This text has been prepared by the ERA-EDTA Working Group EUDIAL for patients on dialysis
The information in this section of the ERA-EDTA Covid-19 webpage is for a large part derived from the website of the Center of Disease Control (CDC). The site’s specific webpage for nephrologists and other professionals working with people on dialysis is very helpful, and contains much practical information. We urge you therefore to consult this webpage:
Please note that information may change over time. Please check this CDC webpage therefore regularly
- A working team consisting of dialysis physicians, nursing staff and technicians should receive training in updated clinical knowledge of epidemic COVID-19, epidemic prevention tools, and guidelines from the government, scientific societies and hospital authorities. Instructions should include how to use facemasks, how to use tissues to cover nose and mouth when coughing or sneezing, how to dispose of, preferably disposable paper, tissues and contaminated items in waste receptacles, and how and when to perform hand hygiene. Training can be done peer to peer or online.
- Latest care recommendations and epidemic information should be updated and delivered to all medical care personnel as needed.
- Staff members should self-monitor their symptoms (if any) and should inform the team leader in case they or their family members develop symptom(s) suggestive of COVID-19 infection. Sick members of the team should stay at home, and in any case should not be in contact with patients or other team members.
- Nurses should be trained to perform nasopharynx swab for COVID-19 PCR, with appropriate dressing (FFP2 mask, goggles, mobcap, disposable surgical blouse, gloves).
- Body temperature should be systematically measured before the start and at the end of the dialysis session in all patients.
- Early recognition and isolation of individuals with respiratory infection is mandatory: 1. dialysis facilities should identify patients with signs and symptoms of fever, cough, upper airway involvement or conjunctivitis before they enter the waiting room and treatment area; 2. instruct patients to call ahead to report fever or respiratory symptoms; thus, the facility can be prepared for their arrival (preferably they should be seen at a first aid department and not on a dialysis department) or triage them to a more appropriate setting (e.g., an acute care hospital); 3. patients must inform staff of fever or respiratory symptoms before arrival at the facility by phone or appropriate electronic means; 4. patients with respiratory symptoms should be brought to an appropriate treatment area as soon as possible in order to minimize time in waiting areas; 5. all patients who have fever, cough, upper airway involvement or conjunctivitis should be screened for novel Coronavirus infection. For sampling, patients should be either in a single-patient room, or in a room dedicated to sampling. Disinfection of the room after sampling is mandatory.
- Ideally, symptomatic patients should be dialyzed in a separate isolated room (if available), in which a negative pressure can be processed, with the door closed. Otherwise, they should wait in a separate isolated room and given dialysis in the last shift of the day until infection is excluded. He/she should wear a proper (surgical or N95) mask filtering 95% of the particulate matter smaller than 2.5 µm in the aerosol of exhaled air.
- Patients with confirmed COVID-19 infection should be admitted to an airborne infection isolation room and should not receive dialysis in an outpatient dialysis facility, unless an airborne infection isolation room is available. All personnel involved in the direct care of patients affected by COVID-19 must undertake full protection, including long-sleeved waterproof isolation clothing, hair caps, goggles, gloves and medical masks (FFP2 or FFP3 mask if available) filtering 95 to 99% of particulate matter and aerosols in inhaled air. Hand hygiene must be strictly implemented: carefully washing hands with soap and water and systematically using alcoholic solutions and disposable gloves.
- Consideration should be given to cohorting more than one patient with suspected or confirmed COVID-19 and the healthcare team caring for them together in the section of the unit and/or on the same shift (e.g., consider the last shift of the day). Avoid, however, mixing of suspected and confirmed cases.
- Healthcare team should be cohorted, i.e., separate teams for management of high-risk and low risk patients. Only the minimum number of assigned healthcare team should enter the isolation room/cohort area, all non-scheduled team-mates should be excluded at all times.
- If a newly confirmed or highly suspected case of novel Coronavirus infection in dialysis centres is identified, disinfection must be carried out immediately. Areas in close contact with these patients must not be used for other patients until cleared.
- The medical waste from confirmed or suspected patients with novel Coronavirus infection must be considered as infectious medical waste and disposed accordingly.
Duration of isolation precautions for patients under investigation for or with confirmed COVID-19
- Until information is available regarding viral shedding after clinical improvement, discontinuation of isolation precautions should be determined on a case-by-case basis, in conjunction with local, regionalstate, and national health authorities.
- Factors that should be considered include: presence of symptoms related to COVID-19 infection, date symptoms resolved, other conditions that would require specific precautions (e.g., tuberculosis, Clostridioides difficile), other laboratory information reflecting clinical status, alternatives to inpatient isolation, such as the possibility of safe recovery at home.
Patients who need vascular access surgery should be screened for COVID-19. Operations on patients with confirmed or suspected COVID-19 infection should be carried out in a designated room with necessary protection for medical staff.
Home haemodialysis and peritoneal dialysis
These patients should be assisted at home as far as is possible, using telereporting assistance or other electronic systems for clinical management and to supplement home visits by healthcare staff, as deemed necessary.
It can be considered to decrease the frequency of hemodialysis sessions from three to two times per week in patients that tolerate such a regimen. This could be considered
- to decrease the need for travelling by taxi / ambulance in case of shortage of such transportation means
- to decrease the chance of dialysis patients getting infected by travelling back and forth to the dialysis unit
- to decrease the chance of dialysis patients spreading the infection to the dialysis unit or the hospital
- to decrease the need for supplies of which shortages are expected. Especially with factories closing down (temporarily) and supply problems, your unit may run into logistical problems with shortage of material needed for dialysis. An early change from three to two hemodialysis sessions per week in a large part of your dialysis population may help to save material, allowing you to run your dialysis unit as long as possible.
ERA-EDTA sharing Milano experience on coronavirus management in dialysis centers
While considering that patients on dialysis treatment are undoubtedly more exposed to contracting infectious diseases and to have more severe manifestations than the non-dialysis population, nephrologists from the Milano dialysis unit argue that there is NO reason to adopt specific prophylactic measures for the entire dialysis population. In their opinion common sense and individual protection rules as for other high risk subjects should prevail.
Author: Professor Mario Cozzolino, MD, PhD, Renal Unit, San Paolo Hospital and San Carlo Hospital, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
Read the complete text here: Milano experience on coronavirus management in dialysis centers by Prof. Mario Cozzolino, Milan, Italy