As the number of cases of illness due to a novel coronavirus continues to increase globally, including in the United States, dialysis facilities have stepped up precautions to protect patients with kidney failure from the pathogen, which can cause severe respiratory illness and death.

Dialysis patients could be particularly hard hit by COVID-19 because of their high prevalence of underlying and debilitating health problems.

Of the 743,624 individuals in the United States with kidney failure as of December 31, 2017, 468,086 (62.9%) received hemodialysis, with 98% of them undergoing the treatment inside dialysis facilities, according to the US Renal Data System. Two companies, DaVita Inc. and Fresenius Medical Care North America, provide dialysis services for the vast majority of patients with kidney failure in the United States.

Task forces formed

“DaVita has been closely monitoring the COVID-19 situation since January,” Jeffrey Giullian, MD, Chief Medical Officer at DaVita, told Renal & Urology News. “At that time, we launched dual task forces, one for our US operations and the other for international. On the domestic front, we have been working with the CDC [Centers for Disease Control and Prevention], ASN [American Society of Nephrology], and KCER [Kidney Community Emergency Response] program to ensure proper prevention efforts as well as contingency plans in the event of a larger scale outbreak.”

DaVita provides outpatient care to in-center and home dialysis patients across the United States as well as to inpatients at more than 900 hospitals, Dr Giullian said. For this reason, the US task force has focused on securing ample supplies, including personal protective equipment such as gloves and masks. DaVita also is working proactively with its pharmaceutical distributor to ensure ongoing access to critical medications, he said. All facilities are in the process of reviewing critical policies for respiratory droplet precautions.

Uptick in concerns expected

“DaVita has been proactive in educating our teammates and patients regarding the COVID-19 situation, including efforts around prevention and response,” Dr Giullian said. “We do expect to see an uptick in vocalized concerns by our patients and their family members. For this reason, we are continuing to maintain open lines of communication and are committed to help our patients best understand how they can protect themselves from this viral illness.”

Fresenius also reports taking vigorous efforts to protect patients and staff from the virus. “We are acutely aware of the danger of COVID-19 to our patient population, as well as the importance of protecting the health of our staff if the virus continues to spread,” said Jeffrey Hymes, MD, Chief Medical Officer for Fresenius Kidney Care. “In an abundance of caution, we have taken many steps over the past 2 months to prepare. In January, we instructed all our clinics to begin preparation, including the ordering of protective masks, and had [staff] conduct pandemic exercises overseen by our disaster response team. As the COVID-19 outbreak continues to spread, we have implemented additional detailed guidance and procedures in our clinics to protect patients and staff.”

Most importantly, he said, Fresenius has re-issued detailed guidance to its clinical staff on the continued importance of strict adherence to infection control policies and procedures.

The CDC is not currently recommending widespread screening in healthcare facilities, but if a patient presents with flu-like symptoms, cough, or other respiratory symptoms, “we are requiring that our clinicians don protective gear before conducting a series of detailed screening questions,” Dr Hymes said. “Those questions could change as recommendations are updated by the CDC.”

Fresenius has suspended treatment for international transient patients visiting the United States for short periods and now offers masks and hand sanitizer to all patients and visitors in clinic waiting room areas upon request, he said.

COVID-19 is short for coronavirus disease 2019, the name the World Health Organization (WHO) gave to the illness caused by the virus. The first reports of the virus, which is named SARS-CoV-2, came from Wuhan, China, in 2019. The virus has since spread to a number of countries outside of China, especially Iran, South Korea, and Italy. At a media briefing in Geneva on March 3, WHO Director-General Tedros Adhanom Ghebreyesus, PhD, said COVID-19 does not transmit as easily as the seasonal flu, but the illness is more severe and the death rate is higher. “Globally, about 3.4% of reported COVID-19 cases have died,” he said in remarks posted on the organization’s website. “By comparison, seasonal flu generally kills far fewer than 1% of those infected.”

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Luciano Pedrini, MD, a medical director at a Fresenius Medical Care dialysis facility in Seriate, Italy, noted that one of the 6 Fresenius dialysis centers in the region is in the midst of a COVID-19 outbreak. To prevent the spread of the infection among patients on dialysis, plans have been made to visit and screen all patients before they enter the dialysis rooms of this high-risk center as well as the other 5 facilities, Dr Pedrini related. Symptomatic patients, such as those with a fever or cough or who are vomiting, will be tested with a rhino-pharyngeal swab and transferred to the Nephrology and Dialysis Center, NephroCare-ASST Bergamo-Est, in Seriate for hospitalization. This center has been equipped with a separate dialysis room so that symptomatic patients can avoid contact with other patients. The most seriously ill patients—those with pneumonia and respiratory distress—can be admitted to an ICU for ventilatory assistance and dialyzed there. Unaffected patients must wear surgical masks throughout dialysis sessions. Medical and nursing staff must wear all protective devices, and repeated daily sterilizations are carried out in the wards.

COVID-19 illness does not seem to be clinically much different from common influenza or to be life threatening even in the presence of pneumonia, except among elderly individuals and those with severe comorbidities, Dr Pedrini said.

ASN Recommendations

ASN has prepared a document to address questions and concerns related to screening and management of COVID-19 in outpatient dialysis centers. ASN recommends that dialysis facilities ensure rapid triage and isolation of patients with symptoms of suspected COVID-19 or other respiratory infection, such as cough or fever. Staff should identify patients before or immediately upon arrival to the dialysis facility, for example, during or before patient triage or registration at the time of patient check-in. Patients with symptoms of suspected COVID-19 should not be allowed to wait among other patients seeking care. Individuals entering a room should be limited to necessary clinical staff, and time in the room should be limited. All providers and clinical staff who enter a room should wear appropriate personal protective equipment (PPE), including gloves, gown, eye protection, and a fit-tested N-95 mask or higher-level respirator. “If N95 masks are not available or healthcare providers have not been fit tested, they should wear a surgical mask and all other appropriate PPE and minimize time in the room.”

All patients should be asked about fever or symptoms of lower respiratory tract infection, including cough or trouble breathing, and whether they have traveled to an affected geographic area in the past 14 days or had contact with a patient with known COVID-19 illness.

This article originally appeared on Renal and Urology News