Clinicians provide first successful delivery of dialysis in Ebola virus disease

Clinicians recently accomplished the first known successful delivery of renal replacement therapy with subsequent recovery of kidney function in a patient with Ebola virus disease. Their protocol was presented at the American Society of Nephrology's Kidney Week 2014. It will also appear in an upcoming issue of the Journal of the American Society of Nephrology (JASN) and was released on the JASN website on Nov. 14th.

Acute kidney injury occurs frequently in Ebola virus disease; but providing hemodialysis to these patients was previously thought to be too risky because it involves large needles or catheters and potential contact with highly infectious blood.

The report, by Michael Connor, Jr., MD, Harold Franch, MD, from Emory University School of Medicine, and their colleagues, details the measures the clinicians took to maximize safety and minimize risk of secondary transmission of Ebola virus, including careful considerations to the types of equipment used and the protocols that clinical staff followed. None of the staff developed Ebola virus disease after a 21-day observation period, and no detectable Ebola virus genetic material was found in the patient’s dialysis waste fluids.

Some of the steps taken included using continuous renal replacement therapy over intermittent hemodialysis to minimize hazards to the staff, use of an ultrasound machine for line placement, and restricting access to the room to one ICU nurse, and allowing consulting physicians to enter the room only when performing a procedure or if it was absolutely necessary. A glass wall allowed visualization of the machine settings and for the nephrologist or dialysis nurses to assist with troubleshooting with the ICU nurse if needed.

Nursing staff underwent additional CRRT training sessions as a refresher because the biocontainment isolation also isolated the bedside nurse, slowing the arrival of rapid help from other support resources. Any nursing error in performing CRRT would trigger additional training.

Proposed clinical guidelines include:

Vascular access

Use a temporary non-tunneled dialysis catheter placed at bedside under direct ultrasound visualization.
The right internal jugular vein is the preferred access site (with the left internal jugular vein as the backup site), given that this presents the lowest bleeding risk.
Subclavian insertion sites should be avoided.
Consider use of nonreflux dialysis grade caps for dialysis vascular access

Anticoagulation

Regional citrate anticoagulation is preferred and recommended in all patients to extend filter life and reduce potential staff exposures with filterexchanges.

Staff

If possible at the institution, all patients should receive RRT using CRRT equipment by extensively trained ICU nurses as primary clinical nurses at bedside.

“In our opinion, this report confirms that with adequate training, preparation, and adherence to safety protocols, renal replacement therapies can be provided safely and should be considered a viable option to provide advanced supportive care in patients with Ebola” said Connor.

In light of their success, the team has proposed a set of clinical practice guidelines for acute renal replacement therapy in Ebola virus disease.

“More than anything else, in our report, we found that extra training of our volunteer ICU nurses made success possible. We thank them for their bravery and commitment.” said Franch. “Our case also shows that dialysis is not a death sentence for patients suffering from Ebola virus disease and recovery of kidney function is possible.” -by Rebecca Zumoff