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How has covid-19 affected end stage kidney patients?

UK hospitals are continuing to deal with the ongoing covid-19 pandemic and the strain that this has put on usual services.

Hemodialysis patients travel to dialysis units three-times-a-week and are exposed to other patients and healthcare workers, both possible carriers of SARS-Cov-2, leaving them more prone to infection and mortality than the general population. From the start of the pandemic up until the 20 May, 2326 in-centre haemodialysis patients were infected and 553 (23.8%) died in the UK. In London, with the highest numbers of deaths (6125) due to covid-19; 1055 or 18.8% of in-center haemodialysis cohort were infected and 249 (4.4%) have died. Interestingly, 4.1% of the mortality in London due to covid-19 was in the end-stage kidney disease patients who comprise just 0.01% of the London population.1-3

In our renal unit in South London, we focused on early identification and separation of the SARS-Cov-2 infected patients to prevent further infection. Patients were screened at the beginning of each dialysis session, and if febrile or coughing, were immediately separated from asymptomatic patients with further isolation for travel and dialysis in a special area for 14 days if positive for SARS-Cov-2. In our experience, we only saw a few peritoneal dialysis patients with covid-19, but with higher mortality.

Kidney transplant recipients are immunosuppressed and hence more prone to SARS-CoV-2 infection, but can isolate themselves better as they do not need to travel to a dialysis unit. Kidney transplant patients in the UK are, on average, 12 years younger and comprise a higher proportion of end-stage kidney disease population compared to haemodialysis patients (55% vs. 37%), and self-isolated during the pandemic on government instructions. Until 15 July, 474 kidney transplant patients in the UK have been reported with the infection and 127 have died. In London, 50 kidney transplant patients (0.6% of the cohort of kidney transplant patients) had died of the 190 (2.4%) infected with SARS-CoV-2.4 In our experience when admitted to hospital, infected transplant patients have done poorly compared to those managed in the community.5 

Most UK kidney transplant centres stopped providing transplantation at the beginning of the covid-19 pandemic. This was done to prevent infection in the peri-operative and early post-operative period when the burden of immunosuppression is high and hospital visits are frequent, and to address the lack of intensive care unit beds, anesthetists, and operating theatres during the pandemic, as transplantation is not considered to be a live-saving procedure in the high-infection-risk population. All five kidney-transplant centres in London were closed for transplantation by the second week of March. This has resulted in a potential loss of 1670 kidney transplants in the UK, increasing numbers of dialysis patients waiting for transplantation while carrying a higher risk of infection, similar to other regions of the world.6

Concern about a second surge of covid-19 has made the reopening of transplant centres a challenge. Each transplant centre is currently designing a safe pathway for kidney transplantation, incorporating stricter infection control measures and pre/post-transplant SARS-CoV-2 free areas served by infection-free staff, assessed by symptoms and virus RNA testing. The immunosuppression burden can be reduced by avoiding lymphocyte-depleting antibodies. Reducing the number of post-operative hospital visits and using remote telephone/video consultation will further prevent exposure to the coronavirus. Careful donor selection will avoid delayed graft function and transmission of covid-19. Recipients, carefully selected in the initial phase to avoid prolonged hospital admission, should be very carefully counselled about the risk of covid-19 infection and the steps to follow to reduce the risk. Rapid and repeated testing for covid-19, to reduce risk of infection in patients and staff, will be needed, often limited by lack of capacity for testing in certain areas. This being said, early experience of kidney transplantation during the pandemic from limited UK centres has been encouraging; and more transplant centres are re-opening.

What can we take away from our experience of managing the first wave of covid-19 infection in our end stage kidney disease patients? 

Constant monitoring of incidence and outcomes of covid-19 infection in dialysis, kidney transplant and general population will be vital. Early identification, with rapid tests if possible, followed by isolation and strict infection control measures with masks, hand hygiene, physical distancing are crucial for haemodialysis patients in preventing the spread of infection. Kidney transplantation, which prolongs and improves quality of life, should re-start safely and continue through the subsequent surges, with strict infection control at home and hospital, proper donor assessment, careful recipient selection and consent, rational immunosuppression and effective post-transplant isolation—until the community incidence and reproduction number for SARS-CoV-2 reaches dangerous levels.

Debasish Banerjee, consultant nephrologist, Care Group Lead, Clinical SubDean, St George’s University Hospitals, NHS Foundation Trust, UK. 

Richard Hull, consultant nephrologist, St George’s University Hospitals, NHS Foundation Trust, UK. 

Daniel Jones, consultant nephrologist, St George’s University Hospitals, NHS Foundation Trust, UK. 

Competing interests: none declared. 

References:

  1. https://renal.org/covid-19/data/, last Accessed on 19 July 2020
  2. https://www.london.gov.uk/coronavirus/coronavirus-numbers-london, last accessed 19 July 2020
  3. https://www.ons.gov.uk/, last accessed on 19 July 2020
  4. From UK Renal Registry https://renal.org/covid-19/data/, last accessed 19 July 2020
  5. Banerjee D, Popoola J, Shah S, Ster IC, Quan V, Phanish M. COVID-19 infection in kidney transplant recipients. Kidney Int. 2020 Jun;97(6):1076-1082. doi: 10.1016/j.kint.2020.03.018. Epub 2020 Apr 9. PMID: 32354637; PMCID: PMC7142878.
  6. Videha Sharma, Alex Shaw, Marcus Lowe, Angela Summers, David van Dellen, Titus Augustine. The impact of the COVID-19 pandemic on renal transplantation in the UK. Clinical Medicine Jul 2020, 20 (4) e82-e86; DOI: 10.7861/clinmed.2020-0183
  7. Domínguez-Gil B, Coll E, Fernández-Ruiz M, Corral E, Del Río F, Zaragoza R, Rubio JJ, Hernández D. COVID-19 in Spain: Transplantation in the midst of the pandemic. Am J Transplant. 2020 May 2:10.1111/ajt.15983. doi: 10.1111/ajt.15983. Epub ahead of print. PMID: 32359194; PMCID: PMC7267131.