By Dr Sandeep Mahajan & Dr Arun
Our knowledge about the novel coronavirus disease (COVID) has been evolving ever since the World Health Organization (WHO) declared the COVID-19 outbreak as a pandemic on 11th March, 2020. Although virtually any person can get infected with COVID, it is clear from available data that, if infected, people with pre-existing medical conditions such as diabetes, heart disease and kidney disease are more likely to have a severe disease manifestation and are prone to develop complications. Among these the patients suffering from kidney disease face unique challenges, but unfortunately are a neglected sub-group.
Patients suffering from end stage kidney disease, who are on hemodialysis compulsorily have to commute to the dialysis center or hospital, two to three times a week, exposing these high-risk individuals to other patients and healthcare team thereby increasing the risk of contracting infection. Because of this risk, it is our responsibility to prevent COVID outbreaks in the hemodialysis units. For this purpose, we have initiated newer protocols such as screening of patients before entering the units, restriction of visitor’s entry, avoiding crowding of dialysis waiting areas, ensuring physical distancing between the patients and universal use of face mask inside the unit. Besides these the heath care professionals have to be in Personal Protective Equipment (PPE) kits and their duties have to be adjusted to have buffer staff ready in case of inadvertent COVID exposure. Kidney patients often do not present with conventional symptoms with absence of fever in most patients and therefore a high index of suspicion is required to detect infection early in these patients. In spite of all these precautions, outbreaks have been reported in the dialysis units all over the world, highlighting the risks and challenges we face in these uncertain times.
Kidney transplant patients are more likely to have complications of COVID as they are on immune-suppressive drugs and have shown to have much worser outcomes as compared to general public. Also, the frequency of hospital outpatient visits have reduced with at times difficulty in procuring life-saving drugs which has affected this group of patients adversely. Transplant patients should continue their drugs as always and contact a healthcare provider if there is any need as before.
Patients admitted with COVID, especially those with co-morbid illnesses, may develop renal complications (even with no prior renal disease) during the course of their illness. Hence, a thorough evaluation with proper management strategy is essential to treat kidney complications in hospitalized patients. The long-term effect of COVID on renal function is still unknown, though from previous experiences, we expect the kidney functions to recover over time. While managing COVID infection in these high-risk patients there are no proven guidelines at present but there is some experience suggesting that treatment strategies do not change in those with and without kidney disease, albeit with some dose modifications.
While stressing the importance of social distancing, it is also imperative to understand that patients with kidney disease should not stay away from hospitals and doctors in times of need. Routine care can be provided by teleconsultation and home-monitoring of tests. Complex issues should be dealt with in the hospital or nursing home, in the hands of experienced physicians to avoid any complications.
COVID 19 pandemic has brought unique challenges to kidney patients and current Nephrology practice necessitating changes in the standard of care. It has adversely affected the transplant programs and has increased the burden on the dialysis units with more patients requiring dialytic support on an already saturated system. At the same time loss of follow-up has adversely affected routine patient care. The promise of a successful protective vaccine with preliminary favorable results from Pfizer, Moderna, AstraZeneca and Bharat Biotech shows promise and instils hope to mankind worldwide.
The writer is Dr Sandeep Mahajan, Nephrologist and Dr Arun at AIIMS.
