Acute kidney injury from COVID-19 coronavirus has compounded with the vulnerability of chronic kidney disease patients (CKD) to infection, to stretch in-patient dialysis resources to the breaking point in some of the hardest hit areas.
"We are utilizing almost all of our dialysis machines, as are other [New York] city hospitals," said Mala Sachdeva, MD, of a Northwell Health hospital in Great Neck, outside of Queens. "We are fortunate enough to have a good number of machines, but others have run out."
One such center is Montefiore Medical Center in the densely populated Bronx, where in-patient dialysis case loads have skyrocketed three- to four-fold. It has turned to acute peritoneal dialysis to fill the gap, along with expanding the dialysis service to all day Sundays; dropping hemodialysis sessions to two a week for 2 to 2.5 hours each instead of the normal three for 3 or more hours; and leaving other patients managed medically with diuretics and potassium binders.
Peritoneal dialysis for ICU patients is not ideal because fluid removal is less predictable, it interferes with proning a patient to improve oxygen saturation, and it doesn't work as well for hypercatabolic patients, Sachdeva noted, although her center too is prepared to resort to acute use if case volumes tip any further.
"I don't know how long we can keep up providing dialysis treatment for all the things we are doing at this level without running out of supplies," said Michele Mokrzycki, MD, of Montefiore. "We're doing unprecedented things."
The major hospital groups in New York City are all facing shortage of the fluid used for the slow, gentle dialysis for hemodynamically-unstable ICU patients, called continuous renal replacement therapy, she said.
Outpatient Issues
The two large outpatient dialysis organizations in the U.S., DaVita Kidney Care and Fresenius Medical Care, declined their request for some of the replacement fluid being used for home patients, "saying they only had enough supply to make sure the home patients are taken care of," she said. However, the American Society of Nephrology successfully negotiated with these companies to get more equipment into the New York area.
have also described equipment shortages and challenges in keeping COVID-19 positive and negative patients separate.
"We're working hard to help keep dialysis patients treating safely in our centers and out of the hospital to reduce the burden on the system," Jeff Giullian, chief medical officer for DaVita Kidney Care, said in a regarding access to COVID-19 care for its patients.
That has meant creating those with, or suspected to have, COVID-19, and allowing patients to be regardless of their usual site of care. The National Kidney Foundation and other groups have urged kidney disease patients to
However, the extra travel, transportation complications, and such are increasing missed sessions for some patients, observed Ashiwa Mbaye, BSN, an acute dialysis nurse for Renal Care, which contracts to provide dialysis at several hospitals just outside New York City.
"Some of [the patients] are not going, then they end up fluid overloaded, and then they're being readmitted into the hospital," she said.
Together with CKD patients being admitted for the usual reasons, and those getting COVID-19, as well as people who acutely go into kidney failure, she said, "all three of those populations are kind of hitting the hospital at the same time creating larger demand. It is making it difficult to meet the demand."
Mbaye said she has been seeing a doubling in case load that's "maxed" their capacity and led to transfer of some patients.
Acute Kidney Injury
At Mokrzycki's center, the in-patient COVID-positive dialysis cases rose from the first patient March 3 to now reach 143 with end-stage renal disease and 308 with acute kidney injury (AKI).
AKI is common with acute respiratory distress syndrome (ARDS), and critically-ill COVID-19 patients with ARDS are no exception.
Published case series have shown variable incidence in critically-ill COVID-19 patients ranging from 0.6% in a Chinese study to 4.5% in Washington state, and up to 29% in one study from Wuhan -- the overall rate was 6.2%, said Eric Hoste, MD, PhD, head of the ICU at Ghent University Hospital in Belgium, in a Thursday from the European Society of Intensive Care Medicine. Renal replacement therapy use likewise ranged widely with an overall average of 5.8%.
Inflammation and the effects of mechanical ventilation on hemodynamics appear to play a role, he said, while direct viral infection seen in kidney tubules and podocytes along with erythrocyte aggregation have been seen on autopsy.
Up to 40% of ventilated patients will have problems with their kidneys, many requiring dialysis, noted Holly Kramer, MD, MPH, president of the National Kidney Foundation.
And on top of the sheer numbers of patients, critically-ill patients often require continuous renal replacement therapy, which demands lots of dialysis fluids, a lot of staffing time, and extra time with the machines, she said.
Also, often, "patients must be dialyzed individually on the floors in their rooms or in the [ICU]," rather than sending them to a central location, Mokrzycki noted.
"It's been a huge strain on our nursing staff," which had already lost manpower to illness and quarantine, she said, and a number of rooms had to have plumbing quickly updated to meet dialysis needs.
"It's been incredibly difficult," she said. "Fortunately, it looks like light may be on the horizon in that the number of COVID-19-positive admissions has now plateaued, and at least is not increasing. So in the New York area, at least, hopefully that will improve in the coming weeks."
Sachdeva noted that the large bolus of patients has actually made it difficult to discharge those with persistent kidney injury. "We do have patients still waiting for discharge because they need a dialysis unit that's accepting a COVID-19 positive patient. A lot of other dialysis units are giving pushback for accepting these patients. Those dialysis units are full."
Severe AKI patients with no preexisting kidney problems also need follow-up with a nephrologist, since it is a risk factor for needing dialysis in the future, Kramer noted.
"Everyone is figuring out what are the long-term health consequences of COVID-19," Kramer noted. "Kidney injury is just one piece of that."