Supply shortage impacts COVID-19 decision-making
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The nephrology community, both patients and physicians, are still grappling with recent reports on the possible rationing of ventilators for critically ill patients with COVID-19, including the exclusion of patients with advanced kidney disease. Now we are faced with news suggesting a shortage of dialysis equipment and staff in some cities across the nation due to high rates of acute kidney injury, especially in “hot spots” for COVID-19. That is leading to crucial decisions on how to manage renal replacement therapy in the face of this global health crisis.
There is wide variation in the reported incidence of AKI in patients with COVID-19. The incidence was initially reported to be low in China, with little concern for a possible dialysis equipment shortage. However, based on recent literature, as well as weekly educational webinars aired by nephrology organizations, the reported incidence of AKI in patients with COVID-19 is 19% to 39%.
Acute tubular necrosis seems to be the cause of AKI in most patients, though some reports have discussed glomerulopathies as well. AKI is associated with a higher risk of mortality in patients with COVID-19, as has been seen in other critical illnesses. The high incidence of AKI and associated increase in need for dialysis equipment and staff may lead to triaging dialysis based on patient candidacy, which is an unprecedented situation, since the patient selection committee of 1961.
Dialysis equipment manufacturers such as Baxter Healthcare and Fresenius Medical Care’s NxStage Medical are trying to ramp up production and allocate resources in a meaningful way to places where the need is the greatest.
This raises several questions on the best ways to manage AKI in patients with COVID-19. Fortunately, there are simple solutions that can be used in the short term that may help us get over this crisis.
The first issue is determining the best time to start renal replacement therapy (RRT) among these patients with COVID-19. Considering the limited data on the benefits of early dialysis start in patients with AKI, it would seem most judicious to use the traditional clinical indications for starting dialysis, rather than an “early start approach.” Is there a role of convective clearance considering the associated “cytokine storm” that leads to AKI? The evidence on benefits is still not well proven, which leads us to believe that this should not be a deciding factor for choosing dialysis modality in the current situation.
What dose of RRT should be used? Dosing studies on RRT in critically ill patients have not shown any clear benefit of higher doses; in the current global crisis, it would be wise to use a standard dose, and even consider using a lower dose if metabolic control can be achieved.
If there is a shortage of dialysis machines, how do we reallocate resources? In centers faced with acute shortage of dialysis machines, many strategies, though unconventional, can be adopted. For patients with ESRD, who have good residual renal function or adequate metabolic control, dialysis can be switched to twice a week instead of thrice a week or shorter dialysis treatments can be considered. Dialysis machines can be re-allocated from the outpatient units to the hospitals, and shifts can be adjusted in the outpatient units. Similarly, to conserve dialysis fluids, the dose of continuous RRT (CRRT) can be reduced, as long as metabolic control can be achieved. In patients being considered for CRRT, 12-hour shifts can be considered to replace the 24/7 shift, hence allowing dialysis for two patients with better utilization of the dialysis equipment.
There is evidence to suggest a higher degree of filter clotting during hemodialysis treatment is taking place in these patients, presumably secondary to the cytokine storm. Streamlining an approach for anticoagulation with either heparin or citrate, and in some circumstances even a combination, along with higher blood flows may prevent recurrent clotting issues.
Peritoneal dialysis is commonly used in the developing world for AKI and has potential applications in this scenario, though thoughtful clinical consideration and patient selection is required considering the possibility of acute respiratory distress syndrome and the need for proning on the ventilators, which can be challenging while doing acute PD. Lastly, using telenephrology can help reduce the burden on nursing staff during dialysis sessions in isolation rooms; the availability of iPads could allow one nurse to dialyze more than one patient at the same time.
Disclosures: Jain and Ahmad report no relevant financial disclosures.
References:
www.nephjc.com/news/covidaki (accessed April 20, 2020).
https://www.medrxiv.org (accessed April 20, 2020).
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