID+, and don’t require hospitalization, we keep them in a dedicated unit or a dialysis shift where nurses and technicians wear full protective equipment. The disease is monitored and dialysis is provided with special attention to evolving symptoms. When patients are feeling better and 14 days have lapsed since their symptom onset, we reintroduce the patient to their usual dialysis shift and location, without retesting for the virus.

Impact on the dialysis workforce

Workload for nephrologists and nursing has increased substantially in both outpatient dialysis units and within hospitals. Nephrologists are called upon to discern possible need for COVID testing among symptomatic patients and need for hospitalization based on clinical presentation. Planning of patient’s subsequent dialysis treatments as cohorted patients under investigation or other status requires the nephrologist to be in frequent communication with facility staff.

Effective and decisive leadership is critical at times of a pandemic. Weekly communication between the medical director and nephrology staff ensures the any up-to-date information are being efficiently communicated to our dialysis nurses and other allied health professionals. In addition, any specific health concerns are also directed conveyed to the team leaders. Health screening is also mandated for all staff entering the dialysis units. We experienced a substantial shortage of non-nephrologist dialysis staff in our hospitals. In contrast, outpatient dialysis staffing remained fairly stable.

There has been a significant shortage of nursing staffing with about 50% nursing out because of sickness. In New York city, several (2-7) faculty and fellows in each Institution got COVID-19 infection. Most faculty and fellows were able to come back in 7-14 days home quarantine. Most outpatient dialysis units have their own COVID shifts. Centralizing these patients in some of these COVID positive units did not work well.

The impact of the pandemic on the local nephrology workforce has also been difficult to assess due to lack of widespread testing in our state, though we are not aware of any large outbreaks within nephrology divisions in our city. However, given the emerging association between COVID-19 and kidney dysfunction, our institution’s demand for nephrology services has been higher than ever. The number of inpatient nephrology consult requests has more than tripled, and 20-30% of the patients who require intensive care unit admission have also required some form of kidney replacement therapy. As a result, our city’s nephrology divisions have expanded their capacity and have been actively recruiting dialysis nurses from outside of the state. Nevertheless, morale among our physicians and staff has persevered, and there has been widespread acceptance of the need for additional clinical duties among our staff, all of whom are eager to help in whatever way possible.

Policies, practices and guidelines.

Our health system is in a joint venture operation with one of the dialysis corporations. The dialysis operations was closely managed with both our health system and overseen by the dialysis corporation leadership. Daily to weekly meetings led to policies and procedures for infection control, proper screening, protective equipment for staff and day to day functioning. In addition, telehealth options were slowly introduced for help in remotely managing some of the acute dialysis issues that would arise.

Further acknowledgements: Kenar D.Jhaveri, Rimda Wanchoo, Jacob S. Stevens

Contributor
Michael J. Ross, MD, Deep Sharma, MBBS, Maureen Brogan, MD

Impact on patient care

New York City is the epicenter of the COVID-19 pandemic in the United States and the Bronx, where Montefiore Medical Center is located, has the highest per capita rate of infection and mortality due to COVID-19 of New York City’s boroughs. The reasons for the higher risk related to COVID-19 in the Bronx is likely due to the high rate of poverty and the high proportion of African American and Hispanic persons, who are approximately twice as likely as White or Asian persons in New York City to die of COVID-19 for reasons that are not yet fully understood. Though many outpatients with ESRD and COVID-19 remain stable and do not require hospital admission, we have observed a high rate of mortality in our population and are currently analyzing our local data. Similarly, the kidney transplant group at Montefiore published their recent experience with COVID-19 and demonstrated a >20% mortality among our kidney transplant patients with COVID-19 despite, aggressive management (Akalin E et al., NEJM 2020). It is not clear whether the socioeconomic and racial/ethnic factors that have increased the prevalence and mortality due to COVID-19 in the Bronx overall are responsible for poor outcomes in patients with kidney disease.

The COVID-19 crisis has severely impacted all aspects of clinical operations at Montefiore. Our hospital acutely doubled its number of inpatient beds, and the number of patients requiring nephrology care exploded, because acute kidney injury is a common complication of COVID-19 and because there was rapid spread of COVID-19 among patients living with ESRD and kidney transplant recipients who required hospital admission. Our ability to provide care to our patients has been challenged by limitations in the number of staff and availability of equipment and supplies for renal replacement therapies.

Continuous renal replacement (CRRT) has been our RRT modality of choice for hemodynamically unstable patients in intensive care units (ICUs), but full implementation of CRRT was initially limited by very high patient/nurse ratios and high incidence of clotting of CRRT circuits. We partnered with perfusionists who were available to run the CRRT machines due to cancellation of elective cardiac surgeries. We have performed CRRT using systemic anticoagulation with bivalirudin, which reduced clotting of CRRT circuits. Montefiore also purchased several additional CRRT machines and we have further increased CRRT capacity by performing prolonged intermittent renal replacement therapy (PIRRT), which allows us to treat more than one patient per day with each machine and reduces burden on staff. Finally, we have also had to work very closely with manufacturers of CRRT solutions in order to maintain adequate supplies, and we are exploring implementation of protocols to produce CRRT dialysate locally.

During the initial phase of the acute expansion of our nephrology services, we partnered with our surgeons and interventional radiologists who placed peritoneal dialysis (PD) catheters in many of our patients with AKI, especially those located in newly established ICUs without suitable water supply for conventional intermittent hemodialysis (iHD). Due to severe nursing constraints, we trained many of our nephrologists to perform manual PD exchanges and to set up and operate automated PD cyclers.

Providing iHD to all inpatients in need of it was challenging due limitations in the number of dialysis nurses, the number of machines with portable water treatment systems, and the number of hospital rooms with adequate plumbing to support portable HD machines. We procured many additional iHD machines and had many additional water hookups installed throughout our hospitals. To further increase iHD capacity, we reduced the default dialysis frequency to twice weekly and reduced the default treatment duration. To reduce the risk of volume overload and hyperkalemia, all inpatients with COVID-19 requiring HD have been treated with strict fluid and potassium restriction and daily oral potassium binders unless they had a contraindication. Due to the marked increase in prescriptions for potassium and phosphate binders, we have had to work closely with hospital pharmacy administration to ensure adequate supplies.

Impact on dialysis workforce

A large proportion of our nephrology providers, and especially dialysis nurses, has been infected with SARS-CoV-2, which resulted in major challenges in providing patient care. In order to protect our most vulnerable clinical staff, those who were pregnant, over age 65, or had medical conditions that significantly increased risk of severe complications of COVID-19 were assigned to care for nephrology outpatients via telemedicine and electronic consults for low acuity inpatients.

To reduce exposure of our dialysis nurses to SARS-CoV-2, we purchased video baby monitors, each equipped with two cameras allowing the nurses to separately monitor patients/vascular access and the dialysis machine from outside the patients’ rooms. Several of our nephrologists also learned to assist dialysis nurses with tasks in the dialysis unit, freeing additional nurses to perform bedside dialysis in the hospital. Though we initially dialyzed all inpatients with COVID-19 at their bedside using portable machines, the number of these patients soon overwhelmed our capacity of nurses and portable machines. To increase capacity, we clustered hemodynamically stable inpatients with COVID-19 on the last shifts of the day. The later time permits terminal cleaning of the unit which was necessary to prevent the spread of the virus among staff. It is also extremely important to perform frequent deep cleaning of areas used by dialysis nurses and ancillary staff and to adopt all appropriate measures to prevent spread of the virus among staff, including avoidance of eating together in close quarters.

Preventative measures

Soon after the initial reports of COVID-19 in New York City in early March 2020, we established a Nephrology COVID-19 Task Force at Montefiore, comprised of leaders of all aspects of inpatient and outpatient nephrology care, including dialysis nurse administrators. Our task force holds daily teleconferences to identify strategies to optimize staffing, equipment and supply chains, and the care for patients with kidney disease.

Our Division has worked closely with large dialysis organizations (DaVita and Fresenius) to coordinate care for patients with known or suspected COVID-19. Both companies have established dedicated dialysis units in New York City that only treat patients who have tested positive for COVID-19 but do not have severe enough disease to warrant inpatient admission. When inpatients with ESRD and COVID-19 are discharged from the hospital and require in-center hemodialysis, they are initially sent to a unit caring only for patients with COVID-19 and then are transferred back to their permanent unit once they are asymptomatic and are no longer positive for SARS-CoV-2 by repeat testing. Outpatient dialysis units are also available for patients with suspected but unconfirmed COVID-19 to decrease the risk of exposure to staff and patients.

Contributor
Associate Professor Kevan Polkinghorne

Preventative Strategies

Like other countries, the COVID-19 pandemic presents huge challenges in how our healthcare system is able to continue to treat and delivery quality care to our dialysis patients while ensuring safety of both staff and patients. In response to the pandemic, The Australia and New Zealand Society of Nephrology (ANZSN) has set up a COVID-19 working group (comprised of nephrologists, renal nursing and patient advocacy expertise) tasked to provide a vehicle for the discussion, development, and dissemination of information including guidelines and protocols to support renal units. A weekly video conference forum, open to all members (nephrology and nursing) has been implemented to assist planning and cooperation during the crisis and provide assistance to all during the crisis. The work group and forum initially identified a number of keys area of focus – dialysis unit preparedness including availability of PPE, work force and AKI.

Dialysis unit preparedness is highlighted as a key concern in Australia, as in other countries. To assist units the ANZSN has developed a checklist, adapted from the Centres for Disease Control and Prevention’s (CDC) COVID-19 Outpatient Dialysis Facility document (https://www.nephrology.edu.au/covid-19-updates.asp). The checklist is intended for use by renal unit senior management to assist them in considering key components of COVID-19 contingency planning for their units while recognising that each unit will have specific circumstances and challenges that will require local solutions. Renal unit heads within regions have been meeting regularly to assist in coordination and develop uniform approach to dialyses preparedness adapted to local conditions.

Workforce capacity in the dialysis unit is a major concern. The majority of centre dialysis units are staffed by specialised dialysis nurses, which, in the case of being unable to work are not easily replaceable. This is particular acute for smaller regional and remote units (such as those in the Northern Territory) which do not have capacity to replace dialysis staff easily. Protection of the front-line health care workers with adequate PPE is paramount. Strategies to help mitigate staffing shortages include cohorting of staff to ensure not overlap between dialysis shifts and relaxing of accreditation procedures to help facilitate of movement across health services where there is acute need have been implemented within a number of health services.

The preparation and management of AKI in COVID-19 patients is also a major focus identified as a major concern of the membership. Uncertainties in the epidemiology of AKI including the incidence and severity of AKI have been highlighted. Renal unit preparedness and capacity to manage additional dialysis dependant AKI is a major focus given the reported experience from Italy, the UK and US.

Finally, the Australian and New Zealand Dialysis and Transplant Registry has facilitated real time tracking of COVID-19 infection in the dialysis and transplant population to provide real time feedback to the Australian and New Zealand nephrology community of the burden and outcome of COVID-19 infection in both countries.

Contributor
Dr Augusto Cesar S Santos Jr

Impact on patient care

In Brazil, the number of COVID-19 cases is steadily rising. By 7 April 2020, we reached 14.049 confirmed cases and 688 deaths. The Southeast region of Brazil includes the States of Minas Gerais, Sao Paulo, and Rio de Janeiro. This region is not only the most important driver for the economy of the country but also, at this point, the region counting the higher numbers of COVID-19 cases. In the State of Minas Gerais, there are currently 49,600 suspected cases under investigation, 559 confirmed and 11 deaths. Besides, since Jan 2020, 44,000 suspected cases of Dengue fever were reported only in the State of Minas Gerais. Co-infection (Dengue, influenza, etc), healthcare and economic inequities (e.g. people living in the favelas), and the winter (bringing the flu season), are adding much uncertainty to our daily exercise to predict the impacts of the COVID-19 pandemic in our location.

Brazil has currently an estimated 140,000 patients on renal replacement therapy, mostly provided by the public healthcare system, Sistema Unico de Saúde (SUS). In our country, the number of patients with end-stage renal disease is steadily increasing, challenging our capacity to expand the infrastructure needed to provide treatment to all. Additionally, despite the large territorial extension, peritoneal dialysis is the modality of choice for only about 7% of the Brazilian population in need of RRT. Currently, we face considerable local differences across States regarding the prevalence of patients on renal replacement therapy. Part of these differences can be justified by economical inequities since a higher prevalence is especially observed in the most economically developed Southeast. Our RRT network is largely dependent on public funds. Additional unexpected increments of patients due to the COVID-19 pandemic, either due to an increased rate of AKI in the hospitals or to an increased number of patients with resulting CKD, will have nationwide consequences. In most regions of the country, the capacity to provide RRT is already at its limit.

Preventative Strategies

The Brazilian Society of Nephrology is closely following the COVID-19 pandemic. Since our first case recommendations were made into guidelines that are being regularly updated. The general perception is that our patients on RRT and healthcare workers are very well informed on the procedures while facing a suspected case of COVID-19 infection. The mobilization, from hospitals to primary care, was possible preceding the expected wave of cases. Since elective procedures are suspended in most locations, renal transplantation in Brazil was seriously affected and, in most locations, only urgent cases are being considered. At this point, the expected big wave of cases has not yet reached us, and we still have very few COVID-19 confirmed cases of CKD on RRT. Finally, both the public and the private healthcare sector are adopting a strategy of telemonitoring patients. This has resulted in a dramatic reduction in emergency room visits. In special, in my location, private healthcare providers have planned to address all CKD on RRT by phone calls and actively inform preventive measures and procedures in case of signs and symptoms of COVID-19 infection.

Policies, practices and guidelines

The Brazilian Society of Nephrology issued recommendations to care for patients undergoing dialysis in the setting of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) related coronavirus 2019 (COVID-19) pandemic on March 17, 2020. As Brazil entered the community phase of transmission, these guidelines are good practice measures to prevent the spread of the viral infection among the dialysis population and health care workers who are particularly vulnerable.