Impact of COVID-19 pandemic on care of renal patients

Gaurav Shekhar Sharma; Hem Lata; Dipankar Bhowmik; Suresh K Sharma

doi:10.4103/JME.JME_15_21

REVIEW ARTICLE

Year : 2021 | Volume : 2 | Issue : 1 | Page : 19-23

Impact of COVID-19 pandemic on care of renal patients

Gaurav Shekhar Sharma¹, Hem Lata², Dipankar Bhowmik³, Suresh K Sharma⁴
¹ Department of Nephrology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
² College of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
³ Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
⁴ College of Nursing, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission	25-Jan-2021
Date of Decision	12-Feb-2021
Date of Acceptance	18-Feb-2021
Date of Web Publication	25-Apr-2021

Correspondence Address:
Prof. Suresh K Sharma
Professor & Principal, College of Nursing, All India Institute of Medical Sciences, Jodhpur, Rajasthan
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_15_21

Abstract

Coronavirus disease 2019 (COVID-19) pandemic has adversely affected the care of patients with renal diseases, who are at a high risk of contracting COVID-19, in several ways. We searched the search engines such as PubMed, Embase and Google Scholar for articles published from March 2020 to October 2020. Data pertaining to the impact of COVID-19 on renal patients and the referral system were extracted from the various published narrative reviews and the guidelines of the professional organisations. In this review, we have tried to focus on all these aspects, including various challenges faced in delivering routine hospital services and of providing renal replacement therapy. We believe that this unprecedented and globally alarming situation has, by now, taught us enough, so that we can be more careful in executing optimal care of renal patients, should similar situation arise in future.

Keywords: Acute kidney injury, COVID-19, end-stage renal disease, renal replacement therapy

How to cite this article:
Sharma GS, Lata H, Bhowmik D, Sharma SK. Impact of COVID-19 pandemic on care of renal patients. J Med Evid 2021;2:19-23

How to cite this URL:
Sharma GS, Lata H, Bhowmik D, Sharma SK. Impact of COVID-19 pandemic on care of renal patients. J Med Evid [serial online] 2021 [cited 2023 Jun 7];2:19-23. Available from: http://www.journaljme.org/text.asp?2021/2/1/19/314616

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has impacted everyone throughout the world.^[1] It is caused by a deadly severe acute respiratory syndrome (SARS-CoV-2) virus. This pandemic has affected the care of patients with chronic illnesses including chronic kidney disease (CKD).^[2],[3] Worldwide, this deadly virus has led to more than 91 million confirmed cases and has caused about two million deaths, more affecting patients with comorbidities.^{[1],[4],[5],[6],[7],[8]} Several articles have reported that patients undergoing maintenance haemodialysis and kidney transplant recipients are at high risk of contracting COVID-19 due to advanced age, immunosuppressive state, frequent visits to hospitals and the presence of other comorbidities such as diabetes mellitus, cardiovascular disease and hypertension.^{[4],[5],[6],[7],[8]} To curb community transmission of COVID-19, many countries like India had adopted the policy of lockdown and quarantine which ultimately has affected the care of renal patients, especially those who are in end-stage renal disease (ESRD). Due to restrictions of public transport and temporary closure of the dialysis units, renal patients have undergone several complications.^[7],[9],[10] It is a challenging period for all clinicians to work to their fullest, in the current era. As renal care providers, we need to analyse the key components where COVID-19 has impacted renal patients, especially those from hilly regions of Uttarakhand, India.

Methods

Search strategy The authors have searched various search engines such as PubMed, Embase and Google Scholar for published articles from March 2020 to October 2020. The articles were extracted using MESH keywords such as COVID-19, care of renal patients, end-stage renal disease, acute kidney injury, renal replacement therapy (RRT), Impact of COVID-19, Haemodialysis and Peritoneal dialysis. We have explored all articles and their references related to our topic for the identification of new relevant studies. Articles were removed that were not relevant to our review. Data extraction Data regarding the impact of COVID-19 on renal patients and the referral system were extracted from the various published narrative review and the guidelines of the professional organisations. Finally, 31 articles were found suitable to be considered for writing this narrative review [Figure 1].

Figure 1: PRISMA flow diagram

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Impact on routine hospital services Outpatient department services At the onset of nationwide lockdown, due to COVID-19 pandemic, the outpatient department (OPD) services were temporarily shut down in many centres. This activity is persisting in some centres and is creating more burden over the emergency services. Certain government and private hospitals have been providing limited access to OPD service.^[7] A large multicentre survey conducted in an Indian scenario showed that there was a significant decline of patients (92.3%) in OPDs during the initial period of nationwide lockdown. As an alternative, there has been an emergence of telemedicine consultations by both public and private hospitals.^{[11],[12],[13]} COVID-19 also adversely affected the patients who required close or regular follow-up, as this was not possible due to curtailment of OPD services. More and more patients have been coming to emergency, with complications. In the above-mentioned survey, it was found that 2.74% of dialysis-dependent patients required emergency dialysis sessions.^[11] It was very challenging for patients with renal failure in the hilly areas like Uttarakhand to avail transportation during the current pandemic as the complete lockdown did not provide public transportation and caused hindrance in providing regular dialysis to needy patients, ultimately worsened their condition and even leading to death.^{[7],[11],[14]} The main alternative to the patient's transportation during the lockdown period was that the concerned hospital had provided ambulance facility to patients doorstep, but this could not have always been possible and might have also get delayed due to logistic reasons from the end of overburdened COVID-19 hospitals.^{[15],[16],[17]} Inpatient department services COVID-19 not only hampered the OPD services but largely affected the inpatient department services as well, in both public and private sector hospitals, mainly because of the following reasons: Nonavailability of beds A large multicentre survey conducted during the nationwide lockdown showed that inpatient services in surveyed centres were found to be reduced by 61%.^[11] Fear of infection Kidney patients who got admitted had to stay in the COVID suspect zone first, depending on the hospital policy. Sometimes, they had to stay for a longer duration in the suspect area, due to longer turnover time in getting the COVID report and due to the nonavailability of beds in the non-COVID area or due to repeat COVID testing because of strong clinical suspicion. This used to put these patients at high risk of acquiring COVID-19 infection during their stay in the suspect area.^[12] Increased treatment cost COVID-19 has also increased the cost of treatment of patients in private hospitals due to the usage of personal protective equipment by health-care workers (HCWs), add-on price of COVID testing and expensive drugs used in the treatment of COVID pneumonia.^[18] Shortage of health-care workers Some HCWs from different departments have been pooled up to serve in COVID areas, thus creating their shortage in non-COVID areas. If HCWs after contracting this virus had to go for home isolation/hospital admission, it further worsened manpower crisis. Overall, this has hampered the optimal delivery of patient care.^[11],[13] Day-care services There is a paucity of data on how COVID-19 pandemic has affected day-care procedures such as performing a renal biopsy, administration of injectable immunosuppressive medications and iron preparations. Depending on hospital protocols, delay in the execution of such procedures can occur, if patients have to first get themselves admitted in the suspect area for ruling out COVID-19 infection. This may cause inconvenience to those who need frequent hospital visits at short intervals. Furthermore, in this COVID-19 era, it has been recommended to be more judicious regarding performing a kidney biopsy. It is to be performed only after assessing the risk–benefit ratio, although it must not be delayed in life-threatening situations.^[19] One has to be cautious before starting immunosuppressive therapy, as it would put patients at increased risk of contracting this infection. In patients newly diagnosed to have a primary glomerular disease, in the background of coexisting moderate-to-severe COVID-19 infection, immunosuppression should be avoided. However, in life-threatening conditions or if there is a rapidly progressive deterioration of renal function, such treatment has to be initiated. It has been suggested to use the lowest possible doses and to increase the interval between two successive doses, as far as possible. It has been proposed to switch patients to suitable oral regimens from ongoing injectable regimens, as this would prevent their multiple hospital visits, partially solve their issues regarding access to their treating physicians and would also put less burden over already overburdened HCWs. It has also been advocated that injection rituximab could be better suited than injection cyclophosphamide in providing fewer hospital visits with less monitoring, although it is more expensive. Thus, the immunosuppressive regimen needs to be more customised and varies from patient to patient. Furthermore, wherever indicated, plasmapheresis can be tried as first-line treatment.^[19],[20] Very limited literature is available regarding modified usage of injectable iron preparations in CKD patients during this pandemic. It has been advised that maintenance intravenous iron therapy should be avoided in a patient infected with SARS-CoV-2, as routinely done. However, oral iron and erythropoietin should be continued.^[19],[20] Challenges faced in delivering renal replacement therapy Major challenges faced by the renal patients and the nephrologists are related to optimal delivery of RRT. Maintenance haemodialysis A survey which recently got published in the Kidney International Report stated that of all hospitals surveyed, only 63% were able to provide haemodialysis facilities for COVID-19-suspect or -positive patients.^[11] A retrospective study analysing the outcome of COVID-19-positive ESRD patients on maintenance haemodialysis (MHD) showed that 29.7% of patients had missed their regular dialysis sessions and 54.5% of patients were refused for dialysis by their primary haemodialysis centres. Overall, 62% of patients survived after suffering from this disease. The reasons for missing upon dialysis sessions by COVID-19-positive patients were refusal of doing dialysis by parent dialysis centre, lack of personal transportation and social stigma attached to COVID-19-positive status.^[21] A study had compared different characteristics of COVID-19-positive patients with ESRD on MHD with those without renal dysfunction. It revealed that in the haemodialysis group, 92% of patients had at least one underlying disorder and the most common symptoms were fatigue (59%) followed by anorexia (57%). However, in the control group, the most common symptoms were fever (90%) followed by fatigue (83%). Important differences in both groups in laboratory tests were noted. Lymphocyte counts were found to be decreased in patients on haemodialysis, while cardiac markers and mean procalcitonin levels were found to be increased in these patients. The characteristic findings in the CT chest of these patients were numerous patchy ground-glass opacities or consolidation in lung fields. Bilateral involvement was more common in the haemodialysis-requiring group as compared to control (82% vs. 69%).^[4] Problems related to vascular access As routine surgeries are being suspended in some institutes, needy patients with CKD could not get their A-V fistula made on time.^[22],[23] In the absence of functional A-V fistula, some patients needed repeated cannulation for haemodialysis, thus putting them at increased risk of infections, i.e., catheter-related bloodstream infections.^[24] Despite these obstacles, it is encouraging to know that around 1100 sessions of haemodialysis were provided to COVID-19-positive patients in 2020 in Dehradun district of Uttarakhand state of India. (Data received as per personal communication with other dialysis providing centres in this area). Peritoneal dialysis Studies have shown the enhanced quality of life among patients with continuous ambulatory peritoneal dialysis (CAPD), and it becomes a choice of treatment during a pandemic as the patient can perform it in home setting and would be having fewer chances of acquiring infection from the hospital.^{[12],[13],[25]} However, various challenges such as non-availability of the CAPD fluids and other consumables, safe disposal system and high cost of treatment have been faced by these patients.^[11] Kidney transplant A thought-provoking aspect seen during this pandemic is the suspension of kidney transplant services in various centres, throughout the country as well as in other countries.^[26] Various hospitals have postponed the transplantation among stable patients as they are at high risk for critical COVID-19 illness and mortality, due to their post-transplant immunosuppressive state. This has led to increased waiting time both for patient on MHD and those awaiting for living donor renal transplantation.^[12] Very little is known about the risk of transmission of infection from the donors. Hence, several international professional societies have advocated for temporary postponement of the living or deceased donor transplant services in this COVID era. In cases, if the transplant is important, particularly for cadaveric transplants, the donor should be cautiously assessed, including mandatory testing for COVID-19 by polymerase chain reaction/nucleic acid test.^[19] Major challenges are being faced by renal allograft recipients (RARs), who had undergone transplantation, especially within 6 months, before the onset of nationwide lockdown, as most of them were unable to see their treating nephrologist and also could not continue with their immunosuppressive drugs during this period, due to various financial and logistic reasons, apart from being at a high risk of contracting COVID-19 infection. Referral system Dialysis-requiring patients from other COVID care centres (CCC) are being referred to those tertiary level CCCs, where this facility is available. Such patients can be either of AKI or of ESRD. COVID-19 can cause AKI by several direct and indirect mechanisms. Incidence of AKI from COVID-19 depends on its severity. AKI incidence among mild-to-moderate infection is low (0.5%–15%), while it is high (14.5%–50% to 18%–37.5%) in patients with severe infection.^[19] Studies have revealed that in patients who had developed AKI from COVID-19 infection, about 1.5%–9% of them required dialysis, in the form of continuous RRT. The fraction of patients requiring RRT had risen to 5.2%–25% with severe infection.^[27] Thus, almost a quarter of critically ill COVID-19 patients, who require dialysis, need to be referred to higher centres providing these facilities. Such referrals are to be timely made, which pose a challenge to the current health-care system, especially in hilly and remote areas. This has also led to delay in the initiation of treatment of such critical patients. These referrals from multiple hospitals to some selected ones have an overburdened limited workforce in referred centres. HCWs involved in the care of such patients have been intermittently facing burnout problems.

Conclusion

COVID-19 pandemic has had a tremendous impact on the entire world and has resulted in high morbidity and mortality. It has especially affected immunosuppressed patients, including those with ESRD and RARs. Infection with this virus has known to cause AKI, the incidence of which varies with its severity. In this review, we have tried to focus on different ways, how COVID-19 pandemic has affected the overall care of patients with kidney diseases and other related issues. Several organisations and professional bodies have had already released guidelines highlighting changes required in our day-to-day clinical practice in delivering optimal care in the current era, which needs to be implemented by us.^{[20],[28],[29],[30],[31]} Further, this review will also help to give us some insight, regarding the necessity of preparations that would be required for executing best possible care of renal patients, in circumstances similar to COVID-19 pandemic, arising in future [Box 1].

Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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