Finding Ways to Reduce Coronavirus Exposure During Dialysis

News & Analysis

Medical News & Perspectives Finding Ways to Reduce Coronavirus Exposure During Dialysis

Rita Rubin, MA

uzanne Watnick, MD, got the call at 9 PM Friday,February 28. A man in his S 50s who received dialysis treatments at a Northwest Kidney Centers facility in Seattle was the first person with coronavirus disease 2019 (COVID-19) to die in the United States. Watnick, the nonprofit dialysis organization’s chief medical officer, immediately called Elizabeth McNamara, RN, vice presi- dent of patient care services and chief nursing officer. The patient had last undergone dialysis at one of Northwest Kidney Cen- ters’ 19 sites a week earlier. That center wasn’t open on Saturdays, “so we had a bit of time to decide what to do,” Watnick recalled in an interview a few weeks later. “We brought in a group to dis- infect the facility head to toe.” They also made lists of patients who had dialyzed next to the man when he could have been infectious and staff who had come in con- Northwest Kidney Centers updated its viduals who require maintenance hemodi- tact with him at the dialysis center and in patient handout twice in the first 3 weeks as alysis can’t wait out the pandemic by con- the hospital where he was treated for more became known about the novel coro- tinuously sheltering in place. They must COVID-19. All were told to self-quarantine navirus that causes COVID-19. spend 3 to 5 hours at a dialysis center 3 days for 14 days, with 1 exception: The patients “We have moved forward with 3 guid- a week, where, typically, rows of machines needed to continue coming into the dialysis ing principles: We have an obligation to dialyze many patients at once. center for treatment. provide dialysis, we are going to follow sci- Detroit nephrologist Joel Topf, MD, said By the time the facility opened for ence, and we are going to provide leader- he met with all 70 of his dialysis patients dur- business early Sunday morning, Northwest ship and support to all of our patients,” ing the last full week of March, and every Kidney Centers had developed a patient said Watnick, who recently coauthored an single one wanted to talk about COVID-19. handout about COVID-19. In addition to dis- article with McNamara describing their “People seemed appropriately nervous, but tributing the handout, “we sat chairside, response—disbelief at first—to the news fine,” Topf said in an interview. one-on-one, to explain what had hap- that the first US COVID-19 death was one Three out of 10 people with ESRD in pened,” Watnick said. “We didn’t want to of their patients. 2017 had received a kidney transplant by the spread fear and have patients not come.” end of the year, according to the USRDS. That night, 10 members of the COVID-19 A High-Risk Group However, that proportion could decline dur- response team from the US Centers for Dis- By the end of 2017, the most recent year for ing the pandemic and lead to increased de- ease Control and Prevention (CDC), which which data are available, approximately mand for in-center dialysis. includes clinicians, epidemiologists, and 750 000 people in the United States had The Centers for Medicare & Medicaid data scientists, arrived in Seattle, at the end-stage renal disease (ESRD), and nearly Services (CMS), which oversees the time the epicenter of the US COVID-19 out- half a million of them were being treated Medicare End Stage Renal Disease Pro- break. Two of them were deployed to with hemodialysis, according to the US gram, the national insurance program for Northwest Kidney Centers. Renal Data System (USRDS), which is people with ESRD, has deemed transplants Also that night, Watnick said, she and funded by the National Institute of Diabe- to be nonelective surgery that shouldn’t be her team learned that a second person in the tes and Digestive and Kidney Diseases. deferred because of the pandemic. How- US with COVID-19 had died. That indi- Simply having ESRD puts people at an ever, many kidney transplants likely are vidual, who resided in a nursing home with increased risk of severe COVID-19, and many being postponed, according to Michael an outbreak, had been treated at the same people with kidney failure are older and have Spigler,vicepresidentofpatientservicesand dialysis center as the first person to die, al- additional risk factors such as diabetes and kidney disease education at the American

AJPhoto/sciencesource.com beit on different days and a different shift. heart disease. But the vast majority of indi- Kidney Fund.

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“Manyofthecentersinthecountryhave alysis nurses, serve on the ASN COVID-19 Re- cerned about having enough masks as the stopped or significantly reduced the num- sponse Team, which has published a list of pandemic continues. ber of transplants that they’re doing,”Spigler regularly updated frequently asked Watnick said Northwest Kidney Cen- said in a video posted March 30, in which he questions based on current CDC guidance. ters lacks the supplies to implement a uni- cited a shortage of beds and personal pro- The 2 nephrologists recently published an versal mask policy: “If we used masks for ev- tective equipment. “Many, many programs article about how dialysis facilities can miti- ery patient who came in and every staff have stopped living donor transplants al- gate the risk of COVID-19. member, we’d be out.”Already,she said, her most completely….Deceased donations are Dialysis facilities should instruct pa- organization, unable to buy enough hand continuing pretty well so far…but it’s al- tients with symptoms or contact with an in- sanitizer, purchased a 55-gallon drum of al- most inevitable that we’re going to see those fected person to call ahead to allow for cohol so it could have a batch made. start to drop soon as well.” proper preparation, Kliger and Silberzweig wrote. The centers should also screen ev- Segregating Centers Minimizing Exposure ery person entering by asking about symp- In late March, DaVita and Fresenius began As of early April, no documented cases of toms or possible exposures. designating certain shifts and, in some cases, severe acute respiratory syndrome corona- Those who answer yes to any of the entire centers for confirmed or suspected virus 2 (SARS-CoV-2) transmission within questions should wear a face mask and be COVID-19–positive patients only. US dialysis centers had been reported, and directed to a room away from the general DaVita implemented a 3-tier system for the facilities had implemented a number of waiting area. If separate rooms are avail- dialysis centers, designating tier 1 for asymp- safety measures to reduce the chance of able, patients with confirmed or suspected tomatic patients; tier 2 for patients with sus- that happening. COVID-19 can be treated behind closed pected infections; and tier 3 for those with However, dialysis centers weren’t de- doors. If a separate room isn’t available, confirmed COVID-19, said Topf, who is a part- signed with a highly infectious virus such as dialysis centers should consider treating owner of several DaVita centers in the De- SARS-CoV-2 in mind. such patients during the same shift or, if troit area. “Some dialysis units have nothing necessary, in a designated COVID-19 facility. As of early April, he said, Davita had but a big open room with people sitting If patients with COVID-19 symptoms must designated 1 Detroit-area dialysis center for around in it,” said Alan Kliger, MD, chair of be treated at the same time as those with- patients with COVID-19. Topf, who said he Nephrologists Transforming Dialysis Safety out symptoms, they should dialyze in a cor- doesn’t have a financial interest in that cen- (NTDS), a partnership between the CDC ner or at the end of a row. ter, visited one of his patients there shortly and the American Society of Nephrology Now that the CDC recommends that ev- after it opened. Because of the staff’s addi- (ASN) whose goal is to eliminate prevent- eryone wear a cloth mask in settings where tional personal protective equipment, able infections in dialysis units. When the social distancing is difficult, Rogosin pro- “It’s like walking onto the set of Contagion,” NTDS was launched in 2016, its focus was vides all staff and patients with masks. Pa- he said, referring to the 2011 film about on hepatitis B, influenza, and Clostrid- tients who don’t have confirmed or sus- a fictional pandemic. ioides difficile infections. pected COVID-19 aren’t required to wear Ashley Henson, DaVita’s director of Kliger, a clinical professor of medicine masks during treatment, Silberzweig said, communications, said the company has at Yale, noted that his dialysis unit has an but they are advised to wear them at least also identified centers in other parts of the isolation room used mainly for patients when traveling between their home and the country that could be restricted to patients with hepatitis B, as well as 2 other rooms dialysis center, which is often via a van that with confirmed COVID-19 or those sus- for patients who need privacy for emo- transports 3 to 5 patients. “In terms of sup- pected of being infected, although she tional or physical reasons, such as a gastro- ply”ofmasks,heacknowledged,“wearethin didn’t know how many had begun treating intestinal infection. but managing.” only those patients. “Isolation in dialysis units is less Even before the recent CDC recommen- Fresenius has both entire dialysis cen- than ideal,” said Jeffrey Silberzweig, MD, dation, DaVita Kidney Care and Fresenius ters and certain shifts at other centers re- cochair of the ASN Emergency Partnership Medical Care North America, the 2 big for- served for people who have tested positive Initiative and chief medical officer of the profit chains that treat approximately 85% as well as persons under investigation Rogosin Institute, a New York City non- of US patients who receive in-center dialy- (PUIs)—people with or without symptoms profit with 9 dialysis centers that also sis, began requiring that every patient and who’ve been exposed to a confirmed focuses on kidney disease research and employee—symptomatic or not—don a mask COVID-19 case but whose own infection sta- prevention. “We don’t have the facilities to when they enter a center. tus is not yet known. The isolation centers truly isolate patients who are COVID-19 When asked how DaVita acquired aredialyzingpatientswithconfirmedCOVID- positive,” he noted in an interview, adding enough masks to implement its policy,Chief 19, symptomatic PUIs, and asymptomatic that one Rogosin dialysis center has no Medical Officer Jeffrey Giullian, MD, said via PUIs on different shifts. separate treatment room at all. email that his company had launched On March 31, DaVita and Fresenius “Obviously, we’re afraid,” Silberzweig COVID-19 task forces in January “to pre- announced that they were creating a nation- said. “Our approach is to try to narrow the pare, prevent, and respond” to the virus. wide contingency plan for smaller dialysis or- exposure as best we can.” “Those task forces began proactively ganizations to send patients who are or may He and Kliger, along with CDC physi- working with our suppliers and vendors,” be infected to the larger companies’ COVID- cians, infectious disease specialists, and di- Giullian said, adding that DaVita is still con- 19–only facilities or shifts.

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The collaboration’s goal is to help TwoweeksaftertheTwitterchat,though, “It won’t be optimal, but we hope it “maintain continuity of care for dialysis the plan had fallen through, University of Ot- would provide enough dialysis for people to patients by creating isolation cohort tawa nephrologist Swapnil Hiremath, MD, at least continue to be with us until we can capacity that can be accessed by these MPH,saidinaninterview.“Givenongoingcon- provide full treatments again,”Watnick said, dialysis providers, if needed,” Fresenius cerns [about COVID-19], we decided that the noting that on average, treatment sessions Chief Medical Officer Robert Kossmann, home dialysis training program should not be are longer at her centers than at other US di- MD, said in an email. shut down,”he explained. alysis facilities. In contrast, Northwest Kidney Cen- Few people with ESRD dialyze at Dialysis centers might eventually have ters, which has 4 facilities without a private home. Among those who do, the vast no choice but to shorten or decrease treat- room, decided against designating centers majority are treated with peritoneal dialy- ment sessions, Silberzweig said: “Depend- for patients with COVID-19 and PUIs. “We sis, which uses the abdominal cavity lining ing on how [the pandemic] progresses, we have discussed it thoroughly and have instead of a hemodialysis machine to filter may need to resort to extreme measures back-up plans along those lines if needed,” blood. At the end of 2017, only about 7% of like that.” Not every patient would be a Watnick said, explaining that her organiza- people with ESRD were treated with perito- candidate for reduced treatment hours, he tion would rather not shift patients to dif- neal dialysis, while 63% were undergoing noted, because some of them build up ferent, unfamiliar centers. “The dialysis clinic hemodialysis—only 2% of them at home, excessive fluid between regular treat- is a patient’s home, so we are trying to main- according to the USRDS. ments, which can cause respiratory and tain that paradigm.” But the COVID-19 pandemic has height- cardiac problems. ened interest in home dialysis, Kliger said, However, Silberzweig emphasized, for No Place Like Home adding that his institution is encouraging all patients with ESRD, the potential harm of A mid-March Twitter chat hosted by the people new to dialysis to consider learning dialyzingfewerhoursperweekisnotasgreat ASN and NephJC, a Twitter-based journal how to do it at home. as that of COVID-19. club, touched on Ottawa Hospital’s plan to Fortunately, Watnick said, COVID-19 create a COVID-19–only dialysis unit. The Fewer Hours? fears have not stopped patients from unit would occupy 6 rooms currently dedi- Dialysis organizations have considered tem- getting treated. They tell her, “We feel cated to training patients how to dialyze porarily reducing the number of hours pa- safer coming to your dialysis facility than at home. Located within the Ontario, tients dialyze each week during the pan- going out in the community to our doctor Canada, hospital’s outpatient dialysis demic, which would limit their potential appointments.” center, the unit would accommodate 36 exposure to COVID-19 and increase dialysis Note: Source references are available through patients each week. centers’ capacity. embedded hyperlinks in the article text online.

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