Safeguarding the Maintenance Hemodialysis Patient Population during the Coronavirus Disease 19 Pandemic

Abstract

The World Health Organization has recognized the pandemic nature of the coronavirus disease 19 (COVID-19) outbreak. A large proportion of positive patients require hospitalization, while 5-6% of them may need more aggressive therapies in intensive care. Most governments have recommended social separation and severe measures of prevention of further spreading of the epidemic. Because hemodialysis (HD) patients need to access hospital and dialysis center facilities 3 times a week, this category of patients requires special attention. In this editorial, we tried to summarize the experience of our centers that hopefully may contribute to help other centers and colleagues that are facing the coming wave of the epidemic. Special algorithms for COVID-19 spreading in the dialysis population, recommendations for isolation and preventive measures in positive HD patients, and finally directions to manage logistics and personnel are reported. These recommendations should be considered neither universal nor absolute. Instead, they require local adjustments based on geographic location, cultural and social environments, and level of available resources.

Keywords: Coronavirus; Coronavirus disease 19; Hemodialysis; Prevention.

Fig. 1

The UZ Leuven flowchart for patients with suspected infection by SARS-CoV-2. The goal is to detect possible cases early, preferably outside of the dialysis ward, and to isolate proven cases from the other dialysis patients. Suspicion may arise at 3 different moments (in yellow). Ambulatory patients (Left yellow diamond) are stimulated to proactively communicate with the dialysis unit as soon as they have symptoms suggestive of COVID-19 (coughing, shortness of breath, fever, unusual abdominal complaints, etc.). We aim to have a diagnostic workup as soon as possible, preferably via the general practitioner, or, if not possible, via a scheduled visit to the emergency room. Second, we triage patients upon arrival at the dialysis unit (middle yellow diamond). Temperature is taken from all patients upon arrival. We use a rule-in strategy (i.e., temperature above 38°C equals suspected case, whereas normal body temperature does not rule out COVID-19). Suspected cases are deviated toward the emergency room. For those patients, we also take an electrolyte panel to see whether dialysis is immediately needed, or that this can be postponed until the results of the nasopharyngeal swab polymerase chain reaction and computer-aided tomography of the chest are known. Finally (right yellow diamond), we scrutinize patients during stay on the dialysis ward. Temperature is taken from all patients multiple times during dialysis. In case we have identified a maintenance dialysis patient as being infected by SARS-CoV-2, we consider the clinical condition (stable enough to be treated as ambulatory patient), home situation (alone, or with vulnerable household contacts?), transportation means (possibility of organized isolated transport). If possible, we opt for continuation of ambulatory care. If not, patients are hospitalized based upon clinical needs on a regular COVID-19 ward, or the intensive care unit. G.P., general practitioner; ER, emergency room; COVID-19, coronavirus disease 19; PCR, polymerase chain reaction; CVVH, continuous venovenous hemofiltration; HD, hemodialysis; ICU, intensive care unit.

Fig. 2

COVID-19 prevention strategies applied in the Vicenza HD units: patients and personnel are instructed on general measures (top panel). At every shift, upon arrival, patients are triaged outside the unit with temperature check and specific questions. If triage is negative, the patient proceeds to the regular session. If positive (symptomatic with at least 2 symptoms) or if he/she refers to have been in contact with a suspected positive individual, protocol #2 is activated. Three different protocols are in place: #1) suspicion of COVID-19 infection at home, #2) suspicion of COVID-19 infection upon arrival (after triage), and #3) suspicion of COVID-19 infection in hospitalized HD patients. ER, emergency room; COVID-19, coronavirus disease 19; PCR, polymerase chain reaction; G.P., general practitioner; HD, hemodialysis; ICU, intensive care unit.

Fig. 3

COVID-19 prevention strategy in the hemodialysis unit in Policlinico-Milano units: patients and personnel are instructed on general measures (top panel). At every shift, a specific triage is scheduled. In case of severe symptoms, the intensivist is immediately involved. IDS, infectious disease specialist; RS, respiratory symptoms; ICU, intensive care unit; HD, hemodialysis; COVID-19, coronavirus disease 19.