Good practices recommendations from the Brazilian Society of Nephrology to Peritoneal Dialysis Services related to the new coronavirus (Covid-19) epidemic



## Resumo
Considerando a nova epidemia de coronavirus (Covid-19), a Sociedade Brasileira de Nefrologia, representada pelo Comite de Dialise Peritoneal, em concordancia com a diretoria e o Departamento de Dialise, desenvolveu uma serie de recomendacoes de boas praticas clinicas para os servicos de dialise peritoneal a serem consideradas durante o periodo da epidemia de Covid-19, com o objetivo de minimizar a disseminacao da doenca, proteger pacientes e funcionarios e garantir a qualidade do tratamento prestado e acompanhamento adequado para os pacientes em DP. As recomendacoes aqui sugeridas devem ser adaptadas a cada realidade de servico e as condicoes estruturais e de recursos humanos e dependem da provisao financeira adequada do sistema publico de saude para sua plena implementacao.
Palavras-chave: Covid-19; Infeccoes por Coronavirus; Dialise Peritoneal; Estrategias de eSaude.

# Abstract
Considering the new coronavirus epidemic , the Brazilian Society of Nephrology, represented by the Peritoneal Steering Committee, in agreement with the and the Dialysis Department, developed a series of recommendations for good clinical practices for peritoneal dialysis (PD) clinics, to be considered during the period of the Covid-19 epidemic. We aim to minimize the disease spread, protecting patients and staff, and ensuring the quality of the treatment provided and adequate follow-up for PD patients. The recommendations suggested at this moment must be adapted to each clinic's reality and the conditions of the structural and human resources, dependent on the adequate financial provision of the public health system for its full implementation.

## Keywords:
Covid-19; Coronavirus infections; Peritoneal dialysis; eHealth Strategies.

# Introduction
The Steering Committee of the Brazilian Society of Nephrology (SBN), together with the Peritoneal Dialysis Committee, prepared recommendations for peritoneal dialysis services concerning coronavirus pandemic. The recommendations contained herein must be adapted to the context and the reality of each service, and depend on adequate funding from public health systems for its complete implementation. - Reinforce for patients the instructions concerning the material used in therapy. Home storage and use at home must be maintained according to the local protocol. - All materials used in each PD session in the clinic or hospital must be cleaned with 70% alcohol before use. - Disposable of fluid bags, circuits, and all other required PD supplies generate by Covid-19 patients must be done following local regulatory rules. - For cases of patients who need to be evaluated in person at the unit, the SBN reinforces the need to maintain technical recommendations for good practices, adapted to the context and local reality, and with adequate funding from the public health system, previously published for hemodialysis services compiled and adapted for peritoneal dialysis, as mentioned below geneRAl cARe foR pResentIAl seRvIce - PD units must educate patients and collaborators on primary preventive care. Emphasize and intensify frequent hand hygiene with 70% alcohol gel or with soap and water for about 20 to 60 seconds. They should also instruct patients and collaborators to avoid touching their eyes, mouth, and nose without having done hand hygiene; avoid close contact with infected individuals; using social etiquette, cover mouth and nose when sneezing or coughing, with a disposable handkerchief and despise it as soon as possible, or use the angle formed by the arm and forearm (elbow); clean and disinfect frequently touched objects and surfaces; avoid sharing personal objects (such as toothbrushes, cutlery, plates, and glasses); and, if infected, avoid contact with other people, choosing to stay at home whenever possible 12,13 . - We recommend intensifying the cleaning of objects and surfaces frequently used by the public, such as door handles, chair arms, and elevator buttons. Recent evidence suggests that some coronaviruses can remain infectious on inanimate surfaces for up to 9 days. Disinfecting surfaces with 0.1% sodium hypochlorite or 62-71% ethanol significantly reduces coronaviruses' infectivity after 1 minute of exposure [bib_ref] Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents, Kampf [/bib_ref].

## Considerations
- Patients and employees should be encouraged to avoid public transportation, if possible. When necessary, wear a cloth mask. - PD units should encourage their patients to vaccinate for influenza, in the absence of contraindications. - Dialysis units should take administrative procedures to reduce, as far as possible, the number of caregivers and companions. - Patient companions and employees with respiratory symptoms should be discouraged from attending the PD Unit. - Rooms should be kept ventilated, as well as the Dialysis Unit. - Meetings via video conference should be encouraged whenever possible. - Care for PD patients in face-to-face outpatient consultation: contact the patient and family for a pre-screening before the consultation via telephone, looking for respiratory symptoms (if any, advise the patient and family to not attend the unit); educate them on signs and symptoms of severity and to seek care according to the reference of each municipality if there is a worsening of the condition. - If patients with suspicion of the disease arrive at the unit, they must undergo a medical evaluation and receive instructions before entering the dialysis clinic. After evaluation, the patient should be treated under the clinical condition and with the current recommendations of the local health authorities and the Ministry of Health. These patients must not stay in the unit; monitoring can be carried out later by telephone 12 . - To evaluate the suspected case, the healthcare professional (doctors and nurses) must wear a disposable apron, surgical mask, goggles and/ or face shield and disposable gloves. - Patients with respiratory symptoms and their companions must wear a surgical mask during the evaluation before entering the dialysis unit. - Other members of the multidisciplinary care team must wear a surgical mask. If the service provides contact that is more direct with the patient, follow the same recommendations as to the second item. We also suggest that the other employees (maintenance, cleaning, receptionists, and security guards) of the dialysis unit also wear a surgical mask. The surgical mask should be replaced with a new one whenever it becomes wet. - Healthcare professionals in the dialysis unit, responsible for assisting confirmed or suspected cases, should wear masks (type N95) whenever performing aerosol-generating procedures, such as orotracheal intubation, non-invasive ventilation, cardiopulmonary resuscitation or manual ventilation before intubation. - If possible, designate a toilet for the exclusive use of the suspected case. If this is not possible, clean the frequently touched surfaces of the bathroom (s) (faucet, handle, trash can cover, counters) with soap and water or disinfectant, according to the procedures described in RDC 56, of 6 August of 2008.

## Final remarks
The aforementioned measures serve as a source of information and alert to mitigate the virus spread and promote adequate assistance to the population with chronic kidney disease undergoing peritoneal dialysis during the Covid-19 pandemic. These measures can, and should, be revised as the health situation changes.