In anticipation of the strain on resources and staff in New York City, part of the battling strategy included deployment calling for providers from all areas to directly devote their efforts in the care of COVID-19 patients. Despite being relieved temporarily of the role of a nephrologist, the COVID-19 population soon showed that managing renal disorders was still part of daily duties.
With COVID-19, providers have been challenged to extend the boundaries of the typical medical-decision making realm that relies on evidence-based medicine. In the initial weeks, we were observing behavior of a virus that clearly extended beyond pneumonia. Patients were acutely decompensating with devastating consequences such as strokes and vascular events – including dramatic and severe acute kidney injury (AKI), and others were improving without any clear pattern of predictive consequences. We have been challenged with a virus for which there is a paucity of data as to the mechanisms of disease and management, along with the accompanying difficulties of poor understanding of risk factors – including for kidney patients – and the emotional toll on patients who are hospitalized alone.
End-stage renal disease (ESRD) and COVID-19: risk factor stratification and mitigation
The mortality for patients with AKI and ESRD remains unclear, with highly variable reported rates – making counseling my hemodialysis patients about the changing circumstances in the COVID environment and what it would mean for their care more difficult. Optimism was the hope that they would be ok, realism was the understanding that not all of them would be – after all, among the earliest deaths from COVID-19 in the USA was a dialysis patient. Despite risk mitigation techniques, including distancing and chair appointment times, almost 20% of my dialysis patients have been lost to COVID-19. Those chairs won’t remain empty, however, as many of those who survived COVID-19 now require dialysis therapy.
On the other hand, several of my outpatient dialysis patients have recovered and returned to their chairs. The questions that remain now are – how can we understand the risk factors that portend a worse prognosis in some ESRD patients rather than others? Are the risk factors related to comorbidities, or also related to socioeconomic and racial disparities? How can we best protect our patients in dialysis units and waiting rooms, as well as facilities such as nursing homes? How do we preserve their access? Would it be feasible to transition patients to home dialysis care for their protection and to also increase the availability of dialysis nursing for hospitalized patients, and if so – what innovations would we need to develop to achieve these goals? In order for us to adequately provide for our dialysis population, we need to invest in obtaining a better understanding of how to also protect them and the capabilities to deliver equitable and safe care.
COVID-19-related renal disease
As we understood the novel virus to behave differently from what we may have anticipated, we have also had to have novel approaches to care in renal disease – but are desperately lacking data. A grassroots information sharing took place to garner opinions on the management of cases – whether we too were seeing extreme dysnatremias, dramatic AKI, and if newly placed dialysis accesses were not functioning after just hours of being placed – a finding which also led to improvisation of an anticoagulation protocol. The severity of AKI and the abundance of cases led to a shortage of staff and capabilities of performing continuous renal replacement therapy (CRRT) and intermittent hemodialysis, such that novel uses of acute PD were improvised. Utilization of potassium-removing agents to temporize time to dialysis was undertaken with mixed effect. All of these measures, however, have limited success, which is perhaps a metaphor for the entirety of treatment options available for kidney diseases, even pre-COVID-19.
The physiology of COVID-19 and AKI remains elusive as yet. There are several pathways proposed as possible mechanisms of injuries, including direct invasion of the renal tubular cells, nephrotoxicity of therapies, low distributive state, and shock. There also appears to be a predilection of vascular disease owing to ACE2 as the entry receptor for SARS-CoV-2, and those with diabetes, hypertension, obesity, and older age are seemingly more afflicted than others. However, a clear pathway for intervention and prevention has not been understood. As we have an onslaught of COVID-19 related kidney injury and possible future waves of infection, we must overcome the handicap in understanding the risk factors for the development of AKI, the effectiveness of potential therapeutic agents and their effect on mortality, as well as adequacy and optimization of renal replacement modalities and accesses.
Kidney disease innovation
In a recent New York Times article, the urgent dialysis needs during the pandemic were given much-needed attention, noting “doctors are sounding an alarm about an unexpected and perhaps overlooked crisis.” The plight of patients suffering from chronic kidney disease has been an overlooked crisis for years, and for nephrologists, it is no surprise that COVID-19 would have an alarming impact on an already suffering disease entity. Dialysis modalities have largely been unchanged for decades with a mortality rate worse than most cancers, at an exorbitant cost to Medicare of $34 billion annually with under-prioritization and utilization of home dialysis modalities. The disparities exposed by COVID-19 are ubiquitous in health care, including within the dialysis community and care of kidney disease, requiring an upheaval in kidney care delivery in collaboration with patients to achieve equity.
COVID-19 has impacted everyone globally, and many of us have or know someone who has either recovered or been taken from it. Not only does the acute management remain a challenge, but the long-term sequelae for those who have survived remain elusive. We are utilizing decades-old therapies for patients with chronic diseases and with novel viruses. We must not only develop therapeutics for the virus and vaccines, but we must also be able to generate new therapies and strategies for equitable care for chronic diseases, including kidney failure. We may see another peak of COVID-19, and we must have the tools to prepare.
Mukta Baweja is a nephrologist.
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