General measures for prevention
The following are general measures advised by Center for Disease Control (CDC)⁶. and the National Institute for Communicable Disease (NICD)⁷. of South Africa to minimize exposure to COVID-19:
General management
All the patients with confirmed COVID-19 should be quarantined. Not all patients need hospital admission. In view of rapidly increasing demand, countries are developing hospitalization policies, In general, high-risk patients, or those with severe infection need admission in isolation units in designated hospitals. Supportive care, namely bed rest, nutritional and fluid support, maintenance of blood pressure and oxygenation are important measures, as for all critically ill patients.
[B] The impact of COVID-19 infection on kidneys
There is no evidence that COVID-19 infection affects the kidneys adversely in those with mild to moderate infection. However, amongst those who develop severe infection and require hospitalization, kidney abnormalities are seen in 25-50% of subjects, manifested as increased excretion of protein and red blood cells in urine. A small proportion (less than 15%) develop a decline in filtration function of kidneys (acute kidney injury). The long-term health effect of kidney injury on survivors of COVID-19 infection is not known.
[C] COVID-19 in patients with chronic kidney disease
COVID-19 infection presents a special threat to patients with CKD, especially to those on dialysis and kidney transplant recipients. Hemodialysis patients may have milder clinical disease than other patients with COVID-19 infection. Kidney transplant patients should undertake the measures above recommended to prevent infection. All patients should continue all medicines in prescribed doses including ACE inhibitors unless advised otherwise by their treating doctors.
Strategies for management of patients on dialysis
COVID-19 infection presents particular challenges for patients on dialysis, in particular, in-center hemodialysis (HD). Uremic patients are particularly vulnerable to infection and may exhibit greater variations in clinical symptoms and infectivity. Further, unlike other individuals who may have COVID-a19 infection, patients with COVID-19 infection still need to come to the dialysis center for regular dialysis. This increases the risk of transmission of infection, including to medical staff and facility workers, other patients and all others in contact.
As part of routine infection control, dialysis facilities should have established policies and protocols in place to prevent or reduce the spread of infectious disease.
The Chinese Society of Nephrology⁸. and the Taiwan Society of Nephrology⁹. have recently developed guidelines for dialysis units during the COVID-19 outbreak, in addition to the American Society of Nephrology/ Centers for Disease Control (CDC)¹⁰. and the European Renal Association (ERA-EDTA)¹¹. . A summary of these guidelines is provided below.
Recommendations for hemodialysis unit staff
Facility and staff
Patient management
The table below suggests the protective gear required for different levels of anticipated contact.
STAFF CATEGORY | HAND HYGIENE | EYE PROTECTION | N95 *** RESPIRATOR | SURGICAL MASK | APRON | GOWNS (Disposable) | GLOVES (Disposable) |
Reception staff | Yes | ||||||
Triage Staff | Yes | Yes | |||||
Healthcare worker* attending to the patient (routine examination) | Yes | Yes | Yes | Yes | Yes | ||
Healthcare worker* Performing aerosol generating procedures ** and caring for a confirmed case of very ill patient | Yes | Yes | Yes | Yes (if gown is not available) | Yes | Yes | |
Housekeeping staff | Yes | Yes | Yes | Yes | |||
Security officer/porter | Yes | Yes (only if the patient does not wear a mask) | |||||
Staff transporting | Yes |
Recommendations for family members and caregiver
In summary, COVID-19, a disease caused by a novel coronavirus, is a major global human pandemic. The impact of this infection in those with CKD has not been fully studied, and the management of patients on dialysis who have been suspected to have been in contact with COVID-19 should be carried out according to strict protocols to minimize risk to other patients and healthcare personnel taking care of these patients.
General measures for prevention
The following are general measures advised by Center for Disease Control (CDC)⁶. and the National Institute for Communicable Disease (NICD)⁷. of South Africa to minimize exposure to COVID-19:
General management
All the patients with confirmed COVID-19 should be quarantined. Not all patients need hospital admission. In view of rapidly increasing demand, countries are developing hospitalization policies, In general, high-risk patients, or those with severe infection need admission in isolation units in designated hospitals. Supportive care, namely bed rest, nutritional and fluid support, maintenance of blood pressure and oxygenation are important measures, as for all critically ill patients.
[B] The impact of COVID-19 infection on kidneys
There is no evidence that COVID-19 infection affects the kidneys adversely in those with mild to moderate infection. However, amongst those who develop severe infection and require hospitalization, kidney abnormalities are seen in 25-50% of subjects, manifested as increased excretion of protein and red blood cells in urine. A small proportion (less than 15%) develop a decline in filtration function of kidneys (acute kidney injury). The long-term health effect of kidney injury on survivors of COVID-19 infection is not known.
[C] COVID-19 in patients with chronic kidney disease
COVID-19 infection presents a special threat to patients with CKD, especially to those on dialysis and kidney transplant recipients. Hemodialysis patients may have milder clinical disease than other patients with COVID-19 infection. Kidney transplant patients should undertake the measures above recommended to prevent infection. All patients should continue all medicines in prescribed doses including ACE inhibitors unless advised otherwise by their treating doctors.
Strategies for management of patients on dialysis
COVID-19 infection presents particular challenges for patients on dialysis, in particular, in-center hemodialysis (HD). Uremic patients are particularly vulnerable to infection and may exhibit greater variations in clinical symptoms and infectivity. Further, unlike other individuals who may have COVID-a19 infection, patients with COVID-19 infection still need to come to the dialysis center for regular dialysis. This increases the risk of transmission of infection, including to medical staff and facility workers, other patients and all others in contact.
As part of routine infection control, dialysis facilities should have established policies and protocols in place to prevent or reduce the spread of infectious disease.
The Chinese Society of Nephrology⁸. and the Taiwan Society of Nephrology⁹. have recently developed guidelines for dialysis units during the COVID-19 outbreak, in addition to the American Society of Nephrology/ Centers for Disease Control (CDC)¹⁰. and the European Renal Association (ERA-EDTA)¹¹. . A summary of these guidelines is provided below.
Recommendations for hemodialysis unit staff
Facility and staff
Patient management
The table below suggests the protective gear required for different levels of anticipated contact.
STAFF CATEGORY | HAND HYGIENE | EYE PROTECTION | N95 *** RESPIRATOR | SURGICAL MASK | APRON | GOWNS (Disposable) | GLOVES (Disposable) |
Reception staff | Yes | ||||||
Triage Staff | Yes | Yes | |||||
Healthcare worker* attending to the patient (routine examination) | Yes | Yes | Yes | Yes | Yes | ||
Healthcare worker* Performing aerosol generating procedures ** and caring for a confirmed case of very ill patient | Yes | Yes | Yes | Yes (if gown is not available) | Yes | Yes | |
Housekeeping staff | Yes | Yes | Yes | Yes | |||
Security officer/porter | Yes | Yes (only if the patient does not wear a mask) | |||||
Staff transporting | Yes |
Recommendations for family members and caregiver
In summary, COVID-19, a disease caused by a novel coronavirus, is a major global human pandemic. The impact of this infection in those with CKD has not been fully studied, and the management of patients on dialysis who have been suspected to have been in contact with COVID-19 should be carried out according to strict protocols to minimize risk to other patients and healthcare personnel taking care of these patients.
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