Cohort Study of Outpatient Hemodialysis Management Strategies for COVID-19 in North-West London

Abstract

Background: Dialysis patients are at risk of severe coronavirus disease 2019 (COVID-19). We managed COVID-19 hemodialysis outpatients in dedicated satellite dialysis units. This provided rare opportunity to study early disease progress in community-based patients. We aimed to (i) understand COVID-19 progression, (ii) identify markers of future clinical severity, and (iii) assess associations between dialysis management strategies and COVID-19 clinical outcomes.

Methods: We conducted a cohort study of all outpatients managed at a COVID-19 hemodialysis unit. We analyzed data recorded as part of providing COVID-19 clinical care. We analyzed associations between features at diagnosis and the first 3 consecutive hemodialysis sessions in patients who required future hospital admission, and those who had died at 28 days.

Results: Isolated outpatient hemodialysis was provided to 106 patients over 8 weeks. No patients received antiviral medication or hydroxychloroquine. Twenty-one patients (20%) were admitted at COVID-19 diagnosis; 29 of 85 patients (34%) were admitted after initial outpatient management; 16 patients (15%) died. By multivariate analysis, nonactive transplant list status, use of institutional transport, and increased white cell count associated with future hospitalization and increased age associated with death. Oxygen saturations progressively decreased over the first 3 dialysis sessions in the cohorts that progressed to future hospital admission or death. Mean ultrafiltration volume of the first 3 hemodialysis sessions was reduced in the same cohorts.

Conclusions: Outpatient hemodialysis in patients with COVID-19 is safe for patients and staff. Features at the first 3 dialysis sessions can identify individuals at risk of future hospitalization and death from COVID-19.

Keywords: COVID-19; SARS-CoV-2; coronavirus; hemodialysis.

Graphical abstract

Figure 1

Flow chart demonstrating cohorts of patients managed on the isolated outpatient hemodialysis unit for individuals with COVID-19 (IsolHD). Following detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and diagnosis of coronavirus disease 2019 (COVID-19), patients received ongoing hemodialysis in isolated clinical areas. Of 106 patients managed on IsolHD, 85 did not require hospitalization at COVID-19 diagnosis and received the first hemodialysis session post COVID-19 diagnosis no IsolHD (IsolHD-first cohort). The remaining 21 patients were admitted at the time of COVID-19 diagnosis and received outpatient IsolHD dialysis after clinical improvement and receiving inpatient hemodialysis. We analyzed both the IsolHD-first and total IsolHD cohorts.

Figure 2

Symptom burden at consecutive isolated hemodialysis (HD) sessions post–coronavirus disease 2019 (COVID-19) diagnosis. Patients were asked about symptoms at every dialysis session. The bar chart shows the percentage of patients reporting each symptom at consecutive HD sessions 1–5 post–COVID-19 diagnosis. The stacked bar chart shows the relative proportion of each symptom as percentages of the total number of symptoms reported at each HD session.

Figure 3

Progression of oxygen saturations (SaO₂) and hypoxia at consecutive hemodialysis sessions in patients with coronavirus disease 2019 (COVID-19) who required future hospital admission or died. Pre- (a and b) and post- (c and d) dialysis peripheral SaO₂ are shown from the first (HD1), second (HD2), and third (HD3) hemodialysis sessions post COVID-19 diagnosis and divided by the presence (Y, yes, yellow squares) or absence (N, no, blue circles) of future hospital admission or death at 28 days form COVID-19 diagnosis. n, number. (e and f) Percentage of patients with hypoxia (peripheral oxygen saturations <93%) at consecutive COVID-19 isolated hemodialysis sessions who progress to (a) future hospital admission or (b) death within 28 days.

Figure 4

Ultrafiltration volume and D-dimer associated with future hospital admissions and death in hemodialysis patients with coronavirus disease 2019 (COVID-19). (a) Net dialysis ultrafiltration (UF) at the first 3 consecutive isolated hemodialysis sessions (HD1, HD2, HD3) and the mean volume of HD1–HD3 in patients who required future hospital admission with COVID-19. UF was not available from HD1 for 1 patient who required future admission. (b) D-dimer at first dialysis post COVID-19 diagnosis and future hospital admission despite mean UF volume (mean UF/weight) from HD1–HD3 of more than 2% predialysis weight. All patients with available D-dimer results were included. N, no, blue circles. Y, yes, yellow squares. n, number.