A view from the front line of the COVID-19 war
Authors: Camillo Carrara, Laura Cappelletti, Valentina Portalupi
Journal: Kidney International (2020)

Just a few weeks ago, I was looking at kidney biopsy slides through the microscope. As a nephrologist with a special interest in renal histopathology, I never thought I would soon find myself at the front line in the coronavirus disease 2019 (COVID-19) pandemic. I started my residency in 2011 at the Papa Giovanni XXIII Hospital in Bergamo, in Lombardy, a northern region of Italy, after having developed a strong interest in nephrology during medical school. I was excited when I managed to get into one of the top-ranked Italian postgraduate nephrology training programs. I soon developed a special interest in renal pathology, which I pursued also by completing my training at the Department of Pathology of the University of Washington in Seattle, WA, with Professor Charles Alpers. Then came the day when 2 Chinese tourists in Rome tested positive for a new form of coronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was January 31, 2020. A week later, an Italian man who had just returned from the city of Wuhan, China, was admitted to a hospital in Lombardy because of severe interstitial pneumonia and found to be positive for coronavirus. A cluster of cases soon was detected, starting with 16 confirmed cases in Lombardy on February 21, 2020, which increased to 60 cases the next day. The first death also was reported. In a few days an increasing number of cases were diagnosed in the Bergamo area, which soon emerged as one of the worst affected areas in Europe. In those early days of the spreading pandemic, the hospital's emergency wards were quickly flooded by incoming patients, most of whom required hospitalization because of respiratory insufficiency of varying severity. It was mandatory to make room for all of these patients, which meant converting a large number of hospital beds to treat SARS-CoV-2 patients. Bergamo Hospital is a tertiary referral center, serving an area of approximately 1 million people, with 1080 beds, including 53 beds in the intensive care unit and 40 beds in subintensive areas, and 9 medical or surgical departments. At the outbreak of the epidemic, the number of intensive care unit beds dedicated to COVID-19 patients increased to 88, with an additional 418 beds in other departments devoted to the treatment of mild to moderate acute respiratory failure secondary to interstitial pneumonia. One problem that soon emerged was the coverage of all shifts, which could not be managed with the staff that during routine practice takes care of pneumonia and respiratory insufficiency (i.e., pneumologists, internists, infectious disease specialists, intensive care doctors). An ad hoc task force was established that proposed involving a number of physicians of any medical subspecialty in the care of COVID-19 patients. Under the supervision of pneumologists and intensivists, physicians (and also the nurses) were trained on the correct use of Venturi masks, reservoir masks, and continuous positive airway pressure devices. New protocols were established within days to standardize therapy for COVID-19 patients based on the available literature. Along with 2 other colleagues in the Renal Division (LC and VP), I volunteered to participate in the COVID-19 task force, after the earlier-mentioned training. I will never forget my first night shift in the COVID-19 unit (Figure 1). I was on duty with 2 colleagues, a plastic surgeon and a senior infectious disease specialist, and we had to take care of 45 quite sick patients during those long hours. I felt like I was on the front lines in a war. I was really impressed with everyone's ability to react quickly and effectively; this huge effort brought together nurses, doctors, biologists, technicians, and all the remaining hospital staff. I cannot deny the fear I felt, of being infected and of bringing the disease home to my family. No one can deny it. However, the desire to be there, to contribute, comes first. Meanwhile, the usual activities of the Renal Department had to be adapted to this unprecedented emergency. Our main concern was how to deal with the kidney transplant program. When we soon realized the magnitude of the COVID-19 outbreak in our area, we believed that newly transplanted patients, who require full immunosuppressive therapies, would have been exposed to an excessive risk. We therefore suspended the transplant program. Among kidney transplant patients who are on long-term follow-up evaluation at our hospital (780 patients), we registered 50 patients with SARS-CoV-2, 8 of whom died. Most of these patients could be managed successfully at home, and only a minority required hospitalization. The Renal Division has a huge outpatient clinic, where patients with chronic kidney diseases, of any stage, routinely are followed up. This activity had to be drastically limited to urgent cases, with the aim to reduce access to the hospital that was so heavily burdened with COVID-19 patients. A lot of patients were assisted by telephone calls and email. The Dialysis Unit has 54 dialysis stations and takes care of 211 patients. Overall, 22 SARS-CoV-2–positive cases and 12 deaths were recorded (during the same period of time in 2019, 3 patients on maintenance dialysis have died). Beyond the shadows of this dramatic experience there could be a glimpse of light. SARS-CoV-2 triggers a multisystemic process whose understanding raises many scientific questions. This is not just a lung disease, but also an inflammatory, vascular, and cardiocirculatory disorder (and probably even more). The scientific community is concentrated in the common effort to find effective therapies and a vaccine. On the other hand, during our shifts in the COVID-19 units, we are learning to be less organ-specific, trying to remove for a while the exoskeleton of our medical subspecialty. The virus is reminding us that everything is interconnected within the human being. As nephrologists, we are picking up many tips from our fellow pneumologists, infectious disease specialists, cardiologists, and hematologists. Young doctors are living a very educational moment that will become part of their cultural and scientific background. In the future, we should be ready to adapt our professional skills to face other possible global emergencies. We thank Dr. Arrigo Schieppati for English language editing. We also thank our colleagues from the Renal Department for the hard work in taking care of the patients during the pandemic: Dr. Piero Ruggenenti, Dr. Patrizia Ondei, Dr. Eliana Gotti, Dr. Vincenzo Gambara, Dr. Ettore Sabadini, Dr. Stefano Rota, Dr. Elena Perticucci, Dr. Maria Rosa Caruso, Dr. Annarita Plati, Dr. Carmelita Condemi, Dr. Valentina Fanny Leone, Dr. Amantia Imeraj, Dr. Federica Tomatis, Dr. Silvia Bernardi, Dr. Antonio Sollazzo, and Dr. Diego Curtò. We especially thank all the nurses at the Papa Giovanni XXIII Hospital in Bergamo for the courage and passion showed. CC had the initial idea and wrote the first draft of the manuscript; VP gathered patient data from the renal department and the other hospital units; and LC and VP critically revised the final paper. All of the authors approved the version of the manuscript to be submitted.