Kidney care needs a paradigm shift before the next virus strikes
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The kidney care community must change the way dialysis is provided to most patients with ESKD before the next pandemic arrives, two nephrologists wrote in a recently published editorial.
“COVID-19 has exposed critical weaknesses in our health care system, notably including our dependence on in-center hemodialysis for more than half a million U.S. residents,” Daniel E. Weiner, MD, MS, and Suzanne G. Watnick, MD, wrote in the editorial. “This dependence not only increases the likelihood that hemodialysis patients will be infected with COVID-19 but also increases the risk to society, given the health care workers and transportation infrastructure needed to provide in-center hemodialysis.”
With 12% of patients with ESKD dialyzing at home, those who are treated in a center have the greatest risk when a pandemic strikes.
“The fact that this fragile population must congregate in order to receive treatment is our major vulnerability,” Weiner and Watnick wrote.
Watnick, who is the chief medical officer of Seattle-based Northwest Kidney Centers, and Weiner, with the division of nephrology at Tufts Medical Center in Boston and a nephrologist for Dialysis Clinics Inc., recommend dialysis clinics follow the latest guidelines released by the CDC and updated regularly on caring for patients with ESKD who have tested positive for the coronavirus.
Steps to reduce the risk of transmission in hemodialysis facilities include “decreasing the number of patients present at any given time by opening additional shifts, enhanced scheduling to reduce congregation in waiting rooms, increased distancing of patients within a hemodialysis facility, and careful placement of [patients under investigation] PUIs in isolation rooms or more isolated areas of hemodialysis facilities,” the authors wrote. “Other adopted strategies include designating either entire facilities or specific shifts within a facility for COVID-positive patients. All of these strategies represent a significant logistic burden but appear essential to optimize use of societal health care resources.”
Increasing the number of patients on home dialysis, the authors wrote, is a logical alternative to in-center care that would help limit the spread of the virus. However, Weiner acknowledged in comments to Healio Nephrology the limits on increasing the use of home dialysis in the midst of the pandemic.
“I think that home dialysis is a solution for the near future but not for the immediate future,” he said. “There are major barriers in getting any dialysis [vascular] access right now, and the entire system is stretched,” he said. “A large-scale shift to PD and home [hemodialysis] HD in the next several months is not feasible for many reasons, including insufficient staff and supplies.”
One way to improve the effectiveness of home dialysis – and offer a safer environment – would be to provide aides to facilitate assisted home dialysis.
“For PD in an older adult who needs help with setting up a cycler for example, the cost of an assistant may not be that different than the cost of transportation to and from in-center hemodialysis,” Weiner said.
Watnick added: “Of course there are other solutions on the table. Improving access to transplant and providing improved CKD care will keep people off dialysis. Investing in innovation might create new solutions – such as artificial kidneys, improved longevity of native and transplanted kidneys, but this takes upfront funding. Additional advocacy from our community could secure support that ultimately will benefit our patients.”
Ultimately, leaders in the kidney community need to learn from the impact of COVID-19 on the kidney disease population, they said.
“[We] as a kidney community need to reduce the vulnerability of kidney patients to future outbreaks and reduce the risks that society faces when providing in-center hemodialysis patients with their life-saving dialysis sessions during a pandemic,” the authors wrote in the editorial. “The only way to accomplish this is to rapidly change the kidney care paradigm by improving non-dialysis kidney care, increasing utilization of home dialysis and transplantation, and innovating such that in-center hemodialysis is replaced by new technologies that allow patients with kidney failure to live free of dialysis facilities.”
Most of those ideas are part of the framework of the Advancing American Kidney Health (AAKH), an initiative begun in July 2019 to improve outcomes for kidney patients. However, Weiner told Healio Nephrology that the initiative, while on the right path, is a too aspirational “and in some senses is a distractor from the major point that we have significant potential to increase home dialysis and transplant ... I do think that, if we had more patients with kidney failure who could stay home, we would have fewer patients with kidney failure with COVID-19, fewer kidney health professionals with COVID-19 and fewer people who transport kidney failure patients with COVID-19, ... reducing one new case now can reduce far more cases that result from exposure to that affected individual. I view the AAKH as highlighting the importance of diversifying our kidney failure treatment options from where they are now and feel strongly that increasing home dialysis and transplant, maybe not to the numbers proposed in the executive order but substantially nonetheless, would have helped decrease the burden of the current COVID-19 pandemic in the kidney care community.”
Added Watnick: “Additional resources to slow down progression of chronic kidney disease, through educational campaigns and more comprehensive care, were also part of the AAKH. These initiatives could also lessen the burden on our patients.” – by Mark E. Neumann
Disclosure: Weiner reports he receives support paid to his institution from Dialysis Clinic Inc.
Perspective
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The COVID-19 pandemic has made the Advancing American Kidney Health Initiative look prescient by highlighting the vulnerability of ESKD patients in our current center-based hemodialysis treatment delivery model.
Although no one saw this pandemic coming, infections as a result of the environment of center-based hemodialysis have been with us for decades. From the hepatitis and human immunodeficiency bloodborne infections of the 1970s and 1990s to the impact of the more recent viral outbreaks influenza and MERS, serious communicable diseases have been a feature of both inpatient and outpatient hemodialysis. Lesser infestations, such as lice and bed bugs, also occur.
The effort to protect hemodialysis patients is immense and will undoubtedly save lives and prevent suffering. However, the easiest way to prevent spread of the COVID-19 in a dialysis center is to not be in a dialysis center. There is likely little we can do now to change this dynamic, although perhaps urgent start peritoneal dialysis for incident patients may help. The clarification by CMS that both peritoneal and hemodialysis vascular access procedures are essential medical procedures has made this possible. Training for PD or home hemodialysis could potentially be done at home, so that centers can limit the risk of spreading the virus.
Several authors from across the spectrum of kidney disease — patients, physicians, technology manufacturers, nurses — have made the point that more home dialysis would help alleviate this crisis in more ways than just decreasing transmission of infection. It would relieve some burden on staff. It would ease the difficult transportation problem. No time would be away from family.
This crisis should also focus our attention on what improvements we still need to make for home care. The first on my list is point-of-care delivery of both peritoneal and hemodialysis fluids, including continuous renal replacement therapy, for both patients’ homes and hospitals to alleviate the possibility of yet another dialysis fluid shortage. Rapid implementation and improvement of telehealth is another; CMS has paved the way for this in revising what is allowed under the monthly capitated payment. The ability for patients to do their bloodwork at home also seems within reach.
Once we put the COVID-19 crisis in our rearview mirror, it will be interesting to see if more in-center dialysis patients start asking their nephrologists and kidney care team about the benefits of home. That would not be a bad thing.
We will get through this and hopefully we will learn the lessons well.
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