Decreasing Non-COVID-19 Hospitalizations in Dialysis Patients

Opinion article

Physician and Physician Extender Clinical Practice Considerations

Caring for Dialysis Patients During the COVID-19 Epidemic

On March 13, 2020, the U.S. administration instituted a national emergency, as nearly 200,000 COVID-19 cases presented worldwide.1 This is a novel disease and a rapidly evolving situation in the U.S., with the number of newly confirmed cases increasing by 20k-30k per day.2

The COVID-19 pandemic has the potential to strain many hospital systems and supply chains, putting hospital beds, tests, masks, gloves, and antibacterial and pharmaceutical supplies at risk. This pandemic could overwhelm, if not overtake, the physical and human capacity of the U.S. health system for several months.3 Like the rest of the population, our patients are likely depressed, anxious, and even scared during this time.

Dialysis patients are immunocompromised and may be at greater risk for worse outcomes with COVID-194

What we know: COVID-19 primarily affects the pulmonary system. Access to necessary resources may become limited for many of our patients. These factors may lead to increased missed treatments and volume issues; further increasing the risk of dialysis patient hospitalizations unrelated to COVID-19 infections.5 And, while we have no medical reports of such, it is logical to assume preventing volume overload could assist in reducing the acute impact of the COVID-19 virus in dialysis patients.

Decreasing Non-COVID-19 Hospitalizations in Dialysis Patients

It is essential to reduce hospitalizations for our patients to mitigate additional strain on our healthcare system and maintain health for our patients. Non-COVID, dialysis-related patient hospitalizations are most often infection-related or fluid-related, cardiovascular complications.6

I ask you to consider ways to decrease hospitalizations in this high-risk population amidst this national health crisis.

Recommendations

  1. Dietary consultation to educate and reinforce the importance of dietary sodium and volume reduction.
  2. Ensure adequate doses of diuretics to increase urine output in patients with residual renal function. Of note: this applies to peritoneal dialysis AND hemodialysis patients.
  3. Reassess dry weight and reduce as clinically indicated.
  4. Patients with persistent elevated ultrafiltration volumes should be considered for home hemodialysis and more frequent dialysis as clinically indicated.
  5. Stress the increased importance for patients to continue with their regularly scheduled dialysis treatments and staying on for their prescribed time.
  6. Discuss the importance of taking medicine(s) as prescribed and ask patients to have 3 months’ supply of medicines when appropriate.
  7. Remind in-center HD patients of proper infection control and the need to wash their access upon entry to the in-center dialysis unit.
  8. Remind and reeducate home HD patients on proper cannulation techniques and both PD and home HD patients on infection control at home.
  9. Remind patients about the appropriate care of their AV access and instruct on monitoring/physical exam of the access. It is important to address issues before thrombosis and access failure.
  10. Ask about fear, depression, and anxiety during this time and refer to social work as needed.
  11. Encourage patients to take proper care to prevent exposure to COVID-19 in the community.
  12. Encourage both physical and mental activity during isolation and encourage patients to keep in touch with others during social distancing or isolation.
  13. Ask patients about food stores, utilities. and transportation, and refer to social work as needed.
  14. Evaluate patients by telehealth, when appropriate, to prevent referral to emergency rooms or hospitals.

Practice social distancing with open communication

Lastly, please remain in communication with one another, watch for warning signs with vigilance, and encourage positivity for both providers and patients during this unprecedented time. If we all work together to reduce hospitalizations, we can help to maintain well-being for everyone.

Disclosure

This article reflects the opinions of the author and do not reflect recommendations or views from NxStage Medical, Fresenius Medical Care North America, or Fresenius Kidney Care.

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References

  1. Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak. Issued on: 3/13/2020.
  2. Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis; published online Feb 19. Accessed 4/24/2020.
  3. Harvard Global Health Institute estimates of hospital bed capacity and Covid-19 infections, in collaboration with ProPublica and The New York Times. Published 3/17/2020. Accessed online 3/24/2020.
  4. Betjes MG (2013) Immune cell dysfunction and inflammation in end-stage renal disease. Nat Rev Nephrol 9(5):255–265.
  5. Cohen DE et al. Impact of Rescheduling a Missed Hemodialysis Treatment on Clinical Outcomes. Kidney Med. 2(1):12-19. Published online December 11, 2019.
  6. 2019 USRDS Annual Data Report Reference Table K.3: Total Medicare inpatient spending ($) of reported ESRD patients: top ten DRG codes (rank order); 2017

Michael Kraus, MD

Indiana University School of Medicine
Associate Chief Medical Officer, Fresenius Medical Care North America

Dr. Kraus has held several positions at Indiana University (IU) School of Medicine. He is a leader in the field of short daily home hemodialysis and an internationally recognized invited speaker. He is a recipient of the Lifetime Achievement Award from the National Kidney Foundation of Indiana.

Articles by Michael Kraus, MD