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Dialysis safely delivered to patient with Ebola
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Case protocol from the first successful hemodialysis delivery to a patient with Ebola virus concerning patient safety and secondary transmission risks recently was presented at the American Society of Nephrology’s Kidney Week 2014 conference in Philadelphia.
Specialists from Emory University School of Medicine received a health care worker who had contracted the virus while working at an Ebola treatment unit in Sierra Leone. The patient also developed hypoxic acute respiratory failure and acute kidney injury secondary to acute tubular necrosis. No irreversible organ failures were demonstrated, and there was an absence of hypotension or shock requiring vasopressor support.
“Our patient had characteristics that were associated with high mortality in a prior study in Africa,” Harold A. Franch, MD, told Infectious Disease News. “He had a very high Ebola virus mRNA level, he had encephalopathy, and he had acute kidney injury, all of which are associated with very high mortality.”
Harold A. Franch
Because high-dose diuretic challenge was unable to induce desired negative fluid balance, continuous renal replacement therapy (RRT) was initiated via a non-tunneled temporary right internal jugular dialysis catheter. Prolonged mechanical ventilation was required for 12 days, and continuous RRT for 11 days. The patient was transitioned to prolonged intermittent RRT, performed 6 to 12 hours daily, and he eventually recovered renal function. RRT was discontinued after 24 days with EGFR results steadily improving 7 days after discontinuation, and none of the staff developed Ebola virus disease throughout the 21-day observation period.
Although a recommended treatment plan of continuous RRT was already established, Franch said this case was the first on record to put the treatment into practice.
“We do not know whether it has ever been attempted before. That’s the bottom line,” Franch said. “We see reports that somebody may have tried it, but certainly not in the modern era.”
Along with documenting the patient’s care, the researchers also developed treatment recommendations for hemodialysis delivery among Ebola patients. Recently published in the Journal of the American Society of Nephrology, the guidelines address complications raised by the comorbidity.
“When we provide dialysis in a situation of a highly infectious illness like Ebola, we have to make sure that we can provide the treatment safely,” researcher Michael J. Connor Jr., MD, told Infectious Disease News. “First and foremost, we have to design a treatment that is going to be safe for the patient with less readily available staff to immediately rush into the room if something were to happen. Secondly, we have to provide dialysis in a way that ensures the safety of the health care workers providing the dialysis and minimize the risk of their exposure to potentially infected material.”
Michael J. Connor Jr.
Connor said that limiting the number of health care workers, as well as ensuring that each has received appropriate training, was critical in limiting infection risk. Similarly, the disposal of fluids and equipment that become compromised during use should be planned in advance in accordance with local health departments, a step that Franch described as “unexpected.”
“We had not anticipated having to treat the dialysate, or the dialysis effluent, because we just assumed that it was sterile. This brought up a huge debate,” Franch said. “They ended up having to take the 5-liter bag and dump it into the toilet, then add an ammonium compound to sterilize it before flushing it down. That was probably the biggest single curveball.”
Connor and Franch said that limited clinical equipment within the Ebola treatment unit and ensuring adequate training for each nurse also presented difficulties, but they were anticipated and accounted for when determining proper procedures.
Although the same standard of care isn’t readily available in the outbreak area, both researchers said the case sets a precedent for patients who otherwise would have been overlooked.
“We took the approach at Emory that this disease, with appropriate supportive care, is a survivable disease, and that organ support therapy … could be safely provided and likely improve the outcome significantly for these patients,” Connor said. “There’s been a lot of discussion that these patients shouldn’t even be offered this sort of support, and we took a very different approach to that. We support, and have supported around the world, that critically ill patients in resource-rich settings such as the US and Western Europe should receive full life support therapies for this illness.”
“Still, it would not take much to bring some of the fluid balance and lab testing to West Africa,” Franch said. “We could improve care there and hopefully improve outcomes, but also we could demystify this disease a little bit. The key thing is to move the battle to the front lines.” – by Dave Muoio
For more information:
Connor M J, Franch H A. Presented at: The American Society of Nephrology’s Kidney Week 2014; Nov. 11-16, 2014; Philadelphia.
Disclosure: The researchers report no relevant financial disclosures.
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