How to Care for Dialysis Patients in the Times of COVID-19

Introduction

Patients with end-stage renal disease (ESRD) and renal replacement therapy (RRT) are more susceptible to adverse outcomes of COVID-19 due to a range of comorbidities (diabetes, hypertension, and cardiovascular diseases). Additionally, patients with RRT infected with the SARS-CoV-2 coronavirus often present atypical symptoms, which can pose a diagnostic challenge.

Another issue is that it is impossible to maintain the recommended distancing in dialysis centers. These patients meet healthcare workers and other patients three times a week, thus being at increased risk of exposure.  

Measures for Patients

COVID-19 patients can be asymptomatic or symptomatic 2–14 days post-exposure. Hemodialysis centers must provide instructions for preventive measures, including proper hygiene and handwashing techniques, cough and sneeze etiquette, and practice distancing from all patients. Each patient should provide information about any possible contact with a COVID-19 positive individual.

Before admitting a patient, there should be a screening for respiratory infection symptoms (fever, cough, shortness of breath). Symptomatic patients should be seated at least 2 meters away from other patients and healthcare workers, ideally in a separate room. They should be present in the dialysis center only at their designated times to minimize the time spent in the healthcare facility. It is advisable to dialyze such a patient in the last shift. All protective and disinfecting agents should be available at triage points and in the waiting room.

Measures for Staff

During shifts, all healthcare personnel should wear masks, and respirators when working with COVID-19 positive patients. After confirmed exposure, the employee should inform their supervisor and cease working if they become symptomatic. If asymptomatic, the next steps depend on the risk level of the exposure and follow guidelines from health authorities or relevant directives. After high or moderate-risk exposure, a 10-day isolation is recommended; after low-risk exposure, monitoring for symptoms is required, but work can continue.

A symptomatic COVID-19 positive individual can end isolation after the fever and respiratory symptoms have subsided and after obtaining at least two negative PCR tests conducted more than 24 hours apart. An asymptomatic COVID-19 positive individual can end isolation if 7 days have passed since the test and no symptoms have developed.

Dialysis of COVID-19 Patients

COVID-19 patients should be dialyzed in an isolated room. If such a room is not available, the dialysis should proceed in the last shift in a corner of the room at least 2 meters away from other patients. The same staff should care for all COVID-19 patients to prevent contamination and infection. All used machines and the entire dialysis station should be disinfected according to protocol after use.

All patients, especially those in inpatient facilities, should be instructed on potassium and fluid restrictions to reduce the need for additional medical interventions. The staff should be proficient in proper nasopharyngeal swab techniques. COVID-19 positive patients should be instructed on home isolation, and family members should be informed to monitor for possible symptoms. The same recommendations for ending isolation apply to healthcare workers.

Conclusion

There is currently a lack of real-world data on hemodialyzed patients with COVID-19. Atypical symptoms and a higher risk of transmission, morbidity, and mortality require a special approach in the care of dialysis patients with COVID-19. During the crisis period significantly affecting public health, it is crucial to prevent virus transmission and rely on evidence-based medicine in managing dialysis patients to maintain standard care procedures.

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Source: Verma A., Patel A. B., Tio M. C., Waikar S. S. Caring for dialysis patients in a time of COVID-19. Kidney Med 2020 Oct 14; 2 (6): 787–792, doi: 10.1016/j.xkme.2020.07.006.