Patients on Hemodialysis before Covid 19 pandemic

# Overview
The Covid-19 infection has high mortality among dialysis patients as compared to normal individuals. One of the factors for increased mortality for dialysis patients as compared to the general population due to COVID-19 infection is the increased age of the patients. Adequate measures should be taken to prevent the spread of COVID-19 infection in dialysis patients.

# Pathophysiology
Patients on hemodialysis have a mild clinical course of COVID 19 infection. It could be due to multiple reasons.
- Patients with chronic kidney disease or end-stage renal disease have low immunity. The low immunity results in low-intensity cytokine storm in response to viral antigens. The patients on maintenance hemodialysis rarely present with a full-blown clinical picture of pneumonia.
- Hypercoagulation plays an important role in aggravating the disease. Hypercoagulation initiates the coagulation cascade resulting in disseminated intravascular coagulation (DIC). DIC results in organ dysfunction and high mortality in COVID 19 infection. Anticoagulants administered during hemodialysis inhibit coagulation cascade preventing hypercoagulation and DIC.
- In a study done at a hemodialysis center at Renmin Hospital in Wuhan, 37 out of a total of 230 patients were infected with covid-19 infections in one month. Four members of the health care staff were also infected. The peripheral blood examination of the covid 19 infected hemodialysis patients had reduced levels of killer T cells, helper T cells, Natural killer cells, and lower level of inflammatory cytokines as compared to non-dialysis infected patients.

# Epidemiology and Demographics
- Patients on maintenance hemodialysis and end-stage kidney disease have low immunity and multiple co-morbidities. They are at an increased risk of contracting the covid-19 infection.  A case series of 5,700 patients with covid-19 infection was done in 12 hospitals under the Northwell Health system in New York. It showed a prevalence of 5% chronic kidney disease and 3.5% end-stage renal disease in hospitalized covid-19 patients.
- A research study done in Japan showed a higher mortality 16.2% (16/99) in dialysis patients as compared to the general population 5.3% (874/16,532). The average age of patients on dialysis was 70 to 90 years while of the general population was 20 to 60 years.
- A study was done in 208 acute care hospitals in the UK. The total patients studied were 20,133. It showed chronic kidney disease was one of the most common co-morbidity in hospitalized covid-19 patients present in 16% of patients.
- Clinical research was done by Alberici et al. at four outpatient dialysis facilities in Italy showed high overall mortality of 29% in dialysis patients.

# Treatment

## Measures to prevent COVID 19 infection in hemodialysis patients
Strict measures should be taken to prevent covid 19 infections in hemodialysis patients and health care workers. The measures include:

### Screening of the patients
- Appropriate screening of patients should be done before dialysis. The best approach is to call patients and inquire about covid-19 symptoms.
- Patients reporting illness or covid-19 symptoms should be placed in the screening area. Hand sanitizers and face masks should be provided to patients.
- A triage protocol should be instituted in dialysis facilities to take patients to testing clinics, particular dialysis facilities, and hospitals.

### Managing patients with suspected illness
- If there are adequate resources in the hospital, patients should have dialysis at a specific shift, or a separate isolation dialysis ward should be made.
- Patients should be instructed to wear masks and cover mouth and nose while coughing and sneezing. This will reduce air droplet transmission of the virus.
- Suspected covid-19 patients should have at least 6 feet (2 meters) apart from each other in all directions. 

### Personnel protective equipment
- A selected group of healthcare personnel should be assigned for suspected covid-19 patients. Personal protective equipment should be given to patients and healthcare personnel.
- Healthcare workers should follow droplet and contact precautions. The workers should wear masks, gowns, goggles, shields, and gloves. Surgical face masks and N95 masks can be used. 
- Eyeshields and goggles can be used to prevent droplet spread via eyes.

### Disinfection
Disinfecting personnel should also wear personal protective equipment while disinfecting the dialysis surface. The dialysis machine, chair, dialysis surface station including BP cuff, stethoscope, the chairside stand should be cleaned with disinfecting wipes and allowed to be air dry.

### Optimum utilization of resources
- As pandemic will be for a long duration, hence resources should be utilized optimally. The gown should ideally be worn by both the health care workers and the patients.
- If there are a limited number of gowns, then health care workers should wear it at the time of initiating and terminating dialysis, manipulating catheters and access sites, disinfecting dialysis station, and assisting to and from the dialysis station. 
- The goggles and eye shields can be reused after proper disinfection procedure. The eye shields and face masks should be used for an extended time period. 
- A track of the personal protective equipment stock should be made.

### Work labor Management
- The healthcare workers are at risk for infection with covid-19 due to exposure. The exposure of health care workers can be minimized by working in shifts.
- In this pandemic, the health care workers can become sick and shortage of health care staff can arise. To encounter it a back up list should be created to fill up the positions. Training courses should be conducted for the health care staff.