PRECAUTIONARY GUIDELINES FOR CKD AND DIALYSIS PATIENTS IN POST UNLOCK PHASE DURING THE CURRENT COVID-19 PANDEMIC
Patients with pre-existing CKD are at increased risk of developing AKI either as a direct effect of COVID-19 infection or due to pyrexia, poor oral intake from anorexia and sore throat, diarrhoea, and NSAIDs used by patients for treatment of myalgia and headache. Also, CKD patients are more susceptible for developing serious or critical infection. Thus patients with kidney disease are likely to be more prone to have serious morbidity and mortality during the ongoing pandemic. This will result in additional and perhaps disproportionate pressure on renal units where the skills for caring for these patients are concentrated.
Infection has been reported in all ages, including children and elderly. The majority of infections are mild, presenting with flu-like symptoms. The common clinical presentations of COVID-19 are fever (98%), cough (76%), myalgia and fatigue (18% each), accompanying leucopenia (25%) and lymphopenia (63%). Symptoms of upper respiratory infection with rhinorrhea and productive cough are uncommon, except in children. About 16% to 20% cases have been classified as severe or critical.
Recent reports have shown higher frequency of renal abnormalities in COVID-19 patients. A study of 59 patients with COVID-19 found that 34% of patients developed massive albuminuria on the first day of admission. Blood urea nitrogen was elevated in 27% overall and in two-thirds of patients who died. Computed tomography scan of the kidneys showed reduced density, suggestive of inflammation and edema. Cheng et al recently reported that amongst 710 consecutive hospitalized patients with COVID-19, 44% had proteinuria and hematuria and 26.7% had hematuria on admission. The prevalence of elevated serum creatinine and blood urea nitrogen was 15.5% and 14.1%, respectively. AKI was an independent risk factor for severity of the COVID-19 disease.
The current treatment of COVID-19 with AKI includes general and supportive management including renal replacement therapy. There is no effective antiviral therapy available at present.
General management would mean that all patients with confirmed COVID-19 need to be quarantined. An N95 fit-tested respirator and protective clothes and equipment are essential. Early admission to intensive care units in designated hospitals is recommended for severely ill patients.
Supportive care, namely bed rest, nutritional and fluid support, and maintenance of blood pressure and oxygenation are important measures for all critically ill patients. Other measures include prevention and treatment of complications by providing organ support, maintaining hemodynamic stability, and preventing secondary infection.
Chronic kidney disease (CKD-5) patients on dialysis are a vulnerable group due to pre-existing co morbidities and immune suppressed state. They are exposed to hospital environment repeatedly as they have to come to dialysis unit 2-3 times a week.
Talking about the General Guidelines, patients on dialysis should adhere to their prescribed schedule. This would ensure their un-necessary emergency dialysis. Only one person should accompany the patient for dialysis. Patient should carry necessary hospital documents related to his/her illness while commuting. Dialysis unit should have an adequate stock of consumables including disinfectant and medicines.They should enquire about fever, cough,
sore-throat or breathlessness telephonically from all the patients scheduled for dialysis on that day. Temperature should be checked necessarily of all the patients entering the dialysis unit.
The dialysis staff should be educated about the features of COVID-19 infection. All universal precautions must be strictly followed .Hand hygiene should be strictly observed by the dialysis staff. If any dialysis staff develops fever, he/she should report to the unit, he should not come to the dialysis facility and should be observed for any symptoms of COVID19. The dialysis staff should learn the donning and doffing of PPE for the dialysis of suspected or COVID positive patients. All suspected patients should be dialyzed in Isolation facility in PPE kit. Dialysis units should be aware of testing, triaging and notification policy of ICMR.
As regard to guidelines for patients, they should report to screening area if they have any symptoms suspicious of COVID-19 or if there is any history of contact .Stable patients should be encouraged to arrive alone. All patients should wear disposable three layer face mask .Patients should follow cough and sneezing etiquettes-to use the tissue paper or inside of the elbow.
Guidelines for dialysis staff are very critical too. Unit should ensure sufficient supply of face masks and sanitizer. It should be ensured that the dialysis staff or a patient should not become a source of infection. Hand hygiene and coughing as well as sneezing etiquettes to be followed by everyone.
Everyone should wear the face mask including the caregiver of the patient inside the dialysis unit. Having meals during dialysis to be discouraged. Ideally COVID suspect or COVID patient should be dialyzed in isolation. If not feasible due to some reason, patient should be dialyzed in the last shift or if that is also not possible, then in the last bed of the row, towards the end; to ensure separation from other patients in the dialysis unit. Staff taking care of COVID patient should not take care of other patients during the same shift.Instruments like stethoscopes, thermometers, oxygen saturation probes and blood pressure cuffs should be kept separate and to be sanitized before using for other patients.