Authors: Michaela Salvo, MD; and Aisha T. Terry, MD, MPH
The US has one of the highest incidence rates of individuals receiving dialysis in the world. Approximately 750,000 people in the US are undergoing dialysis treatment, and African Americans are three times more likely than Caucasians to require this therapy. Many are older (>65 years) and nonwhite, both of which are independently associated with an increase in COVID-related mortality. Additionally, end-stage renal disease (ESRD) rarely exists as an isolated problem, and most ESRD patients have comorbidities such as cardiac dysfunction, hypertension, diabetes, or underlying lung dysfunction. To add to their risk, uremia associated with chronic kidney disease leaves ESRD patients inherently immunocompromised, which is demonstrated by the statistics that ESRD patients have higher rates of infections and hospitalizations than patients with normal renal function. ESRD patients in the pre-COVID era suffered mortality rates approaching 25% per year, with a 5-year survival rate of 35%.
While the key strategy to minimizing the spread and mitigating the risk of COVID-19 contraction in the US is currently centered on social distancing, ESRD patients requiring dialysis find themselves in dialysis centers three to five times a week. Treatments occur with a cohort of 4 to 25 individuals, usually in open-air facilities, and last approximately 4 hours at a time. Additionally, these patients must travel to and from these centers, sit in waiting areas, and interact with staff and health care workers (HCWs) weekly, who may themselves be vectors for the virus. For all of these reasons, patients with ESRD requiring dialysis are at a particularly high risk of contracting and experiencing fatality as a result of COVID-19.
To minimize the spread of COVID-19 via dialysis centers, the CDC has issued guidelines for dialysis centers to facilitate readiness. The initial step involves provider education regarding appropriate donning and doffing of personal protective equipment (PPE), HCW infection and exposure policies, machine cleaning, triage and recognition of signs and symptoms of the illness, and patient educational materials about COVID-19. All dialysis centers are urged to contact patients and instruct them to call ahead if they are experiencing respiratory symptoms or fevers, to redirect possible COVID-positive or suspected patients to an acute care facility for appropriate testing and care. If patients are noted to have a fever or respiratory symptoms on arrival to a dialysis center, it is reasonable to have them wait for transport to another facility (or for their treatment) in a quarantined waiting area or outdoors to avoid infecting others. Facilities should be arranged so that dialysis chairs are moved a minimum of 6 feet from one another, and patients undergoing treatment should wear a surgical mask at all times. If patients coming in for dialysis are known to be positive for COVID, which will happen at an increasing rate as the virus progresses and inpatient centers are overloaded, dialysis centers are urged to cohort COVID-positive patients to minimize the risk of exposure to others or to place them in isolation rooms, if possible. Visitor access should be restricted at this time, and HCWs should be monitored on a regular basis for signs and symptoms of COVID-19.
When admitting ESRD patients with COVID-19 to the hospital for inpatient dialysis, contact and airborne precautions apply, and whenever possible, dialysis should be completed in the patient’s room. If this is impossible, follow the above guidelines to minimize the exposure risk to other patients. ESRD patients with COVID-19 who are suitable for outpatient management require care coordination prior to discharge. The emergency department clinician should contact the nephrology team as well as the patient’s dialysis center to ensure that the patient will be able to receive dialysis at their normal time and location. If the patient’s dialysis center is not equipped to manage patients that are positive for COVID-19, the patient may require admission until alternative outpatient arrangements can be made.
April 3, 2020
The American Society of Nephrology and the American College of Emergency Physicians issued this joint statement on the appropriate use of emergency departments during the COVID-19 pandemic.
Dialysis facilities should implement measures to identify patients with signs and symptoms of respiratory infection (such as fever and cough) at or prior to arrival at a dialysis facility (before patients enter the treatment area).
When COVID-19 is suspected or confirmed in a hemodialysis patient, dialysis staff should follow the CDC’s “Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.”
Unless a patient is too sick, dialysis is most appropriately provided at an outpatient dialysis center. In the context of COVID-19, mild symptoms that do not require hospitalization should not be referred to the emergency department.
This guidance will ensure that dialysis is delivered safely, as prescribed, in the dialysis facility, and the patient will avoid exposure to an already overburdened hospital emergency department, unless the patient’s signs or symptoms warrant such care.
If a patient is being referred to the emergency department for a complaint that is not a time-dependent emergency, the dialysis center should discuss the case with their medical director and with the emergency department before sending the patient.