Kidney patients urged to take extra precautions during pandemic
Dr. John Foringer is getting a lot of calls from patients with chronic kidney disease.
His patients want to know if they are more likely than others to contract the coronavirus and whether they are susceptible to greater complications.
“We don’t know the answer yet,” said Foringer, chief of medicine at Lyndon B. Johnson Hospital and professor of internal medicine in the Division of Renal Diseases and Hypertension at UTHealth.
There isn’t yet enough data to understand specific risks or complications. But it’s not too soon to recommend that patients with kidney disease take extra precaution. As part of the larger group of patients with chronic medical conditions, they are simply at higher risk.
“I’ve been telling my patients to isolate themselves as much as they can,” Foringer said. “This is definitely a concern for them.”
Kidney patients, including those with transplants who are taking anti-rejection or immunosuppressive medicines, should take extra precautions, according to Dr. Donald Molony, a nephrologist with Memorial Hermann Texas Medical Center and professor of renal diseases and hypertension at UTHealth. He noted that individuals who are already on dialysis cannot be socially isolated if they receive regularly scheduled treatment outside of their home; if dialysis is not continued, it can jeopardize a patient’s health.
“It’s a lifesaving treatment,” Molony said.
“There is a growing acknowledgment that many patients would be best served by doing dialysis at home,” Molony said. “The problem with that is that patients who go home need to be trained. And that’s another barrier.”
Additionally, there’s a new population of individuals diagnosed with COVID-19, who develop acute kidney injury and leave the hospital in need of continued dialysis treatment.
For each group, Molony said, medical teams are taking steps to ensure that needs are met. “All of the providers are working diligently together to make sure that patients are safe,” he said.
Kidney failure and COVID-19
Acute kidney injury related to COVID-19 has been mounting, leading some researchers to question whether the coronavirus specifically targets the kidneys.
“At this stage, it’s too early to tell,” said Dr. David SheikhHamad, professor of medicinene-phrology at Baylor College of Medicine.
Patients with COVID-19 develop what is known as a “cytokine storm,” or an overproduction of cytokines, due to the inflammatory response triggered by the coronavirus, Sheikh-Hamad said. This can affect multiple organs and cause leakage in blood vessels of the lungs, resulting in what is known as acute respiratory distress syndrome (ARDS), which leads to respiratory failure, SheikhHamad explained.
Patients with acute respiratory distress syndrome are placed on ventilators.
“At this point in the disease, the patient usually has low blood pressure and needs support with medicines that raise blood pressure,” Sheikh-Hamad said. “As blood pressure drops, kidney failure develops and the patient needs to have dialysis.”
He said that emergency dialysis can simulate normal kidney function.
Sheikh-Hamad added that with COVID-19, patients will often experience increased blood clotting. Doctors use anticoagulants to prevent the clots.
Foringer said that the reported number for acute kidney injury in COVID-19 patients ranges from 0.5 percent to 29 percent, with the largest figures coming from China and Italy. “We are seeing numbers around 10 to 20 percent here in Houston,” he said.
The incidence of acute kidney injuries in COVID-19 patients with acute respiratory distress syndrome is significantly higher, at 40 to 50 percent, he said. Foringer added that 20 to 30 percent of COVID-19 patients with acute respiratory distress syndrome require dialysis.
Molony explained that the amount of time discharged patients will need to remain on dialysis is still unknown.
“It’s going to take weeks and months for the kidney to rebuild and recover,” he said. “It might never recover fully, but it might recover to the point that they do not need dialysis.”
Still, the need for dialysis equipment will increase in Houston, as will the demand for trained nurses and technicians.
A greater need for dialysis
In other cities, dialysis units have already been in high demand and low supply. SheikhHamad points to New York City as an example.
“All of these cases came in at once, and the resources could not keep up,” he said.
“This is not the case in Houston,” he continued, noting that there are fewer cases, a slower rise and a sufficient supply of available beds, ventilators and other resources.
“It is not at a number that is overwhelming our system or our capacity to provide care, including dialysis,” he said.
Further, the large number of dialysis treatment centers in the state, provide patients with a number of options after they leave the hospital, according to Molony. Already, dialysis nurses and technicians have been taking extra precautions to treat both existing patients and individuals who are recovering from the coronavirus. “They are trying very carefully to separate populations,” Molony said.
Because of the protective measures in place, Foringer has not seen a rise in hospitalization for coronavirus in dialysis patients.
“In Houston, we were quick to start putting masks on patients and trying to spread the chairs out as much as we could,” Foringer said. “The staff in dialysis units are doing everything they can to protect the patients.”
As patient numbers rise, however, staffing is a concern. “We just don’t have enough dialysis nurses in Houston,” Foringer said.
That becomes a greater problem when a patient tests positive for coronavirus and must be treated one on one by a nurse.
“It spreads our nurses even thinner,” Foringer said.
Already, staff hours have extended into the night — and hospitals are recruiting nurses and technicians.
“I think we’re going to see more kidney failure, and we need to take care of the patients,” Molony said.
Testing for coronavirus is still fairly difficult, he added. As the state moves to reopen, he cautions kidney patients to continue to wear masks and stay socially distanced.
“We need to remain vigilant, or we could see more people on dialysis,” he said.
Elderly already on dialysis
With a number of existing dialysis patients residing in nursing homes, private companies like Dialyze Direct are trying to treat them in the facilities and reduce their chances of exposure to coronavirus.
Jonathan Paull, general counsel and chief compliance officer from Dialyze Direct, said the business is already serving several nursing homes in the Houston area.
“The most at-risk population to COVID-19 are the geriatric patients in nursing homes,” Paull said. “They need ongoing dialysis treatment.”
He said that many nursing homes have gone into lockdown to stop people from coming in or going out. “For dialysis, it’s a significant issue,” he said.
If seniors leave the nursing home for treatment, Paull explained, they have increased the risk not only to themselves but also to other residents and staff.
To meet the need, Dialyze Direct offers the service inside the nursing home with trained technicians and nurses.
Molony explained that in nursing homes, patients should still be treated on an individual basis and in a dedicated room for the treatment.
“There is concern about quality issues,” he said.
A lot remains to be learned about the coronavirus and treatments for the infection, Foringer explained.
“In the end, when we’re able to crunch numbers and look at info, we’ll know how to prepare for this infection,” he said. “It’s going to change everything. Right now, we just want data.”