COVID-19 Vol. 42 Nº2 Suppl 1 2020 Table of Contents | Sumário
Official Organ of the Brazilian Society of Nephrology Volume 42, Issue 2, Suppl. 1 Órgão Oficial da Sociedade Número Especial - Covid 19 Brasileira de Nefrologia ISSN 0101-2800 Quarterly Edition Publicação Trimestral
Editorials | Editoriais
The Brazilian Society of Nephrology and the Covid-19 Pandemic 1 A Sociedade Brasileira de Nefrologia e a pandemia pela Covid-19 Andrea Pio de Abreu • Miguel Carlos Riella • Marcelo Mazza do Nascimento
Recommendations | Recomendações
Recommendations from the Brazilian Society of Nephrology for approaching Covid-19 Diagnostic Testing in Dialysis Units 4 Recomendações da Sociedade Brasileira de Nefrologia para abordagem de exames diagnósticos da Covid-19 nas unidades de diálise José A. Moura-Neto • Lilian M. P. Palma • Gabriel F. Marchiori • Raquel S. B. Stucchi • Ana Maria Misael • Ronaldo D’Avila • Dirceu Reis da Silva • Maria Claudia Cruz Andreoli • Angiolina Kraychete • Kleyton Bastos • Marcelo Mazza do Nascimento Recommendations from the Brazilian Society of Nephrology regarding the use of cloth face coverings, by chronic 9 kidney patients in dialysis, during the new coronavirus pandemic (Covid-19) Recomendações da Sociedade Brasileira de Nefrologia quanto ao uso de máscaras de pano por pacientes renais crônicos em diálise, durante a pandemia pelo novo coronavírus (Covid-19) Andrea Pio de Abreu • José Andrade Moura Neto • Vinicius Daher Alvares Delfino • Lilian Monteiro Pereira Palma • Marcelo Mazza do Nascimento Covid-19 (Sars-Cov-2 Infection) Information for Patients with Predialytic Chronic Kidney Disease 12 Informações para pacientes com doença renal crônica pré-dialítica sobre Covid-19 (infecção pelo SARS-CoV-2) Vinicius Daher Alvares Delfino • Marcelo Mazza do Nascimento • Jose de Rezende Barros Neto Good Practice Recommendations from the Brazilian Society of Nephrology to Dialysis Units Concerning the 15 Pandemic of the New Coronavirus (Covid-19) Recomendações de boas práticas da Sociedade Brasileira de Nefrologia às unidades de diálise em relação à pandemia do novo coronavírus (Covid-19) José A. Moura-Neto • Andrea Pio de Abreu • Vinicius Daher Alvares Delfino • Ana Maria Misael • Ronaldo D’Avila • Dirceu Reis da Silva • Maria Claudia Cruz Andreoli • Angiolina Kraychete • Kleyton Bastos • Marcelo Mazza do Nascimento Good practices recommendations from the Brazilian Society of Nephrology to Peritoneal Dialysis Services 18 related to the new coronavirus (Covid-19) epidemic Recomendaçes de boas praticas da Sociedade Brasileira de Nefrologia aos Serviços de dialise peritoneal em relaço à epidemia do novo coronavirus (Covid-19) Viviane Calice-Silva • Alexandre Silvestre Cabral • Sérgio Bucharles • Jose Andrade Moura- Neto • Ana Elizabeth Figueiredo • Ricardo Portiolli Franco • Andrea Pio de Abreu • Marcelo Mazza do Nascimento Technical note and clinical instructions for Acute Kidney Injury (AKI) in patients with Covid-19: Brazilian Society of 22 Nephrology and Brazilian Association of Intensive Care Medicine Nota técnica e orientações clínicas sobre a Injúria Renal Aguda (IRA) em pacientes com Covid-19: Sociedade Brasileira de Nefrologia e Associação de Medicina Intensiva Brasileira José Hermógenes Rocco Suassuna • Emerson Quintino de Lima • Eduardo Rocha • Alan Castro • Emmanuel de Almeida Burdmann • Lilian Pires de Freitas do Carmo • Luis Yu • Mauricio Younes Ibrahim • Gustavo Navarro Betônico • Américo Lourenço Cuvello Neto • Maria Olinda Nogueira Ávila • Anderson R. Roman Gonçalvez • Ciro Bruno Silveira Costa • Nilzete Liberato Bresolin • Andrea Pio de Abreu • Suzana Margareth Ajeje Lobo • Marcelo Mazza do Nascimento
I Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):I-II Recommendations | Recomendações Recommendations Of The Brazilian Society Of Nephrology Regarding Pediatric Patients On Renal Replacement 32 Therapy During The Covid-19 Pandemic Recomendações da Sociedade Brasileira de Nefrologia para Pacientes Pediátricos em Terapia de Substituição Renal Durante a Pandemia Covid-19 Marcelo de Sousa Tavares • Maria Goretti Moreira Guimarães Penido • Olberes Vitor Braga de Andrade • Vera Hermina Kalika Koch • Rejane de Paula Bernardes • Clotilde Druck Garcia • José A. Moura-Neto • Marcelo Mazza Nascimento • Lilian Monteiro Pereira Palma COMDORA-SBN recommendations for patients with rare kidney diseases in relation to the Covid-19 pandemic 36 Recomendações do COMDORA-SBN a pacientes portadores de doenças renais raras em relação à pandemia de Covid-19 Vinícius Sardão Colares • Silvana Maria Miranda • Luis Gustavo Modelli de Andrade • Lilian Monteiro Pereira Palma • Maria Cristina Ribeiro de Castro • Cassiano Augusto Braga Silva • Maria Goretti Moreira Guimarães Penido • Roberta Sobral • Maria Helena Vaisbich Hemodialysis Vascular access maintenance in the Covid-19 pandemic: Positioning paper from the Interventional 41 Nephrology Committee of the Brazilian Society of Nephrology Manutenção de acessos vasculares para hemodiálise na pandemia da Covid-19: posicionamento do Comitê de Nefrologia Intervencionista da Sociedade Brasileira de Nefrologia Ricardo Portiolli Franco • Ciro Bruno Silveira Costa • Clayton Santos Sousa • Anderson Tavares Rodrigues • Precil Diego Miranda de Menezes Neves • Domingos Candiota Chula Palliative Renal Care and the Covid-19 Pandemic 44 Cuidado paliativo renal e a pandemia de Covid-19 Cássia Gomes da Silveira Santos • Alze Pereira dos Santos Tavares • Carmen Tzanno-Martins • José Barros Neto • Ana Maria Misael da Silva • Leda Lotaif • Jonathan Vinicius Lourenço Souza Position Paper of the Department of Hypertension of the Brazilian Society of Nephrology: Use of renin-angiotensin 47 system blockers during the course of Covid-19 infection Posicionamento do Departamento de Hipertensão da Sociedade Brasileira de Nefrologia: Bloqueadores do sistema renina-angiotensina durante o curso de infecção pela Covid-19 Cibele Isaac Saad Rodrigues Position statement from the Brazilian Society of Nephrology regarding chloroquine and hydroxychloroquine 49 drug dose adjustment according to renal function Nota da Sociedade Brasileira de Nefrologia em relação ao ajuste das drogas cloroquina e hidroxicloroquina pela função renal José A. Moura-Neto • Ana Maria Misael • Dirceu Reis da Silva • Ronaldo D’Avila • Maria Claudia Cruz Andreoli • Angiolina Kraychete • Kleyton Bastos • Marcelo Mazza do Nascimento
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):I-II II Brazilian Society of Nephrology
Executive Board 2019/2020
President: Marcelo Mazza do Nascimento Director of Associative policies: Cinthia Kruger Sobral Vieira National Vice President: Daniel Costa Chalabi Calazans Vice President North: Karla Cristina Silva Petrucelli General Secretary: Andrea Pio de Abreu Vice President Northeast: Wagner Moura Barbosa First Secretary: Ricardo Portiolli Franco Vice President Midwest: Ciro Bruno Silveira Costa Treasurer: David José de Barros Machado Vice President Southeast: Osvaldo Merege Vieira Neto Scientific Director: Vinicius Daher Alvares Delfino Vice President South: Denise Rodrigues Simão
Audit Committee Department of Epidemiology and Renal Disease Prevention Carmen Tzanno Branco Martins (President) Gianna Mastroianni Kirsztajn (Director) Miguel Carlos Riella (President) Cristina Gatto Coelho da Rocha (Vice-director) José Osmar Medina de Abreu Pestana (President) Artur Quintiliano Bezerra da Silva Ana Maria Misael da Silva (Vice-president) Marcus Vinicius de Pádua Netto Dirceu Reis da Silva (Vice-president) Patrícia Ferreira Abreu Elisa Mieko Suemitsu Higa (Vice-president) Patrícia Maria Pereira Albuquerque Viviane Calice da Silva Legal Department Alexandre Silvestre Cabral (Director) Department of Clinical Nephrology João Damásio Sottero Simões (Vice-director) Irene de Lourdes Noronha (Director) Alessandro Barilli Alves José de Resende Barros Neto (Vice-director) José Mario Franco de Oliveira Jenner Cruz Marta Vaz Dias de Souza Boger Leda Aparecida Daud Lotaif Ricardo Furtado de Carvalho Maria Izabel Neves de Holanda Silvia Corradi de Faria Mary Carla Estevez Diz Nathalia da Fonseca Pestana Department of Dialysis Ana Maria Misael da Silva (Director) Department of Pediatric Nephrology Jose Andrade Moura Neto (Vice-director) Maria Goretti Moreira Guimarães Penido (Director) Angiolina Campos Kraychete Lilian Monteiro Pereira Palma (Vice-director) Dirceu Reis da Silva Marcelo de Sousa Tavares Kleyton de Andrade Bastos Olberes Vitor Braga de Andrade Maria Cláudia Cruz Andreoli Rejane de Paula Meneses Bernardes Ronaldo D’Avila Vera Hermina Kalika Koch
Department of Education and Certification Department of Acute Renal Failure Carmen Tzanno Branco Martins (Director) José Hermogenes Rocco Suassuna (Director) Marilda Mazzali (Vice-director) Eduardo Rocha (Vice-director) Elizabeth de Francesco Daher Alan Castro Jocemir Ronaldo Lugon Emmanuel de Almeida Burdmann Lúcio Roberto Requião Moura Lilian Pires de Freitas do Carmo Marcus Gomes Bastos Luis Yu auricio ounes brahim Maria Almerinda Ribeiro Alves M Y I Department of Mineral Bone Metabolism Disorders in epartment of enal hysiology and athophysiology D R P P Chronic Kidney Disease Carlos Perez Gomes (Director) Fellype de Carvalho Barreto (Director) rissia amile inger allbach ice director K K S W (V - ) Aluizio Barbosa de Carvalho (Vice-director) Elias Marcos Silva Flato Leandro Junior Lucca Elisa Mieko Suemitsu Higa Melani Ribeiro Custódio Marcelo Augusto Duarte Silveira Rodrigo Bueno de Oliveira Mariana Fontes Turano Rosa Maria Affonso Moysés Vanda Jorgetti Department of Hypertension Cibele Isaac Saad Rodrigues (Director) Department of Kidney Transplants Carlos Eduardo Poli Figueiredo (Vice-director) Álvaro Pacheco e Silva Filho (Director) Fernando Antonio de Almeida Gustavo Fernandes Ferreira (Vice-director) Maria Eliete Pinheiro Fernando das Mercês Lucas Junior Rogério Andrade Mulinari Hélady Sanders Pinheiro Rogério Baumgratz de Paula Maria Cristina Ribeiro de Castro Sebastião Rodrigues Ferreira Filho Miguel Moyses Neto Tainá Veras de Sandes Freitas
III Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):III Official Organ of Brazilian Society of Nephrology Órgão Oficial da Sociedade Brasileira de Nefrologia Quarterly Edition Publicação Trimestral
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Brazilian Journal of Nephrology (Jornal Brasileiro de Nefrologia) has as principle to publish scientific articles resulting of clinical and experimental investigation related to nephrologic themes.
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Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):IV Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):IV IV Organization
Marcelo Mazza do Nascimento Sociedade Brasileira de Nefrologia, São Paulo, SP, Brasil | Brazil Universidade Federal do Paraná, Curitiba, PR, Brasil
Andrea Pio de Abreu Sociedade Brasileira de Nefrologia, São Paulo, SP, Brasil | Brazil Universidade de São Paulo, São Paulo, SP, Brasil | Brazil
Acknowledgment Collaboration Alan Castro Ana Verena Almeida Mendes Alexandre Silvestre Cabral Bento Fortunato Cardoso dos Santos Alze Pereira dos Santos Tavares Carlos Eduardo Poli de Figueiredo Américo Lourenço Cuvello Neto Daniela Ponce Ana Elizabeth Figueiredo David José Machado Ana Maria Misael da Silva Elias Flato Anderson R. Roman Gonçalvez Fellype Barreto Anderson Tavares Rodrigues Fernando Antonio de Almeida Angiolina Kraychete Gilson Bianchini Carmen Tzanno-Martins Gina Moreno Cássia Gomes da Silveira Santos Henrique Carrascossi Cassiano Augusto Braga Silva Hugo Abensur Cibele Isaac Saad Rodrigues João Luiz Ferreira da Costa Ciro Bruno Silveira Costa José David Urbaéz Brito Clayton Santos Sousa Lucimary Sylvestre Clotilde Druck Garcia Maria Eliete Pinheiro Dirceu Reis da Silva Maria Izabel de Holanda Domingos Candiota Chula Mario Ernesto Rodrigues Eduardo Rocha Patrícia Pontes Emerson Quintino de Lima Rogério Baumgratz de Paula Emmanuel de Almeida Burdmann Rogério de Andrade Mulinari Gabriel F. Marchiori Sebastião Rodrigues Ferreira-Filho Gustavo Navarro Betônico Thiago Reis Jonathan Vinicius Lourenço Souza Valéria S. P. Veloso José Andrade Moura Neto Jose de Rezende Barros Neto José Hermógenes Rocco Suassuna Kleyton Bastos Leda Lotaif Lilian Monteiro Pereira Palma Lilian Pires de Freitas do Carmo Luis Gustavo Modelli de Andrade Luis Yu Marcelo de Sousa Tavares Maria Claudia Cruz Andreoli Maria Cristina Ribeiro de Castro Maria Goretti Moreira Guimarães Penido Maria Helena Vaisbich Maria Olinda Nogueira Ávila Mauricio Younes Ibrahim Miguel Carlos Riella Nilzete Liberato Bresolin Olberes Vitor Braga de Andrade Precil Diego Miranda de Menezes Neves Raquel S. B. Stucchi Rejane de Paula Bernardes Ricardo Portiolli Franco Roberta Sobral Ronaldo D’Avila Sérgio Bucharles Silvana Maria Miranda Suzana Margareth Ajeje Lobo Vera Hermina Kalika Koch Vinicius Daher Alvares Delfino Vinícius Sardão Colares Viviane Calice-Silva
V Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):V Editorial Board
Editor-in-Chief Prof. Dr. Miguel Carlos Riella Evangelic School of Medicine - Curitiba, PR, Brazil (Professor of Medicine) Pro-Renal Brazil Foundation - Curitiba, PR, Brazil (President)
Associated Editors Adriano Ammirati - USP – São Paulo, SP, Brazil Marina Pontello Cristelli - Hrim, São Paulo, SP, Brazil Andrea Emilia Marques Stinghen - UFPR – Curitiba, PR, Brazil Paulo Novis Rocha - UFBa – Salvador, BA, Brazil Andrea Pio de Abreu - USP – São Paulo, SP, Brazil Roberto Ceratti Manfro - UFRGS – Porto Alegre, RS, Brazil Anderson Ricardo Roman Gonçalves - UNIVILLE – Joinville, SC, Brazil Rodrigo Bueno de Oliveira - UNICAMP – Campinas, SP, Brazil Arif Asif - Jersey Shore Univeristy Medical Center – Neptune City, NJ, USA Sérgio Gardano Elias Bucharles - UFPR – Curitiba, PR, Brazil Daniela Ponce - UNESP – Botucatu, SP, Brazil Thyago Proença de Moraes - PUCPR – Curitiba, PR, Brazil Fellype Carvalho Barreto - UFPR – Curitiba, PR, Brazil Viviane Calice-Silva - Fundação Pró-Rim – Joinville, SC, Brazil Geraldo Bezerra Júnio - UFC – Fortaleza, CE, Brazil
Editors Emeriti Prof. Dr. José Augusto Barbosa de Aguiar (in memorian) - 1979-1981 Prof. Dr. Décio Mion Jr.-1994-2001 Prof. Dr. César Costa - 1982 Prof. Dr. João Egídio Romão Junior-2002-2004 Prof. Dr. Emil Sabbaga (in memorian) -1983-1984 Prof. Dr. Jocemir Ronaldo Lugon-2005-2006 Prof. Dr. José Francisco Figueiredo-1985-1989 Prof. Dr. Marcus Gomes Bastos -2007-2012 Prof. Dr. Horácio Ajzen (in memorian) -1990-1993 Prof. Dr. João Egídio Romão Junior – 2013-2014
Section Editors
Acute Renal Injury Genetics Daniel Costa Calazans - FSFX - Ipatinga, MG, Brazil Cristian Vidal Riella - Harvard Medical School - Boston, MA, USA Daniela Ponce - UNESP - Botucatu, SP, Brazil Luiz Fernando Onuchic - USP - São Paulo, SP, Brazil Emmanuel Burdmann - USP - São Paulo, SP, Brazil José Hermogenes Rocco Suassuna - UERJ - Rio de Janeiro, RJ, Brazil Glomerulopathies and Tubulointerstitial Diseases Lucia da Conceição Andrade - USP - São Paulo, SP, Brazil Cristiane Bitencourt Dias - USP - São Paulo, SP, Brazil Luis Yu - USP - São Paulo, SP, Brazil Elizabeth de Francesco Daher - UFC - Fortaleza, CE, Brazil Maurício Younes Ibrahim - UERJ - Rio de Janeiro, RJ, Brazil Gianna Mastroiani Kirsztajn - UNIFESP - São Paulo, SP, Brazil Marcio Dantas - USP - Ribeirão Preto, SP, Brazil Arterial Hypertension Rui Toledo Barros - USP - São Paulo, SP, Brazil Cibele Isaac Saad Rodrigues - PUC - Sorocaba, SP, Brazil Giovanio Silva - USP - São Paulo, SP, Brazil Hemodialysis Luis Cuadrado Martin – UNESP – Botucatu, SP, Brazil Jocemir Lugon - UFF - Niterói, RJ, Brazil Rogério de Paula - UFJF - Juiz de Fora, MG, Brazil Jorge Paulo Strogoff De Mattos - UFF - Niterói, RJ, Brazil Sebastião Rodrigues Ferreira Filho - UFU - Uberlândia, MG, Brazil Manuel Carlos Martins Castro - USP - São Paulo, SP, Brazil Marcelo Mazza do Nascimento - UFPR - Curitiba, PR, Brazil Chronic Kidney Disease Maria Eugênia F. Canziani - UNIFESP - São Paulo, SP, Brazil José Hermogenes Rocco Suassuna - UERJ - Rio de Janeiro, RJ, Brazil Rosilene Motta Elias - USP - São Paulo, SP, Brazil Maria Eugênia F. Canziani - UNIFESP - São Paulo, SP, Brazil Rafael Weissheimer - PUCPR - Curitiba, PR, Brazil Interventional Nephrology Domingos Candiota Chula - Fundação Pró-Renal - Curitiba, PR, Brazil Communicable Diseases Lilian Pires de Freitas do Carmo - UFMG - Belo Horizonte, MG, Brazil Elizabeth de Francesco Daher - UFC - Fortaleza, CE, Brazil Marcus Gomes Bastos - UFJF - Juiz de Fora, MG, Brazil Ricardo Portiolli Franco - Fundação Pró-Renal - Curitiba, PR, Brazil Disorders of Bone and Mineral Metabolism Rodrigo Peixoto Campos - UFAL - Maceió, AL, Brazil Aluizio Barbosa de Carvalho - UNIFESP - São Paulo, SP, Brazil Melani Ribeiro Custodio - USP - São Paulo, SP, Brazil Kidney Transplantation Rosa M. Affonso Moyses - USP - São Paulo, SP, Brazil Andrea Carla Bauer - UFRS - Porto Alegre, RS, Brazil Claudia Felipe - UNIFESP - São Paulo, SP, Brazil Experimental Nephrology Elizete Keitel - UFCSPA - Porto Alegre, RS, Brazil Antonio Carlos Seguro - USP - São Paulo, SP, Brazil Flávio Teles de Farias Filho - UNCISAL - Maceió, AL, Brazil Niels Olsen Saraiva Camara - USP - São Paulo, SP, Brazil Gisele Meinerz - Santa Casa de Misericordia de Porto Alegre - Porto Roberto Zatz - USP - São Paulo, SP, Brazil Alegre, RS, Brazil Irene L. Noronha - USP - São Paulo, SP, Brazil General Nephrology Juliana Mansur - UNIFESP - São Paulo, SP, Brazil Leonardo Vidal Riella - Harvard Medical School - Boston, MA, USA Elizabeth de Francesco Daher - UFC - Fortaleza, CE, Brazil Marilda Mazzali - UNICAMP - Campinas, SP, Brazil Jocemir Ronaldo Lugon - UFF - Niterói, RJ, Brazil Mario Abbud Filho - FAMERP - São José do Rio Preto, SP, Brazil José Hermogenes Rocco Suassuna - UERJ - Rio de Janeiro, RJ, Brazil Taina Sandes Freitas - UFC - Fortaleza, CE, Brazil Manuel Carlos Martins Castro - USP - São Paulo, SP, Brazil Valter Duro Garcia - Santa Casa - Porto Alegre, RS, Brazil Marcelo Mazza do Nascimento - UFPR - Curitiba, PR, Brazil
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):VI-VII VI Lithiasis Daltro Zunino - Hospital Universitário Evangelico de Curitiba - Ita Pfefermann Heilberg - UNIFESP - São Paulo, SP, Brazil Curitiba, PR, Brazil José Augusto Meneses da Silva - Núcleo de Nefrologia de B. Lucimary de Castro Sylvestre - PUCPR - Curitiba, PR, Brazil Horizonte - Belo Horizonte, MG, Brazil Maria Goretti M. Penido - UFMG - Belo Horizonte, MG, Brazil Maurício de Carvalho - UFPR - Curitiba, PR, Brazil Vera Koch - USP - São Paulo, SP, Brazil Peritoneal Dialysis Nephrology and Clinical Epidemiology Hugo Abensur - USP - São Paulo, SP, Brazil Gianna M. Kirsztajn - UNIFESP - São Paulo, SP, Brazil Kleyton de Andrade Bastos - UFSE - Aracaju, SE, Brazil Guillermo Garcia Garcia - University of Guadalajara - Guadalajara, Jalisco, Mexico Physical Therapy Specialty Ricardo Cintra Sesso - UNIFESP - São Paulo, SP, Brazil Luciana Chiavegato - UNIFESP - São Paulo, SP, Brazil Nutritional Sciences Physiology Andreia Watanabe - USP - São Paulo, SP, Brazil Antonio Carlos Seguro - USP - São Paulo, SP, Brazil Christiane Ishikawa Ramos - UNIFESP - São Paulo, SP, Brazil Claudia Maria de Barros Helou - USP - São Paulo, SP, Brazil Cristina Martins - Fundação Pró-Renal - Curitiba, PR, Brazil Fabiana Baggio Nerbass - Fundação Pró-Rim - Joinville, SC, Brazil Social Media and Visual Abstract Lilian Cuppari - Fundação Oswaldo Ramos - São Paulo, SP, Brazil Bianca Garcez Massignan – Curitiba, PR, Brazil Pediatric Nephrology Geraldo Bezerra da Silva Junior – UNIFOR, Fortaleza, CE, Brazil José Andrade Moura-Neto – Salvador, BA, Brazil Andreia Watanabe - USP - São Paulo, SP, Brazil Pablo Rodrigues Costa Alves – UFPB – João Pessoa, PB, Brazil Clotilde Druck Garcia - Santa Casa - Porto Alegre, RS, Brazil Rodrigo Dias de Meira – UPF, Passo Fundo, RS, Brazil Thiago de Azevedo Reis – Brasília, DF, Brazil Wallace Stwart Carvalho Padilha – Brasília, DF, Brazil
Editorial Board
Aldo Peixoto - University de Yale - New Haven, CT, USA Luis Alberto Batista Peres - UNIOESTE - Cascavel, PR, Brazil Allan Collins - University of Minnesota - Lexington, MA, USA Luiz Antonio Miorin - Santa Casa - São Paulo, SP, Brazil Aluizio Barbosa De Carvalho - UNIFESP - São Paulo, SP, Brazil Luiz Carlos Ferreira Andrade - UFJF - Juiz de Fora, MG, Brazil Amy Barton Pai - Albany Medical College - Albany, NY, USA Marcello Tonelli - University de Alberta - University of Alberta - Ana Maria Cusumano - Instituto Universitário CEMIC - Buenos Alberta, Canada Aires, Argentina Maria Fernanda Soares - Fundação Pró - Renal - Curitiba, PR, Brazil Anupam Agarwal - University of Alabama at Birmingham, AL, USA Mario Abbud Filho - FAMERP - São José do Rio Preto, SP, Brazil Bengt Lindholm - Karolinska Instituted - Estocolmo, Suécia Mauricio Younes Ibrahim - UERJ - Rio De Janeiro, RJ, Brazil Brett Cullis - Greys e St Annes Hospital - Pietermaritzburg, Kwazulu Maurilo Nazaré Leite Jr. - UFF - Rio de Janeiro, RJ, Brazil - Natal, South Africa Natalia Fernandes - UFJF - Juiz de Fora, MG, Brazil Charles O’neil - Hospital Ar North Adams - Atlanta, GA, USA Nathan Levin - Good Health Medical - New York, NY, USA Cristianne Da Silva Alexandre - UFPB - João Pessoa, PB, Brazil Paulo Benigno Pena Batista - EBMSP - Salvador, BA, Brazil Domingos D´Ávila - PUC - Porto Alegre, RS, Brazil Paulo C. Koch Nogueira - Unifesp - São Paulo, SP, Brazil Edison Souza - UERJ - Rio de Janeiro, RJ, Brazil Pedro Gordan - UEL - Londrina, PR, Brazil Eduardo Rocha - UFRJ - Rio de Janeiro, RJ, Brazil Peter Blake - University of Western Ontario London - Edmonton, Eleonora Moreira Lima - UFMG - Belo Horizonte, MG, Brazil Canada Elias David Neto - USP - São Paulo, SP, Brazil Peter Stenvinkel - Karolinska Instituted - Estocolmo, Sweden Fernando C. Fervenza - Campus Rochester Nathodist - Rochester, Rashad S. Barsoum - Cairo University - Cairo, Egito MN, USA Richard Glassock - School of Medicina at UCLA - Los Angeles, USA Fernando Neves - British Hospital - Lisboa, Portugal Richard Johnson - University of Colorado - Denver, CO, USA Francisco de Assis Rocha Neves - UnB - Brasília, DF, Brazil Rogério Baumgratz - UFJF - Juiz De Fora, MG, Brazil Francisco Veronese - UFRGS - Porto Alegre, RG, Brazil Saraladevi Naicker - University of the Witwatersrand - Johannesburg, Georgi Abraham - University Sri Ramachandra - Chennai, TN, India ZA, South Africa Guillermo Garcia Garcia - University of Guadalajara Health Sciences Sergio Mezzano - Faculdade de Medicina Va - Valdivia, Chile Center - Guadalajara, Jalisco, Mexico Steve Ash - Nercy Medical Center - Des Moines - Lafayette, CA, USA Helady Sanders Pinheiro - UFJF - Juiz de Fora, MG, Brazil Vanda Jorgetti - USP - São Paulo, SP, Brazil Jochen Raimann - Renal Research Institute - New York, NY, USA Vinicius Daher A. Delfino - UEL - Londrina, PR, Brazil Joel Kopple - Roanld Reagan University of California - Los Angeles, Vivekanand Jha - University de Oxford - Chandigarh, Punjabe, India CA, USA William Couser - University of Washington in Seattle - Seattle, USA Jorge Paulo Strogoff De Mattos - UFF - Niterói, Rj, Brazil Wolfgang Winkelmeyer - Baylor College of Medicina Houston - Jose Pacheco M. Ribeiro Neto - Instituto Materno Infantil Prof. Houston, TX, USA Fernando Figueira - Recife, PE, Brazil Yusuke Tsukamoto - Laboratory of computational Astrophysics - Joseph Bonventre - Hospital Brighan - Boston, MA, USA Riken - Tokio, Japan Juan Fernandez Cean - Centromed - Montevideo, Uruguay Yvoty Alves Sens - Santa Casa - São Paulo, SP, Brazil Lucila Maria Valente - UFPE - Recife, PE, Brazil Ziad Massy - UniParis Ouset University (UVSQ) - Amiens, France
VII Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):VI-VII Editorial | Editorial
The Brazilian Society of Nephrology and the Covid-19 Pandemic A Sociedade Brasileira de Nefrologia e a pandemia pela Covid-19
Authors Covid-19, a disease caused by the new patients, who may need dialysis. Another Andrea Pio de Abreu1,2,3 betacoronavirus, called SARS-CoV-2, implication is that a large number of 1,2 Miguel Carlos Riella was first reported in China In December nephrological patients are part of the risk 1,4 Marcelo Mazza do Nascimento of 20191. On January 30, 2020, the group for complications from the disease. World Health Organization (WHO) In addition, there are implications con- 1Sociedade Brasileira de Nefrologia, São Paulo, SP, Brazil. declared that the Covid-19 epidemic cerning the dialysis treatment of patients 2Brazilian Journal of Nephrology, constituted a Public Health Emergency undergoing chronic dialysis. Such treat- São Paulo, SP, Brazil. 2 3Universidade de São Paulo, São of International Importance (ESPII) . On ment must continue during the pandemic Paulo, SP, Brazil. February 3, 2020, the Brazilian Ministry period, with care and procedures to be 4Universidade Federal do Paraná, of Health (MS) declared a Public Health adopted by patients, healthcare profes- Curitiba, PR, Brazil. Emergency of National reach3. There had sionals, dialysis center managers and been no cases reported in the country healthcare authorities. by then, but this happened on February Faced with this new world scenario, 26, 2020, with confirmation of the first the Brazilian Society of Nephrology imported case, coming from Italy4. On (SBN) acted promptly, outlining a plan March 11, 2020, the day before World of recommendations with the support Kidney Day, the WHO declared it to be of its various departments and commit- a pandemic. A few days later, on March tees, to help nephrologists and health- 20, the Brazilian Ministry of Health care authorities to cope with the vari- recognized its community transmission ous clinical situations resulting from this throughout the national territory5. new disease. Our first recommendation, There are reports that the infection concerning the care of patients on dial- affects age groups with variable severity ysis, was published on March 1, 2020, spectrum. Most patients who get more preceding the WHO’s statement that severely ill, have pre-existing diseases, Covid-19 was a pandemic. Since this is or are elderly. Approximately 80% of a new virus in Brazil and in the world, the cases are asymptomatic or have mild the recommendations went hand-in-hand flu-like symptoms6. About 20% of the with the evolution of knowledge about cases have worse outcomes, progressing the disease, and followed the recom- to severe pneumonia, requiring hospital- mendations and determinations of the ization. Of these, 5% are critical, evolv- Federal Board of Medicine (CFM) and ing with Acute Respiratory Discomfort the Ministry of Health (MS). Moreover, Syndrome, having the need for the SBN brought together other special- intensive care7. ist associations, to make the documents Covid-19 has several and important more scientifically robust. In this sense, implications from a nephrological point we published thirteen recommendations of view. First, is the kidney involvement, and opinions involving the various areas with hematuria and proteinuria; and may of nephrologists’ activities. Correspondence to: progress to acute renal failure (ARF), The greatest concern during the first Andrea Pio de Abreu E-mail: [email protected] which occurs mainly in critically ill cases reported in our country, was about
DOI: 10.1590/2175-8239-JBN-2020-S101
1 SBN and COVID-19
Covid-19`s behavior within hemodialysis (HD) units, to nephrological patients, as well as to the team since social isolation could not be applicable to such of professionals involved in different areas of population, extremely susceptible to complications nephrology. Since the beginning of the pandemic, of the disease. Thus, the SBN Dialysis Department wearing protection masks has been the subject of drew up an “SBN good practices recommendations intense debate in the scientific and lay communi- to dialysis units regarding the epidemic of the new ties. Information note No. 3/2020-CGGAP/DESF/ Coronavirus (COVID-19)” listing the main measures SAPS/MS, in which the MS recommends the use to prevent the spread of the virus and, with that, pro- of a cloth mask by the entire population outside vide greater safety to patients and professionals within the home, was also the object of a statement by these units. Another recommendation that addressed our entity through the “SBN Recommendations specific aspects of HD was “Maintenance of vascular regarding the use of cloth masks by chronic renal access during the COVID 19 pandemic”, prepared patients on dialysis, during the pandemic of the by the SBN Interventional Nephrology Committee. new coronavirus (COVID-19)”. We developed such In this document, the committee proposes actions recommendations with the help of members of the regarding the need to establish new vascular accesses, Brazilian Society of Infectious Diseases (SBI), add- managing their dysfunction, and intervention proce- ing greater scientific support to this topic, which dures that can be considered of emergency or elective has dominated the media and the general public during the pandemic. opinion. It is noteworthy that this recommendation Still in relation to chronic dialysis, the Peritoneal establishes the need for healthcare professionals Dialysis Committee issued the “SBN Good Practices and patients with suspicion or confirmation of the Recommendations to Peritoneal Dialysis Services disease to wear surgical masks. in Relation to the New Coronavirus (COVID-19) Concerning the clinical management of nephro- Epidemic”, which guides the treatment for this logical patients in the face of this pandemic, we also group of patients, both with regards to medical and created recommendations involving several areas nursing care during home treatment, as well as care of the specialty. There are important guidelines in face-to-face visits. Within these recommendation, for these patients, described in the “Information telemedicine (tele-guidance, telemonitoring, and for patients with Chronic Kidney Disease (CKD), tele-consultation) is an important tool, after a let- about the COVID-19 infection”, contextualized ter issued by the CFM (CFM Letter No. 1756/2020) in clinical nephrology, regarding prevention and recognizing the possibility of such practice, given the treatment, including the use of immunosuppres- pandemic`s context. sants. In the “Guidance protocol for colleagues who Since the beginning of the pandemic, the running treat patients with rare kidney diseases due to the and interpreting tests within the hemodialysis units SARS COV2 epidemic (Severe Acute Respiratory have been, and continue to be, an important con- Syndrome, Coronavirus - 2)”, there are general rec- cern of nephrologists. The “SBN Recommendations ommendations for patients and nephrologists con- for approaching Covid-19 diagnostic tests in hemo- cerning the management of clinically stable patients dialysis units”, instructs on laboratory tests for and immunosuppressive treatment when necessary, Covid-19, the clinical criteria for decision making among other guidelines. Where clinical management in the discontinuation of patient isolation, and for is concerned, readers will also find recommenda- healthcare professionals and collaborators with sus- tions concerning “Palliative care and the Covid-19 picion or confirmation of the disease to return to pandemic” addressing important concepts related to their practices. We developed practical flowcharts shared decision-making (staff, patient and family), to assist in dialysis routines so that these exams the priority management of symptoms, and assis- could be interpreted in a practical and objective way tance with bereavement. within the units. This supplement also includes how to approach As far as prevention is concerned, many of pediatric nephrology patients, through the the recommendations include important aspects Department of Pediatric Nephrology, which created related to the virus contagion aspects, adapting the the “Recommendations for pediatric patients on MS recommendations to the general population, hemodialysis, peritoneal dialysis and kidney transplant
2 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):1-3 SBN and COVID-19 in the Covid-19 (SARS-CoV-2) pandemic”, and the patients”. It is a robust document prepared together “SBN Recommendations for Pediatric Patients on with the Brazilian Association of Intensive Care Dialysis during the COVID-19 Pandemic”. It also Medicine (AMIB), on recommendations regarding the encompasses guidelines concerning the management diagnosis of ARF, vascular access, as well as the appli- of children on dialysis, before and after kidney trans- cable modalities for renal replacement therapy at the plantation, as well as those on peritoneal dialysis. It bedside, customized to the reality of each location. also includes instructions for healthcare profession- We wish to thank all SBN departments and com- als, clinics and transplant centers, in addition to a mittees for their hard work in formulating these rec- proposed flow chart model for dialysis centers. ommendations and statements that now materialized In addition to the aforementioned recommen- in the form of papers in this special supplement of dations, SBN issued statements at two different our Brazilian Journal of Medicine, always maintain- times concerning the prescription of specific drugs. ing that this work does not end here, being in fact the In the first case, the SBN Department of Arterial beginning of a continuous effort to improve these rec- Hypertension expressed its opinion on “The use ommendations, which should be periodically updated of ARS Blockers, especially angiotensin-convert- due to the speed of publications, and the unveiling of ing enzyme (ACE) inhibitors and All AT1 recep- Covid-19 pathophysiological mechanisms. This sup- tor antagonists, during the COVID-19 Infection plement is an example of SBN’s effort, which mirrors Pandemic”. Such a statement was necessary, in view that of the entire national and international scientific of the broad discussion by the scientific community community, in tackling this pandemic, which we have as to the possible association of these drugs with the to overcome. greater risk of serious infection by Covid-19. In view We wish you a good read. of due scientific support, and in line with several national and international opinions, they recom- References mend the continuous use of these classes of drugs, 1. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, even in individuals suspected or infected by Covid- 2019. N Engl J Med. 2020 Feb;382:727-33. doi:10.1056/NEJ- 19, except in cases of hypotension. Moa2001017 2. Sohrabi C, Alsafi Z, O’Neill N, Khan M, Kerwan A, Al-Jabir A, In the second case, due to the approval of Opinion et al. World Health Organization declares global emergency: a No. 04/2020 by the CFM, establishing criteria review of the 2019 novel coronavirus (COVID-19). Int J Surg. 2020 Apr;76:71-76. doi: 10.1016/j.ijsu.2020.02.034. and conditions for the prescription of chloroquine 3. Brasil. Ministério da Saúde. Portaria MS/GM nº 188, de 3 de and hydroxychloroquine in patients with a con- fevereiro de 2020. Declara Emergência em Saúde Pública de importância Nacional (ESPIN) em decorrência da Infecção firmed diagnosis of Covid-19, we issued the “SBN Humana pelo novo Coronavírus (2019-nCoV) [Internet]. Diá- Note Concerning the Adjustment of Chloroquine rio Oficial da União, Brasília (DF), 2020 fev; Seção Extra: 1. and Hydroxychloroquine Drug Doses by Renal Disponível em: http://www.in.gov.br/en/web/dou/-/portaria- -n-188-de-3-de-fevereiro-de-2020-241408388. Function”, to educate on the necessary dose adjust- 4. Oliveira WK, Duarte E, França GVA, Garcia LP. How Brazil can hold ment for patients with chronic kidney disease, stress- back COVID-19. Epidemiol Serv Saude. 2020;29(2):e2020044. doi:10.5123/s1679-49742020000200023. ing the lack of studies, so far, that provide scientific 5. Ministério da Saúde (BR). Ministério da Saúde declara trans- support for the use of these drugs in the treatment missão comunitária nacional [Internet]. Brasília: Ministério da Saúde; 2020. Disponível em: https://www.saude.gov.br/ of Covid-19. noticias/%20agencia-saude/46568-ministerio-da-saude-decla- The Covid-19 pandemic impact on intensive care ratransmissao-comunitaria-nacional 6. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. units in our country is being very intense. Critical Clinical characteristics of coronavirus disease 2019 in China. patients developing ARF is an increasingly frequent N Engl J Med. 2020. Disponível em: https://doi.org/10.1056/ NEJMoa2002032. complication, involving diagnostic and therapeu- 7. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course tic aspects, which were reasons for the SBN ARF and risk factors for mortality of adult in patients with COVID- 19 in Wuhan, China: a retrospective cohort study. Lancet. Department to publish this: “Technical Note and 2020 Mar 28;395(10229):1054-1062. doi: 10.1016/S0140- Guidelines on Renal Injury Acute (ARI) in COVID-19 6736(20)30566-3.
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):1-3 3 Recommendations | Recomendações
Recommendations from the Brazilian Society of Nephrology for approaching Covid-19 Diagnostic Testing in Dialysis Units Recomendações da Sociedade Brasileira de Nefrologia para abordagem de exames diagnósticos da Covid-19 nas unidades de diálise
Authors Abstract Resumo José A. Moura-Neto1,2 Lilian M. P. Palma1,3 The Covid-19 pandemic brought sev- A pandemia da Covid-19 trouxe desafios ao Gabriel F. Marchiori4,5 eral challenges to the healthcare system: sistema de saúde em diversas esferas: diag- Raquel S. B. Stucchi3 diagnosis, treatment and measures to nóstico, tratamento e medidas para evitar Ana Maria Misael1 prevent the spread of the disease. With a disseminação da doença. Com a maior Ronaldo D’Avila1,6 the greater availability and variety of di- disponibilização e variedades de testes diag- agnostic tests, it is essential to properly nósticos, torna-se fundamental sua ade- Dirceu Reis da Silva1,7 interpret them. This paper intends to quada interpretação. Este posicionamento Maria Claudia Cruz Andreoli1,8 help dialysis units concerning the use of pretende orientar unidades de diálise em Angiolina Kraychete1 clinical criteria and diagnostic tests for relação ao uso de critérios clínicos e testes Kleyton Bastos1,9 decision making regarding the discon- diagnósticos para a tomada de decisão re- Marcelo Mazza do Nascimento1,10 tinuation of isolation of patients with ferente à descontinuação do isolamento de suspected or confirmed Covid-19, as pacientes com suspeita ou confirmação de 1 Sociedade Brasileira de well as the return to work activities for Covid-19, assim como para o retorno às Nefrologia, São Paulo, SP, Brazil 2Grupo CSB, Salvador, BA, Brazil. employees with suspected or confirmed atividades laborais de colaboradores com 3Universidade Estadual de Covid-19. suspeita ou confirmação de Covid-19. Campinas, Campinas, São Paulo, SP, Brazil. Keywords: Covid-19; Coronavirus infec- Palavras-chave: Covid-19; Infecções por 4Sociedade Brasileira de Patologia tions; Diagnosis; Hemodialysis Hospital Coronavirus; Diagnóstico; Unidades Hos- Clínica, São Paulo, SP, Brazil. Units; Renal Dialysis; Healthcare Person- pitalares de Hemodiálise; Diálise Renal; 5Laboratório Franceschi, nel; Pandemics. Pessoal de Saúde; Pandemias. Campinas, São Paulo, SP, Brazil. 6Pontifícia Universidade Católica de São Paulo, Faculdade de Medicina, Sorocaba, SP, Brazil. 7Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil. Introduction example, the availability and financial 8 Hospital do Rim, Fundação support to carry out laboratory tests for Oswaldo Ramos, Universidade This document intends to help dialy- COVID-19, and to define the flow of col- Federal de São Paulo, São Paulo, sis units regarding the use of labora- SP, Brazil. lection from regional laboratories. Still, 9Universidade Federal de Sergipe, tory tests for COVID-19, and the use of decision-making must be individualized. São Cristóvão, SE, Brazil. clinical criteria as tools to aid decision 10Universidade Federal do Paraná, Finally, we emphasize the lack of Curitiba, PR, Brazil. making regarding: 1) ending the isola- tion of patients with suspected or con- well-established data on virus behavior, firmed COVID -19 and 2) return to the the natural history of the disease and test activities of healthcare professionals and availability. Changes to this document employees with suspected or confirmed may be necessary due to new information COVID-19. and evidence that may crop up. These technical recommendations, mostly adapted from the guidelines 1. COVID-19 Testing Considerations of the Center for Disease Control and Today, we have two types of tests to diag- Prevention (CDC - United States of nose COVID-19: RT-PCR and serology, 1 Correspondence to: America) , must be adapted for our which are available in the usual modes, José A. Moura-Neto local context and reality, and depend on such as ELISA, Chemiluminescence and E-mail: [email protected] the support of public managers, as for Immunochromatography, with antigen DOI: 10.1590/2175-8239-JBN-2020-S102
4 Diagnostic tests for Covid-19 and immunoglobulin dosage, in the most diverse analytical sensitivity (detection threshold) and analyt- combinations (Antigens, Total Antibodies, ical specificity (less interference from other substances Immunoglobulins A, M and G)2. or antigens)3. The gold standard test in the acute phase for Ten days after the condition onset, immuno- active infection still is RT-PCR (reverse transcrip- globulin sensitivity (IgA, IgM and IgG) increases tion polymerase chain reaction)3, which consists progressively, reaching between 79.8% to 94.3%,4,5 of a qualitative or quantitative assessment of viral depending on the antibody evaluated, close to 14 days RNA, collected from two different sites. However, after symptoms onset. The tests do not have a high its methodology and complex validation phase make Negative Predictive Value; thus, it should not be used it difficult to carry out this type of test en masse2. to help decide if a person should return to work, end Given their low cost, serological tests have a of isolation and other measures of this nature2. good diagnosis rate in the late phase, in view of the available methodologies, and wide distribution in 2. End of isolation of patients with suspected or laboratories (public and private). The essential fac- confirmed COVID-19 in dialysis units tor is the time between symptoms onset/contact with After clinical suspicion or laboratory confirmation, a person with a confirmed diagnosis and the test ideally the patient should undergo dialysis in an isola- being performed2. tion room, following the measures recommended in Regardless of antibodies showing up in the indi- the “SBN good practices recommendations to dialysis vidual, the ability to measure these antibodies by lab- units regarding the epidemic of the new Coronavirus oratory methods depends on a series of test character- (COVID-19)”, described in the flowchart below istics, which make up the test performance, such as (Figure 1)6,7.
Figure 1. Flowchart for the evaluation and management of patients suspected of having COVID-19 in dialysis units.
Before going to the clinic: Patient arrives for dialysis f s to atic re ort efore co ing Ask upon arrival: to t e session ever Co g es irator distress ore t roat Place disposable mask on the patient and take him her to isolation Undergo dialysis in as ands the regular shift ait c inica assess ent void nnecessar contact no es Disinfect t e roo after C ean ands t e atient eaves Co g snee ing rotection rovide ta e and erc iefs efer to igns of t of es e ergenc severit reat Dro in no sat ration
A PATI NTS - void agg o erations and Dialyze in isolation (last shift) nnecessar trave s to atient it as 1 eter no re se disinfection as t e os ita er g ides tea it - e tea if t ere are s to s efore co ing to t e session PP staff with direct contact: - aniti e ands ear dis osa e go n PP staff without direct contact: it s rgica as eg ar ite coat 9 if roced res generate aeroso s rgica as and saniti ing Consider supplementary shift 1 distance if multiple cases rotection gogg es g oves ca nc ding c eaning tea
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):4-8 5 Diagnostic tests for Covid-19
The flowchart below helps on criteria for discon- with a disposable apron for the healthcare profes- tinuing the isolation and other precautions against sional in direct contact6 and 4) the minimum distance COVID-19 transmission in the dialysis unit, insti- of 1 meter8. However, we consider it prudent in case tuted during suspected (Figure 2) or confirmed cases the patient is removed from isolation before the end (Figure 3), such as, 1) patient wearing a surgical of 14 days, to keep wearing a surgical mask until mask6, 2) not reuse of lines and dialyzers6, 3) dressing 14 days after the onset of symptoms9.
Figure 2. Flowchart with criteria for removing patients with suspected COVID-19 from isolation.
Adapted from CDC, 2 2 atient s s ected of C D-19 in iso ation and it reca tion eas res to avoid trans ission
Criteria to s s end iso ation
C inica criteria a oratoria criteria
o rs it o t fever no anti retic C D-19 test - C after t e to reso tion t ird da or sero og after t e ini of da s of s to onset sevent da
e s o egative ositive
Consider re eating t e test if ig c inica s s icion
Consider Co ete Consider Co ete s s ending 1 da s of s s ending 1 da s of iso ation iso ation iso ation iso ation
Consider earing s rgica as nti co eting 1 da s
The flowchart defines two strategies: one that con- temporarily removed from work. Their return to siders exclusively clinical criteria, and another which is activities will depend on laboratory diagnostic a laboratory strategy, based on COVID-19 testing. All confirmation and/or clinical evolution (symptoms criteria must be met according to the strategy adopted. improvement and fever resolution). The flowchart The laboratory strategy should be preferable in hospi- presented below guides these decisions (Figure 4), talized and severely immunodepressed patients1. also defining two strategies: one that considers It should be emphasized that decision-making exclusively clinical criteria and another laboratory must be individualized, considering the context, local strategy, based on testing for COVID-19. Again, particularities and clinical perception, sometimes sub- it is important to stress that the approach must jective, of the patient. be individualized, and consider the context and local particularities, as well as the epidemiological 3. Recommendations for healthcare professionals moment of the pandemic9. and staff with suspected or confirmed COVID-19 This strategy based on clinical criteria can be in dialysis units to return to their activities used in cases with mild symptoms, low suspicion Dialysis staff suspected of having COVID-19, of COVID-19 or if the laboratory test (serology or regardless of symptom severity, should be RT-PCR) is not available1.
6 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):4-8 Diagnostic tests for Covid-19
Figure 3. Flowchart with criteria for removing from isolation those patients with confirmed COVID-19
Adapted from CDC, 2 2 Patient with COVID-19 (confirmed) in isolation and with precaution measures to avoid transmission
Criteria to suspend isolation
Clinical criteria Laboratorial criteria
• 72 hours without fever (no antipyretic) • Fever resolution (without medication) • Symptom resolution • Symptom resolution • Minimum of 7 days of symptom onset • Two consecutive negative RT-PCR results (interval longer than 24 hours) from nasopharynx swab
Ye s No
Negative Positive
Considerar repetir teste se alta suspeição clínica Consider Complete suspending 14 days of isolation isolation Consider Complete suspending 14 days of Consider wearing surgical mask isolation isolation until completing 14 days
Figure 4. Flowchart with criteria for employees of Dialysis Units with suspicion or confirmation of COVID-19 to return to work.
Employee with confirmed Employee with suspected COVID-19 COVID-19 Initial leave of 7 days
Clinical criteria Laboratorial criteria
• 72 hours without fever (no antipyretic) • COVID-19 test (RT-PCR after • Symptom resolution the third day or serology after the • Minimum of 7 days of symptom onset seventh day)
Ye s No Negative Positive
14 days Consider Complete Consider Complete on leave return 14 days return 14 days to work of leave to work of leave
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):4-8 7 Diagnostic tests for Covid-19
References 6. Sociedade Brasileira de Nefrologia (SBN). Recomendações de boas práticas da Sociedade Brasileira de Nefrologia às 1. Centers for Disease and Control Prevention. Discontinuation unidades de diálise em relação à pandemia do novo coro- of Transmission-Based Precautions and Disposition of Patients navírus (Covid-19). Braz. J. Nephrol. (J. Bras. Nefrol), with Covid-19 in Healthcare Settings (Interim Guidance). In press. https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition- 7. Sociedade Brasileira de Nefrologia (SBN). Recomendações da -hospitalized-patients.html. Sociedade Brasileira de Nefrologia para pacientes pediátri- 2. Sociedade Brasileira de Patologia Clínica. Métodos Laboratoriais cos em terapia de substituição renal durante a pandemia de para Diagnóstico da Infecção pelo SARS-CoV-2. Recomendações Covid-19. Braz. J. Nephrol. (J. Bras. Nefrol), In press. da Sociedade Brasileira de Patologia Clínica/Medicina Laborato- 8. Agência Nacional de Vigilância Sanitária (BR). Nota Téc- rial. 2020. http://www.sbpc.org.br/wp-content/uploads/2020/04/ nica GVIMS/GGTES/ANVISA Nº 04/2020. Orientações MetodosLaboratoriaisDiagnosticoSARS-CoV-2.pdf. para Serviços de Saúde: Medidas de Prevenção e Controle 3. World Health Organization. (2020). Laboratory testing of que Devem Ser Adotadas durante a Assistência aos Casos 2019 novel coronavirus (2019-nCoV) in suspected human Suspeitos ou Confirmados de Infecção pelo Novo Coro- cases: interim guidance, 17 January 2020. World Health Orga- navírus (SARS-Cov-2). 2020. http://portal.anvisa.gov.br/ nization. https://apps.who.int/iris/handle/10665/330676. documents/33852/271858/Nota+T%C3%A9cnica+n+04- 4. Xiao SY, Wu Y, Liu H. Evolving status of the 2019 novel coro- -2020+GVIMS-GGTES-ANVISA/ab598660-3de4-4f14-8e6f- navirus infection: Proposal of conventional serologic assays for b9341c196b28 disease diagnosis and infection monitoring. J Med Virol. 2020 9. Hassel Dias VMC, Cunha CA, Vidal CFL, Corradi MFB, May;92(5):464-467. doi: 10.1002/jmv.25702. Epub 2020 Feb 17. Michelin L, Muglia V et al. Orientações sobre diagnóstico, 5. Guo L, Ren L, Yang S, Xiao M, Chang D, Yang F, et al. Pro- tratamento e isolamento de pacientes com COVID-19. Jour- filing Early Humoral Response to Diagnose Novel Coronavi- nal of Infection Control 2020; 9(2): 56-75. Disponível em: rus Disease (Covid-19). Clin Infect Dis. 2020 Mar 21:ciaa310. http://jicabih.com.br/index.php/jic/article/view/295. doi: 10.1093/cid/ciaa310.
8 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):4-8 Recommendations | Recomendações Recommendations from the Brazilian Society of Nephrology regarding the use of cloth face coverings, by chronic kidney patients in dialysis, during the new coronavirus pandemic (Covid-19) Recomendações da Sociedade Brasileira de Nefrologia quanto ao uso de máscaras de pano por pacientes renais crônicos em diálise, durante a pandemia pelo novo coronavírus (Covid-19)
Authors Abstract Resumo Andrea Pio de Abreu1 José Andrade Moura Neto2 These recommendations were created As presentes recomendações foram elaboradas Vinicius Daher Alvares Delfino3 after the publication of informative após a publicação da Nota Informativa Lilian Monteiro Pereira Palma4 note 3/2020- CGGAP/DESF/SAPS/MS, nº 3/2020 CGGAP/DESF/SAPS/MS, em 4 de Marcelo Mazza do Nascimento5 of April 4, 2020, in which the Brazilian abril de 2020, na qual o Ministério da Saúde Ministry of Health recommended the recomenda o uso de máscara de pano por toda
1Universidade de São Paulo, use of a cloth mask by the population, a população, em locais públicos. Levando-se São Paulo, SP, Brazil. in public places. Taking into account the em consideração a necessária priorização do 2Grupo CSB, Salvador, BA, Brazil. necessary prioritization of the provision fornecimento de Equipamentos de Proteção 3Universidade Estadual de of Personal Protective Equipment (PPE) Individual (EPIs) para pacientes com suspeita Londrina, Londrina, PR, Brazil. for patients with suspected or confirmed ou confirmação da doença, assim como 4Universidade Estadual de Campinas, Campinas, SP, Brazil. disease, as well as for healthcare para profissionais de saúde, a Sociedade 5Universidade Federal do Paraná, professionals, the SBN is favorable Brasileira de Nefrologia (SBN) posicionou-se Curitiba, PR, Brazil. concerning the wear of cloth masks by favoravelmente ao uso de máscaras de pano chronic kidney patients in dialysis, in por pacientes renais crônicos em diálise, em public settings, except in the dialysis ambientes públicos, exceto no ambiente da setting. The present recommendations diálise. As presentes recomendações englobam have eleven items, related to this onze itens relativos ao que é racional para rationale, the procedures, indications, posicionamento, procedimentos, indicações, contraindications, as well as appropriate contraindicações, assim como tecidos fabrics for the mask, and hygiene care apropriados para confecção e os cuidados de to be adopted. These recommendations higiene a serem adotados. Essas recomendações may change, at any time, in the light of poderão ser modificadas a qualquer momento, new evidence. à luz de novas evidências. Keywords: Cloth Mask; Protection; Palavras-chave: Máscara de Pano; Proteção; Severe Acute Respiratory Syndrome, Síndrome Respiratória Aguda Grave; Coronavirus infection; Covid-19. Coronavirus Infections; Covid-19.
Recommendations for chronic kidney 2. The cloth mask can prevent the spread patients wearing masks during the of droplets expelled from the nose or pandemic mouth of people in the environment, act- 1. Considering the scarcity of Personal ing as a mechanical barrier, thus reducing Protective Equipment (PPE), the SBN spread of the disease by asymptomatic or recommends that all asymptomatic pre-symptomatic infected people, who chronic renal patients, as well as the gen- can transmit the virus, especially in places eral population, should wear protection of community transmission, and where masks, based on recommendations from measures of social distance are difficult to Correspondence to: the Ministry of Health (MH), through follow. Nonetheless, these masks do not Andrea Pio de Abreu E-mail: [email protected] Informative Note 3/2020-CGGAP/DESF/ protect healthy individuals from contract- DOI: 10.1590/2175-8239-JBN-2020-S103 SAPS/MS1. ing the virus1,2.
9 Use of cloth face coverings, by chronic kidney patients in dialysis
3. We recommend that all chronic kidney patients on 8.2 The use of the mask is for one individual only, so dialysis wear a cloth mask when going out for essential the patient should not share it, even if it is sanitized. activities and during transportation to the dialysis clinic. The use of the mask aims to reduce the spread of the 8.3 Upon leaving the dialysis clinic, the patient virus by asymptomatic patients in these environments. must be able to put on the mask without assistance. Healthcare professionals should not assist the patients 4. Patients with Covid-19 infection suspicion or con- in this, due to the risk of contamination. firmation should wear a surgical mask, as well as adopt other precautionary measures already described 8.4 When arriving at the clinic, the used mask must be in the SBN Good Practice Recommendations3. removed and packed in a plastic bag exclusively for that purpose, and should not be kept in the same compart- 5. Even though there is a shortage of PPE, there is no ment (bag, backpack) as the plastic bag that houses the evidence to support the recommendation for the use of clean mask that will be used on the return home. cloth masks within dialysis centers. There is a possibil- ity of contamination at the site, favoring the spread of 8.5 When arriving home, the patient must clean the the virus; concurrently, we know understood that rec- masks according to the guidelines contained in the ommending the use of surgical masks by all asymptom- MH technical note: immerse the mask in a container atic patients while on dialysis may worsen the current with drinking water and bleach (2.0 to 2.5%) for situation of PPE scarcity. Healthcare professionals, 30 minutes. The dilution ratio is 1 part of bleach to employees and patients with suspected or confirmed 50 parts of water (for instance: 10 ml of bleach to infection must have priority on having masks. This rec- 500 ml of drinking water). After the immersion time, ommendation may change, depending on the effective rinse the mask under running water and wash it with supply of these materials in the country. soap and water. After washing the mask, wash your hands with soap and water. The mask must be dry for 6. The fabrics recommended for making a mask are, reuse. After drying the mask, iron it with a hot iron in decreasing order of their ability to filter viral par- and put it in a plastic bag1. ticles: a) vacuum cleaner bag fabrics; b) cotton (com- posed of 55% polyester and 45% cotton); c) cotton 9. It is important to maintain the other preventive mea- fabric (such as 100% cotton T-shirts); and d) pillow- sures already recommended, such as social distance cases of antimicrobial tissue1. on days when hemodialysis is not performed, avoid touching the eyes, nose and mouth, in addition to hand 7. According to guidelines from the MH, some pre- hygiene with water and soap or 70% alcohol gel.1,3 cautions need to be taken regarding the use of the fabric masks. The instructions for making them and 10. Cloth masks should not be worn by people who hygiene measures are included in the technical note have difficulty breathing, are unconscious and unable from the MH, available at:
8. Hereby, we stress some recommendations provided 11. These recommendations may change at any time, by the MH link (item 6) regarding the use of cloth in the light of new evidence. In this sense, one should masks: look for possible updates.
8.1 The mask should be changed whenever there is Acknowledgement dirt or moisture. Chronic kidney patients on hemodi- alysis should calculate the number of masks required, Infectologists and members of the Brazilian Society of depending on the time spent traveling to the clinic, Infectious Diseases José David Urbaéz Brito and Ana and the return home. It is estimated that each mask Verena Almeida Mendes collaborated in the review of can be used for a period of two hours. this recommendation.
10 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):9-11 Use of cloth face coverings, by chronic kidney patients in dialysis
References of Significant Community-Based Transmission. https://www. epistemonikos.org/documents/944b40b571b549b656f76f9e8f 1. Ministério da Saúde (BR). NOTA INFORMATIVA Nº 3/2020- 6ad1e083cc0430# CGGAP/DESF/SAPS/MS. https://www.saude.gov.br/images/ 3. Sociedade Brasileira de Nefrologia (SBN). Recomendações de pdf/2020/April/04/1586014047102-Nota-Informativa.pdf. boas práticas da Sociedade Brasileira de Nefrologia às uni- 2. Center for Disease Control and Prevention. Recommendation dades de diálise em relação à pandemia do novo coronavírus Regarding the Use of Cloth Face Coverings, Especially in Areas (Covid-19). Braz. J. Nephrol. (J. Bras. Nefrol), In press.
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):9-11 11 Recommendations | Recomendações
Covid-19 (Sars-Cov-2 Infection) Information for Patients with Predialytic Chronic Kidney Disease Informações para pacientes com doença renal crônica pré-dialítica sobre Covid-19 (infecção pelo SARS-CoV-2)
Authors Abstract Resumo Vinicius Daher Alvares Delfino1 Marcelo Mazza do Nascimento2 Patients with Chronic Kidney Disease Pacientes com Doença Renal Crônica estão Jose de Rezende Barros Neto3 are among those individuals at increased entre os indivíduos de risco aumentado risk for developing more serious forms para desenvolvimento de formas mais 1Universidade Estadual de of Covid-19. This increased risk starts sérias de Covid-19. Esse risco aumentado Londrina, Londrina, PR, Brasil. in the pre-dialysis phase of the disease. inicia-se já na fase pré-dialítica da doença. 2Universidade Federal do Paraná, Providing useful information for these Fornecer informações úteis para esses Curitiba, PR, Brasil. patients, in language that facilitates pacientes, em linguagem que facilite o 3 NefroClínicas, Belo Horizonte, the understanding of the disease, can entendimento da doença, pode ajudar MG, Brasil. help nephrologists and other healthcare nefrologistas e outros profissionais de professionals to establish a more saúde a estabelecerem uma comunicação effective communication with these mais efetiva com esses pacientes e ajudar patients and help minimize contagion a minimizar o contágio e os riscos de and the risks of serious illness in this doença grave nessa população. population. Palavras-chave: Insuficiência Renal Crônica; Keywords: Chronic Kidney Failure; Pré-diálise; Infecções por Coronavirus; Pre-dialysis; Covid-19. Covid-19.
Some individuals are more likely to international nephrology societies, the develop a more serious COVID-19 infec- opinions of experts in the field, and sci- tion. This group includes elderly patients, entific papers on prevention, severity rec- patients with major chronic diseases such ognition and action plan for the suspected as diabetes mellitus, systemic arterial possible Covid-19.1-8 hypertension, lung disease, heart disease • The coronavirus that is causing this and patients with chronic kidney disease pandemic is the SARS-Cov2 and the (CKD). For a complete view of risk con- disease it causes is the Covid-19; ditions, we advise the reader to look for • The vast majority of people with them in the reference 1. Covid-19 have a mild form of the Although the impact of COVID-19 disease, but the disease can be infection on patients with CKD has not serious and affect several organs, yet been widely studied, innate and adap- especially the lungs, and cause tive immunity is reduced in people from serious complications, including, in stage 3 CKD onwards and is further some cases, death; reduced as the disease progresses.1.2 • There is still no vaccine available The following information was writ- for Covid-19 prevention; therefore, ten in colloquial language for better prevention is the main weapon to understanding of the disease by patients be used; Correspondence to: Vinicius Daher Alvares Delfino with CKD who are not on dialysis or are • The disease is transmitted mainly E-mail [email protected] not kidney transplanted. They represent by air or by personal contact with DOI: 10.1590/2175-8239-JBN-2020-S104 a compilation of recommendations from contaminated secretions such as
12 Information for Patients with Predialytic Chronic Kidney Disease
droplets of saliva, sneezing, coughing and • Stay at home as long as you can; as much as phlegm; close personal contact such as touching possible, you need to feel alive and calm: try to or shaking hands; contact with contaminated keep in touch with other people through social objects or surfaces, followed by contact with networks, listen to music, read good books, the mouth, nose or eyes. watch TV (stay informed about the disease in • Therefore, pay attention to some daily precau- your region, but avoid getting flooded by daily tions: avoid contact with sick people, avoid information about Covid-19), develop some shaking hands, “kisses” and hugs; keep a dis- kind of leisure and if you can, move around fre- tance of at least two meters when talking or in quently; if you really have to go out, use masks contact with someone (remember that people that cover your nose and mouth well (cloth who are infected with the virus, even if they masks can be used in these cases); have no symptoms can transmit the infection • Eat well, but reduce the amount of salt in your to you); diet; if your nephrologist or nutritionist has • Wash your hands with soap and water frequen- told you that you need to reduce your intake of tly, for at least 20 seconds (remember that you foods rich in potassium, phosphorus or fluids, need to wash your fists, between your fingers, follow the guidelines strictly for your safety and and your nails) especially after blowing your to avoid going to healthcare services that will be nose, coughing, sneezing, entering public places overwhelmed with the pandemic; or having touched items such as elevator but- • Do not stop using your usual medications (the tons, door handles, mail, supermarket products ones you should take daily), unless you are or home deliveries; instructed to do this by your doctor. If you • If you don’t have soap and water at any given are using medications that reduce immunity time, clean your hands with products that con- (known as immunosuppressants) for the treat- tain at least 60% alcohol (but remember, if you ment of kidney diseases or autoimmune disea- have a choice, wash your hands with soap and ses, do not stop using these remedies on your water). Strive to dry your hands with paper own. It is generally recommended to keep taking towels or other disposable paper and throw these medications. You should talk to your doc- them in the trash (do not throw in the recycla- tor about this so that he can explain the risks ble trash; this same care must be used in the or the need to withdraw/reduce the dose of the case of used disposable masks); immunosuppressive medications you are using. • Upon arriving home, always leave your shoes It is strongly recommended, and your doctor outside the house; will tell you this, whenever possible, avoid/pos- • Clean and disinfect your home regularly to tpone the use of a medication called Rituximab remove germs, especially surfaces frequently (anti-CD20) at the present time, as this drug used as counters, tables, switches, door handles, can impair the formation of antibodies (against sinks, taps, toilets and cell phones; SARS-Cov-2, for example); • Avoid any non-essential travel and avoid con- • Establish a plan in case you get sick - stay in gregations (even small meetings); touch with others by phone, WhatsApp, email: • Avoid elective surgery. Please note that if your you may need help from friends, family, neigh- nephrologist has indicated that you should have bors, healthcare workers, etc., if you get sick. In dialysis access (arteriovenous fistula or perito- this case, consider a way to get food delivered neal catheter implant), these surgeries are not to your home by your family or food delivery elective, but necessary; networks; • Do not go to Hospitals or other healthcare ser- • Watch out for warning and emergency signs for vices, unless you really need to; if you need a Covid-19: medical consultation, see if in the place where » Warning signs: fever, cough and “shortness of you live provide access to teleconsultation or breath”. In this case, contact your treatment telemedicine, (consultation or guidance via the center or the nearest healthcare center by internet), guidance by phone or WhatsApp; phone to find out what to do in this situation.
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):12-14 13 Information for Patients with Predialytic Chronic Kidney Disease
» Emergency signs: difficulty breathing, persis- disease during the novel coronavirus disease 2019 (COVID-19) epidemic, Chronic Dis Transl Med. 2020 May 13;6(2):119–23. tent pain or pressure in the chest (chest), men- doi: 10.1016/j.cdtm.2020.05.001. tal confusion or purplish lips or face. If you 4. Armsby C et al. Patient education: Coronavirus disease 2019 are feeling unwell, even if there are no signs of (COVID-19) overview (The Basics). Martin KA ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com emergency, you should contact/seek healthcare (Acessado em 25 de maio de 2020.) quickly! Stay tuned for reference hospitals for 5. European Renal Association-European Dialysis and Trans- Covid-19 that are recommended by the heal- plant Association (ERA-EDTA). Covid-19, the novel corona vírus- News and information for the ERA-EDTA community thcare authorities of your city or region. and patients. https://www.era-edta.org/en/covid-19-news-and- -information/#toggle-id-3 (acessado em 25 de março de 2020). 6. National Kidney Foundation (NKF). Be Prepared: kidney References Patient Prep for Coronavirus. https://www.kidney.org/con- 1. Schnake-Mahl AS, Carty MG, Sierra G, Ajayl T. Identifying tents/be-prepared-kidney-patient-prep-coronavirus (acessado Patients with Increased Risk of Severe Covid-19 Complica- em 25 de março de 2020). tions: Building an Actionable Rules-Based Model for Care 7. Kidney Care UK. Coronavirus (Covid-19) guidance for patients Teams. NEJM Catalyst Innovations in Care Delivery 2020. with kidney disease: the latest news and information about DOI: 10.1056/CAT.20.0116, https://catalyst.nejm.org. Covid-19 for kidney patients. https://www.kidneycareuk.org/ 2. Kurts, C, Panzer U, Hans-Joachim Anders H-J, Andrew J. Rees news-and-campaigns/coronavirus-advice/ (acessado em 25 de AJ. The immune system and kidney disease: basic concepts and março de 2020). clinical implications. Nature Rev. Immunol. 2013;13:738-753. 8. Naicker S, Yang CW, Hwang SJ, Liu B-C, Chen J-H, Jha V. The 3. Li J, Shuang-Xi Li S-X, Zhao L-F, Kong D-L, Guo Z-Y. Mana- Novel Coronavirus 2019 epidemic and kidneys. Kidney Int. gement recommendations for patients with chronic kidney 2020;97(5):824-828. doi:10.1016/j.kint.2020.03.001.
14 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):12-14 Recommendations | Recomendações Good Practice Recommendations from the Brazilian Society of Nephrology to Dialysis Units Concerning the Pandemic of the New Coronavirus (Covid-19) Recomendações de boas práticas da Sociedade Brasileira de Nefrologia às unidades de diálise em relação à pandemia do novo coronavírus (Covid-19)
Authors Abstract Resumo José A. Moura-Neto1,2 Andrea Pio de Abreu1,3 Dialysis units are environments potentially Unidades de diálise são ambientes Vinicius Daher Alvares Delfino1,4 prone to the spread of Covid-19. Patients potencialmente propensos à disseminação da Ana Maria Misael1 cannot suspend treatment, and they often Covid-19. Os pacientes não podem suspender Ronaldo D’Avila1,5 have comorbidities, which assigns them o tratamento, e são frequentemente portadores Dirceu Reis da Silva1,6 a higher risk and worse prognosis. The de comorbidades, o que confere maior risco Brazilian Society of Nephrology prepared e pior prognóstico. A Sociedade Brasileira Maria Claudia Cruz Andreoli1,7 this document of good practices, whose de Nefrologia elaborou esse documento de Angiolina Kraychete1 technical recommendations deal with boas práticas, cujas recomendações técnicas Kleyton Bastos1,8 general measures that can be implemented tratam de medidas gerais que podem ser Marcelo Mazza do Nascimento1,9 to reduce the risk of transmission and implementadas para reduzir o risco de prevent the spread of the disease in transmissão e evitar a disseminação da doença 1Sociedade Brasileira de Nefrologia, São Paulo, SP, Brazil. the unit. na unidade. 2Grupo CSB, Salvador, BA, Brazil. Keywords: Covid-19; Coronavirus Palavras-chave: Covid-19; Coronavirus 3Universidade de São Paulo, Faculdade de Medicina, Hospital Infections; Hemodialysis Hospital Units; Infections; Unidades Hospitalares de das Clínicas, São Paulo, SP, Brazil. Renal Dialysis; Pandemics. Hemodiálise; Diálise Renal; Pandemias. 4Universidade Estadual de Londrina, Londrina, PR, Brazil. 5Pontifícia Universidade Católica de São Paulo, Faculdade de Medicina, Sorocaba, SP, Brazil. 6Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil. 7Hospital do Rim, Fundação On March 1, 2020, with the confirma- the disease, when the number of cases Oswaldo Ramos, Universidade tion of the second case of coronavirus increases exponentially and there is no Federal de São Paulo, São Paulo, infection (Covid-19) in the country, the longer the possibility of identifying the SP, Brazil. 8Universidade Federal de Sergipe, Dialysis Department and the Board of the transmitting source. São Cristovão, SE, Brazil. Brazilian Society of Nephrology (SBN) In view of the epidemiological sce- 9Universidade Federal do Paraná, Curitiba, PR, Brazil. prepared recommendations for Dialysis nario and scientific advances, the SBN Units concerning the epidemic by the new updated its recommendations, which coronavirus. With the pandemic state are technical indications of good prac- decreed by the World Health Organization tices and must be adapted to the context on March 11, other international organi- and local reality, depending on adequate zations, such as the Centers for Disease funding by public managers. The SBN Control and Prevention (CDC), the has been striving in search of resources American Society of Nephrology (ASN) for renal replacement therapy in Brazil at and the Sociedad Latinoamericana de this time of the pandemic. Nefrología e Hipertensión (SLANH), There is still a scarcity of well-estab- also published recommendations directed lished data on the behavior of the virus to dialysis units on March 10, March 11 and the natural history of the disease,1 so and March 13, respectively. In the prog- any changes to this document may be nec- Correspondence to: ress, Brazil entered the epidemiologi- essary due to other scientific evidence that José A. Moura-Neto E-mail: [email protected] cal phase of community transmission of may appear.
DOI: 10.1590/2175-8239-JBN-2020-S105
15 Recommendations to Dialysis Units
General measures for Dialysis Units2-5: force by the local health authorities and the • Dialysis units must provide adequate infor- Ministry of Health. mation to their patients and employees about • Before attending to a suspected or confirmed basic preventive measures. One is to emphasize case, the healthcare professional must wear a and intensify frequent hand hygiene with 70% waterproof disposable apron, surgical mask, alcohol gel or washing with soap and water. disposable cap, gloves and goggles. It should also educate patients and employees • The use of a surgical mask is recommended to avoid touching their eyes, mouth and nose for patients with respiratory symptoms and without proper hand hygiene; avoid close con- their companions throughout their stay in tact with infected individuals; cover mouth the dialysis unit4. and nose when sneezing or coughing, use a • The multidisciplinary clinical care team must disposable handkerchief; clean and disinfect wear a surgical mask. It is also suggested that frequently touched objects and surfaces; avoid the other employees (maintenance, cleaning, sharing personal objects (such as toothbrushes, receptionists, and security guards) of the dialy- cutlery, plates and glasses); and, if they are sis unit use a surgical mask. The surgical mask infected, avoid contact with other people, stay- should be replaced with a new one whenever it ing at home whenever possible. is wet. • We recommend intensifying the hygiene of • Healthcare professionals at the Dialysis Unit objects and surfaces frequently used by the responsible for the assistance of confirmed or sus- public, such as door handles, chair arms, tele- pected cases should wear masks type N95, N99, phones and elevator buttons. Recent evidence N100, PFF2 or PFF3 whenever they are going to suggests that some coronaviruses can remain perform aerosol-generating procedures, such as, infectious on inanimate surfaces for up to 9 for example, orotracheal intubation, non-inva- days. Disinfecting surfaces with 0.1% sodium sive ventilation, cardiopulmonary resuscitation hypochlorite or 62-71% ethanol significantly or manual ventilation before intubation. reduces coronavirus infectivity after 1 minute • If possible, assign a toilet for the exclusive use of exposure6. of the suspected case. If this is not possible, • Patients and employees should be encouraged clean the normally touched surfaces of the toilet to avoid, if possible, public transportation. (faucet, door handle, trash can cover, counters, • We recommend Dialysis Units to encourage light switch) with soap and water or disinfec- their patients’ to vaccinate against the influenza tant, according to the procedures described in virus, in the absence of contraindications. Technical Note 26/2020/SEI/COSAN/GHCOS/ • Dialysis Units must take administrative mea- DIRE3/ANVISA7. sures to reduce, as far as possible, the number • If the patient is unable to wear a surgical mask of passers-by and companions. because of breathing difficulties, towels should • Companions of patients and staff with respi- be provided and asked to cover the nose and ratory symptoms should be discouraged from mouth when coughing or sneezing. The towels attending the Dialysis Unit. used must be collected and destined for cleaning • The Dialysis Unit and its rooms must be well and disinfection, or disposed in a milky white ventilated. bag for management as group A solid waste, • Meetings via video conference should be according to the RDC ANVISA No. 222 guide- encouraged whenever possible. lines, of March 28, 2018. • In Dialysis Units with a private isolation Care for dialysis patients2-5: room, patients with suspected or confirmed • Suspected cases must receive medical evalua- Covid-19 infection should be dialyzed in an tion and guidance before entering the dialysis isolation room. site. After assessment, the conduct should be • In Dialysis Units where there is no room for taken in accordance with the patient’s clinical isolation, patients with suspected or confirmed condition and with the recommendations in Covid-19 infection should preferably be dialyzed
16 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):15-17 Recommendations to Dialysis Units
in a separate ward and on the last shift. The treatment in suspected or confirmed cases of patient must be separated by at least 1.82 meters Covid-19 infection. from the nearest patient (in all directions)3. • In Dialysis Units with many suspected or con- The proposed measures serve to inform and alert, firmed cases, it is recommended, if possible, an preventing the spread of the virus and promoting exclusive dialysis shift or the opening of addi- preservation of care to the population with Chronic tional shifts. Kidney Disease undergoing dialysis treatment. • We suggest considering single use of the dia- lyzer in patients with confirmed or suspected References cases of Covid-19. 1. Naicker S, Yang CW, Hwang SJ, Liu BC, Chen JH, Jha V. • The suspected case should be encouraged to The Novel Coronavirus 2019 Epidemic and Kidneys, Kid- ney International (2020), doi: https://doi.org/10.1016/j. perform hand washing or frequently use alco- kint.2020.03.001. holic solution for hand hygiene, especially after 2. CDC (Center for Disease Control) - Interim Infection Preven- coughing or sneezing, making available the nec- tion and Control Recommendations for Patients with Confir- med Coronavirus Disease 2019 (COVID-19) or Persons under essary supplies. Investigation for COVID-19 in Healthcare Settings. https:// • During the dialysis procedure, keep the patient www.cdc.gov/coronavirus/2019-ncov/infection-control/con- trol-recommendations.html. Acessado em 01/03/2020. with a surgical mask, as well as patients close to 3. Interim Additional Guidance for Infection Prevention and Con- the one under suspicion of infection. trol Recommendations for Patients with Suspected or Confir- med COVID-19 in Outpatient Hemodialysis Facilities. Centers • Regarding the duration of isolation and pre- for disease and control prevention (CDC). Mar 10, 2020. cautionary contact measures in confirmed https://www.cdc.gov/coronavirus/2019 ncov/healthcarefacili- cases, the duration of isolation and the time ties/dialysis.html. Acessado em 16/03/2020. 4. Chinese Society of Nephrology. Recommendations for preven- of discontinuation must be an individualized tion and control of new coronavirus infection in blood puri- decision on a case-by-case basis. Some factors fication center (room) (First trial version). Chinese Society of Nephrology. Acessado em 16/03/2020. should be considered in this decision-making 5. Hwang S-J. Guideline for dialysis facilities during COVID-19 process, such as the presence or disappearance outbreak, Taiwan Society of Nephrology, 16 February 2020. of symptoms related to the infection, date of Acessado em 16/03/2020. 6. Kampf G, Todt D, et al. Persistence of coronaviruses on ina- the infection and the clinical and laboratory nimate surfaces and their inactivation with biocidal agents. J status with a confirmatory test (PCR) for Hosp Infect. 2020; Feb 6. pii: S0195-6701(20)30046-3. 7. Saneantes: população deve usar produtos regularizados. Covid-19. http://portal.anvisa.gov.br/noticias/-/asset_publisher/FXr- • In patients with Chronic Kidney Disease on px9qY7FbU/content/saneantes-populacao-deve-usar-produ- tos-regularizados/219201/pop_up?_101_INSTANCE_FXr- dialysis, SBN does not recommend measures px9qY7FbU_viewMode=print&_101_INSTANCE_FXr- that reduce the time or frequency of dialysis px9qY7FbU_languageId=pt_BR
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):15-17 17 Recommendations | Recomendações Good practices recommendations from the Brazilian Society of Nephrology to Peritoneal Dialysis Services related to the new coronavirus (Covid-19) epidemic Recomendaçes de boas praticas da Sociedade Brasileira de Nefrologia aos Serviços de dialise peritoneal em relaço à epidemia do novo coronavirus (Covid-19)
Authors Abstract Resumo Viviane Calice-Silva1, 2 Alexandre Silvestre Cabral3 Considering the new coronavirus epidemic Considerando a nova epidemia de coronavírus Sérgio Bucharles4 (Covid-19), the Brazilian Society of (Covid-19), a Sociedade Brasileira de Jose Andrade Moura- Neto5 Nephrology, represented by the Peritoneal Nefrologia, representada pelo Comitê de Ana Elizabeth Figueiredo6 Steering Committee, in agreement with the Diálise Peritoneal, em concordância com Ricardo Portiolli Franco4 and the Dialysis Department, developed a diretoria e o Departamento de Diálise, Andrea Pio de Abreu7 a series of recommendations for good desenvolveu uma série de recomendações de boas práticas clínicas para os serviços Marcelo Mazza do Nascimento8 clinical practices for peritoneal dialysis (PD) clinics, to be considered during de diálise peritoneal a serem consideradas durante o período da epidemia de Covid-19, 1Fundação Pró-Rim, Joinville, SC, the period of the Covid-19 epidemic. com o objetivo de minimizar a disseminação Brasil. We aim to minimize the disease spread, 2Faculdade de Medicina da da doença, proteger pacientes e funcionários protecting patients and staff, and ensuring Universidade da região de e garantir a qualidade do tratamento the quality of the treatment provided Joinville (UNIVILLE), Joinville, SC, prestado e acompanhamento adequado Brasil. and adequate follow-up for PD patients. para os pacientes em DP. As recomendações 3Instituto de Saúde do Rim The recommendations suggested at this Alexandre Cabral, Campo Grande, aqui sugeridas devem ser adaptadas a MS, Brasil. moment must be adapted to each clinic’s cada realidade de serviço e às condições 4Fundação Pró-Renal, Curitiba, PR, reality and the conditions of the structural estruturais e de recursos humanos e Brasil. and human resources, dependent on the 5 dependem da provisão financeira adequada Clínica Senhor do Bonfim, adequate financial provision of the public Salvador, BA, Brasil. do sistema público de saúde para sua plena 6Pontifícia Universidade Católica health system for its full implementation. implementação. do Rio Grande do Sul, Porto Keywords: Covid-19; Coronavirus Alegre, RS, Brasil. Palavras-chave: Covid-19; Infecções por 7Hospital das Clínicas da FMUSP, infections; Peritoneal dialysis; eHealth Coronavirus; Diálise Peritoneal; Estratégias São Paulo, SP, Brasil, Strategies. de eSaúde. 8Hospital Universitário Evangélico, UFPR, Curitiba, PR, Brasil.
Introduction replacement therapy (RRT) modal- ity performed at home, that enables The Steering Committee of the Brazilian patients to maintain their continu- Society of Nephrology (SBN), together ous treatment without having to with the Peritoneal Dialysis Committee, attend the dialysis unit several prepared recommendations for perito- times a week, allowing monthly neal dialysis services concerning corona- outpatient follow-up to review and virus pandemic. The recommendations adjust treatment when necessary, contained herein must be adapted to the electively1. context and the reality of each service, • Considering the risks chronic kid- and depend on adequate funding from ney disease patients are exposed public health systems for its complete to, most of whom have multiple implementation. comorbidities, associated with the low immunity that the disease Correspondence to: Considerations Viviane Calice-Silva itself causes them, and the recom- E-mail: [email protected] • Considering that peritoneal dialy- mendations of social isolation to DOI: 10.1590/2175-8239-JBN-2020-S106 sis (PD) therapy consists of renal minimize the spread Covid-19,
18 Good practices recommendations to Peritoneal Dialysis Services
established by the Ministry of Health and • Patient visiting the units should be kept to a other agencies2. minimum number, and restricted to essential • Considering the letter issued by the Medicine cases only, if the patient has any clinical compli- Federal Board (Official Letter CFM No. cations, such as peritonitis, infection related to 1756/2020), recognizing the possibility and the catheter (tunnel and/or exit site), changes in ethics of using telemedicine, in addition to body volume, or if there are no tools needed to CFM provisions in Resolution No. 1,643, be assisted remotely safely and ethically. of 26 August 2002, as following: Tele- • Peritoneal catheter implants from patients education: medical professionals can provide in immediate need to start therapy, as well as remote guidance and referral to patients in repositioning catheters with dysfunction and isolation; telemonitoring: an act performed removed because of infections, are not consid- under medical advice and supervision for ered elective procedures; therefore, they must remote monitoring or enforcement of health be performed taking all precautions aimed to and/or disease parameters; tele-interconsulta- reducing the risk of Covid-19 transmission. tion: exclusively exchanging information and • Training of patients needing to start dialysis opinions between physicians, for diagnostic must be prioritized and scheduled at spaced or therapeutic assistance3. times (which allows the cleaning of the environ- • Considering the guidelines stated in Ordinance ment between sessions), controlling the num- No. 467, of 20 March 2020, subsequently pub- ber of patients seen per period in the clinic and lished in the Official Gazette by the Ministry of speeding up all procedures to reduce as much as Health, which provides, on an exceptional and possible the number of patients in the waiting temporary basis, telemedicine rules, for regulat- area, always respecting all Covid-19 prevention ing and operationalizing the measures to deal measures specified by the Ministry of Health with the public healthcare emergency of inter- (MS), SBN and World Health Organization national importance, provided for in art. 3 of (WHO), and continuously screening patients Law No. 13,979, of 6 February 2020, resulting before entering the clinic. from the Covid-19 epidemic4. • Non-essential procedures, such as changing trans- • Considering the determination of many states fer set 6'', peritoneal equilibrium test (PET) and in the country to suspend outpatient care, to KT/V, should be avoided during the pandemic, to minimize the circulation of people and the minimize risks and unnecessary patient exposure. quickly disease propagation, and since Brazil • We also suggest that the patient wear a cloth has entered the epidemiological phase of com- mask when he or she eventually has to go out, munity transmission of the disease (when the according to the latest recommendations from the number of cases increases exponentially and Ministry of Health. SBN does not recommend the the ability to identify the transmitting source use of a cloth mask while performing PD. is lost), SBN, through its Peritoneal Dialysis • In line with what was recently advised in the Committee and its Steering Committee, drafted recommendations of the International Society the recommendations listed below. of Peritoneal Dialysis (ISPD), the SBN suggests that elective and non-urgent hospital admis- Recommendations sions be rescheduled, and surgical and elective • The peritoneal dialysis clinics must be struc- hospital procedures postponed6. tured, as far as possible, to assist their patients • Also, if the PD nursing team is involved with in these pandemic times, via telemedicine, hospital care for patients, it is preferable to within the modalities recognized by the CFM have separate groups responsible for outpatient (tele-education, telemonitoring or tele-inter- and hospital PD care. If this is not possible, we consultation), according to the technical capac- recommend that hospital visits occur at the end ity of each clinic, with the rules established by of each work shift, so that, after being carried Ordinance No. 467, published in the Official out with the proper hygiene precautions, the Gazette3-5. healthcare professionals can go directly home.
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):18-21 19 Good practices recommendations to Peritoneal Dialysis Services
• Reinforce for patients the instructions concern- • Patients and employees should be encouraged ing the material used in therapy. Home storage to avoid public transportation, if possible. and use at home must be maintained according When necessary, wear a cloth mask. to the local protocol. • PD units should encourage their patients to • All materials used in each PD session in the vaccinate for influenza, in the absence of clinic or hospital must be cleaned with 70% contraindications. alcohol before use. • Dialysis units should take administrative proce- • Disposable of fluid bags, circuits, and all other dures to reduce, as far as possible, the number required PD supplies generate by Covid-19 of caregivers and companions. patients must be done following local regula- • Patient companions and employees with respi- tory rules. ratory symptoms should be discouraged from • For cases of patients who need to be evaluated attending the PD Unit. in person at the unit, the SBN reinforces the • Rooms should be kept ventilated, as well as the need to maintain technical recommendations Dialysis Unit. for good practices, adapted to the context and • Meetings via video conference should be local reality, and with adequate funding from encouraged whenever possible. the public health system, previously published • Care for PD patients in face-to-face outpatient for hemodialysis services compiled and adapted consultation: contact the patient and family for peritoneal dialysis, as mentioned below7-11: for a pre-screening before the consultation via telephone, looking for respiratory symptoms (if General Care For Presential Service any, advise the patient and family to not attend • PD units must educate patients and collabo- the unit); educate them on signs and symptoms rators on primary preventive care. Emphasize of severity and to seek care according to the ref- and intensify frequent hand hygiene with 70% erence of each municipality if there is a worsen- alcohol gel or with soap and water for about ing of the condition. 20 to 60 seconds. They should also instruct • If patients with suspicion of the disease arrive patients and collaborators to avoid touching at the unit, they must undergo a medical evalu- their eyes, mouth, and nose without having ation and receive instructions before entering done hand hygiene; avoid close contact with the dialysis clinic. After evaluation, the patient infected individuals; using social etiquette, should be treated under the clinical condition cover mouth and nose when sneezing or and with the current recommendations of the coughing, with a disposable handkerchief and local health authorities and the Ministry of despise it as soon as possible, or use the angle Health. These patients must not stay in the formed by the arm and forearm (elbow); clean unit; monitoring can be carried out later by and disinfect frequently touched objects and telephone12. surfaces; avoid sharing personal objects (such • To evaluate the suspected case, the healthcare as toothbrushes, cutlery, plates, and glasses); professional (doctors and nurses) must wear a and, if infected, avoid contact with other disposable apron, surgical mask, goggles and/ people, choosing to stay at home whenever or face shield and disposable gloves. possible12,13. • Patients with respiratory symptoms and their • We recommend intensifying the cleaning of companions must wear a surgical mask during objects and surfaces frequently used by the pub- the evaluation before entering the dialysis unit. lic, such as door handles, chair arms, and eleva- • Other members of the multidisciplinary care tor buttons. Recent evidence suggests that some team must wear a surgical mask. If the service coronaviruses can remain infectious on inani- provides contact that is more direct with the mate surfaces for up to 9 days. Disinfecting patient, follow the same recommendations as surfaces with 0.1% sodium hypochlorite or to the second item. We also suggest that the 62-71% ethanol significantly reduces coronavi- other employees (maintenance, cleaning, recep- ruses’ infectivity after 1 minute of exposure14. tionists, and security guards) of the dialysis unit
20 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):18-21 Good practices recommendations to Peritoneal Dialysis Services
also wear a surgical mask. The surgical mask 3. Conselho Federal de Medicina (BR). Ofício Conselho Federal de Medicina, Nº1756/2020 – COJUR, 19 de Março de 2020. should be replaced with a new one whenever it http://portal.cfm.org.br/images/PDF/2020_oficio_telemedi- becomes wet. cina.pdf Published 2020. Accessed. • Healthcare professionals in the dialysis unit, 4. Ministério da Saúde (BR). PORTARIA Nº 467, DE 20 DE MARÇO DE 2020. Diário Oficial da União, Edição: 56-B, responsible for assisting confirmed or suspected Seção: 1. http://www.in.gov.br/en/web/dou/-/portaria-n-467- cases, should wear masks (type N95) whenever -de-20-de-marco-de-2020-249312996. 5. El Shamy O, Tran H, Sharma S, Ronco C, Narayanan M, Uri- performing aerosol-generating procedures, such barri J. Telenephrology with Remote Peritoneal Dialysis Moni- as orotracheal intubation, non-invasive ventila- toring during Coronavirus Disease 19. American journal of nephrology. 2020:1-3. tion, cardiopulmonary resuscitation or manual 6. Committee IG. Strategies regarding COVID-19 in PD patients. ventilation before intubation. International Society of Peritoneal Dialysis. https://ispd.org/ wp-content/uploads/ISPD-PD-management-in-COVID-19_ • If possible, designate a toilet for the exclusive ENG.pdf. Published 2020. Accessed. use of the suspected case. If this is not possible, 7. Hwang S-J. Guideline for dialysis facilities during COVID-19 clean the frequently touched surfaces of the outbreak. Taiwan Society of Nephrology 2020. 8. Nephrology. CSo. Recommendations for prevention and con- bathroom (s) (faucet, handle, trash can cover, trol of new coronavirus infection in blood purification center counters) with soap and water or disinfectant, (room) from the Chinese Medical Association Nephrology Branch. Chin J Nephrol. 2020; 36(2): 82-84. DOI: 10.3760/ according to the procedures described in RDC cma.j.issn.1001-7097.2020.02.002 56, of 6 August of 2008. 9. Ortiz PdS, Gili BQ, Gabriel de Arriba de la Fuente, Heras MM, Lazo MS, Pino MDdPy. Protocolo de actuación ante la epide- mia de enfermedad por coronavirus en los pacientes de diá- Final Remarks lisis y trasplantados renales. Nefrologia. 2020;40(3):253-257. doi:10.1016/j.nefro.2020.03.001 The aforementioned measures serve as a source of 10. Epidemiology Working Group for NCIP Epidemic Response, Chinese Center for Disease Control and Prevention. [[The information and alert to mitigate the virus spread and epidemiological characteristics of an outbreak of 2019 novel promote adequate assistance to the population with coronavirus diseases (COVID-19) in China]. Zhonghua Liu chronic kidney disease undergoing peritoneal dialy- Xing Bing Xue Za Zhi. 2020 Feb 10;41(2):145-151. Chinese. doi: 10.3760/cma.j.issn.0254-6450.2020.02.003. sis during the Covid-19 pandemic. These measures 11. Basile C, Combe C, Pizzarelli F, et al. Recommendations for can, and should, be revised as the health situation the prevention, mitigation and containment of the emerging SARS-CoV-2 (COVID-19) pandemic in haemodialysis centres. 15 changes . Nephrol Dial Transplant. 2020;35(5):737-741. doi:10.1093/ ndt/gfaa069 12. Center for Disease Control and Prevention. Interim Additional Acknowledgments Guidance for Infection Prevention and Control Recommen- dations for Patients with Suspected or Confirmed COVID-19 We are grateful for the contribution and support of in Outpatient Hemodialysis Facilities. https://www.cdc.gov/ the other members of the SBN Peritoneal Dialysis coronavirus/2019ncov/healthcarefacilities/dialysis.html. Publi- shed 2020. Accessed. committee, Dr. Mario Ernesto Rodrigues, Dr. Elias 13. Center for Disease Control and Prevention. Interim Infec- Flato, Dr. Gina Moreno, Dr. Henrique Carrascossi tion Prevention and Control Recommendations for Patients and Dr. Hugo Abensur. with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings. https://www.cdc.gov/coronavirus/2019-ncov/infec- References tion-control/control-recommendations.html. Published 2020. Accessed. 1. Associação Médica Brasileira. Recomendação Associação 14. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence Médica Brasileira: suspensão atendimentos ambulatoriais. of coronaviruses on inanimate surfaces and their inactiva- https://amb.org.br/noticias/amb-recomenda-suspensao-do- tion with biocidal agents. The Journal of hospital infection. -atendimento-ambulatorial-eletivo-em-todo-o-pais. Published 2020;104(3):246-251. 2020. Accessed. 15. Ma Y, Bo Diao, L X, et al. 2019 novel coronavirus disease 2. Naicker S, Yang CW, Hwang SJ, Liu BC, Chen JH, Jha V. The in hemodialysis (HD) patients: Report from one HD center in Novel Coronavirus 2019 Epidemic and Kidneys, Kidney Int. Wuhan. https://www.medrxiv.org/content/10.1101/2020.02.2 2020 May;97(5):824-828. doi: 10.1016/j.kint.2020.03.001. 4.20027201v2.full.pdf. Published 2020. Accessed.
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):18-21 21 Recommendations | Recomendações Technical note and clinical instructions for Acute Kidney Injury (AKI) in patients with Covid-19: Brazilian Society of Nephrology and Brazilian Association of Intensive Care Medicine Nota técnica e orientações clínicas sobre a Injúria Renal Aguda (IRA) em pacientes com Covid-19: Sociedade Brasileira de Nefrologia e Associação de Medicina Intensiva Brasileira
Authors Abstract Resumo José Hermógenes Rocco Suassuna1 We produced this document to bring Este documento foi desenvolvido para Emerson Quintino de Lima2 pertinent information to the practice trazer informações pertinentes à prática Eduardo Rocha3 of nephrology, as regards to the renal nefrológica em relação ao conhecimento Alan Castro4 involvement with COVID-19, the sobre o acometimento renal da COVID-19, Emmanuel de Almeida Burdmann5 management of acute kidney injury cases, conduta frente aos casos de injúria renal Lilian Pires de Freitas do Carmo6 and practical guidance on the provision of aguda e orientações práticas sobre a Luis Yu5 dialysis support. provisão do suporte dialítico. Mauricio Younes Ibrahim1 As information on COVID-19 evolves Como as informações sobre a COVID-19 Gustavo Navarro Betônico7 at a pace never before seen in medical evoluem a uma velocidade jamais Américo Lourenço Cuvello Neto8 science, these recommendations, vista na ciência médica, as orientações Maria Olinda Nogueira Ávila9 although based on recent scientific apresentadas, embora baseadas em Anderson R. Roman Gonçalvez10 evidence, refer to the present moment. evidências científicas recentes, referem-se The guidelines may be updated when ao momento presente. Essas orientaços Ciro Bruno Silveira Costa11 published data and other relevant poderão ser atualizadas à medida que Nilzete Liberato Bresolin12 information become available. dados publicados e outras informações Andrea Pio de Abreu5 relevantes venham a ser disponibilizadas. Suzana Margareth Ajeje Lobo2 Keywords: Acute Kidney Injury; Marcelo Mazza do Nascimento13 Coronavirus Infections; Covid-19; Palavras-chave: Lesão Renal Aguda; Critical Care. Infecções por Coronavirus; Covid-19; 1 Universidade do Estado do Rio de Cuidados Críticos. Janeiro, Rio de Janeiro, RJ, Brasil. 2Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brasil. 3Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil. 4Complexo Hospitalar de Niterói, Niterói, RJ, Brasil. Context and assist in decision-making, recogniz- 5Universidade de São Paulo, São ing that the situation does not allow for Paulo, SP, Brasil. The Covid-19 pandemic is a global threat 6Universidade Federal de Minas establishing strict guidelines. Gerais, Belo Horizonte, MG, Brasil. with the potential to deplete national The Brazilian Society of Nephrology 7Faculdade de Medicina de healthcare systems. The colossal volume Adamantina, Adamantina, SP, Brasil. (SBN) and the Brazilian Association of 8 of reports and discussions produced in Hospital Alemão Oswaldo Cruz, Intensive Care Medicine (AMIB) under- São Paulo, SP, Brasil. such a short term is an unprecedented 9Universidade do Estado da Bahia, fact in medicine, not only in traditional stand that there are different scenarios Salvador, BA, Brasil. of assistance to patients with Acute 10Universidade da Região de vehicles of scientific dissemination, Joinville, Joinville, SC, Brasil. but also in blogs, websites, social net- Kidney Injury (AKI) in our country. It is 11 Hospital de Acidentados, works and conversations between peers. inevitable that there will be variations in Goiânia, GO, Brasil. 12Universidade Federal de Santa Evidence is published at a rapid pace and practice, resulting from individualities Catarina, Florianópolis, SC, Brasil. no recommendation can be considered in the clinical picture, the availability of 13 Universidade Federal do Paraná, human and material resources and other Curitiba, PR, Brasil. definitive. Like the first version, made available online, this second edition is aspects, associated with the resources Correspondence to: based on information available until the of each healthcare institution, including José Hermógenes Rocco Suassuna E-mail: [email protected] moment of its publication. The objec- the type of organization and the type of
DOI: 10.1590/2175-8239-JBN-2020-S107 tive is to inform, recommend practices contracting of nephrological care.
22 Technical note and clinical instructions for AKI in patients with Covid-19
Every professional involved in nephrological Causes of acute kidney injury with Covid-19 care must provide the best possible assistance to the There is ample literature on the association of acute patients under their responsibility, adopt practices respiratory distress syndrome (ARDS) with AKI, that minimize their personal risk of contamination, within the pathophysiological model of the cross- that of their patients and the whole range of other talk between the organs. It is not surprising to see professionals who participate in hospital kidney sup- the development of AKI in patients with the exten- port, including nurses and technicians, dialysis staff, sive pulmonary damage that characterizes the severe healthcare professionals from all areas (for example, forms of Covid-19 and the adverse renal effects of doctors and nurses in intensive care medicine), labo- the highly complex ventilatory support that these ratory and radiology technicians, cleaning and trans- port staff, etc. patients need. In a large series in New York, the main Each institution must define its bed allocation pol- cause attributed to the development of AKI was the icy for patients with Covid-19, as well as that of the systemic collapse that follows orotracheal intubation 3 professionals responsible for the treatment, either by and the beginning of mechanical ventilation . isolation of a cohort in a specific physical area, in a In some cases, disease progression is much more general inpatient unit or in a general hospital inten- severe, with hyperinflammation, often associated sive care unit. Protocols for the entry and circulation with acute cardiac injury. The striking feature of these of nephrology team members in the environment of cases is the significant increased circulating levels of patients with Covid-19 must be defined in advance, inflammatory cytokines, notably IL-6, IL-18 and in order to minimize the use of personal protective IFN-ɣ, and other markers, such as troponin, ferritin equipment (PPE) and to limit nonessential traffic in and D-dimer4,5. These patients have a poor prognosis isolation environments. and evidently difficult-to-manage AKI. Since a larger contingent of patients with AKI will Autopsy studies have produced variable find- be under intensive or semi-intensive care, interaction ings. One of the first series reported severe tubular and collaboration between nephrologists and inten- necrosis, associated with lymphocytic tubulointersti- sivists is essential. It is advisable to adapt visiting tial nephritis, with macrophages and tubular deposi- routines to digital format and all documentation/pre- tion of the complement membrane attack complex6. scription to electronic format, avoiding the movement Immunohistochemistry demonstrated direct renal of papers and documents between the inpatient unit infection by SARS-CoV-2, which is not surprising, and other institutional sectors. given the high expression of ACE2 receptor in the It is imperative, during interactions with renal tubular epithelium. The possibility of cyto- patients, that nephrologists and other members of pathic action by direct viral invasion of the renal epi- the dialysis team follow the guidelines for safety thelium has been reinforced with ultrastructural and and use of PPE. molecular studies7-9. As these samples are skewed for the patients that died, it is not possible to assess the Covid-19 clinical phenotypes relevance of the findings in relation to the AKI cases As Covid-19 spreads, awareness of its manifesta- reported in clinical studies. tions also increase. It is now evident that Covid-19 In conclusion, the term AKI is used for a wide has different clinical phenotypes1, not necessarily variety of diseases that result in acute and subacute sequential, which may have direct implications in decrease in renal function, including, among others, the risk of AKI. processes of mechanical, ischemic, toxic, infectious The vast majority of symptomatic cases are benign, origin and the branches of innate, adaptive humoral with flu-like syndrome and mild pulmonary involve- and cellular immunity. It is interesting to note that ment. Phenotypes that are more serious include acute AKI cases with Covid-19 seem to reproduce this respiratory distress syndrome (ARDS) with alveolar diversity. The etiologic factors involved are multiple damage due to viral cytopathic effect, systemic hyper- and include direct viral cytopathic effect, decreased inflammation syndrome (or cytokine storm) and blood oxygen content and renal plasma flow, angio- hypercoagulability syndrome with micro and macro- tensin II activation, glomerulopathies, crosstalk vascular manifestations2. injury, inflammatory deregulation, hyperviscosity,
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):22-31 23 Technical note and clinical instructions for AKI in patients with Covid-19
thrombotic microangiopathy, secondary sepsis and well as human resources to face the epidemic in places drug toxicity3,6-8, 10-14. where the pandemic is still in the initial phase of dis- semination through the population. Epidemiology of acute kidney injury in patients with Covid-19 Prognosis of acute kidney injury in patients In the first published series, almost all from China, with Covid-19 the average incidence of AKI associated with As with other causes for ARDS, the development of Covid-19 was relatively low. On average, only 5.8% AKI in patients with Covid-19 correlates with a worse (0.5 to 23%) affecting severe cases and only 2.1% overall prognosis and impacts mortality.5,17 In a series of patients (0.8 to 11.0%) needing renal replacement with AKI staging by the KDIGO system (Table 1), therapy (RRT)4,5.15-24. These data did not suggest a there was a progressive increase in the odds ratio for higher incidence of AKI in patients with Covid-19 lethality, reaching 9.8 in patients staged as KDIGO 3. when compared to other patients with the same sever- In the American series mentioned above, the mortal- 17 ity profile . In publications, the existence of two AKI ity initially reported was 35%, although 39% of the patterns was also highlighted; one early and one late. patients were still hospitalized3. The latter was assigned a worse prognosis5,17. In late cases, the average time from admission to AKI was When to call the nephrologist seven days5,25. The experience in the West seems to be diverse Even though it is always necessary, in the current and still in the process of being published. However, situation it is essential to reinforce the need for close in a large series from New York, AKI in the three collaboration between intensivists and nephrolo- KDIGO stages was seen in 37% of 5449 patients3. Of gists, sharing opinions at the bedside, and reviewing these, 14% required artificial renal support. Of the hemodynamic parameters and volume status. In the patients who died, 34% were in the KDIGO stage1; discussion of each case, priorities and the best treat- 64%, in stage 2; and 91% in KDIGO stage 3. ment strategies are expected to be established in a In particular, there was a strong association with shared way. ventilatory support, with 98% of patients on mechan- Within this perspective, the nephrologist shall ical ventilation developing AKI, versus 22% of those be contacted in any situation of need, even with not ventilated.3 Again in opposition to the initial pub- discrete degrees of renal dysfunction, since the lications, the majority of cases seen in the New York nephrological involvement in intensive care is not large serie occurred in the first two days of hospital- limited to AKI. The nephrologist’s contribution ization, 52% in the first 24 hours3. Anecdotal reports includes additional situations, such as electrolyte from European and Brazilian centers also point to a disturbances, adjustment of medication doses, etio- high incidence of AKI in patients on mechanical ven- logical diagnosis and management of kidney dis- tilation, between 20% to 50% of cases. eases of various etiologies. This information is especially important to plan KDIGO qualifies the severity of AKI in stages the allocation of dialysis machines and supplies as (Table 1). In this sense, we recommend that patients
Table 1 KDIGO classification for acute kidney injury Stage Serum creatinine (Cr) Score the largest deviation (diuresis or creatinine) Hourly diuresis ↑ ≥ 0,3 mg/dl in 48h 1 or or < 0,5 mL/kg/h for 6-12h ↑ 1,5-1,9 x Cr within 7 days 2 ↑ 2,0-2,9 x Cr of baseline or < 0,5 mL/kg/h for ≥ 12h ↑ ≥ 3,0 x Cr of baseline < 0,3 mg/kg/h for ≥ 24h 3 or or or ↑ Cr ≥ 4,0 mg/dl or RRT Anuria ≥ 12 h
24 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):22-31 Technical note and clinical instructions for AKI in patients with Covid-19 with Covid-19 in stage 2 be already the subject of Whenever possible, portable reverse osmo- communication and discussion between the intensive sis equipment and systems should be exclusive and care team and the nephrologist. remain in the areas allocated to Covid-19 patients, Patients classified as stage 3 have a high probabil- avoiding their displacement to other areas of the ity of requiring artificial renal replacement therapy hospital. Throughout the procedure, we recommend (RRT), justifying the immediate call of the nephrol- keeping the equipment outside or close to the bed ogy team. Practical details on the possible prescrip- access entrance. By the same perspective, we recom- tion/performance of RRT will be discussed below. mend that dialysis nurses remain in proximity and not inside the box/room. Protection of the workforce in nephrology and RRT The use of standard procedures for disinfecting Healthcare professionals are at increased risk of RRT equipment is suitable for the elimination of exposure to SARS-CoV-2, which is reflected in mul- SARS-CoV-2, including systems with a glass tank, tiple morbidity and mortality reports. Even when which uses peracetic acid. There is no evidence of the infection evolves favorably, the mandatory tem- significant passage of SARS-CoV-2 across RRT porary medical leave can overwhelm the remaining filters. staff. For this reason, there was an initial recommen- In bedside hemodialysis procedures, the dialysate dation to restrict the entry of nephrologists and dialy- waste should be drained in the hospital wastewater sis nurses in the cohorts allocated Covid-19 patients. system. Peritoneal dialysate can be discarded in the The RRT prescription (and subsequent adjustments) same way, keeping the PPE on throughout the pro- was to be done remotely, as long as close contact cess. Although infrequent, there was a first report of with the medical team within the isolated cohort was detection, and persistence for more than 40 days, of assured. In the same way, the management of RRT SARS-CoV-2 in the peritoneal effluent of a patient 26 procedures by ICU nurses were encouraged, as long with Covid-19 . Bags of wasted peritoneal dialysate as they were properly trained. can also be depleted in the sanitary network, with The experience with this strategy proved to be ade- particular care to prevent spilling and the dispersion quate while the number of cases remained relatively of its contents. low. However, the excess of patients with Covid-19 complicated by AKI has caught many centers by Vascular access surprise. In many places, the strategy of restrict- In compliance with the policy of restricting non- ing the access of nephrology personnel proved to be essential entry of personnel in Covid-19 isolated inadequate by overburdening intensive care teams, areas, and to prevent wasting by having the nephrol- which were already overwhelmed with other priori- ogist donning PPE solely for the purpose of catheter ties. There was also occasional compromise in the insertion, we advise that RRT access insertion ought exchange of information between doctors inside and to be performed the intensivist. However, with the outside the isolation units, and the impact on logistics work overload represented by the almost total occu- that involved the insertion of vascular access and the pation of ICUs by patients with Covid-19, experi- flow of orders for the beginning, postponement, con- ence has shown that the nephrologist must enter the duction and/or discontinuation of procedures. isolated environment to insert dialysis catheters and Thus, in settings with a high prevalence of AKI, perform other activities. we recommend that the direct participation of the The selection of catheters with adequate length nephrologist and nephrology nursing in the care and diameter is of paramount importance to ensure within isolated areas is convenient, giving preference optimal blood flow. Dialysis accesses with inconsis- to professionals who have already developed anti- tent or unsatisfactory flow promote clotting of the bodies against SARS-CoV-2. For better operational system, which results in blood loss and interruption capacity, we also recommend that patients be installed of RRT. One should not insist on repeated flush- in contiguous, frontal or close beds, to enable simul- ing or other maneuvers. The most cost-effective taneous procedures to be carried out, supervised by solution is usually to replace the catheter. Table 2 the same dialysis technician or nurse. shows dialysis catheter lengths recommended for
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):22-31 25 Technical note and clinical instructions for AKI in patients with Covid-19
Table 2 Optimum catheter length for ARS, Chlorhexidine antisepsis is associated with a according to the venipuncture site lower incidence of local and bloodstream infections. (adults) When available, the use of transparent dressings with Venous territory ARS catheter length (cm) chlorhexidine gluconate gel (CHG) can reduce the Right jugular 15-18 number of exchanges and the need for handling. Left jugular 18-24 The routine of access care must also include the Left or right daily inspection of the insertion site and the integrity 20-30 femoral of the fixation points. In the absence of contrain- Right subclavian 15-18 dications, all patients with Covid-19 and a central Left subclavian 20-24 vascular line should receive prophylaxis with low molecular weight heparin1, in order to reduce the thrombotic risk27. different sites of central venipuncture. The different ranges stem from the diversity of biotypes in the Renal replacement modalities population. RRT modalities include continuous renal replacement Catheters and dialysis lines are not a contrain- therapy (CRRT), prolonged intermittent hemodialy- dication the placement of the patient in the prone sis (PIRRT), conventional intermittent hemodialysis position, but requires specific attention to avoid (IHD) and peritoneal dialysis (PD). The modality traction during pronation and supination maneu- choice must be individualized, considering logistical vers. Whenever possible, particularly in the case aspects and the experience of each institution. It is not of intermittent hemodialysis, it is recommended to advisable to implement a new protocol or treatment temporarily disconnect the circuit. Immediately after modality in the midst of the Covid-19 emergency. these maneuvers, the access must be inspected for Unfamiliarity increases the risk of adverse effects, traction, twisting and patency. increases the likelihood of errors, is detrimental to The preferred site for vascular access implanta- patient safety, and poses a higher risk of contamina- tion for RRT is the right internal jugular vein. It is tion to the team. common, however, that this route is no longer avail- able due to the need of multiple simultaneous vas- Continuous renal replacement methods cular lines in patients with severe Covid-19. The left internal jugular vein is the second option. The CRRT represent an efficient and safe treatment strat- femoral access, which is easier to cannulate, may be egy, have an excellent stability profile, is performed inappropriate for patients under pronation protocols in a closed system, and reduce physical contact with or ECMO. Depending on the room layout, femoral the patient. Its preferential use, when available, access can reduce the risk of professional contamina- can decrease the number of nurses and technicians tion at the time of insertion27 and facilitate the posi- exposed to SARS-CoV-2. tioning of the equipment in an area that minimizes the As there is concern about the low worldwide risk of contamination by professionals. availability of kits and supplies for CRRT, and to Dialysis access through subclavian veins is often dis- minimize the team’s contact with infected patients, it couraged, because of the risk of accidents and of resid- is possible to skip scheduled exchange of filters, kits ual stenosis. However, they carry a lower risk of infec- and systems, as long as these remain with optimal tion and may be the only remaining option for patients operational parameters. with inaccessible femoral internal jugular veins, under In some settings, intensive care nurses have ade- ECMO, or following a pronation protocol. quate training and routinely conduct continuous ther- Due to the risks and difficulties associated with apies. This type of organization can reduce the need performing bedside chest x-rays, its routine use for dialysis nurses to enter the isolated areas and help should be reconsidered. In services with availability conserve PPE stocks. In other scenarios, the dialysis and proper training, chest ultrasonography can be nurse prepares the equipment, connects lines and used to confirm the central positioning of the line and solutions and performs the procedure. In this situa- the absence of complications27. tion, machine setup and preparation must be done
26 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):22-31 Technical note and clinical instructions for AKI in patients with Covid-19 outside the patient’s room or outside the isolation During the procedure, we advise the nursing staff ICU. Only afterwards, and properly protected with to avoid remaining inside the patient’s box/room, PPE, should the nurse or technician enter the box/ rather controlling the procedure from the corridor or room to start the procedure. from a nearby area. If he/she needs to enter the box, Once RRT starts, the assigned healthcare profes- we recommend proper paramentation, according to sional must constantly wear PPE, without leaving the the routine established by the unit. treatment unit until the end of the work shift. Should As previously mentioned, we recommend that such professional need to enter the box, he/she must nurses or dialysis technician perform simultaneous wear personal protective clothing, as established by procedures, in order to save PPE in situations of high the institutional’s infection control committee. demand, to reduce the risk of widespread staff con- Units with different arrangements must follow tamination and, particularly, to assure that RRT will official guidelines and develop strategies along the not be denied to all patients who needs it. same safety lines. The underlying logic should always It is advisable that the professional responsible be to minimize the inflow and outflow of profession- for performing RRT eat meals in the ICU, avoiding als and equipment. going out and returning for food. At the end of the procedure, the professional must dispose of all sup- Prolonged or conventional hemodialysis plies safely, by placing them in bags for infectious intermittent modalities substances. Still inside the box/room and donning the Most patients admitted to the ICU will not have PPE, he/she must perform the surface disinfection of access to CRRT, since the number of these machines the equipment and program a chemical disinfection in Brazil is relatively limited. In this sense, the main cycle with peracetic acid. options for extracorporeal treatment will be PIRRT We recommend a second surface cleaning cycle, and IHD, evidently without reprocessing lines in a common area, before using the equipment on and capillaries. another patient. At the end of the daily use of the PIRRT combines operational simplicity, reason- equipment, a final thermal disinfection cycle must be able cost, a good hemodynamic stability profile and carried out, using citric acid or sodium hypochlorite, excellent solute clearance, being widely used in the according to the manufacturer’s recommendations. country. Adaptations to the procedure make it possi- When using tank systems with central dialysate ble to couple a convection component or use high cut- preparations, it must be brought to the ICU door off filters. IHD is the procedure most commonly per- by the professional responsible for the preparation, formed in the hospital environment, especially after and delivered to the dialysis nurse. Before being hemodynamic improvement of critically ill patients. transported to the patient’s bed, the equipment must However, both are not routinely performed by inten- undergo surface disinfection. At the end of the proce- sive care doctors and nurses. dure, there must be a new surface cleaning in the box/ Intermittent methods are usually prescribed room, and the equipment must be brought to the ICU by the nephrologist and conducted by dialysis entrance to be collected by the professional responsi- nurses and/or technicians. In some institutions, ble for its transport. We recommend a second surface these professionals are part of the hospital staff, cleaning cycle at the preparation center. while in others RRT is outsourced. Whichever the case, we recommend avoiding unwanted internal Peritoneal dialysis or interinstitutional circulation of machines and In services with due experience, automated perito- service providers. neal dialysis with a flexible catheter, is a good treat- When facing Covid-19, it is essential to develop ment option, with the potential to reduce the length strategies that minimize occupational exposure and of stay of professionals at the bedside. To meet the spread of SARS-CoV-2. We strongly recommend needs of ultrafiltration, it may be necessary to work the local stationing of equipment and advise against with hypertonic solutions (with a high glucose con- the relocation of the nursing staff from the Covid-19 centration), which can hinder glycemic control and cohort area for the treatment of uninfected patients require the addition of regular insulin to the dialy- during the same work shift. sate bag.
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):22-31 27 Technical note and clinical instructions for AKI in patients with Covid-19
When available, the installation of a flexible cath- Until further information, it is our recommenda- eter using the Seldinger technique can reduce the risk tion that the conventional indicators for RRT imple- of team contamination, enabling the procedure to mentation prevail in treating patients with Covid-19. start more quickly and allowing the adoption of the These include volume control, prolonged anuria/oli- prone position, if necessary. guria, metabolic acidosis, uremia and electrolyte dis- In theory, the increase in abdominal pressure deter- turbances, notably hyperkalemia. mined by the infusion of dialysate may interfere with In view of the risk that RRT intensification could the dynamics of mechanical ventilation in patients result in greater contact and contamination of health- with ARDS that are difficult to manage. In such cases, care workers, cause depletion of consumables and we recommend reserving the PD for a later period, compromise the availability of equipment, it is advis- after the improvement of the ventilatory parameters. able to pay attention to the lack of evidence concern- ing improvements in AKI prognosis when using high Other extracorporeal therapies doses of RRT29,30. Regarding the AKI of Covid-19 patients, our rec- There is the potential to treat Covid-19’s severe hyper- ommendation is that each institution maintains its inflammatory phenotype with more sophisticated policy on RRT dose, without seeking further incre- extracorporeal modalities, which have been shown ments. Evidently, sub-dialysis, whether due to a to decrease the circulating levels of proinflammatory reduction in treatment time or spacing in the interval mediators and other harmful substances, at least in between sessions, should not be practiced. experimental studies. These therapies include devices capable of adsorb- Volume management ing cytokines and high-volume hemofiltration tech- The clinical picture of severe Covid-19 is funda- niques. At present, it is not possible to endorse the mentally dominated by severe acute respiratory syn- use of these approaches, which are in the process of drome (SARS) and associated complications4,25. In clinical experimentation. addressing these cases, there is no consistent infor- mation to guide optimal fluid management. The RRT indication and dosage tendency is to be based on strategies recommended The ideal timing for RRT initiation in patients with for classic ARDS, where only a fraction of the lung critical illness, whether early or according to conven- parenchyma is aerated and the inflammatory lung tional indications at a later moment, is under intense injury is characterized by increased vascular per- investigation. The theoretical rationale for the early meability and diffuse alveolar damage, with an start of RRT consists in preventing homeostatic increase in physiological dead space and decreased imbalances caused by renal dysfunction, which could pulmonary compliance.31,32 help prevent or mitigate AKI complications. Since volume overload and hydrostatic pulmo- In contrast, the "early" start may be unnecessary nary edema are frequent reasons for indicating RRT, and harmful for some patients. In the two largest it should be considered that excessive fluid resuscita- published multicenter studies, AKIKI and IDEAL- tion might precipitate its need, increase the risk of ICU, the result was indifferent in relation to survival. exposure of the workforce and consume resources However, among patients allocated to the late strat- in a situation of scarcity. In this context, it makes egy, 49% of AKIKI and 38% of IDEAL-ICU patients sense to approach volume management in a conser- never came to need RRT28. vative way, which is associated with improved lung During the Covid-19 epidemic, the decision about function and less time on mechanical ventilation and the initiation of RRT must necessarily be shared intensive care, while not increasing the risk of AKI33. between the nephrologist and intensivist, and indi- This strategy has been recommended in pandemic- vidualized for the patient’s particularities. However, related consensuses34,35. we recommend considering whether it is opportune Nonetheless, there is concern about the possibility to expose workers and deplete supplies in the absence that volume restriction strategies may not be suitable of a strong indication for RRT, seeking the unproven for all patients. In fact, there seems to be heteroge- benefit of early intervention. neity of clinical presentation on arrival at healthcare
28 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):22-31 Technical note and clinical instructions for AKI in patients with Covid-19 services, which implies in some patients presenting molecular weight heparin. During citrate anticoagu- with classic ARDS, while others, even with extensive lation, the post-filter ionised calcium target level can pulmonary opacities, due to low intake, vomiting or be decreased. diarrhea, are hypovolemic36. In these patients, adopt- ing a “zero” water balance policy can worsen renal Nephrotoxicity And Drug Dose Adjustments perfusion, accelerate functional loss and increase the Many patients with severe Covid-19 are treated with need for RRT. complex empirical or experimental protocols, which In view of this new knowledge, we recom- combine drugs in poorly studied associations. There mend that the volume management be individu- is a clear risk of toxicity to the kidneys and to other alized, with assessment on a case-by-case basis. organs and systems. We recommend daily monitoring Hypervolemia should not be tolerated, to avoid of renal function biomarkers, including biochemical or minimize the expansion of extravascular pul- parameters, acid-base, fluid and electrolytic balance, monary water. Care should be taken with routine and urine volume and composition. maneuvers in intensive care, such as hydration Nephrotoxicity is not a frequent effect of chloro- maintenance, nutritional support with high volume quine or hydroxychloroquine, but there is a risk of and repeated use of volume responsiveness tests37. serious pharmacological interactions40. There is no In contrast, hypovolemia can decrease pulmonary evidence from a solid source to guide the eventual perfusion, increase dead space, worsen hypoxemia need to adjust the doses of these drugs in patients and increase the adverse effects of positive pressure with kidney disease. After analyzing the available ventilation on renal blood flow. In selected patients, evidence, the Brazilian Society of Nephrology recom- if possible based on consolidated strategies for mended a 50% reduction in the dose of chloroquine guiding volume management, it may be necessary or hydroxychloroquine for patients with advanced to resort to volume expansion maneuvers34,38. kidney dysfunction41. Every patient with AKI requires a daily prescrip- Anticoagulation tion review, discontinuing drugs that are no longer The purpose of anticoagulation during RRT is to needed, identifying undesirable drug interactions and maintain patency of the extracorporeal circuit. adjusting medication doses. Anticoagulation seeks to balance the risk of bleeding against the activation of coagulation by the underly- Recovery of renal function and discontinuation ing disease and by the contact of the blood with the of RRT artificial surfaces of the circuit. The patient flow after recovery from Covid-19 Severe Covid-19 cases can present with hyper- in patients that remains dialysis-dependent is still coagulation, which has been correlated with more unclear, notably the transfer from Covid-19 isolation unfavorable progress39. This coagulopathy can also areas to conventional hospital sectors and/or hospital interfere with RRT provision. Decreased filter and discharge for outpatient dialysis treatment. The pro- extracorporeal circuit lifespan has been reported fre- visional guideline issued by the CDC is not always quently with Covid-1912. applicable to Brazilian hospitals42. In many units, In patients with Covid-19, we recommend that, transfer to Covid-19 free areas have occurred after initially, each service follow its usual anticoagula- 48 hours of absence of fever and respiratory symp- tion routine. When there is concern about a possible toms, in association with negative oral/nasopharyn- hypercoagulable condition and in order not to waste geal RT-PCR for SARS-CoV-2. consumables, we do not recommend to perform Apparently, most patients who manage to over- repeated saline flushing maneuvers to maintain circuit come the critical phase of Covid-19 appear to regain patency without the use of anticoagulants. independent kidney function, but little information is Like any patient with AKI treated with RRT, the available on renal outcomes in patients with Covid- first measure in cases of recurrent filter loss is to 19 complicated by AKI. In AKI associated with isch- check the adequacy of vascular access. If this is not emia/sepsis, patients remain for approximately two the case, it may be necessary to intensify anticoagu- weeks on RRT43-45. In 2003, in patients with SARS, lation, increasing the dose of conventional or low the period of dialysis dependence was longer, three
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):22-31 29 Technical note and clinical instructions for AKI in patients with Covid-19
weeks on average46. Perhaps patients with AKI associ- 13. Larsen CP, Bourne TD, Wilson JD, et al. Collapsing Glo- merulopathy in a Patient With Coronavirus Disease 2019 ated with Covid-19 also need a longer time to wean (COVID-19). Kidney Int Rep 2020; 5. from RRT. In a French series, a third of the patients 14. Ronco C, Reis T, Husain-Syed F. Management of acute kid- were still on dialysis, even three weeks after treatment ney injury in patients with COVID-19. The Lancet Respira- tory Medicine 2020; DOI: 10.1016/S2213-2600(20)30229-0 onset. More time is needed to confirm these prelimi- [Online ahead of print]. nary impressions. 15. Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coro- navirus Disease 2019 in China. N Engl J Med 2020; 382: Weaning strategies for ARS for patients with good 1708-1720. urine output and adequate biochemistry should fol- 16. Rodriguez-Morales AJ, Cardona-Ospina JA, Gutierrez- -Ocampo E, et al. Clinical, laboratory and imaging featu- low the usual practice of each service. Many patients res of COVID-19: A systematic review and meta-analysis. are discharged with improving kidney function but Travel Med Infect Dis 2020; 34: 101623. DOI:10.1016/j. tmaid.2020.101623 still without complete recovery. However, the long- 17. Cheng Y, Luo R, Wang K, et al. Kidney disease is associated term risk of chronic residual kidney disease is still with in-hospital death of patients with COVID-19. Kidney Int unknown. Only over the months will it be possible 2020; 97: 829–838. 18. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical to establish whether there will be a persistent effect of characteristics of 99 cases of 2019 novel coronavirus pneumo- COVID-19 on residual renal function. nia in Wuhan, China: a descriptive study. The Lancet 2020; 395: 507-513. 19. Hu B, Wang D, Hu C, et al. Clinical features of critically ill Outside collaborators patients with COVID-19 infection in China. 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34. World Health O. Clinical management of COVID-19: inte- 41. Nascimento MMd, Moura-Neto JA, Silva AMMd. Nota da rim guidance, 27 May 2020. World Health Organization: Sociedade Brasileira de Nefrologia em relaço ao ajuste das Geneva, 2020. drogas cloroquina e hidroxicloroquina pela funço renal. 35. Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Sociedade Brasileira de Nefrologia: Sao Paulo - SP, 2020. Campaign: guidelines on the management of critically ill adults 42. National Center for Immunization and Respiratory Disea- with Coronavirus Disease 2019 (COVID-19). Intensive Care ses (NCIRD), Division of Viral Diseases. Discontinuation of Med 2020; 46: 854-887. Transmission-Based Precautions and Disposition of Patients 36. Phua J, Weng L, Ling L, et al. Intensive care management of coro- with COVID-19 in Healthcare Settings (Interim Guidance). navirus disease 2019 (COVID-19): challenges and recommenda- Centers for Disease Control and Prevention (CDC), 2020. tions. The Lancet Respiratory Medicine 2020; 8: 506-517. 43. Liaño F, Junco E, Pascual J, et al. The spectrum of acute renal 37. The Australian and New Zealand Intensive Care Society. failure in the intensive care unit compared with that seen in ANZICS COVID-19 Guidelines. Planning for a Pandemic: An other settings. The Madrid Acute Renal Failure Study Group. Operational Guide for Intensive Care Units in Australia and Kidney Int Suppl 1998; 66: S16-24. New Zealand. ANZICS: Melbourne, 2020. 44. Intensity of Renal Support in Critically Ill Patients with Acute Kid- 38. Hasanin A, Mostafa M. Evaluation of fluid responsiveness ney Injury. New England Journal of Medicine 2008; 359: 7-20. during COVID-19 pandemic: what are the remaining choices? 45. Intensity of Continuous Renal-Replacement Therapy in Criti- J Anesth 2020; DOI: 10.1007/s00540-020-02801-y [Online cally Ill Patients. New England Journal of Medicine 2009; 361: ahead of print]. 1627-1638. 39. Tang N, Li D, Wang X, et al. Abnormal coagulation para- 46. Chu KH, Tsang WK, Tang CS, et al. Acute renal impairment meters are associated with poor prognosis in patients with in coronavirus-associated severe acute respiratory syndrome. novel coronavirus pneumonia. J Thromb Haemost 2020; Kidney Int 2005; 67: 698-705. 18: 844-847. 47. Rubin S, Orieux A, Prevel R, et al. Characterisation of 40. Ducharme J, Farinotti R. Clinical Pharmacokinetics and Meta- Acute Kidney Injury in Critically Ill Patients with Severe bolism of Chloroquine. Clinical Pharmacokinetics 1996; Coronavirus Disease-2019 (COVID-19). medRxiv 2020: 31: 257-274. 2020.2005.2006.20069872.
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):22-31 31 Recommendations | Recomendações
Recommendations Of The Brazilian Society Of Nephrology Regarding Pediatric Patients On Renal Replacement Therapy During The Covid-19 Pandemic Recomendações da Sociedade Brasileira de Nefrologia para Pacientes Pediátricos em Terapia de Substituição Renal Durante a Pandemia Covid-19
Authors Abstract Resumo Marcelo de Sousa Tavares1,3 Maria Goretti Moreira Introduction: The impact of the new Introdução: O impacto do novo Guimarães Penido1,3,4 coronavirus (SARS-COV-2) and its coronavírus (SARS-CoV-2) e as suas Olberes Vitor Braga de worldwide clinical manifestations manifestações clínicas (Covid-19) em Andrade1,5 (COVID-19) imposed specific regional todo o mundo impôs recomendações Vera Hermina Kalika Koch1,6 recommendations for populations in regionais específicas a populações que Rejane de Paula Bernardes1,7 need of specialized care, such as children necessitam de cuidados especializados, Clotilde Druck Garcia2,8,9 and adolescents with kidney diseases, como crianças e adolescentes com doenças José A. Moura-Neto3 particularly in renal replacement therapies renais, particularmente em terapias de Marcelo Mazza Nascimento4,11 (RRT). We present the recommendations substituição renal (TRS). Apresentamos as Lilian Monteiro Pereira Palma1,2,12 of the Brazilian Society of Nephrology recomendações da Sociedade Brasileira de regarding the treatment of pediatric Nefrologia em relação ao tratamento de 1Sociedade Brasileira de Nefrologia, patients with kidney diseases during pacientes pediátricos com doenças renais Departamento de Nefrologia the COVID-19 pandemic. Methods: durante a pandemia Covid-19. Método: Pediátrica, São Paulo, SP, Brazil. 2Associação Brasileira de Articles and documents from medical Foram avaliados e analisados os artigos Transplante de Órgãos, societies and government agencies on e documentos sobre recomendações Departamento de Transplante specific recommendations for children específicas para Covid-19 de sociedades Pediátrico, São Paulom SP, Brazil. 3Santa Casa de Belo Horizonte, on RRT in relation to COVID-19 as médicas e órgãos governamentais sobre Unidade de Nefrologia Pediátrica, well as those focused on epidemiological crianças em TRS, bem como aqueles Belo Horizonte, MG, Brazil. aspects of this condition in Brazil Were focados em aspectos epidemiológicos 4Universidade Federal de Minas Gerais, Faculdade de Medicina, evaluated and analyzed. Results: We dessa condição no Brasil. Resultados: Belo Horizonte, MG, Brazil. present recommendations on outpatient Apresentamos as recomendações sobre 5Santa Casa de São Paulo, care, transportation to dialysis centers, atendimento ambulatorial, transporte Faculdade de Ciências Médicas, Unidade de Nefrologia Pediátrica, peritoneal dialysis, hemodialysis, and para centros de diálise, diálise peritoneal, São Paulo, SP, Brazil. kidney transplantation in children and hemodiálise e transplante renal em crianças 6Universidade de São Paulo, adolescents during the COVID-19 e adolescentes durante a pandemia de Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, pandemic in Brazil. Discussion: Despite Covid-19 no Brasil. Discussão: Apesar São Paulo, SP, Brazil. initial observations of higher mortality das observações iniciais de taxas de 7Clínica Nefrokids, Curitiba, PR, Brazil. rates in specific age groups (the mortalidade mais altas em grupos etários 8Santa Casa de Porto Alegre, Unidade de Nefrologia Pediátrica, elderly) and with comorbidities (obese, específicos (idosos) e com comorbidades Porto Alegre, RS, Brazil. diabetics, and those with cardiovascular (obesos, diabéticos e aqueles com doenças 9Universidade Federal de Ciências diseases), patients with chronic kidney cardiovasculares), pacientes com doença da Saúde de Porto Alegre, Porto Alegre, RS, Brazil. disease (CKD) on RRT are particularly renal crônica (DRC) em TRS apresentam 10Nefrologista Grupo CSB, prone to develop COVID-19. Specific risco significativo de evoluir com Salvador, BA, Brazil. measures must be taken to reduce Covid-19. Medidas específicas devem ser 11 Universidade Federal do Paraná, Curitiba, PR, Brazil. the risk of contracting SARS-CoV-2 tomadas para reduzir o risco de contrair 12Universidade Estadual de and developing COVID-19, especially SARS-CoV-2 e desenvolver a Covid-19, Campinas, Campinas, SP, Brazil. during transport to dialysis facilities, as principalmente durante o transporte well as on arrival and in contact with para instalações de diálise, bem como na other patients. chegada e no contato com outros pacientes. Keywords: Coronavirus; SARS-CoV-2; Palavras-chave: Coronavírus; SARS-CoV-2; COVID-19; Pediatric; Hemodialysis; Covid-19; Pediátrico; Hemodiálise; Correspondence to: Peritoneal dialysis; Kidney transplant; Diálise Peritoneal; Transplante Renal; Marcelo de Sousa Tavares Immunosuppression; Recommendations Imunossupressão; Recomendações. E-mail: [email protected]
DOI: 10.1590/2175-8239-JBN-2020-S108
32 Recommendations Regarding Pediatric Patients On Renal Replacement Therapy
Introduction Recommendations The pandemic involving the new coronavirus The care for pediatric patients involves many family SARS-CoV-2 and its clinical manifestations (COVID- and social aspects that should be considered by the 19) to the World Health Organization recommend- Nephrology Center, which, in turn, must also be a ing procedures in order to limit the spread as well as center for continuing education regarding knowledge minimize the sudden and increasing lethality in dis- in all aspects of the COVID-19 pandemic, including tinct population groups. The Department of Pediatric isolation, prevention, and waste disposal at home. Nephrology of the Brazilian Society of Nephrology (SBN in Portuguese) prepared this manuscript regard- Patients on Hemodialysis ing recommendations for children and adolescents Transport to dialysis facilities by bus or other mode with kidney diseases and their respective families to provided by health authorities (with other patients) mitigate the risk of acquiring and spreading the dis- is a common practice by children and their families. ease in Brazil. 1. Transportation to dialysis facilities should be In Brazil, different profiles of children with provided by health authorities when not pos- chronic kidney disease (CKD) were described by sible by the patient/family; standing patients Konstantiner et al1 (2015) emphasizing that areas during transport should not be allowed. The with lower social and economic indexes have following procedures are recommended during unsatisfactory access to medical facilities, which transport to dialysis facilities10,11: is corroborated by a higher proportion of patients 1.1. Use of cloth face covering or surgical mask with undefined etiology for CKD in such areas. Fernandes et al2 (2010) have reported that as much when available, even in asymptomatic patients as 30% of patients live more than 50 km away from and accompanying persons. Potential virus the referral Nephrology center. spreading should be minimized even during Each country has its own particularities regarding transport. A medical/surgical mask must be the management of COVID-19 in children and ado- used by anyone who has respiratory symp- lescents with kidney diseases. Nephrology Societies toms; hand hygiene should be performed after around the globe have adapted WHO recommen- disposing of the mask; dations3 to local conditions and realities, such as 1.2. Social distancing (at least 1 m) from individu- the Sociedad Española de Nefrología4, the British als with respiratory symptoms. 5 Association for Paediatric Nephrology , the EUDIAL 2. The frequency of dialysis sessions should be 6 Working Group of ERA-EDTA , the Chinese Society maintained as prescribed by the medical staff. 7 of Pediatric Nephrology , and the National Kidney We strongly recommend that patients do not 8 Foundation . The Brazilian Society of Nephrology is skip or shorten dialysis sessions. the main medical society involved in the care of this pediatric population on dialysis and nephrology care. 3. In hemodialysis clinics, patients and families The present article summarizes the main recommen- should be actively asked about respiratory dations for specific care and management of children complaints and symptoms of COVID-19 (fever, and adolescents with chronic kidney disease, dialysis, cough, sore throat, shortness of breath, muscle transplantation, and under immunosuppression dur- aches, malaise) before entering the treatment ing the COVID-19 pandemic. area. Body temperature measurement is strongly The present recommendations are based on doc- recommended. According to health status and uments of the Brazilian Society of Nephrology and respiratory complaints at arrival, the following Brazilian Association of Organ Transplantation procedures should be considered to all patients: (ABTO)9, both dated March 16th, 2020, and are in 3.1. Symptomatic, suspected, or COVID-19 con- accordance with the Technical Note of the Brazilian firmed: patients should be dialyzed in the last Agency of Sanitation Surveillance (ANVISA) session of the usual scheduled dialysis day n.04/2020 from March 21st, 2020, and based on a preferably and when possible at a dedicated brief review of medical literature and recommenda- COVID-19 dialysis unit; they should wear dis- tions of other medical societies. posable surgical masks. Health professionals
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):32-35 33 Recommendations Regarding Pediatric Patients On Renal Replacement Therapy
Figure 1. Flow chart of management of suspect and confirmed cases of COVID-19 in pediatric patients on hemodialysis facilities.
At arrival Prior to arrival: ith symptoms Clinical assessment ontact acility e ore arri al hec or e er co gh shortness o reath sore throat
Dialysis in regular shift Patient should wear a disposable mask oid nnecessary contact and be evaluated in an isolated room no yes and cleaning ash hands o gh toilette ait or clinical e al ation pro ide tiss es lean room a ter patient lea es Send to mergency e er Proper R g idelines yes ritical signs hortness A PATI NTS ample collection o reath oid gatherings and nnecessary oti y a thorities no o O isit to hospital sat ration n orm team i symptoms o O are present or i had DIA SIS IN ISO ATION AST SHIFT contact ith symptomatic people Patient ith disposa le mas eet distance e ore attending sessions o re se o material acility disin ection PP or personnel re ent hand cleaning PP for personnel ITH direct contact PP for personnel (including cleaning staff): ITHOUT direct contact: If there are multiple cases, isposa le go n and s rgical mas hite coat a dedicated shift should i proced re creates aerosol rgical mas hand cleaning be considered Protection googles shield glo es head cap aintain eet distance
should wear N95 or FFP2 masks when avail- 3.4. The Nephrology team should be informed if able (or disposable surgical masks otherwise), someone in the patient’s home has had recent eye protection (goggles or face shield), gloves, respiratory symptoms. and gown. Lines and materials should be dis- charged to avoid contamination of personnel Patients with Chronic Kidney Disease under evaluation for a Kidney Transplant involved with reuse. At the present time, Brazil is under quarantine and 3.2. A minimal distance of 1 m between patients the urge for kidney transplantation must be evalu- should be kept and unnecessary contact ated on an individual basis, according to the Brazilian avoided. Ideally, COVID-19 confirmed or sus- Association of Organ Transplantation recommenda- pected cases should be dialyzed in the same tions. Donor and recipient must be considered at risk. dialysis machines in the subsequent sessions; 3.3. Asymptomatic and non-suspicious patients: Pediatric Kidney Transplant Recipients following WHO recommendations, hand In order to minimize the exposure to the virus, non- hygiene should be done frequently with an emergency consultations and hospital visits should be alcohol-based hand rub if hands are not vis- avoided. Use of a surgical mask when at hospitals or for blood sampling is advisable. In case of respiratory ibly dirty or with soap and water if hands are symptoms and/or fever, the transplantation center dirty; touching eyes, nose, and mouth should must be communicated. In confirmed cases, the same be avoided; respiratory hygiene should be procedures as for children with COVID-19 on dialysis practiced by coughing or sneezing into a should be followed: health professionals should wear bent elbow or tissue and then immediately N95 or FFP2 masks preferably (or disposable surgi- disposing of the tissue. The immunization cal masks), eye protection (goggles or face shield), schedule should be up-to-date (especially gloves, and gown. Immunosuppression therapy will against influenza); be changed according to the Center’s preferences.
34 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):32-35 Recommendations Regarding Pediatric Patients On Renal Replacement Therapy
The most common approach is stopping the anti- neal dialysis in Brazil: analysis of a cohort of 5,819 patients (BRAZPD). J Bras Nefrol. 2010 Jul-Sep;32(3):268-74. metabolite drug. In vitro studies showed that calcineu- 3. World Health Organization (2020). Rational use of per- rin inhibitors may play a protective role in coronavi- sonal protective equipment for coronavirus disease 2019 rus infections12. Clinical evidence of this approach for (Covid-19). Available at https://apps.who.int/iris/bits- tream/handle/10665/331215/WHO-2019-nCov-IPCPPE_ COVID-19 remains to be defined. Hospital admission use-2020.1-eng.pdf?sequence=1&isAllowed=y is advisable in specific cases. 4. de Sequera Ortiz P, Quiroga Gili B, de Arriba de la Fuente G, Macía Heras M, Salgueira Lazo M, Del Pino Y Pino MD; en representa- ción de la Sociedad Española de Nefrología. Protocol against coro- Pediatric Patients on Peritoneal Dialysis (PD) navirus diseases in patients on renal replacement therapy: Dialysis and kidney transplant. Nefrologia. 2020 May-Jun;40(3):253-257. Children and adolescents on PD with fever and/or English, Spanish. doi: 10.1016/j.nefro.2020.03.001. respiratory symptoms must notify the referral cen- 5. The Renal Association. Coronavirus (SARS-CoV-2) and its associated illness (COVID-19): Information and Guidance for ter. The patient’s condition must be reviewed and the Children on Haemodialysis, Peritoneal Dialysis and Immune dialysate aspect has to be evaluated (fever can be the suppression (including Renal Transplants). https://renal.org/ only initial sign of peritonitis). Social isolation for at wp-content/uploads/2020/03/BAPN-COVID-19-patient-info- -for-HD.PD_.Immunosuppression-17March20.pdf. least 14 days is recommended (including from house 6. Basile C, Combe C, Pizzarelli F, Covic A, Davenport A, Kan- contacts). Dyspnea should be promptly evaluated in bay M, Kirmizis D, Schneditz D, van der Sande F, Mitra S. Recommendations for the prevention, mitigation and contain- the dialysis facility, and the health staff should be ment of the emerging SARS-CoV-2 (Covid-19) pandemic in notified of the patient’s arrival in order to minimize haemodialysis centres. Nephrol Dial Transplant. 2020 May 1;35(5):737-741. doi: 10.1093/ndt/gfaa069. contamination risks at the unit. The delivery team 7. Shen Q, Wang M, Che R, Li Q, Zhou J, Wang F, Shen Y, Ding (for dialysis materials) should be warned in order to J, Huang S, Yap HK, Warady BA, Xu H, Zhang A; Chinese minimize contact (avoid entering the patient’s house, Society of Pediatric Nephrology and Chinese Medical Doctor Association of Pediatric Nephrology. Consensus recommenda- use of surgical mask, and handwashing by the driver/ tions for the care of children receiving chronic dialysis in asso- delivery team is strictly recommended). ciation with the Covid-19 epidemic. Pediatr Nephrol. 2020 Apr 24. doi: 10.1007/s00467-020-04555-x. 8. National Kidney Foundation. Dialysis & Covid-19. Availa- Conclusions ble at https://www.kidney.org/coronavirus/dialysis-covid-19. Downloaded April 26th, 2020. Considering the continental proportion of Brazil, 9. Comissão De Infecção Em Transplantes, Associação Bra- sileira De Transplantes De Órgãos Abto. Novo Coro- regional differences will demand emphasis on spe- navírus – SARS-COV-2. Recomendações no Cenário de cific aspects of nephrology care of pediatric patients, Transplantes de Órgãos Sólidos. Atualização 16/03/2020. mainly outpatient dialysis units (such as during trans- Downloaded April 26th, 2020. http://www.abto.org.br/ abtov03/Upload/file/Coronavi%CC%81rus%20-%20 port). The interface between the health team and Recomendac%CC%A7o%CC%83es.pdf [in portuguese] patients on any form of RRT should be maintained 10. Center for Disease Control and Prevention. Interim Additio- nal Guidance for Infection Prevention and Control Recom- and strengthened during the pandemic. The pres- mendations for Patients with Suspected or Confirmed ent recommendations will need to be updated in the Covid-19 in Outpatient Hemodialysis Facilities. Downloa- ded at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ future as more research on COVID-19 is conducted. dialysis.html?CDC_AA_refVal=https%3A%2F%2Fwww. cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare- References -facilities%2Fdialysis.html, April 27th, 2020. 11. Kliger AS, Silberzweig J. Mitigating Risk of Covid-19 in Dialy- 1. Konstantyner T, Sesso R, De Camargo MF, De Santis Fel- sis Facilities. Clin J Am Soc Nephrol. 2020 May 7;15(5):707- tran L, Koch-Nogueira PC. Pediatric chronic dialysis in 709. doi: 10.2215/CJN.03340320. Brazil: Epidemiology and regional inequalities. PLoS One. 12. Willicombe M, Thomas D, McAdoo S. Covid-19 and Calci- 2015;10(8):1–15. neurin Inhibitors: Should They Get Left Out in the Storm? 2. Fernandes NM, Chaoubah A, Bastos K, Lopes AA, Divino- J Am Soc Nephrol. 2020 Apr 20. pii:ASN.2020030348. -Filho JC, Pecoits-Filho R, Bastos MG. Geography of perito- doi: 10.1681/ASN.2020030348.
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):32-35 35 Recommendations | Recomendações
COMDORA-SBN recommendations for patients with rare kidney diseases in relation to the Covid-19 pandemic Recomendações do COMDORA-SBN a pacientes portadores de doenças renais raras em relação à pandemia de Covid-19
Authors Abstract Resumo Vinícius Sardão Colares1 Silvana Maria Miranda2 During the Covid-19 pandemic, the Durante a pandemia da Covid-19, fica a Luis Gustavo Modelli de Andrade3 issue is how to maintain adequate questão de como manter o atendimento Lilian Monteiro Pereira Palma4 care for people with other diseases. In adequado aos portadores de outras Maria Cristina Ribeiro de Castro5 this document, the SBN Rare Diseases doenças. O Comitê de Doenças Raras Cassiano Augusto Braga Silva6 Committee (COMDORA) gives some (COMDORA) da SBN neste documento guidelines on the care of patients with dá algumas orientações ao atendimento de Maria Goretti Moreira Guimarães Penido7 rare kidney diseases. These patients pacientes com doenças renais raras. Estes Roberta Sobral8 should follow the recommendations pacientes devem seguir as recomendações Maria Helena Vaisbich9 for the general population, bearing in destinadas à população geral tendo em mind that, as they have chronic kidney mente que, por serem portadores de 1Santa Casa de Misericórdia de disease, they are included in the risk doença renal crônica, estão incluídos Juiz de Fora, Juiz de Fora, MG, group for more serious outcomes if no grupo de risco para desfechos mais Brazil. they develop Covid-19. Non-essential graves, caso venham a desenvolver a 2Santa Casa de Belo Horizonte, decision-making procedures should Covid-19. Procedimentos não essenciais Belo Horizonte, MG, Brazil. be postponed. In stable cases under para tomada de decisão devem ser adiados. 3Universidade Estadual Paulista, Faculdade de Medicina, Botucatu, appropriate treatment, we must choose Deve-se optar por contatos a distância, SP, Brazil. to contact our patients remotely, using como teleconsultas, e coletas de exames 4Universidade Estadual de teleconsultations and home exam domiciliares (se possível) nos casos estáveis Campinas, Campinas, SP, Brazil. collections (if possible). In the presence sob tratamento adequado. Na presença 5 Universidade de São Paulo, of a symptom or sign of decompensation de sintoma ou sinal de descompensação Unidade de Transplante Renal, São Paulo, SP, Brazil. of the underlying disease, or infection da doença de base ou infecção pelo Sars- 6Grupo CSB, Departamento de with Sars-cov-2, advise the patient to cov-2, orientar o paciente a procurar Nefrologia, Feira de Santana, BA, seek medical assistance. The patient a equipe médica. O paciente não deve Brazil. should not be waiting to get worse. ficar esperando o quadro agravar-se. 7 Santa Casa de Belo Horizonte, Changes to the prescription should Alterações na prescrição só devem ser Unidade de Nefrologia Pediátrica, Belo Horizonte, MG, Brazil. only be made on a scientific basis. feitas com embasamento científico. Não 8Universidade Federal da Bahia, Dosage suspension or change is not se recomenda a suspensão ou alteração Nefrologia Pediátrica, Salvador, recommended, even in cases in which the posológica, mesmo nos casos em que o BA, Brazil. patient needs to go to a center to receive paciente necessita ir a um centro para 9 Universidade de São Paulo, his medication; in this case, the infusion receber sua medicação; neste caso o centro Instituto da Criança, São Paulo, SP, Brazil. center must follow the recommendations de infusão deve seguir as recomendações of the Ministry of Health. If the patient do Ministério da Saúde. Caso o paciente develops Covid-19 and uses any drugs, desenvolva a Covid-19 e faça uso de alguma check the need for dose adjustment droga, verificar a necessidade de ajuste nas of the routine medications. Avoid the doses dos medicamentos rotineiros. Evitar use of antimetabolics and anti-CD20 o uso de antimetabólicos e antiCD20 nos in patients with Covid-19, as they pacientes com a Covid-9, por reduzirem o reduce viral clearance and predispose to clareamento viral e predisporem a infecções bacterial infections. Contact between the bacterianas. O contato entre paciente e patient and the medical team is essential; equipe médica é essencial; alterações são changes are recommended only with recomendadas apenas com orientação Correspondence to: specialized medical guidance. médica especializada. Maria Helena Vaisbich E-mail: [email protected] / Keywords: Chronic kidney disease, rare Palavras-chave: Doença Renal Crônica; [email protected] diseases, Covid-19, Sars-cov-2. Doenças Raras; Covid-19; Sars-cov-2. DOI: 10.1590/2175-8239-JBN-2020-S109
36 Recommendations for patients with rare kidney diseases
1. General recommendations • Instruct the patient to contact the medical team if symptoms suggestive of SARS-CoV-2 infec- • Social isolation. tion occur, so that he/she can receive instruc- • Thoroughly sanitize hands with water and soap tions regarding the need to go to a medical ser- (liquid or foam), or alcohol gel with a final con- vice for clinical, laboratory or imaging exam, centration of 70%. or any intervention if necessary. THE PATIENT • Wear a protective mask in public environments SHOULD NOT WAIT FOR THE SYMPTOMS in general. Look for guidelines as to the type TO WORSEN AND THEN LOOK FOR of fabric used to make the mask, its durabil- MEDICAL ASSISTANCE. ity and the possibility of being properly reused The symptoms seen in transplanted patients using or discarded. immunosuppressants and who developed Covid-19 • If you need to cough or sneeze the moment were similar to those in the general population, as per you are without the mask, cover your nose and shown in Table 12,3,4. mouth with your flexed elbow or tissue (and discard it immediately after use). • Use disposable tissue for nasal hygiene (dispose Table 1 Symptoms and signs at the clinical of it immediately after use and perform hand presentation of patients with Covid-19 hygiene). in the general population and in • Avoid touching mucous membranes of the eyes, immunocompromised patients: reference nose and mouth - if necessary, perform hand data compilation2,3,4 Signs/ General hygiene previously. Immunosuppressed** symptoms population • Keep the rooms ventilated. Fever 88 – 99 % 70 and 87 % • Keep clean those surfaces that can be touched Dry cough 59 – 68 % 59 and 67 % frequently (cell phones, computers, door han- Fatigue 38 – 70 % 28 and 60 % dles, etc.). Anorexia 40 % ----- Myalgia 15 – 35 % 13 % 2. How to handle cases of patients with rare kidney diseases during the pandemic Dyspnea 19 – 31 % 27 and 43 % Diarrhea ----- 3 and 20 % • The most important thing is not to lose contact ** Data taken from two case series of transplanted patients with the patient and have a channel available undergoing immunosuppression, with 90 and 15 patient, respectively. for the patient or family to make contact with the medical team. Therefore, keep the patient’s contact updated in the medical record. • Assess, on a case-by-case basis, the possibility • Postpone, if possible, in-person medical consulta- of initiating immunosuppression in the indi- tions and collection of non-essential tests. Use tele- cated cases and try to postpone it in patients medicine and, if possible, blood collection at home1. in whom this is possible (stable renal function, • Instruct the patient to make contact with the oligosymptomatic patients, without risk of sig- medical team to receive the guidelines, or the 1 professional himself can make contact with the nificant complications) . patient to pass on the guidelines. • At this time of the Covid-19 pandemic, renal • Carry out face-to-face consultations and tests biopsy for diagnostic clarification should be when there are doubts about the patient’s evo- performed only in critical cases for decision- lution, or if new symptoms or signs arise. making purposes. Protocol biopsies should 1 • Instruct the patient to seek medical care if he be postponed . has any symptoms related to decompensation • Patients with glomerular diseases, in which the of the underlying disease or any complication delay in immunosuppressive treatment may that may be related to the treatment of the determine worsening of renal function, this underlying disease. should be promptly instituted, as, for example,
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):36-40 37 Recommendations for patients with rare kidney diseases
in patients with SLE classes III and IV, or in the blood pressure, as well as worsening cardiac case of rapidly progressive glomerulonephritis, function in patients with insufficiency. Studies as well as in patients with active nephrotic syn- have shown no association between the use drome, symptomatic and at risk for thrombo- of SARS inhibitors and a higher likelihood embolic phenomena1. of contracting SARS-CoV-2 or developing • Avoid the use of anti-CD20 therapy, such as Covid-19; there is data showing that SARS rituximab, since there are but a handful of inhibitors improve clinical outcomes in hyper- reports in the literature, and patients with low tensive patients with Covid-196. levels of immunoglobulin have a higher risk of • Patients taking specific medications at referral secondary infection and less viral clearing1. centers (such as Fabry’s disease and atypical • Patients compensated for glomerulopathy hemolytic-uremic syndrome [AHUS]) should under immunosuppression should not have continue treatment. Infusion centers must fol- their medication suspended, due to the risk low the protocols established by the Ministry of recurrence. If possible, maintain the treat- of Health. ment with the same doses of immunosuppres- • According to new knowledge, severe and fatal sants or reduce slowly, when indicated, moni- cases may be more likely to develop thrombotic toring side effects and clinical and laboratory microangiopathy through pathogenic activa- evolution, in order to avoid decompensation tion of the complement system7. Therefore, and the need for hospitalization1. The home there is contraindication to change the dos- use of test tape or test with sulfosalicylic acid age of eculizumab administration in patients or trichloroacetic acid to assess proteinuria is using this medication, such as those with very appropriate, as it can alert you early on AHUS or paroxysmal nocturnal hemoglobin- the loss of proteins, before the patient clini- uria. A clinical study is even underway using cally decompensates. In this case, the patient complement inhibition as an alternative to should be instructed to contact the medical treat Covid-198. team promptly. • In all rare kidney diseases in which the patient • The attending physician must individually uses specific medications for his treatment, it assess the possibility of early weaning and must be maintained in the recommended dos- suspension of immunosuppression in cases age schedule, unless there is any interaction of stable patients in complete remission of with drugs used to treat Covid-19. the underlying disease and without immedi- • Non-hormonal anti-inflammatory drugs (ibu- ate risk of relapse. Do not abruptly suspend profen, diclofenac, ketoprofen, among others) corticosteroids, due to the risk of adrenal should not be used due to the risk of acute kid- insufficiency. ney injury, use only dipyrone or paracetamol. • In infected patients, when desired to reduce the dose of prednisone, a reduction of 0.2 mg/kg/ 3. Instructions on the interaction of day is indicated1. medications used by the patient and medications • In infected patients, watch the lymphocyte that may be used in selected Covid-19 cases. count and discontinue cytotoxic and antimeta- There are several treatments being tested to treat bolic medications1. Covid-19 and its complications. The physician seeing • There is no evidence for suspending renin- patients with rare kidney diseases needs to assess a angiotensin-aldosterone system (RAAS) possible interaction between the drugs routinely used inhibitors, such as ACEI or BRA. These drugs by the patient and the drugs/treatments used to treat must be maintained5, as withdrawal can lead Covid-199. to renal and/or cardiological decompensa- Figure 1 shows studies registered in the Clinical tion, with increased levels of proteinuria and Trials for the treatment of Covid-19.
38 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):36-40 Recommendations for patients with rare kidney diseases
Figure 1. Studies registered in the Clinical Trials for the treatment 6 mg for 10 days, compared to 4,321 patients of Covid-19. Reproduced with the permission of the author - L.G.M. de Andrade. in the placebo group (usual treatment) in a ran- domized design. In patients on mechanical ven- t dies Re istred in inica ria s to treat tilation, there was a 35% reduction in mortality ydro ych oro ine (RR 0.65 [95% CI: 0.48 - 0.88], p = 0.0003) oci i ma r s and a 20% reduction in mortality in patients in opina ir accine a Remdesi ir h oro ine a need of oxygen (RR 0.8 [ 95% CI: 0.67 - 0.96], a p asma a ipira ir ydro ych oro ine a p = 0.0021). No benefit was found in patients itric ide opina ir a itamin ethy predniso ene a without the need for oxygen or ventilatory sup- h oro ine itric ide a port (RR 1.2 (95% CI: 0.86 - 1.75), p = 0.14). ethy predniso ene p asma a Remdesi ir a So far, although results are not yet available in itamin oci i ma a a ipira ir itamin a a peer-reviewed publication, the results show a accine itamin a survival benefit with the prevention of one death
for every 8 patients and one death in 25 of the ota patients who needed oxygen supplementation12. Source:
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):36-40 39 Recommendations for patients with rare kidney diseases
» Remdesivir: Little is known about the interac- plant Recipients in New York. JASN 2020;31. doi:10.1681/ ASN.2020030375. tion of this drug with immunosuppressive agents 3. Joseph T on behalf of International Pulmonologist’s Consensus or other medications. Thus, it is important to On Covid-19. 2nd Edition. Published on 22nd April 2020. 4. Pereira MR, Mohan S, Cohen DJ, Husain SA, Dube GK, Rat- remember that remdesivir is being used as a ner LE et al. Covid-19 in Solid Organ Transplant Recipients: research drug. There are still no pharmacokinetic Initial Report from the US Epicenter. Am J Transplant 2020. doi: 10.1111/AJT.15941. studies in patients with impaired renal or liver 5. Vaduganathan M, Vardeny O, Michel T, McMurray JJV, function. The recommendation, when used, is to Pfeffer MA, Solomon SD. Renin–Angiotensin–Aldosterone System Inhibitors in Patients with Covid19. N Engl J Med monitor the glomerular filtration rate and liver 2020;382(17):1653-1659. doi: 10.1056/NEJMsr2005760. function tests, remembering that urinary excre- 6. Meng J, Xiao G, Zhang J, He X, Ou M, Bi J, Yang R, Di W, tion is approximately 74%, 49% as remdesivir Wang Z, Li Z, Gao H, Liu L, Zhang G. Renin-angiotensin system inhibitors improve the clinical outcomes of Covid-19 triphosphate metabolite, and 18% in feces14. patients with hypertension, Emerging Microbes & Infections 2020; 9:1, 757-760. doi: 10.1080/22221751.2020.1746200. 7. Su H, Yang M, Wan C, Yi LX, Tang F, Zhu HY, et al. Renal 4. Differential diagnosis histopathological analysis of 26 postmortem findings of patients with Covid-19 in China. Kidney International 2020. Do not forget about other flu-like syndromes that can doi: 10.1016/j.kint.2020.04.003. potentially also be involved in the complement system 8. Campbell CM, Kahwash R. Will Complement Inhibition be the New Target in Treating Covid-19 Related Systemic activation, as in the case of the H1N1 influenza virus15. Thrombosis? Circulation 2020. doi.10.1161/CIRCULATIO- NAHA.120.047419. 9. Kalil AC. Treating COVID-19-Off-Label Drug Use, Compas- 5. Vaccination schedule sionate Use, and Randomized Clinical Trials During Pande- mics. JAMA. 2020 Mar 24. doi: 10.1001/jama.2020.4742. It is recommended that patients keep the vaccination 10. Grein J, Ohmagari N, Shin D, Diaz G, Asperges E, Castagna schedule up to date and receive the influenza vaccine. A et al. N Engl J Med 2020. doi: 10.1056/NEJMoa2007016. 11. FDA. Coronavirus (COVID-19) Update: FDA Issues Emer- gency Use Authorization for Potential COVID-19 Treatment. Collaborators https://www.fda.gov/news-events/press-announcements/coro- navirus-covid-19-update-fda-issues-emergency-use-authoriza- Lucimary Sylvestre, Fellype Barreto, Maria Izabel de tion-potential-covid-19-treatment. 12. Oxford University News Release. 16 June 2020. Low-cost Holanda, David José Machado, Valéria S P Veloso, dexamethasone reduces death by up to one third in hospitalised Patrícia Pontes and Gilson Bianchini. patients with severe respiratory complications of COVID-19. Acessed at: https://www.recoverytrial.net/news/low-cost-dexa- methasone-reduces-death-by-up-to-one-third-in-hospitalised- References -patients-with-severe-respiratory-complications-of-covid-19. 13. University of Liverpool. Cocvid-19 Drug Interactions. 1. Bomback AS, Canetta PA, Ahn W, Ahmad SB, Radhakrishnan http://www.covid19-druginteractions.org/ J, Appel GB. How Covid19 has changed the management of 14. FDA. Fact Sheet for Health Care Providers EUA of Remdesivir. glomerular diseases. CJASN 2020;15. https://doi.org/10.2215/ https://www.fda.gov/media/137566/download. CJN.04530420]. 15. Bitzan M, Zieg J. Influenza-associated thrombotic microan- 2. The Columbia University Kidney Transplant Program. Early giopathies. Pediatr Nephrol. 2018;33(11):2009-2025. Description of Coronavirus 2019 Disease in Kidney Trans- doi:10.1007/s00467-017-3783-4
40 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):36-40 Recommendations | Recomendações Hemodialysis Vascular access maintenance in the Covid-19 pandemic: Positioning paper from the Interventional Nephrology Committee of the Brazilian Society of Nephrology Manutenção de acessos vasculares para hemodiálise na pandemia da Covid-19: posicionamento do Comitê de Nefrologia Intervencionista da Sociedade Brasileira de Nefrologia
Authors Abstract Resumo Ricardo Portiolli Franco1 Ciro Bruno Silveira Costa2,3 Vascular accesses for hemodialysis are Os acessos vasculares para hemodiálise são Clayton Santos Sousa5 considered the patient’s lifeline and their considerados a linha da vida do paciente, Anderson Tavares Rodrigues6,7 maintenance is essential for treatment e sua manutenção é essencial para o Precil Diego Miranda de continuity. Following the example of seguimento do tratamento. A exemplo Menezes Neves8,9 institutions in other countries affected de instituições de outros países atingidos Domingos Candiota Chula1,4 by the Covid-19 pandemic, the Brazilian pela pandemia da Covid-19, a Sociedade Society of Nephrology developed these Brasileira de Nefrologia elaborou estas 1 Fundação Pró-Renal, Centro guidelines for healthcare services, orientações para os serviços de saúde, de Nefrologia Intervencionista, elaborating on the importance of esclarecendo a importância da realização dos Curitiba, PR, Brazil. carrying out procedures for the procedimentos de confecção e preservação 2 Clínica TRS, Nefrologia e preparation and preservation of vascular de acessos vasculares. Consideramos como Hemodiálise, Goiânia, Goiás, Brazil. 3 Hospital de Acidentados, accesses. Creating definitive accesses for não eletivos os procedimentos de confecção Goiânia, Goiás, Brasil. hemodialysis, grafts and arteriovenous de acessos definitivos para hemodiálise, 4 Universidade Federal do Paraná, fistulas are non-elective procedures, próteses e fístulas arteriovenosas, bem Hospital de Clínicas, Curitiba, PR, as well as the transition from the use como a transição do uso de cateteres não Brazil. of non-tunneled catheters to tunneled tunelizados para cateteres tunelizados, os 5 Nefrocare Goiânia, GO, Brazil. 6 Pró-Renal Centro de Nefrologia, catheters, which cause less morbidity. quais acarretam menor morbidade. Nos Barbacena, MG, Brasil. In the case of patients with suspected casos de pacientes com infecção suspeita ou 7Fundação José Bonifácio or confirmed coronavirus infection, one confirmada por coronavírus, é aceitável o Lafayette de Andrada, Faculdade may postpone the procedures for the adiamento dos procedimentos pelo período de Medicina de Barbacena, quarantine period, to avoid spreading de quarentena, para evitar disseminação Barbacena, MG, Brazil. 8Universidade de São Paulo, the disease. da doença. Faculdade de Medicina, Keywords: Dialysis; Arteriovenous fistula; Descritores: Diálise; Fístula Arteriovenosa; Hospital das Clínicas, Divisão de Nefrologia, São Paulo, SP, Brazil. Fistula; Nephrology; Interventional Fístula; Nefrologia; Radiologia 9Hospital Alemão Oswaldo Radiology; Angioplasty; Balloon Intervencionista; Angioplastia; Angioplastia Cruz, Centro Especializado em Angioplasty; Catheters; Endovascular com Balão; Cateteres; Procedimentos Nefrologia e Diálise, São Paulo, Procedures; Coronavirus infections. Endovasculares; Infecções por Coronavirus. SP, Brazil.
Due to the uncertainty about the duration to performing procedures on an outpa- of the Covid-19, pandemic and the impor- tient facility. Whenever possible, sus- tance of vascular access in maintaining pected or confirmed cases of Covid-19 hemodialysis (HD), the Brazilian Society should have their procedures postponed of Nephrology (SBN) prepared this tech- for the quarantine period, to prevent the nical note with instructions on how to virus from spreading. perform these procedures. Patients with short-term catheters With the overload of health systems represent the most critical cases from the Correspondence to: 1 Ricardo Portiolli Franco and the risk of contamination in the hos- vascular access point of view; therefore, E-mail: [email protected] pital setting, preference should be given they must be a priority when exchanging
DOI: 10.1590/2175-8239-JBN-2020-S110
41 Hemodialysis Vascular access maintenance in the Covid-19 pandemic
for a tunneled catheter or confection of a fistula, as • Exchange of catheters with dysfunction: these accesses need less exchange procedures for » In cases of catheter dysfunction, the adminis- patency maintenance. tration of thrombolytics, if available at the clinic, is the preferred method of treatment, New HD accesses avoiding surgical procedures for exchanges Procedures that guarantee vascular access for HD and patient exposure.1,6 should NOT be considered elective procedures; there- • Endovascular intervention in arteriovenous fis- fore, they should not be postponed. Delaying the tulas or grafts with clinical signs of dysfunction onset of RRT due to lack of vascular access carries a (for example, low flow, impossibility of punc- risk of worsening the patient’s clinical condition. This tures, cloth aspiration, etc.), to avoid loss of definition includes: access and consequent catheter implantation. • Exchanges of short-term catheters for tunneled These procedures should be performed on an catheters should NOT be considered elective, outpatient basis if possible.7 due to the morbidity associated with the pro- • Procedures for arteriovenous fistulas or grafts 1,2 longed use of short-term catheters. salvage (thrombolysis or thrombectomies). • Catheter insertions in patients starting HD.
• Creating fistulas in HD patients: Other emergencies that are NOT considered » Creation of arteriovenous fistulas is NOT an elective elective procedure. Patients who are candi- • Infections associated with vascular access dates for arteriovenous fistula creation and requiring a surgical approach are also NOT who would benefit from ealry catheter considered elective. This definition includes: removal should be sent to surgery, preferably » Withdrawal or exchange of tunneled catheters in an outpatient facility. due to catheter-related bacteremia. » As for arteriovenous fistulas creation, » Deactivation of arteriovenous fistulas with patients must be assessed individually. For infection without response to the use of example, in elderly patients, already using antibiotics. tunneled catheters and without complica- » Removal of infected arteriovenous grafts. tions, fistula creation may be delayed due to the mortality of this population with • Bleeding related to vascular accesses requir- Covid-19. ing surgical approach are NOT considered elective procedures. » In the post-operative period, we suggest reducing the number of consultations. The Elective procedures are considered and, therefore, assessment can be done by the nephrologist must be postponed: at the HD facility, usually at 7 and 30 days, • Outpatient consultations to monitor vascular with physical examination or Doppler ultra- access. sound if avaiable. If a consultation with a • Preoperative mapping for fistula creation. vascular surgeon is needed , we suggest using These guidelines are issued on an urgent basis and electronic consultation if possible, to reduce in the face of an uncertain evolution of the magnitude patient exposure. of the epidemic in Brazil and in dialysis units; there- fore, they may be updated in the coming weeks. The HD access dysfunction conducts must be reassessed weekly in each service. In cases of patients already on HD and at risk of access loss due to stenosis or cases with thrombosis, References treatment avoids the need for catheter implantation 1. NKF-K/DOQI. Clinical practice guidelines for vascular access. and the need for more procedures,1,3–5 with greater Am J Kidney Dis [Internet]. 2006;48 Suppl 1:S248-73. Availa- patient exposure and healthcare system overload. ble from: http://www.ncbi.nlm.nih.gov/pubmed/16813991 2. Maki DG, Kluger DM, Crnich CJ. The Risk of Bloodstream This definition includes and should NOT be consid- Infection in Adults With Different Intravascular Devices: ered elective procedures: A Systematic Review of 200 Published Prospective Studies.
42 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):41-43 Hemodialysis Vascular access maintenance in the Covid-19 pandemic
Mayo Clin Proc [Internet]. 2006 Sep [cited 2020 May 5. Agarwal AK, Patel BM, Haddad NJ. Central Vein Stenosis: 19];81(9):1159–71. Available from: https://linkinghub.else- A Nephrologist’s Perspective. Semin Dial. 2007;(7). vier.com/retrieve/pii/S0025619611612275 6. Mendes ML, Castro JH, Silva TN, Barretti P, Ponce D. Effective 3. Beathard G a., Arnold P, Jackson J, Litchfield T. Aggressive Use of Alteplase for Occluded Tunneled Venous Catheter in treatment of early fistula failure. Kidney Int. Hemodialysis Patients. 2014;38(5):399–403. 2003;64(4):1487–94. 7. Mishler R, Sands JJ, Ofsthun NJ, Teng M, Schon D, Lazarus 4. Coentrão L, Bizarro P, Ribeiro C, Neto R, Pestana M. Percuta- JM. Dedicated outpatient vascular access center decreases hos- neous treatment of thrombosed arteriovenous fistulas: clinical pitalization and missed outpatient dialysis treatments. Kidney and economic implications. Clin J Am Soc Nephrol. 2010; Int. 2006 Jan;69(2):393–8.
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):41-43 43 Recommendations | Recomendações
Palliative Renal Care and the Covid-19 Pandemic Cuidado paliativo renal e a pandemia de Covid-19
Authors Abstract Resumo Cássia Gomes da Silveira Santos1,2 Introduction: Palliative care is an Introdução: O cuidado paliativo é uma Alze Pereira dos Santos approach aimed at relieving suffering, abordagem voltada para alívio do Tavares1,3 controlling symptoms and seeking to sofrimento, controle de sintomas e melhora Carmen Tzanno-Martins1,4 improve quality of life. It must be offered da qualidade de vida. Deve ser oferecido José Barros Neto1,5,6 in conjunction with standard treatment em conjunto com o tratamento padrão de Ana Maria Misael da Silva1 for any disease that threatens the qualquer doença que ameace a continuidade Leda Lotaif 7, 8 continuation of life, such as a Covid-19 da vida, como, por exemplo, a infecção pela Jonathan Vinicius Lourenço infection. Discussion: The bioethical Covid-19. Discussão: Os princípios bioéticos Souza1,9 principles and strategies used by palliative e as estratégias utilizadas pela medicina medicine can assist nephrologists in the paliativa podem auxiliar os nefrologistas 1Sociedade Brasileira de Nefrologia, care of patients with renal dysfunction, no cuidado dos pacientes com disfunção Comitê de Cuidado Paliativo Renal who face the difficulties of isolation at renal, que, além de serem do grupo de risco da São Paulo, SP, Brasil. 2Universidade Federal do Paraná, the beginning and follow-up of dialysis in para evolução mais grave da infecção por Complexo Hospital de Clínicas do outpatient treatment, and those who are coronavírus, enfrentam as dificuldades do Paraná, Curitiba, PR, Brasil. at risk for a more serious disease progress. isolamento no seguimento do tratamento 3Hospital Santa Paula, São Paulo, Some of them: - a Shared decision dialítico e ambulatorial. Essas ferramentas SP, Brasil. making, which enables the patient and são: I) tomada de decisão compartilhada, 4Renal Class, Clínica de Hemodiálise, São Paulo, SP, Brazil. family to participate as facilitators in the que proporciona a participação do paciente 5Sociedade Mineira de Nefrologia, systematization of the team’s reasoning, e dos familiares como facilitadores na Belo Horizonte, MG, Brasil. in addition to respecting the principle sistematização do raciocínio da equipe, além 6Hospital Felício Rocho, Belo of autonomy; - Symptom Management: de respeitar o princípio da autonomia; II) Horizonte, MG, Brasil. which should be a priority to ensure manejo de sintomas, que deve ser prioridade 7Instituto Dante Pazzaneze de Cardiologia, São Paulo, SP, Brasil. relief of suffering even in times of social para a garantia do alívio do sofrimento 8Hospital do Coração, São Paulo, isolation; - Communication skills: mesmo em momento de isolamento social; SP, Brasil. making it possible to alleviate suffering III) habilidades em comunicação, sendo 9Universidade Federal do Paraná, in announcing bad news or complex possível amenizar dificuldades em anunciar Complexo Hospital de Clínicas decisions through communication más notícias ou decisões complexas através do Paraná, Serviço de Cuidado Paliativo do Curitiba, PR, Brasil. techniques;; - Bereavement assistance: de técnicas de comunicação; IV) assistência which in acute situations such as the ao luto, em que, em situações agudas pandemic, causing unexpected losses, the como a pandemia, de perdas inesperadas, importance of sympathy from healthcare a importância do acolhimento dos professionals becomes even greater. profissionais de saúde torna-se ainda maior. Conclusion: The principles of palliative Conclusão: Os princípios dos cuidados care are essential to face the challenges of paliativos são essenciais para enfrentar os a planet-wide crisis, which raises human desafios de uma crise humanitária, que suffering in all dimensions, and which causa sofrimento ao ser humano em todas as requires the construction of strategies that dimensões e exige a construção de estratégias can keep patients assisted, comfortable que possam manter os pacientes assistidos, and with measures proportional to their confortáveis e com medidas proporcionais à clinical condition and preferences. sua condição clínica e às suas preferências. Keywords: Palliative Care; Patient Palavras-chave: Cuidado Paliativo; Con- Correspondence to: Comfort; Coronavirus Infections; forto do Paciente; Infecções por Corona- Cássia Gomes da Silveira Santos E-mail: [email protected] Covid-19. virus; Covid-19.
DOI: 10.1590/2175-8239-JBN-2020-S111
44 Palliative renal care
According to the World Health Organization of advanced life support, including the failure (WHO), the role of palliative care is fundamental in to perform renal replacement therapy, requires facing large human crises like this. These crises are systematization of clinical reasoning, and must defined by large-scale events that affect populations take into account a number of factors. In an or societies, causing a variety of difficult and distress- attempt to follow the bioethical principle of not ing consequences, which can include massive loss of causing harm, nephrologists must careful assess life, disruption of livelihoods, society collapse, forced the real benefits of offering dialysis to patients displacement and other political and economic fac- with other chronic diseases in progress that are tors, psychological and spiritual effects, such as, for not responding to the standard treatment alre- example: pandemics, natural disasters and civil wars1. ady in place; to very old patients (but not as How to we explain the link between palliative care an isolated factor); fragile and totally depen- and a pandemic, a situation of acute and unexpected dent patients; to people with previous cognitive nature? impairment and without social support. Thus, Palliative care is an approach aimed at relieving it is important to be aware of the fact that many suffering, controlling symptoms and improving qual- patients infected by the coronavirus may alre- ity of life. It should be offered in conjunction with ady have such conditions, and therefore, regar- standard treatment for any disease that threatens the dless of an acute situation such as Covid-19, continuity of life. In a time of Covid-19 pandemic, they would not benefit from intensive treatment although the main goal of care is to save lives, it is involving more invasive measures, if their clini- not the only one. Not all lives can be saved, and even cal condition requires it. Transfer to the inten- the saved ones will go through a process of great suf- sive care unit, orotracheal intubation, dialysis, fering, either in the physical sphere, with the appear- cardiopulmonary resuscitation, among others, ance of symptoms that need to be controlled, or in can become procedures out of proportion to the the social sphere (family support, isolation, access to health condition of some patients. proper hygiene); and emotional, expressed by fear, • Symptom management: Patients who are alre- anxiety and sadness, from patients, their family mem- ady receiving renal palliative care should be bers and the care team2. reassessed periodically; especially those who In this context of public calamity, with different have chosen not to undergo dialysis therapy rules, the collapse of the healthcare system is a real and those who are rapidly progressing from risk; with healthcare professionals often physically an underlying disease. Uremic symptoms are and emotionally exhausted, and in which the very expected to worsen over time, and with the pro- important presence of family members is not rec- gression of kidney disease, making the mana- ommended, knowledge of palliative care can greatly gement of symptoms a priority to ensure suffe- contribute to assistance in the Covid-19 pandemic. ring relief. Since they are a high-risk group, it is Professionals on the front lines may face unprec- recommended to avoid travel and exposure in edented situations, which will require skills and tech- face-to-face consultations and opt for telecon- nical knowledge, common to palliative care profes- sultation. The relief of human suffering invol- sionals who routinely deal with human suffering. ves the mastery of techniques and specific kno- Some palliative care tools are also very relevant for wledge to control symptoms at any stage of the nephrologists at this time of crisis: disease, especially in the case of patients who • Shared decision-making: Although deci- inevitably progress to the end of life. sion-making is a technical issue and, therefore, • Communication skills: Many conflicts related related to the care team, it can be improved to death, clinical worsening or the feasibility and even facilitated when we know the values, of certain treatments, such as dialysis, could be previous health information, social support mitigated by means of communication techni- and patient’s wishes in a shared decision (team, ques that ensure clarity of information, liste- patient and family). This is an example of good ning, acceptance, respect for emotions and the medical practice in complex situations, and one cognitive ability of each one. It is necessary to of the pillars of palliative care. The limitations be careful when communicating bad news and
Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):44-46 45 Palliative renal care
that is why we must prepare, with an appro- and the fear and risk of exposure increases, both for priate environment, take time and plan the the team and the patient. Hemodialysis clinics need approach, always respecting the emotions of to adapt for this new reality, requiring greater allo- each one, including the desire to be informed or cation of financial resources, which are insufficient not of certain aspects of the disease. to date. All these new difficulties can generate physi- • Bereavement assistance: In acute situations such cal and emotional stress on the healthcare team and as a pandemic, the risk of unexpected loss is on the dialysis patients, who need to be valued and higher. A family member who takes his loved cared for, in order to avoid the collapse of dialysis one to the hospital on one day, and never sees clinics. this person again, and on another day receives The principles of palliative care are essential to the news of the death, without having followed face the challenges of a huge crisis, which causes suf- the illness process and without even being able fering to human beings in all dimensions. The human- to attend a funeral or a farewell event, has grea- itarian commitment focuses not only on the needs of ter difficulty in accepting the loss. In these situa- the individual as an individual, but on the context in tions, the risk of complicated mourning is high, which he/she lives, gathering resources that ensure so the sympathy of health professionals beco- basic human rights, such as dignity. In a time of pan- mes essential and must be maintained in the demic, we must understand that it is our role to fight follow-up and care of the family members.2,3,4 to save lives, but not less important, it is also our role to alleviate the suffering of patients, family members To enable the best care during social isolation, and the healthcare team. the nephrologist can use telemedicine, which has been properly authorized by the Federal Board of References Medicine, and not suspend family meetings to deal 1. World Health Organization. Integrating palliative care and sympton relief into the response to humanitarian emergencies with the most diverse subjects, such as shared deci- and crises [2018]. Acessado em 18 de maio de 2020. Dispo- sion making, provide information about the progress nível em https://www.who.int/publications-detail/integrating- of the patient, and assist in grieving. At this moment, a -palliative-care-and-symptom-relief-into-the-response-to- -humanitarian-emergencies-and-crises. hug and the expression of a touch should be replaced 2. Academia Nacional de Cuidados Paliativos. Manual de Cui- by a phone call or a videoconference, and not by the dados Paliativos ANCP: Ampliado e atualizado. Organização: Ricardo Tavares de Carvalho, Henrique Afonseca Parsons. São silence of the lack of information, which can be mis- Paulo: ANCP. 2012:1-592. interpreted by abandoning care5. 3. Ballentine JM. The Role of Palliative Care in a Covid-19 Pandemic. Disponível em: https://csupalliativecare.org/pallia- In nephrology, we also live an unprecedented sce- tive-care-and-covid-19/. Acessado em 19 de maio de 2020. nario in the care of nephropathic patients. Despite 4. Minnesota Department of Health Emergency Preparedness and Response. Disponível em https://www.health.state.mn.us/com- the universal recommendation of social isolation, munities/ep/surge/crisis/index.html. Acessado em 19 de maio for dialysis patients (specifically, those on hemodi- de 2020. 5. Conselho Federal de Medicina. Ofício CFM 1756/2020. Dis- alysis - 93%) this is not a reality. They cannot stay ponível em http://portal.cfm.org.br/images/PDF/2020_oficio_ at home, as they depend on treatment to stay alive, telemedicina.pdf. Acessado em 20 de maio de 2020.
46 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):44-46 Recommendations | Recomendações Position Paper of the Department of Hypertension of the Brazilian Society of Nephrology: Use of renin-angiotensin system blockers during the course of Covid-19 infection Posicionamento do Departamento de Hipertensão da Sociedade Brasileira de Nefrologia: Bloqueadores do sistema renina-angiotensina durante o curso de infecção pela Covid-19
Authors Abstract Resumo Cibele Isaac Saad Rodrigues1,2 This position statement of the Este posicionamento do Departamento 1Pontifícia Universidade Católica Department of Hypertension of the de Hipertensão da Sociedade Brasileira de São Paulo, Faculdade de Brazilian Society of Nephrology (SBN) de Nefrologia (SBN) trata da polêmica Ciências Médicas e da Saúde, São addresses the controversy surrounding gerada em torno do uso ou da suspensão/ Paulo, SP, Brazil. the use or suspension/replacement substituição dos bloqueadores do 2Sociedade Brasileira de Nefrologia, Departamento de of the renin-angiotensin-aldosterone sistema renina-angiotensina-aldosterona Hipertensão, São Paulo, SP, Brazil. system blockers (particularly inhibitors (particularmente inibidores da enzima de of the angiotensin-converting enzyme or conversão da angiotensina ou bloqueadores
angiotensin II AT1 receptor blockers) dos receptores AT1 da angiotensina II) prophylactically in individuals using profilaticamente em indivíduos que utilizam these drugs, due to the possibility of esses medicamentos, devido à possibilidade allegedly worsening the prognosis of de supostamente piorar o prognóstico de hypertensive patients infected with pacientes hipertensos infectados pelo SARS- SARS-CoV-2. The SBN Hypertension CoV-2. O Departamento de Hipertensão Department recommends individualizing da SBN recomenda a individualização treatment and maintaining these do tratamento e a manutenção dessas medications until better scientific medicações até que melhores evidências evidence is available. científicas estejam disponíveis. Keywords: Coronavirus infections; Palavras-chave: Infecções por Coronavírus; Hypertension; Renin-Angiotensin System. Hipertensão; Sistema Renina-Angiotensina.
Considering the correspondence called despite the lack of scientifical, clinical or “Are patients with hypertension and dia- experimental evidence; betes mellitus at a higher risk of infection Furthermore, considering that arterial by Covid-19?”1, recently published in The hypertension per se may not be directly Lancet, in which the authors suggest the correlated with the risk of infection or association of renin-angiotensin-aldoste- its worsening, there would be no indica- rone system blockers (RAAS), particularly tion for suspending these drugs or their angiotensin-converting enzyme inhibitors preventive replacement in hypertensive or angiotensin II AT1 receptor blockers, patients during a pandemic outbreak; in patients with heart disease, high blood In addition, considering that, para- pressure or diabetes mellitus at increased doxically, there are divergences between risk of severe Covid-19 infection, who the recommendations of the publications should therefore be monitored. available to date, with arguments in favor2 Based on this, and considering the and against its use1, even in hypertensive beginning of speculations at a national individuals proven to be infected; Correspondence to: Cibele Isaac Saad Rodrigues and international level about the harm Moreover, considering that there is E-mail: [email protected]; of maintaining these antihypertensive new data from observational studies con- [email protected] drugs in those infected with SARS-CoV-2, cerning possible protection of the RAAS DOI: 10.1590/2175-8239-JBN-2020-S112
47 Renin-angiotensin system blockers
blockers against negative outcomes, including mortal- 3. Zhang P, Zhu L, Cai J, et al. Association of inpatient use of angio- tensin converting enzyme inhibitors and angiotensin II receptor blo- ity, in those infected with SARS-CoV-2 using these ckers with mortality among patients with hypertension hospitalized antihypertensive classes;3,4 with Covid-19. Circ Res. 2020; (published online April 17). Finally, considering that the risk of cardiovascular 4. Bean DM, Kraljevic Z, Searle T et al. Treatment with ACE- -inhibitors is associated with less severe disease with SARS- and renal morbidity and mortality is directly associ- -Covid-19 infection in a multi-site UK acute hospital trust. ated with the lack of blood pressure control. medRxiv. 2020; (published online April 11.) (preprint). 5. Sociedade Brasileira de Hipertensão. Posicionamento da Socie- The Department of Arterial Hypertension of the dade Brasileira de Hipertensão em Relação à Polêmica do uso Brazilian Society of Nephrology, as well as other de Inibidores do Sistema Renina Angiotensina no Tratamento 5,6 7,8,9,10,11,12 de pacientes Hipertensos que Contraem Infecção pelo Corona- Societies of National and International vírus. Available at: https://www.sbh.org.br/arquivos/posicio- medical specialties, recommend the maintenance of namento-da-sbh/. Accessed [22 May 2020]. these classes of drugs, even in those with suspected 6. Sociedade Brasileira de Cardiologia. Segundo Posicionamento do Departamento de Hipertensão Arterial da Sociedade Bra- or confirmed Covid-19 infection, unless hypotension sileira de Cardiologia (DHA/SBC) sobre inibidores da enzima occurs due to sepsis or another cause, which would de conversão da angiotensina (IECA), bloqueadores dos recep- tores da angiotensina (BRA) e Coronavírus (Covid-19), em 30 lead to the suspension of any and all antihypertensive de março de 2020. Available at: http://departamentos.cardiol. drugs, and not specifically of RASS blockers, always br/sbc-dha/profissional/noticias/20200330-segundo-posiciona- taking into account the individualized treatment that mento-covid19.asp. Accessed [22 May 2020]. 7. Society of Hypertension. A statement from the International results in the greatest possible benefit to the patient. Society of Hypertension on Covid-19. Available at: https://ish- This position statement may change in status at -world.com/news/a/A-statement-from-the-International-Society- -of-Hypertension-on-Covid-19/. Accessed [22 May 2020]. any time when better scientific evidence emerges. 8. Bozkurt B, Kovacs R, Harrington B. HFSA/ACC/AHA Sta- tement Addresses Concerns. Re: Using RAAS Antagonists in Covid-19. Available at: https://www.acc.org/latest-in-cardio- Acknowledgment logy/articles/2020/03/17/08/59/hfsa-acc-aha-statement-addres- ses-concerns-re-using-raas-antagonists-in-covid-19. Accessed We would like to thank the members of the [22 May 2020]. Department of Hypertension, professors Carlos 9. Danser AHJ, Epstein M, Batlle D. Renin-Angiotensin System Eduardo Poli de Figueiredo, Fernando Antonio de Blockers and the Covid-19 Pandemic. At Present There Is No Evidence to Abandon Renin-Angiotensin System Blockers. Almeida, Sebastião Rodrigues Ferreira-Filho, Maria Hypertension 2020;75:1382–1385. Eliete Pinheiro, Rogério de Andrade Mulinari and 10. Council on Hypertension of the European Society of Cardio- logy. Position Statement of the ESC Council on Hypertension on Rogério Baumgratz de Paula. ACE-Inhibitors and Angiotensin Receptor Blockers. Available at: https://www.escardio.org/Councils/Council-on-Hypertension- -(CHT)/News/position-statement-of-the-esc-council-on-hyperten- REFERENCES sion-on-ace-inhibitors-and-ang. Accessed [22 May 2020]. 1. Fang L, Karakiulakis G, Roth M. Are patients with hyper- 11. Council on Hypertension of the European Society of Cardio- tension and diabetes mellitus at increased risk for Covid-19 logy. Statement of the European Society of Hypertension (ESH) infection. The Lancet. Respiratory Medicine 2020;8(4):e21. on Hypertension, Renin-Angiotensin System (RAS) blockers Available at: https://www.thelancet.com/action/showPdf?pi and Covid 19 – April 15th 2020. Available at: https://www. i=S2213-2600%2820%2930116-8. Acessed [22 May 2020]. eshonline.org/spotlights/esh-statement-on-covid-19/. Accessed 2. Gurwitz D. Angiotensin receptor blockers as tentative SARS- [22 May 2020]. -CoV-2 therapeutics [published online ahead of print, 2020 12. The Canadian Cardiovascular Society and the Canadian Heart Mar 4]. Drug Dev Res. 2020;10.1002/ddr.21656. Available at: Failure Society. Available at: https://www.ccs.ca/images/ Ima- https://onlinelibrary.wiley.com/doi/10.1002/ddr.21656. Acces- ges_2020/CCS_CHFS_statement_regarding_Covid_EN.pdf. sed [22 May 2020]. Accessed [22 May 2020].
48 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):47-48 Recommendations | Recomendações
Position statement from the Brazilian Society of Nephrology regarding chloroquine and hydroxychloroquine drug dose adjustment according to renal function Nota da Sociedade Brasileira de Nefrologia em relação ao ajuste das drogas cloroquina e hidroxicloroquina pela função renal
Authors Abstract Resumo José A. Moura-Neto1,2 Ana Maria Misael1 Chloroquine and hydroxychloroquine Em razão de resultados preliminares Dirceu Reis da Silva1,3 have shown promising preliminary promissores, a hidroxicloroquina e a Ronaldo D’Avila1,4 results and have been discussed as cloroquina têm sido discutidas como opção Maria Claudia Cruz Andreoli1,5 therapeutic options for patients with terapêutica para pacientes com Covid-19. Angiolina Kraychete1 Covid-19. Despite the lack of robust Apesar da ausência de estudos robustos evidence demonstrating the benefits and que evidenciem o benefício e justifiquem o Kleyton Bastos1,6 justifying the use of one of these drugs, uso de uma dessas drogas, a decisão final Marcelo Mazza do Nascimento1,7 the final decision is the responsibility compete ao médico assistente, devendo ser of the attending physician and should individualizada e, sempre que possível, 1Sociedade Brasileira de Nefrologia, São Paulo, Brazil. be individualized and shared, whenever compartilhada. A presente nota pretende 2Grupo CSB, Salvador, Bahia, possible. This position statement orientar o ajuste posológico dessas drogas Brazil. recommends dosage adjustment for these no contexto da disfunção renal. 3Hospital de Clínicas de Porto drugs in the context of renal impairment. Alegre, Rio Grande do Sul, Brazil. Palavras-chave: Cloroquina; Hidroxiclo- 4Faculdade de Medicina da Keywords: Chloroquine; Hydroxychlo- roquina; Antimaláricos; Posologia; Cálcu- Pontifícia Universidade Católica roquine; Antimalarials; Posology; Drug los da Dosagem de Medicamento; Insufi- de São Paulo, Sorocaba, São Dosage Calculation; Renal Failure. ciência Renal. Paulo, Brazil. 5Hospital do Rim, Fundação Oswaldo Ramos, Universidade Federal de São Paulo, São Paulo, Brazil. 6Universidade Federal de Sergipe, On the first day of April 2020, Informative patients with a confirmed diagnosis of São Cristovão, SE, Brazil. Note nº 6/2020-DAF/SCTIE/MS was Covid-193. The CFM, in its understand- 7Universidade Federal do Paraná, Curitiba, Paraná, Brazil. published, establishing that the Brazilian ing, concluded that there is no solid evi- Ministry of Health (MS) would make the dence that these drugs have a confirmed medications available for use, in confirmed effect on the prevention and treatment cases and at medical criteria, chloroquine of this disease. However, considering and hydroxychloroquine as adjunctive the exceptional nature of the situation, therapy in the treatment of severe forms and during the declared period of the in hospitalized patients, without other Covid-19 pandemic, CFM considered it supportive measures being neglected in possible to prescribe these drugs in three their favor1. On April 6, the MS pub- specific situations: lished “Guidelines for the diagnosis and 1. The use of chloroquine or hydroxy- treatment of Covid-19”, in which it also chloroquine in patients with mild instructed on the use of chloroquine and symptoms, in the onset of the clini- hydroxychloroquine as adjuvant therapy cal picture, after other viruses (such in severe forms of the disease, in confirmed as influenza, H1N1, dengue) and cases and upon medical discretion2. a confirmed diagnosis of Covid-19 On April 23, the Federal Board of can be considered. Medicine (CFM) published its Note No. 2. Patients with important symptoms, Correspondence to: 04/2020, which establishes criteria and but still without the need for inten- José A. Moura-Neto E-mail: [email protected] conditions for the prescription of chlo- sive care, with or without a recom-
DOI: 10.1590/2175-8239-JBN-2020-S113 roquine and hydroxychloroquine for mendation for hospitalization.
49 Dose adjustment of Chloroquine/Hydroxychloroquine according to renal function
3. Patients in critical condition receiving intensive Given the above and the associated risks, the care, including mechanical ventilation. Brazilian Society of Nephrology advises its associ- In these situations, the principle that must, manda- ate doctors to prescribe one of these drugs accord- torily, guide the treatment of the patient is that of the ing to the recommendations established by CFM physician’s autonomy, as well as upholding the doctor- and MS, which recommend a 50% reduction in the patient relationship, “this being the closest possible, with recommended dose of chloroquine and hydroxy- the objective of offering the best treatment currently chloroquine in patients with glomerular filtration available to the patient”. In all contexts, the prescription rate <10 mL/min/1.72 m2, in dialysis or conservative of drugs will be the responsibility of the attending physi- treatment. The doctor should also note that, regard- cian, in a decision shared with the patient3. less of the modality of renal replacement therapy, no additional dose of the drug is required after dialysis. Use of chloroquine and hydroxychloroquine in patients with chronic kidney disease References 1. BRASIL. Ministério da Saúde. Secretaria de Ciência, Tecnolo- The Brazilian Society of Nephrology understands gia, Inovação e Insumos Estratégicos em Saúde, Departamento that there is no solid evidence that these drugs have de Assistência Farmacêutica e Insumos Estratégicos. Nota Informativa No. 6/2020 - DAF/ SCTIE/MS. a confirmed effect on the prevention and treatment 2. BRASIL. Ministério da Saúde. Secretaria de Ciência, Tecnolo- of Covid-19. If the doctor chooses to use one of gia, Inovação e Insumos Estratégicos em Saúde. Diretrizes para o Diagnóstico e Tratamento da Covid-19. Versão 1. these drugs in the population with Chronic Kidney 3. Conselho Federal de Medicina (CFM). Tratamento de pacien- Disease, especially in dialysis patients, he/she must tes portadores de Covid-19 com cloroquina e hidroxicloro- consider its long half-life (up to 40-50 days). Both quina. Parecer nº 04/2020. 4. Rainsford KD, Parke AL, Clifford-Rashotte M, Kean WF. The- are not excreted by dialysis and have renal excre- rapy and pharmacological properties of hydroxychloroquine tion of around 40-50%, with 50% protein binding4-7. and chloroquine in treatment of systemic lupus erythematosus, rheumatoid arthritis and related diseases. Inflammopharmaco- Therefore, chloroquine and hydroxychloroquine logy 2015; 23(5): 231-69. should be used with extreme caution in patients with 5. Manganelli R, Manganelli S, Iannaccone S, De Simone W. Ges- tione dei farmaci antireumatici nell’insufficienza renale. G Ital chronic or acute renal dysfunction, especially due to Nefrol. 2015 Nov-Dec;32(6). the arrhythmogenic potential of the drug. 6. Aronoff GR, Bennett WM, Berns JS, et al. Drug Prescribing in Real Failure: Dosing Guidelines for Adults and Children. 5th While the manufacturer and some sources do not ed. Philadelphia, PA: American College of Physicians – Ameri- advise on dose adjustment for renal function, other rec- can Society of Internal Medicine; 2007. 7. Smit C, et al. Chloroquine for SARS-CoV-2: Implications of Its ommendations suggest a 50% dose reduction in patients Unique Pharmacokinetic and Safety Properties. Clin Pharma- with glomerular filtration rate <10 mL/min/1.72m2 on cokinet 2020 Apr 18; 1-11. hemodialysis, hemodiafiltration, peritoneal dialysis or 8. Ashley C, Dunleavy A (eds). The Renal Drug Handbook. The Ultimate Prescribing Guide for Renal Practitioners. 5th under conservative treatment6,8. Edition. 2018.
50 Braz. J. Nephrol. (J. Bras. Nefrol.) 2020;42(2 Supl. 1):49-50