Dialysis in COVID times

• Dr Kiran Kumar MD DM
• July 20,2020

Dialysis in patients with End Stage Kidney Disease (ESKD) is life saving or life sustaining medical procedure. Dialysis can be Henodialysis – HD ( blood dialysis) or peritoneal dialysis ( water or home dialysis). The patients on HD need to undergo dialysis at least thrice a week for 4 hours. Ninety nine percent of HD patients take dialysis treatments in the hospitals while patients on PD take their dialysis at home. COVID 19 pandemic, caused by novel corona virus SARS-CoV2 , has disrupted the lives of ordinary citizens as well as patients of chronic illnesses. Dialysis patients have been affected to a larger extent as they need to visit hospitals twice or thrice a week.

All the dialysis patients should know the symptoms of COVID 19. Most of the symptoms of COVID 19 are non specific and comprise fever, sore throat , dry cough, muscle pains, fatigue. Some of the patients present with diarrhoea ( loose motions) , anosmia ( loss of smell sense),running nose, loss of taste sensation. Moderate to severe patients come to hospitals with breathlessness requiring oxygen and ventilator support. Oxygen saturation measured by pulse oximeter is typically less than 80-90% while the normal value is 98-100%.

Maintainance Hemodialysis (MHD) patients are at high risk of contracting COVID 19 due to :

• MHD patients tend to be of older age group
• Have multiple co-morbid conditions like diabetes , hypertension, cardiac disease
• CKD patients are generally immunosuppressed
• Frequent exposure to hospital environment because of regular visits to dialysis units
• Unavoidable patient clustering during dialysis shifts

MHD patients face many hardships during this COVID pandemic. Lack of appropriate education among the dialysis workforce has impacted smooth functioning of dialysis centres. Operations of HD units are impacted by interruptions of medical and dialysis disposable supply chains. Sudden demand for PPE has led to surge in pricing and this led to hikes in dialysis costs. Many dialysis facilities have been closed for non COVID patients in designated COVID hospitals. HD units had to be closed completely or partially as staff exposed to COVID suspects or positive patients had to go into quarantine. Patients referred to other centres for dialysis had to be tested for COVID before dialysis can be done. The duration of HD sessions was decreased from 4 hours to 3 hours in certain centres to compensate for staff shortages and time slots during lock down.

The following are general guidelines to the patients undergoing Henodialysis in hospital settings :

• Patients on regular dialysis should adhere to prescribed schedule and not to miss any dialysis session so as to avoid any emergency dialysis / admission
• Patients who are stable are encouraged to come alone to the dialysis unit without any attendant
• Patients should preferably come by personal transport as far as possible
• Patients opting for public transport like taxis should make sure the seats are wiped with disinfectants
• Do not touch your faces / eyes/ nose/ mouth when outside your homes
• Patients should follow the dialysis timings strictly ; should come to the dialysis unit on time so as to avoid waiting time to minimise exposure to other individuals in the waiting hall
• Patients should confirm with the dialysis unit personnel before starting from their homes if their dialysis times are delayed ( because of uncertainty regarding in patient dialysis sessions, staff shortages , PPE shortages , machine availability.
• All dialysis patients should wear N95 masks or three ply masks , preferably wear hand gloves when visiting dialysis units
• Maintain social distancing with other patients , household contacts
• Dialysis patients with upper respiratory symptoms like cough, sore throat , running nose should wear mask all throughout the time in the unit
• Patients should wash their hands with a soap for attest 20 seconds , using proper hand washing methods. Alcohol based hand sanitiser may be used if soap and water are not readily available
• All patients should follow proper cough etiquette – sneeze or cough into the inside of the elbow or use tissue paper
• The dialysis patients should volunteer to inform the hospital personnel if they have respiratory symptoms
• Dialysis patients with COVID 19 should be dialysed in isolation / separate unit for at least 14 days
• Preferably RT PCR for SARS – CoV 2 should be repeated after 14 days
• Patients should make sure that standard treatment principles in dialysis patients should be followed meticulously

• Blood pressure control with anti-hypertensives
• Control of inter-dialytic weight gain
• Maintaining dry weight
• Sugar control
• Adequate nutrition
• Maintaining hemoglobin

COVID 19 had and has been taking a toll on the lives of everyone around us. If hospitals , doctors , nursing staff , dialysis technicians , house keeping staff , patients , care givers are determined to tackle the pandemic with compassionate understanding and mutual respect , its possible to ride these difficult times with minimal discomfort.