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CME

COVID-19 and Patients with Chronic Kidney Disease (CKD) and End-stage Renal Disease (ESRD)

Overview

  • Coronavirus Disease 2019 (COVID-19) is an acute respiratory disease caused by novel coronavirus SARS-CoV-2 (Centers for Disease Control and Prevention 2020 Mar 22)
  • patients with existing conditions can be more susceptible to COVID-19 and are likely to experience more severe illness, including patients with chronic kidney disease (CKD), patients on chronic dialysis, and those living with a kidney transplant
  • kidney abnormalities associated with increased in-hospital mortality in patients with COVID-19; kidney abnormalities may include proteinuria, hematuria, elevated serum creatinine, elevated blood urea nitrogen, and estimated glomerular filtration rate (GFR) < 60 mL/minute/1.73 m2
  • for patients with chronic kidney disease (CKD)
  • for patients on chronic dialysis
    • management of patients on dialysis should be carried by strict adherence to protocols to minimize spread of infection
    • strategies to mitigate risk and spread of COVID-19 infection in dialysis facilities include
      • following policies and protocols that should already be in place to reduce spread of contagious respiratory pathogens
      • early recognition and isolation of patients requiring dialysis if presenting with signs and symptoms consistent with respiratory infection; patients with symptoms must inform facility personnel prior to arrival and wear face mask at all times
      • ensuring maintenance of distance (≥ 6 feet or ≥ 2 meters) between infected patients and those who are not infected at all times, including in waiting rooms and in treatment areas
      • providing updated information on precautionary measures and tools (for example, alcohol-based hand-sanitizers and personal protection equipment) to protect both patient and personnel
      • use of isolation rooms, if available, for treatment
      • cohorting patients with suspected or confirmed COVID-19 infection and personnel caring for them together in 1 section of the unit or on same shift
      • routine cleaning, disinfection, or disposal (if appropriate) of all surfaces, materials, and equipment, especially if they have come in close contact (within 6 feet or 2 meters) of infected patient
    • patients on dialysis who have a family member or caregiver who is in quarantine as part of precautionary isolation (14 days), but not presenting with symptoms of infection, may undergo dialysis during quarantine period
    • once family member or caregiver has been confirmed as having COVID-19 infection, patient must be upgraded and treated in accordance with those who are suspected of having COVID-19 infection
  • for patients with kidney transplant
    • kidney transplant recipients and patients using immunosuppressive therapy can be more susceptible to COVID-19 and are likely to experience more severe illness, and should take measures to prevent infection
    • for management of kidney transplant patients with COVID-19 hospitalized with pneumonitis, might consider replacement therapy with methylprednisolone 16 mg and concurrent withdrawal of mycophenolate mofetil and azathioprine, calcineurin inhibitors, and mTOR inhibitors
  • for patients with COVID-19 who develop acute kidney injury requiring renal replacement therapy, see also Acute Kidney Injury - Approach to the Patient
  • see also COVID-19 (Novel Coronavirus) for additional information

Patients With Chronic Kidney Disease (CKD)

General Consideration

  • PubMed32204907Kidney internationalKidney Int20200307patients with existing conditions can be more susceptible to COVID-19 and likely to experience more severe illness (Kidney Int 2020 Mar 7 early online, International Society of Nephrology Mar 2020, European Renal Association-European Dialysis and Transplant Association)
  • existing conditions include
  • advise patients to remain on medications at prescribed doses, including angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) unless indicated otherwise by treating clinician (International Society of Nephrology Mar 2020)
  • PubMed32208987Hypertension (Dallas, Tex. : 1979)Hypertension20200325HYPERTENSIONAHA12015082HYPERTENSIONAHA12015082available evidence does not support discontinuation of renin-angiotensin system (RAS) antagonists (including ACE inhibitors and ARBs) in patients currently treated with such agents (Hypertension 2020 Mar 25 early online, Elife 2020 Apr 6 early online)
  • CKD or end-stage renal disease (ESRD) reported as comorbidities in patients with confirmed COVID-19 admitted to hospital
    • PubMed32250385JAMAJAMA20200406CKD in 3% at admission in cohort study with 1,591 patients (median age 63 years) with laboratory-confirmed COVID-19 admitted to intensive care units in Lombardy, Italy, between February 20 and March 18, 2020 (JAMA 2020 Apr 6 early online)
    • CKD requiring continuous renal replacement therapy (CRRT) in 4% at admission in cohort study with 116 patients (median age 54 years) with confirmed COVID-19 admitted to Renmin Hospital in Wuhan, China between January 14 and February 13, 2020 (Am J Nephrol 2020 Mar 31 early online)
    • CKD reported in 4.7% and ESRD reported in 3.2% at admission in 5,700 patients (median age 63 years, 60.3% males) with confirmed COVID-19 admitted to 12 hospitals in New York City between March 1 and April 4, 2020 (JAMA 2020 Apr 22 early online)
  • Study Summary
    CKD appears to be associated with risk of severe COVID-19 infection
    Details
    Renal_Disorders_(Nephrology)CKD appears to be associated with risk of severe COVID-19 infection (Int Urol Nephrol 2020 Mar 28 early online)03/31/2020 02:45:01 PMstudySummary
    • Systematic Review based on systematic review of observational studies
    • systematic review of 4 observational studies evaluating association between CKD and severity of COVID-19 infection in 1,389 patients
    • all patients had COVID-19 infection, including 273 patients (19.7%) with severe COVID-19 infection
    • CKD associated with severe COVID-19 infection (odds ratio 3.03, 95% CI 1.09-8.47)
    • PubMed32222883International urology and nephrologyInt Urol Nephrol20200328Reference - Int Urol Nephrol 2020 Mar 28 early online
  • Study Summary
    kidney abnormalities associated with increased in-hospital mortality in patients with COVID-19
    Details
    Renal_Disorders_(Nephrology)kidney abnormalities associated with increased in-hospital mortality in patients with COVID-19 (Kidney Int 2020 Mar 24 early online)03/31/2020 02:45:52 PMstudySummary
    • Cohort Study based on prospective cohort study
    • 701 patients (median age 63 years, 52% males) with COVID-19 hospitalized in China in 2020 were analyzed
    • comorbidities at admission
      • hypertension in 33.4%
      • diabetes in 14.3%
      • cancer in 4.6%
      • chronic kidney disease in 2%
      • chronic obstructive pulmonary disease in 1.9%
    • kidney abnormalities at admission
      • proteinuria in 43.9%
      • hematuria in 26.7%
      • elevated serum creatinine in 14.4%
      • elevated blood urea nitrogen (BUN) in 13.1%
      • estimated glomerular filtration rate (GFR) < 60 mL/minute/1.73 m2 in 13.1%
    • acute kidney injury (AKI) during hospitalization in 5.1%
    • in-hospital mortality 16.1%
    • renal factors associated with increased in-hospital mortality
      • elevated baseline serum creatinine (hazard ratio [HR] 2.04, 95% CI 1.32-3.15)
      • elevated baseline BUN (HR 4.2, 95% CI 2.74-6.45)
      • AKI
        • stage 2 (HR 3.53, 95% CI 1.5-8.27)
        • stage 3 (HR 4.72, 95% CI 2.55-8.75)
      • proteinuria
        • 1+ (HR 2.47, 95% CI 1.15-5.33)
        • 2+ or 3+ (HR 6.8, 95% CI 2.97-15.56)
      • hematuria
        • 1+ (HR 3.05, 95% CI 1.43-6.49)
        • 2+ or 3+ (HR 8.89, 95% CI 4.41-17.94)
    • PubMed32247631Kidney internationalKidney Int20200320Reference - Kidney Int 2020 Mar 20 early online

Patients With COVID-19 and With CKD Treated With Immunosuppressive Therapy

  • Renal_Disorders_(Nephrology)European Renal Association (ERA)-European Dialysis and Transplant Association (EDTA) Immunosuppression Working Group guidance for management of patients with CKD receiving immunosuppressive therapy (ERA-EDTA Immunosuppression Working Group)05/06/2020 03:17:10 PMEuropean Renal Association (ERA)-European Dialysis and Transplant Association (EDTA) Immunosuppression Working Group guidance for management of patients with CKD receiving immunosuppressive therapy
    • for patients exposed to SARS-CoV-2 but no symptoms or infection not confirmed
      • isolation at home advised
      • testing for COVID-19 advised since patients receiving immunosuppressive therapy may shed virus longer and when asymptomatic
      • consider reducing steroids to equivalent of a prednisolone dose of 0.2mg/kg/day if possible
      • if leukopenia or lymphopenia detected, reducing dose of cytotoxic drugs until white blood cell count recovers; lymphopenia might be a sign of active COVID-19
      • if patients have hypogammaglobulinemia, consider IgG IV to protect from secondary infections
      • continue use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), unless there is acute kidney injury
    • for patients with COVID-19 and no or mild symptoms
      • consider stopping or reducing antimetabolites including mycophenolate mofetil (MMF) and azathioprine (AZA)
        • avoid stopping corticosteroids abruptly
        • reduce prednisolone to 0.2mg/kg/day
        • calcineurin inhibitor (CNI) or ciclosporin might reduce virus replication
      • postpone planned cyclophosphamide and rituximab drug administrations
      • consider hospitalization based on symptoms and risk factors
        • consider follow-up by phone every 24-48 hours
        • ask patient to be observant of progressive symptoms with difficulties breathing or high temperatures not responding to antipyretic treatment
      • assess levels of immunosuppression with
        • white blood cell count
        • immunoglobulins
        • CD19
        • T-cell counts
      • if patients have hypogammaglobulinemia, consider IgG IV to protect from secondary infections
      • continue use of ACE inhibitors and ARBs
    • for patients with COVID-19 and overt symptoms, consider contacting infection medicine specialist for immunosuppressive therapy adjustment and therapy regimen
    • Reference - ERA-EDTA Immunosuppression Working Group

Use of Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin Receptor Blockers (ARBs)

Patients on Chronic Dialysis

General Information

  • introduction
    • COVID-19 is associated with high morbidity in older adults and in patients with comorbid conditions, including patients with uremia on chronic dialysis
    • patients on chronic hemodialysis are at higher risk of developing severe infectious disease compared to the general population because they are usually older, have less efficient immune systems, and are potentially exposed to and reexposed to infection during the dialysis procedure
    • hemodialysis facilities are under strain from increased need for specialized resources and staff to ensure isolation, control, and prevention of infection
    • management of patients on dialysis should be carried by strict adherence to protocols to minimize spread of infection
    • for patients on home hemodialysis or peritoneal dialysis, provide as much assistance as possible using telereporting assistance or other electronic systems to manage and supplement home visits by staff
    • PubMed32196116Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal AssociationNephrol Dial Transplant20200320Reference - Nephrol Dial Transplant 2020 Mar 20 early online
  • cases of COVID-19 reported in hemodialysis facilities
    • findings from 1 hemodialysis center in Wuhan, China from January 14, 2020 (day of first confirmed case at center) to February 17, 2020
      • 37 out of 230 patients on hemodialysis and 4 out of 33 staff confirmed to have COVID-19
      • measures taken in response to epidemic included
        • upgrading prevention and protection measures starting on January 21, 2020
        • universal screening, isolating, and distributing infected cases starting on February 4, 2020
      • outcomes
        • no new cases of COVID-19 reported since February 13, 2020 (study posted on February 27, 2020)
        • 7 patients on hemodialysis died including 6 patients with COVID-19 and 1 patient without COVID-19
        • deaths were not related to pneumonia, but due to other causes, such as cardiovascular and cerebrovascular disease, and hyperkalemia
      • symptoms and laboratory findings among patients with COVID-19 on chronic hemodialysis compared to hemodialysis patients without COVID-19, nonhemodialysis patients with COVID-19, and healthy volunteers
        • relatively mild symptoms which did not require admission to intensive care unit
        • decreased levels of T-cell lymphocytes, Th-cells, killer T-cells, and NK-cells in peripheral blood samples
        • lower level of inflammatory cytokines
      • Reference - medRxiv 2020 Feb 27:doi:https://doi.org/10.1101/2020.02.24.20027201
    • Study Summary
      28% mortality reported in patients with ESRD on chronic dialysis hospitalized for COVID-19 without access to intensive care in Spain during surge
      Details
      Infectious_Diseases Renal_Disorders_(Nephrology)28% mortality reported in patients with ESRD on chronic dialysis hospitalized for COVID-19 without access to intensive care in Spain during surge (Kidney Int Rep 2020 May 1 early online)05/18/2020 11:18:43 AMstudySummary
      • Cohort Study based on cohort study
      • 51 patients with ESRD on chronic dialysis or with kidney transplant hospitalized for COVID-19 infection in Spain were evaluated during hospital stay (mean follow-up of 13.7 days)
      • 25 patients (mean age 66 years, 68% men) were on chronic dialysis
      • therapies
        • medications included antibiotics in 100%, hydroxychloroquine in 96%, prophylactic anticoagulation in 68%, lopinavir/ritonavir in 48%, IV methylprednisone for 3 days in 40%, interferon beta 1b in 11%, and tocilizumab in 4%
        • some patients met criteria for intensive care unit admission, but none were transferred due to capacity constraints
      • outcomes
        • 28% died (mean age 77 years)
        • 40% developed acute respiratory distress syndrome
        • no thrombotic or hemorrhagic events observed
      • PubMed32363253Kidney international reportsKidney Int Rep20200501Reference - Kidney Int Rep 2020 May 1 early onlinefull-text
    • 2 dialysis centers in Lombardy, Italy reported cases of COVID-19
      • 18 out of 60 patients were infected within a span of a week and immediately isolated and treated in dedicated ward, separate from main dialysis treatment area; no staff were infected
      • 4 out of 170 patients were infected and immediately isolated; no new cases have been confirmed since (as of publication on March 23, 2020)
      • PubMed32207068Journal of nephrologyJ Nephrol20200323Reference - J Nephrol 2020 Apr;33(2):193
    • PubMed32207068Journal of nephrologyJ Nephrol20200323development of gastroenteritis and severe pulmonary disease in 56-year-old man in the United States on maintenance hemodialysis for ESRD secondary to IgA nephropathy with COVID-19 in case report (Am J Nephrol 2020 Mar 28 early online)
    • PubMed32222703NephronNephron202003271-31COVID-19 infection in 75-year-old man on continuous renal replacement therapy for ESRD in case report (Nephron 2020 Mar 27 early online)
    • PubMed32240718American journal of kidney diseases : the official journal of the National Kidney FoundationAm J Kidney Dis20200331COVID-19 infection in 5 patients (aged 47-67 years) on maintenance hemodialysis presenting with diarrhea (in 80%), fever (in 60%), and fatigue (in 60%) but no severe symptoms in case series (Am J Kidney Dis 2020 Mar 31 early onlinefull-text)
  • see COVID-19 (Novel Coronavirus) for general information regarding clinical presentation, evaluation, and management of patients with COVID-19

Strategies to Reduce Risk and Spread of COVID-19 in Dialysis Facilities

Centers for Disease Control and Prevention (CDC) Recommendations

  • Renal_Disorders_(Nephrology)Centers for Disease Control and Prevention (CDC) recommendations for patients with suspected or confirmed COVID-19 in outpatient hemodialysis facilities (CDC 2020 Mar 24)05/06/2020 03:06:11 PMrecommendations for patients with suspected or confirmed COVID-19 in outpatient hemodialysis facilities
    • this guidance should be followed together with CDC interim infection prevention and control recommendations for patients with suspected or confirmed COVID-19 in healthcare settings found in CDC 2020 Mar 19
    • follow policies and protocols that should already be in place to reduce spread of contagious respiratory pathogens
    • recognition and isolation of individuals with any respiratory infection
      • healthcare personnel
        • personnel should stay at home when ill
        • flexible and nonpunitive sick leave policies should be implemented according to public health policies
      • patients
        • identify signs and symptoms of respiratory symptoms, such as fever or cough prior to entering treatment area
          • instruct patients to call ahead if fever or respiratory symptoms present, so that facilities can be prepared for their arrival or triage to appropriate setting (for example, acute care hospital)
          • patients should inform staff of fever or respiratory symptoms immediately upon arrival (for example, at registration check in)
        • patients with signs and symptoms of respiratory symptoms
          • patient should wear face mask at check in and for the duration of the visit at the facility
          • patient should be placed in separate waiting areas, away from other patients by ≥ 6 feet; if medically stable, patient may wait in personal vehicle or outside the facility and be contacted by mobile phone when read to be seen
          • bring patient to treatment area as soon as possible and minimize time in waiting areas
          • utilize dialysis isolation room, if available
      • both patients and healthcare personnel should be provided with instructions on (in appropriate languages)
        • proper hand hygiene, respiratory hygiene, and cough etiquette
        • proper use of face masks, use of tissues to cover nose and mouth when coughing or sneezing, disposal of tissues and other contaminated items, and how and when to perform hand hygiene
      • facilities
        • signs should be posted at facility entrances instructing patients to inform staff of fever or symptoms of respiratory infection so that appropriate precautionary measures can be taken
        • supplies such as tissues, no-touch receptacles for tissue disposal, and hand hygiene supplies (for example, alcohol-based hand sanitizer) should be placed close to dialysis chairs and nursing stations to ensure hand and respiratory hygiene and cough etiquette
    • considerations during treatment
      • isolation of symptomatic patients
        • maintain ≥ 6 feet separation in all directions between masked, symptomatic patients and other patients during treatment; use separate rooms if possible, with door closed
        • only use hepatitis B dialysis rooms for patients with symptoms of respiratory infection if either
          • patient is hepatitis B surface antigen positive
          • facility has no patient on the census with hepatitis B infection who would require treatment in isolation
        • if separate room is not available, treat masked symptomatic patient at a corner or station at end of the row, away from main traffic flow, if possible
        • if patient cannot tolerate wearing a mask, separate by ≥ 6 feet in all directions from nearest patient station
      • personal protective equipment for personnel
        • follow Standard, Contact, and Droplet Precautions with eye protection, unless Airborne Precautions is required (for example, tuberculosis); this includes use of
          • gloves
          • face mask
          • eye protection - goggles or disposable face shield that covers front and sides of the face (glasses and contact lenses are not considered proper protection)
          • isolation gown
            • isolation gown should be worn over or worn instead of cover gown normally worn by hemodialysis personnel
            • if there is a shortage, use should be prioritized for initiating and terminating dialysis, manipulating access needles or catheters, helping patient in and out of the dialysis station, and cleaning and disinfection of equipment and dialysis station
            • gowns should be placed in dedicated disposal or linen container after use; disposable gown should be discarded and cloth gowns laundered after each use
    • when COVID-19 is suspected or confirmed in a patient at dialysis facility
      • notify health department
      • healthcare personnel should follow CDC interim infection prevention and control recommendations for patients with suspected or confirmed COVID-19 in healthcare settings found at CDC 2020 Mar 19
      • routine cleaning and disinfection are appropriate for COVID-19 in dialysis facilities
      • any surface, materials, or equipment located ≤ 6 feet of symptomatic patients must be disinfected or discarded
      • list of Environmental Protection Agency (EPA)-registered disinfectants that are qualified for use against COVID-19 can be found at EPA 2020 Apr 9
      • for dialysis facilities treating ≥ 1 patient with suspected or confirmed COVID-19
        • consider cohorting patients and personnel caring for them together in 1 section of the unit or on same shift (for example, last shift of the day)
        • patients with different respiratory infection etiologies should not be cohorted; for example, patients with influenza and COVID-19 should not be cohorted
    • Reference - CDC Interim guidance for infection prevention and control recommendations for patients with suspected or confirmed COVID-19 in outpatient hemodialysis facilities (CDC 2020 Mar 24)

European Dialysis Working Group (EUDIAL) of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Recommendations

  • Renal_Disorders_(Nephrology)European Dialysis Working Group (EUDIAL) of the ERA-EDTA recommendations for prevention, mitigation, and containment of COVID-19 in hemodialysis centers (Nephrol Dial Transplant 2020 Mar 20 early online)05/06/2020 03:12:01 PMrecommendations for prevention, mitigation, and containment of COVID-19 in hemodialysis centers
    • guidance for infection prevention for healthcare personnel
      • dialysis physicians, nursing staff, and technicians should be trained on updated information regarding COVID-19 epidemic, infection prevention tools, and recommendations from local government, medical societies, and hospitals
        • information should include
          • proper use of different types of face mask
          • proper use and disposal of tissues used to cover nose and mouth while coughing or sneezing
          • how to and when to practice hand hygiene
        • deliver information to all personnel as they are updated
      • personnel should self-monitor for symptoms (if they present) and report to team leader in case they or their family members develop symptoms suggestive of COVID-19 infection
      • personnel who are ill should stay at home, and avoid coming in contact with patients or other team members
      • consider training nurses to take nasopharynx swabs for COVID-19 polymerase chain reaction (PCR) using appropriate personal protection equipment, which consists of
        • filtering face piece 2 (FFP2) mask, which filters 95% of particulate matter and aerosols in inhaled air
        • goggles
        • mobcap
        • disposable surgical blouse and gloves
    • guidance for infection prevention for dialysis patients and dialysis facilities
      • instruct patients to
        • stay at home on nondialysis days and use individual transport to and from dialysis facility
        • avoid public transportation
        • avoid travel
        • avoid personal contact and public and private events (for example, family reunions, marriages, and funerals)
      • patients who are parents or grandparents should consider limiting personal contact with their children and grandchildren because younger individuals may act as vectors of the disease without presentation of symptoms
      • dialysis facility should provide instructions (in appropriate languages) regarding
        • hand hygiene (when to perform and how), respiratory hygiene, and cough etiquette
        • proper use of face masks, tissues to cover nose and mouth when coughing or sneezing, and proper disposal of contaminated items
      • alcohol-based hand sanitizers should be placed in facility waiting rooms
      • patients should perform hand hygiene at least on arrival at facility, at time of departure, and if in contact with respiratory secretions
      • patients who are ill should be separated by ≥ 2 meters from other patients in waiting areas; medically stable patients may wait in their personal vehicles or outside the dialysis facility
      • maintain distance of ≥ 2 meters between dialysis stations
      • treatment and waiting areas should have good air conditioning and ventilation, to allow for removal of particles and aerosol droplets from air
      • body temperature should be measured before start and at end of dialysis session in all patients
    • recognition and isolation of patients with respiratory infections
      • identify patients with signs and symptoms of fever, cough, upper airway involvement, or conjunctivitis prior to entering dialysis facility
      • patients must inform facility personnel regarding fever or respiratory symptoms prior to arrival at facility so that appropriate actions can be planned for upon arrival (for example, triaging patient to acute care center or first-aid department)
      • patients presenting with respiratory symptoms should be brought to treatment area as soon as feasible so that time spent in waiting area can be minimized
      • all patients with signs and symptoms of fever, cough, upper airway involvement, or conjunctivitis should be tested for COVID-19; perform sampling in single-patient room or in room dedicated to sampling and disinfect room afterwards
    • considerations during treatment
      • symptomatic patients should be dialyzed in separate isolation room with door closed, if possible, where negative pressure atmosphere can be established
      • if separate isolation room is not available, patients should wait in separate room and receive dialysis during last shift of the day
      • personnel attending to the patient should wear proper protective equipment including surgical or N95 mask that filters out 95% of particulate matter < 2.5 micrometers in aerosol of exhaled air
    • when patient at a facility is confirmed to be infected with COVID-19
      • patient should be admitted to airborne infection isolation room; dialysis should not be performed in outpatient dialysis facility unless airborne infection isolation room is available
      • all personnel involved in care of infected patient must be fully protected with
        • long-sleeved waterproof isolation clothing
        • hair caps
        • goggles
        • gloves
        • medical masks (FFP2 or FFP3, if available) which filters out 95%-99% of particulate matter and aerosols in inhaled air
        • strict adherence to hand hygiene, which involves careful washing of hands with soap and water, and use of alcohol-based hand sanitizers and disposable gloves
      • consider cohorting ≥ 1 patients with suspected or confirmed COVID-19 and personnel taking care of these patients in same section of the unit and/or on the same shift (for example, last shift of the day); however, suspected and confirmed patients should not be cohorted together
      • personnel should be placed on separate teams for management of high-risk and low-risk patients; only assigned personnel should enter isolation room/cohort area and all other nonscheduled personnel should be excluded at all times
      • immediately disinfect facility upon confirmation of COVID-19 or if highly suspected; areas that have been in close contact with such patients must not be used until cleared
      • medical waste from infected patients should be considered highly contagious and must be disposed of appropriately
    • duration of isolation precautions for patients suspected of or with confirmed COVID-19
      • decision to discontinue isolation precautions should be made on case-by-case basis, taking into consideration local, state, and federal recommendations, until more information regarding viral shedding after clinical improvement becomes available
      • factors that may influence duration of isolation precautions include
        • continued presence of symptoms associated with COVID-19
        • date of symptom resolution
        • presence of other conditions that may require isolation, such as tuberculosis and Clostridium difficile infection
        • other laboratory results that might reflect clinical status
    • additional considerations
      • patients requiring vascular access surgery should be tested for COVID-19; vascular access surgery must be performed in designated room with appropriate protection for staff
      • family members and caregivers
        • all protocols regarding precautions and regulations to prevent person-to-person and within-family transmission of COVID-19 must be followed, which include
          • body temperature measurement
          • good personal hygiene
          • hand-washing
          • immediate reporting of infected persons
        • patients on dialysis who have a family member or caregiver who is in quarantine as part of precautionary isolation (14 days), but not presenting with symptoms of infection, may undergo dialysis during quarantine period
        • once family member or caregiver has been confirmed as having COVID-19, patient must be upgraded and treated in accordance with those who are suspected of having COVID-19
    • Reference - Nephrol Dial Transplant 2020 Mar 20 early online

Strategies for Patients Receiving Peritoneal Dialysis at Home

  • American Society of Nephrology recommendations for patients receiving peritoneal dialysis at home
    • consider automated peritoneal dialysis (APD) to reduce exposure of caregivers
    • if volume control cannot be maintained, consider temporary hemodialysis catheter placement and transition to intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT)
    • Reference - American Society of Nephrology 2020 Mar 21 PDF

Patients With Kidney Transplant

  • kidney transplant recipients and patients using immunosuppressive therapy can be more susceptible to COVID-19 and are likely to experience more severe illness, and should take measures to prevent infection (Kidney Int 2020 Mar 7 early online, International Society of Nephrology Mar 2020, European Renal Association-European Dialysis and Transplant Association)
  • Renal_Disorders_(Nephrology)Brescia Renal Covid Task Force suggested management of kidney transplant patients with COVID-19 (ERA-EDTA PDF)05/06/2020 03:35:37 PMBrescia Renal Covid Task Force suggested management of kidney transplant patients with COVID-19 hospitalized with pneumonitis includes both
  • for ERA-EDTA Immunosuppression Working Group guidance for management of patients with CKD receiving immunosuppressive therapy, see Patients with COVID-19 and with CKD Treated with Immunosuppressive Therapy section
  • Evidence Synopsis


    Current evidence regarding kidney transplant recipients with COVID-19 infection is limited to observational studies.
    • mortality from COVID-19 infection in kidney transplant recipients
      • Study Summary
        7.7% mortality reported in patients with kidney transplant hospitalized for COVID-19 in Spain
        Details
        Infectious_Diseases Renal_Disorders_(Nephrology)7.7% mortality reported in patients with kidney transplant hospitalized for COVID-19 in Spain (Am J Transplant 2020 May 5 early online)05/18/2020 02:20:19 PMstudySummary
        • Cohort Study based on cohort study
        • 33 patients (median age 57 years, 58% men) with kidney transplant at single center in Spain who were diagnosed with COVID-19 infection from February 1, 2020 through April 13, 2020 were evaluated
        • median time since transplantation 10 years (range 4-14 years)
        • management setting
          • 39.4% admitted to intensive care unit (ICU)
          • 39.4% admitted to hospital (not in ICU)
          • 21.2% managed as outpatients
        • among 26 patients admitted to hospital
          • 79% had withdrawal of ≥ 1 immunosuppressant (maintenance immunosuppression based on prednisone 15-20 mg/day until improvement)
          • outcomes
            • 2 patients aged 72 and 87 years (7.7%) died
            • 7.7% remained in ICU
            • graft loss occurred in 1 patient with chronic graft dysfunction
            • no arrhythmic events or opportunistic infections observed
        • PubMed32368838American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant SurgeonsAm J Transplant20200505Reference - Am J Transplant 2020 May 5 early online
      • Study Summary
        23% mortality reported in patients with kidney transplant hospitalized for COVID-19 without access to intensive care in Spain during surge
        Details
        Renal_Disorders_(Nephrology)23% mortality reported in patients with kidney transplant hospitalized for COVID-19 without access to intensive care in Spain during surge (Kidney Int Rep 2020 May 1 early online)05/18/2020 02:31:19 PMstudySummary
        • Cohort Study based on cohort study
        • 51 patients with ESRD on chronic dialysis or with kidney transplant hospitalized for COVID-19 infection in Spain were evaluated during hospital stay (mean follow-up of 13.7 days)
        • 26 patients (mean age 61 years, 46% men) had kidney transplant
        • cessation of maintenance immunosuppression therapy in 73%
        • some patients met criteria for ICU admission, but none were transferred due to capacity constraints
        • outcomes
          • 23% (mean age 70 years) died
          • 39% developed acute respiratory distress syndrome (ARDS)
          • no thrombotic or hemorrhagic events observed
          • no rejection episodes or development of donor-specific antibodies observed
        • PubMed32363253Kidney international reportsKidney Int Rep20200501Reference - Kidney Int Rep 2020 May 1 early onlinefull-text
      • Study Summary
        25% mortality reported in patients with kidney transplant hospitalized for SARS-CoV-2 pneumonia in Italy
        Details
        Renal_Disorders_(Nephrology)25% mortality reported in patients with kidney transplant hospitalized for SARS-CoV-2 pneumonia in Italy (Kidney Int 2020 Apr 9 early online)05/18/2020 02:37:22 PMstudySummary
        • Cohort Study based on cohort study
        • 20 patients (median age 59 years, 80% men) with kidney transplant hospitalized for SARS-CoV-2 pneumonia in single center in Italy from February 27, 2020 through March 24, 2020 were evaluated during inpatient stay (median of 7 days)
        • median time since transplant was 13 years (range 9-20 years)
        • all patients had regular immunosuppression therapy withdrawn and started methylprednisolone 16 mg/day
        • outcomes
          • 25% died at median of 11 days from admission
          • 30% developed acute kidney injury (1 patient required hemodialysis)
          • 15% discharged from hospital
        • PubMed32354634Kidney internationalKidney Int20200409Reference - Kidney Int 2020 Apr 9 early onlinefull-text
      • PubMed32301155American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant SurgeonsAm J Transplant2020041627.8% mortality reported in 18 adult solid organ transplant recipients (including 8 [44%] kidney transplant recipients) with confirmed COVID-19 infection hospitalized in Madrid, Spain, between March 5 and March 23, 2020 in case series (Am J Transplant 2020 Apr 16 early online)
      • PubMed32400099American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant SurgeonsAm J Transplant20200513fatal COVID-19 pneumonia reported in 63 years old female kidney transplant recipient in case report (Am J Transplant 2020 May 13 early online)
      • PubMed32243697American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant SurgeonsAm J Transplant20200403fatal COVID-19 pneumonia reported in 2 transplant recipients (59 years old kidney transplant recipient, and 51-year-old allogeneic bone marrow transplant recipient) treated with methylprednisolone plus prophylactic antibiotics therapy, maximum mechanical ventilation, and withdrawal of immunosuppressive therapy in case series (Am J Transplant 2020 Apr 3 early online)
    • recovery from COVID-19 infection in kidney transplant recipients
      • PubMed32181990American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant SurgeonsAm J Transplant20200317recovery from pneumonia due to COVID-19 reported in kidney transplant recipient treated with low-dose methylprednisolone-based therapy and reduced immunosuppressant in case report (Am J Transplant 2020 Mar 17 early online)
      • PubMed32243690American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant SurgeonsAm J Transplant20200403recovery from COVID-19 reported in 3 patients from familial cluster in Wuhan, China, including 1 kidney transplant recipient treated with immunosuppressant reduction or cessation and low-dose methylprednisolone-based therapy in case series (Am J Transplant 2020 Apr 3 early online)
      • PubMed32243672American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant SurgeonsAm J Transplant20200403recovery from COVID-19 infection reported in kidney transplant recipient man aged 50 years presenting with mild symptoms and not requiring changes to immunosuppressive therapy in case report (Am J Transplant 2020 Apr 3 early online)
      • PubMed32301198Transplant infectious disease : an official journal of the Transplantation SocietyTranspl Infect Dis20200416e13296e13296recovery from COVID-19 infection reported in kidney transplant recipient woman aged 28 years presenting with mild symptoms and not requiring discontinuation of immunosuppressive therapy in case report (Transpl Infect Dis 2020 Apr 16 early online)
      • PubMed32301198Transplant infectious disease : an official journal of the Transplantation SocietyTranspl Infect Dis20200416e13296e13296recovery from COVID-19 infection reported in kidney transplant recipient woman aged 36 years who was initially treated with antiviral therapy (lopinavir plus ritonavir for first 2 days, then darunavir plus cobicistat) plus hydroxychloroquine plus ceftriaxone and reduction of maintenance tacrolimus, but then required discontinuation of both antiviral therapy and tacrolimus due to adverse drug-drug interaction effects in case report (Transpl Infect Dis 2020 Apr 12 early online)
    • clinical course of COVID-19 infection in kidney transplant recipients
      • PubMed32354637Kidney internationalKidney Int20200409COVID-19 infection in 7 kidney transplant recipients (median age 54 years) admitted to 3 London, England hospitals in March 2020, presenting with respiratory symptoms, fever, hypoxia, chest crepitation, lymphopenia, and high C-reactive protein, and 6 requiring reduced immunosuppressive therapy, in case series (Kidney Int 2020 Apr 9 early onlinefull-text)
      • PubMed32249089European urologyEur Urol20200402COVID-19 infection in 5 kidney transplant recipients (mean age 45 years) hospitalized in China between January and February 2020, all treated with antiviral therapy (oseltamivir or arbidol) and 4 requiring reduced dose of maintenance immunosuppressive therapy in case series (Eur Urol 2020 Apr 2 early online)
      • PubMed32233067American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant SurgeonsAm J Transplant20200331COVID-19 infection in 2 kidney transplant recipients (52-year-old woman and 75-year-old man) requiring noninvasive ventilation, hydroxychloroquine and antiretroviral therapy, and withdrawal of immunosuppressive therapy in case series (Am J Transplant 2020 Mar 31 early online)
      • PubMed32198834American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant SurgeonsAm J Transplant20200320progression in 48 hours to respiratory symptoms reported in kidney transplant recipient with COVID-19 initially presenting with symptoms of gastrointestinal viral disease and fever in case report (Am J Transplant 2020 Mar 20 early online)
  • Renal_Disorders_(Nephrology)American Society of Transplantation (AST) guidance for COVID-19 and organ donation and transplantation (AST 2020 Mar 11)05/06/2020 03:09:27 PMAmerican Society of Transplantation (AST) preliminary recommendations to mitigate risk of COVID-19 donor-derived infection
    • screen both living and deceased donors for COVID-19 infection; screening methods include
      • epidemiologic screening for travel and potential exposures; inquire for
        • travel to or residing in area with local COVID-19 transmission ≤ 21 days
        • direct contact with known or suspected case of COVID-19 ≤ 21 days
        • confirmed diagnosis of COVID-19 ≤ 28 days
      • screening for symptoms suggestive of COVID-19 ≤ 21 days, including fever (> 38 degrees C or 100.3 degrees F), flu-like symptoms with or without myalgias, new cough, and shortness of breath
      • laboratory screening with nucleic acid testing of specimens
    • preliminary deceased donor recommendations
      • for deceased donor with any of the following at time of death, avoid use of organs
        • active COVID-19 infection
        • test positive for COVID-19
        • classified as high risk based on screening
      • for deceased donor classified as intermediate risk, test for COVID-19; if testing not available, use caution with considerations for risks and benefits
      • for deceased donor classified as low risk, may use organs
      • for deceased donor that met epidemiological or clinical criteria and tested negative, use organs with caution due to possible false-negative test
      • for deceased donor who had recovered from COVID-19 > 28 days and repeated negative testing, use of organ likely safe
    • preliminary living donor recommendations
      • for living donor with active COVID-19 infection, avoid use of organs
      • for living donor classified as high risk, defer donation > 28 days after symptoms resolve and polymerase chain reaction (PCR) test for COVID-19 negative
      • for living donor classified as intermediate risk based on exposure and with no symptoms for ≥ 14 days, consider deferring transplant
        • advise donor about ways to decrease transmission
        • test for COVID-19 before transplant to confirm negative
      • for active local transmission of COVID-19 infection, consider temporary suspension of elective living donor transplantation
    • Reference - AST Infectious Disease Community of Practice Guidance for COVID-19 and Organ Donation and Transplantation 2020 Mar 11

Guidelines and Resources

Guidelines and Resources

Guidelines

United States Guidelines

  • Centers for Disease Control and Prevention (CDC)
    • interim infection prevention and control recommendations for patients with suspected or confirmed COVID-19 in healthcare settings can be found at CDC
    • interim guidance on infection prevention and control recommendations for patients with suspected or confirmed COVID-19 in outpatient dialysis facilities can be found at CDC 2020 Mar 24
  • American Society of Nephrology (ASN) recommendations on renal replacement therapy in hospitalized patients with COVID-19 and kidney failure can be found at ASN 2020 Mar 21
  • American Society of Transplantation (AST) Infectious Disease Community of Practice guidance for COVID-19 and organ donation and transplantation can be found at AST 2020 Mar 11

United Kingdom Guidelines

  • National Institute for Health and Care Excellence (NICE)

European Guidelines

  • European Renal Association (ERA)-European Dialysis and Transplant Association (EDTA)
  • Società Italiana di Nefrologia - Sezione Regionale Emilia-Romagna recommendations on treatment of patients on hemodialysis or with acute renal failure can be found at ERA-EDTA PDF
  • Brescia Renal Covid Task Force protocol on management of patients on dialysis and with kidney transplant during COVID-19 coronavirus infection can be found at ERA-EDTA PDF

Australian and New Zealand Guidelines

  • Kidney Health Australia information on coronavirus (COVID-19) can be found at Kidney Health Australia
  • National Aboriginal Community Controlled Health Organisation (NACCHO) coronavirus (COVID-19) updates and information can be found at NACCHO
  • National Indigenous Kidney Transplantation Taskforce (NIKTT) COVID-19 information for the Indigenous kidney community can be found at NIKTT
  • Queensland Health kidney patient COVID-19 information sheet can be found at Queensland Health

Review Articles

Patient Information

References

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