Nephrologists debate value, risk of reduced treatments during pandemic
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During the COVID-19 pandemic, temporarily reducing the number of dialysis treatments in an outpatient setting could help limit potential exposure to the virus for patients and staff and save personal preventive equipment, suggest Stanford University nephrologist Timothy W. Meyer, MD, and colleagues.
However, with limited data available on the impact of cutting dialysis sessions from three to two per week, the benefits may not outweigh the risk of fluid overload, even temporarily, noted Rajnish Mehrotra, MD, of the Kidney Research Institute at the University of Washington, in Seattle.
“Hemodialysis care may come under great stress with the coronavirus disease 2019 pandemic,” Meyer and colleagues wrote in an editorial. “A change from the standard thrice-weekly treatments to twice weekly could relieve some of this stress.”
The clinicians suggested there were multiple advantages to reducing dialysis treatments, including less exposure to the virus for patients and staff; a reduction in dialysis staff work, including reduced time for cleaning of dialysis machines; greater spacing of patients during treatments; a reduced need for transporting patients to the clinics; and saving personal protective equipment.
“Considerable data suggest that two hemodialysis treatments per week are not much inferior to three treatments per week, and a change made in the face of the pandemic would likely be relatively short term,” the authors wrote. “ ... United States Renal Data System (USRDS) data from the 1990s did not show higher mortality with twice-weekly treatment even among patients on prevalent hemodialysis who had been maintained on dialysis for an average of [more than] 3 years.”
While more recent data from a U.S. dialysis provider did show higher mortality among incident patients with residual urea clearance of less than 3 mL/min, “Dialysis Outcomes and Practice Patterns Study (DOPPS) data from China, however, revealed neither higher mortality nor lesser quality of life with twice-weekly treatment, even in patients who had a urine output of [less than] 200 mL/d and had been on dialysis for an average of 3 years,” the authors wrote. “Collectively ... these data suggest that twice-weekly treatment is less dangerous than commonly supposed.”
Mehrotra acknowledged that the COVID-19 pandemic “has rightfully generated considerable anxiety” on the part of dialysis staff and patients, but countered in an opposing editorial that moving to a twice-weekly schedule “could be counterproductive and could result in increasing risk to the health and welfare of patients with resultant increasing — rather than decreasing — health care utilization.”
Data comparing outcomes with twice- and thrice weekly hemodialysis “are extremely limited, and they are simply insufcient to conclude that the two regimens are equivalent,” Mehrotra wrote. Studies from the United States and China are primarily observational, and twice-weekly hemodialysis is used by only 0.5% of patients, “and it is often reserved for otherwise healthy individuals with signicant residual kidney function,” he wrote.
Dialysis providers that follow CDC guidelines to screen patients prior to every treatment, followed by appropriate testing and cohorting “allows us to provide the same level of care to our patients as prior [to COVID-19] while keeping them safe ... Alternatively, dialysis treatments could be shortened to 2.5 [hours to] 3.5 hours per treatment while maintaining thrice-weekly treatment frequency. The next step would be to selectively transfer patients with signicant residual kidney function to twice-weekly treatments while continuing thrice-weekly dialysis for most of the other patients,” Mehrotra suggested.
Finally, without any changes from CMS to adjust for fewer treatments, dialysis providers would see a reduction to payments for dialysis care, which could lead to reductions in employment and stafng of dialysis facilities.
“These unprecedented times require us to consider all options for their care to ensure the safety of both patients and health care workers while conserving precious resources,” Mehrotra wrote. “Hence, we should retain twice-weekly hemodialysis as an option but only as an option of last resort, and it should be implemented with substantial boosting of clinical and biochemical monitoring and supportive care to minimize harm to patients.” – by Mark E. Neumann
Disclosures: Mehrotra reports he has received honoraria from Baxter Healthcare as an ad hoc consultant and that he is a member of the board of trustees of the Northwest Kidney Centers. Meyer and his co-authors report no relevant financial disclosures.
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Mehrotra R. Jrnl Am. Soc of Nephrology. 2020;doi:10.1681/ASN.2020040412.
Meyer TW, et al. Jrnl Am. Soc of Nephrology. 2020;doi:10.1681/ASN.2020030361.
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