Peritoneal Dialysis in the time of COVID-19

Survey of Peritoneal Dialysis Patients' Challenges and Experiences during the COVID-19 Pandemic: A Multicenter Study in the United States

Key Points

The adjustments made by the dialysis units during the peak of the pandemic were effective in maneuvering the challenges faced by our patients during the COVID-19 pandemic. Patients who remained on PD were satisfied with the quality of care, felt supported by the unit staff, and did not report feeling anxious or depressed.

Background

During the coronavirus disease 2019 (COVID-19) pandemic, adjustments were made to peritoneal dialysis (PD) practices in the outpatient units. These were decisions made by dialysis providers, clinical staff, and governments with input from patient organizations in some instances. The patient perspective regarding these changes during the pandemic has not been explored. We sought to evaluate patient experiences and perceptions of the challenges they faced, institutional adjustments, and their mental health during the height of the COVID-19 pandemic in the United States.

Methods

We conducted a cross-sectional survey of PD patients across four home dialysis units affiliated with four large academic centers, who were on PD between March 2020 and March 2021.

Results

Ninety-eight participants completed the survey across the four outpatient PD clinics. Over 95% of patients did not have to change their home accommodations during the pandemic, and over 80% did not have issues getting their dialysis supplies and medications delivered. Ninety-three percent of patients felt comfortable coming to the dialysis unit if they needed to during the pandemic. Almost all patients (98%) felt supported by their dialysis staff during the peak of COVID-19 and had modified Patient Health Questionnaire 2 (91%) and Generalized Anxiety Disorder 2-item (96%) scores not consistent with depression or anxiety. Less than 10% of patients considered changing their dialysis modality.

Conclusions

The adjustments made by the dialysis units during the peak of the pandemic were effective in maneuvering the challenges faced by our patients during the COVID-19 pandemic. Overall, patients who remained on PD were satisfied with the quality of care, felt supported by the unit staff, and did not report feeling anxious or depressed.

COVID-19 incidence and outcomes among patients with kidney replacement therapy

BACKGROUND

We aimed to investigate the incidence, fatality, and associated factors in patients with hemodialysis (HD), peritoneal dialysis (PD), and kidney transplantation (KT) hospitalized for coronavirus disease 2019 (COVID-19) infection and reimbursed from the National Health Security Office (NHSO).

METHODS

The retrospective cohort analysis was conducted from an electronic-claimed database, and COVID-19 vaccination status was evaluated in patients with HD, PD, and KT from January 2020 to December 2021. There were 85,305 patients reimbursed for HD, PD, and KT by the NHSO. The rates of COVID-19 infection, COVID-19 vaccination, comorbidities, fatalities, and the cost of treatment were evaluated.

RESULTS

COVID-19 infection was observed in 1,799 of 36,982 HD cases (4.9%), 1,531 of 45,453 PD cases (3.4%), and 95 of 2,870 KT cases (3.3%). Patients receiving COVID-19 vaccinations were most common in the KT group, followed by those with HD and PD (76.93% vs. 70.65% vs. 51.34%, respectively). KT patients had a lower fatality rate compared to those with PD and HD (8.42% vs. 18.41% vs. 21.40%, respectively). Advanced age, diabetes, cardiovascular diseases, and COVID-19 vaccination status were associated with fatality. The adjusted odds ratios of fatality after receiving one or two doses of vaccines were 0.7 (95% confidence interval [CI], 0.6-0.9) and 0.3 (95% CI, 0.2-0.4), respectively. The cost of treatment was highest in patients with HD, followed by PD and KT.

CONCLUSION

The incidence of COVID-19 infection was higher in patients with HD than in those with PD or KT. COVID-19 vaccination following the national health policy should be encouraged for these patients to prevent fatality.

Experience of the homecare of children on automatic peritoneal dialysis during the COVID-19 outbreak: A qualitative descriptive study

AIMS

To describe the home care experience, challenges and coping strategies of caregivers with children on automatic peritoneal dialysis (PD) in mainland China during the early stage of the COVID-19 outbreak.

DESIGN

A qualitative descriptive approach was adopted. Semi-structured telephone interviews were conducted among 14 families with children on automatic peritoneal dialysis from February 2nd to 10th, 2020. The care routine, stress and coping strategies of caregivers of children on peritoneal dialysis were collected. The data were analysed using thematic analysis.

METHODS

Four key themes were defined: (1) concerns about PD treatment intertwined with worries about COVID-19; (2) retaining a sense of normality in the middle of the challenges; (3) staying safe; and (4) staying positive and carrying on.

RESULTS

Families with children on automatic PD addressed the stress from COVID-19 and its containment measures by closely adhering to COVID-19 preventative measures, actively adjusting mentality and maintaining a sense of normality during the outbreak. This implies that healthcare staff need to be more aware of the complex medical needs of families with children on automatic PD, advocate for them and facilitate their navigation through the repurposed healthcare system.

Highly pathogenic coronaviruses and the kidney

Since the end of 2019, the outbreak of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has triggered a pneumonia epidemic, posing a significant public health challenge in 236 countries, territories, and regions worldwide. Clinically, in addition to the symptoms of pulmonary infection, many patients with SARS-CoV-2 infections, especially those with a critical illness, eventually develop multiple organ failure in which damage to the kidney function is common, ultimately leading to severe consequences such as increased mortality and morbidity. To date, three coronaviruses have set off major global public health security incidents: Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV), Middle East Respiratory Syndrome Coronavirus (MERS-CoV), and SARS-CoV-2. Among the diseases caused by the coronaviruses, the coronavirus disease 2019 (COVID-19) has been the most impactful and harmful. Similar to with SARS-CoV-2 infections, previous studies have shown that kidney injury is also common and prominent in patients with the two other highly pathogenic coronaviruses. Therefore, in this review, we aimed to comprehensively summarize the epidemiological and clinical characteristics of these three pandemic-level infections, provide a deep analysis of the potential mechanism of COVID-19 in various types of kidney diseases, and explore the causes of secondary kidney diseases of SARS-CoV-2, so as to provide a reference for further research and the clinical prevention of kidney damage caused by coronaviruses.

Clinical outcomes of automated versus continuous ambulatory peritoneal dialysis for end-stage kidney disease: protocol of a systematic review and meta-analysis

INTRODUCTION

An increasing number of studies comparing automated peritoneal dialysis (APD) with continuous ambulatory peritoneal dialysis (CAPD) in clinical outcomes have been published since the publication of a systematic review and meta-analysis including three randomised controlled trials in 2007. We will conduct a systematic review and meta-analysis to explore more clinical outcomes of APD versus CAPD for end-stage kidney disease.

METHODS AND ANALYSIS

The protocol is conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. Three databases-PubMed, EMBASE and the Cochrane Library-will be searched comprehensively from inception to 16 June 2022, without language restriction. Studies reporting clinical outcomes comparing APD with CAPD will be included. Two independent reviewers will screen the titles and abstracts and then obtain and assess full texts of potential relevant articles for eligibility following the inclusion and exclusion criteria. The methodological quality of included observational studies will be assessed by using the Newcastle-Ottawa Scale. The risk of bias of included randomised controlled studies will be assessed by using the Cochrane Risk of Bias tool. Relative risk for dichotomous outcomes and standard mean difference for continuous outcomes with corresponding 95% CIs will be pooled for summary effects. Cochrane Q test and I ² values will be used to assess heterogeneity between studies. To assess and explore the source of heterogeneity, subgroup analyses and sensitivity analyses will be conducted, and meta-regression, funnel plot and Egger's test will be performed if there are no less than 10 studies. Analyses will be performed using STATA software, V.13.0 (STATA Corporation, College Station, Texas, USA).

ETHICS AND DISSEMINATION

Ethics approval is not applicable as no personal information is collected from patients. The results will be published in a peer-reviewed journal or disseminated in relevant academic conferences.

PROSPERO REGISTRATION NUMBER

CRD42022311401.

Peritoneal dialysis in the modern era

The practice and clinical outcomes of peritoneal dialysis (PD) have demonstrated significant improvement over the past 20 years. The aim of this review is to increase awareness and update healthcare professionals on current PD practice, especially with respect to patient and technique survival, patient modality selection, pathways onto PD, understanding patient experience of care and use prior to kidney transplantation. These improvements have been impacted, at least in part, by greater emphasis on shared decision-making in dialysis modality selection, the use of advanced laparoscopic techniques for PD catheter implantation, developments in PD connecting systems, glucose-sparing strategies, and modernising technology in managing automated PD patients remotely. Evidence-based clinical guidelines such as those prepared by national and international societies such as the International Society of PD have contributed to improved PD practice underpinned by a recognition of the place of continuous quality improvement processes.

Dialysis During the COVID-19 Pandemic: Experiences from 4 Dialysis Centers in Iran

Background: Despite all of the research on the risk factors for severe COVID-19, there are still many unknowns about the course of COVID-19 in various populations. Inevitable exposure of dialysis patients, one of the more vulnerable groups for infectious diseases, to COVID-19 concerns many researchers. Furthermore, studies on the mortality rate and risk factors regarding dialysis patients are somewhat inconsistent. Also, it has been suggested that factors such as ethnicity can contribute to that matter. Objectives: We aimed to evaluate the mortality rate of dialysis patients who contracted COVID-19 in the Iranian population. Methods: In this cross-sectional study, we presented the experiences of 4 dialysis centers with a total of 309 dialysis patients (Tehran, Iran) during the COVID-19 pandemic to assess the mortality rate and associated risk factors. Results: Among 309 dialysis patients, 58 patients contracted the disease, and the total mortality rate in this study was 41%. It was observed that although the guidelines for screening patients were similar in these 4 centers, the centers with regular COVID-19 screening for staff members had much lower mortality and infection rate. The most common symptoms in patients were fever, dry cough, and chills. Furthermore, comorbidities such as diabetes can also increase the risk of mortality. Conclusions: This study, along with other studies, can be utilized in developing guidelines for dialysis centers in the COVID-19 pandemic and future pandemics.

Treatment Decision Making for Older Kidney Patients during COVID-19

BACKGROUND AND OBJECTIVES

Coronavirus disease 2019 (COVID-19) disrupted medical care across health care settings for older patients with advanced CKD. Understanding how shared decision making for kidney treatment decisions was influenced by the uncertainty of an evolving pandemic can provide insights for supporting shared decision making through the current and future public health crises.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed thematic and narrative analyses of semistructured interviews with patients (CKD stages 4 and 5, age 70+), care partners, and clinicians from Boston, Portland (Maine), San Diego, and Chicago from August to December 2020.

RESULTS

We interviewed 76 participants (39 patients, 17 care partners, and 20 clinicians). Among patient participants, 13 (33%) patients identified as Black, and seven (18%) had initiated dialysis. Four themes with corresponding subthemes emerged related to treatment decision making and the COVID-19 pandemic: (1) adapting to changed educational and patient engagement practices (patient barriers to care and new opportunities for telemedicine); (2) reconceptualizing vulnerability (clinician awareness of illness severity increased and limited discussions of patient COVID-19 vulnerability); (3) embracing home-based dialysis but not conservative management (openness to home-based modalities and limited discussion of conservative management and advanced care planning); and (4) satisfaction and safety with treatment decisions despite conditions of uncertainty.

CONCLUSIONS

Although clinicians perceived greater vulnerability among older patients CKD and more readily encouraged home-based modalities during the COVID-19 pandemic, their discussions of vulnerability, advance care planning, and conservative management remained limited, suggesting areas for improvement. Clinicians reported burnout caused by the pandemic, increased time demands, and workforce limitations, whereas patients remained satisfied with their treatment choices despite uncertainty.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Decision Aid for Renal Therapy (DART), NCT03522740.

COVID-19: mortality rates of patients on hemodialysis and peritoneal dialysis

Objective

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection might have a higher mortality rate in patients with end-stage renal disease due to immunosuppression. This study investigates the mortality rates of SARS-CoV-2 infection and the factors affecting mortality among patients who were on maintenance hemodialysis and continuous ambulatory peritoneal dialysis.

Materials and methods

A total of 200 patients, including 157 maintenance hemodialysis and 43 continuous ambulatory peritoneal dialysis patients followed in our hospital, were included in the study. The patients' sociodemographic characteristics, comorbidities, history of SARS-CoV-2 infection in the previous year, death event, source of death (SARS-CoV-2 or not), presence of hospitalization due to SARS-CoV-2 infection, need for intensive care unit, need for ventilatory support in intensive care unit were obtained from the clinical file records.

Results

85 of the 200 patients had a history of SARS-Cov-2 infection during the last 12 months. Forty-two (49.5%) patients with SARS-CoV-2 infection were hospitalized. Patients with SARS-CoV-2 had longer dialysis time, increased mortality, and significantly higher comorbidities such as coronary artery disease, congestive heart failure. Besides, heart failure and hypertension were the determining factors in the risk factor analysis for SARS-CoV-2 infection. In dialysis patients, the mortality rate in the last year, due to all causes, including SARS-CoV-2 infection, was 23% while the mortality rate due to "SARS-CoV-2 infection only" was 13%) (p > 0.05). Our findings are important in guiding clinical decision-making and informing the public and health authorities about the risk of death associated with COVID-19 in this patient group.

Angiogenic Role of Mesothelium-Derived Chemokine CXCL1 During Unfavorable Peritoneal Tissue Remodeling in Patients Receiving Peritoneal Dialysis as Renal Replacement Therapy

Peritoneal dialysis (PD) is a valuable ‘home treatment’ option, even more so during the ongoing Coronavirus pandemic. However, the long-term use of PD is limited by unfavourable tissue remodelling in the peritoneal membrane, which is associated with inflammation-induced angiogenesis. This appears to be driven primarily through vascular endothelial growth factor (VEGF), while the involvement of other angiogenic signaling pathways is still poorly understood. Here, we have identified the crucial contribution of mesothelial cell-derived angiogenic CXC chemokine ligand 1 (CXCL1) to peritoneal angiogenesis in PD. CXCL1 expression and peritoneal microvessel density were analysed in biopsies obtained by the International Peritoneal Biobank (NCT01893710 at www.clinicaltrials.gov), comparing 13 children with end-stage kidney disease before initiating PD to 43 children on chronic PD. The angiogenic potential of mesothelial cell-derived CXCL1 was assessed in vitro by measuring endothelial tube formation of human microvascular endothelial cells (HMECs) treated with conditioned medium from human peritoneal mesothelial cells (HPMCs) stimulated to release CXCL1 by treatment with either recombinant IL-17 or PD effluent. We found that the capillary density in the human peritoneum correlated with local CXCL1 expression. Both CXCL1 expression and microvessel density were higher in PD patients than in the age-matched patients prior to initiation of PD. Exposure of HMECs to recombinant CXCL1 or conditioned medium from IL-17-stimulated HPMCs resulted in increased endothelial tube formation, while selective inhibition of mesothelial CXCL1 production by specific antibodies or through silencing of relevant transcription factors abolished the proangiogenic effect of HPMC-conditioned medium. In conclusion, peritoneal mesothelium-derived CXCL1 promotes endothelial tube formation in vitro and associates with peritoneal microvessel density in uremic patients undergoing PD, thus providing novel targets for therapeutic intervention to prolong PD therapy.

Effect of Combining Conventional and Telehealth Methods on Managing Peritoneal Dialysis Patients: A Retrospective Single-Center Study

OBJECTIVE

This study aimed to explore follow-up mode changes for peritoneal dialysis (PD) patients and their effects on PD quality during the COVID-19 pandemic.

METHODS

A retrospective single-center study was conducted. All patients who received PD treatment at the Second Affiliated Hospital of Soochow University between January 2018 and March 2020 were enrolled in this study. Patient data during the first quarter of 2018 (Q1-2018), the first quarter of 2019 (Q1-2019), and the first quarter of 2020 (Q1-2020) were collected.

RESULTS

No significant differences were observed for any serum examinations in different follow-up periods (P > 0.05). A significantly reduced outpatient follow-up rate was observed in Q1-2020 compared with Q1-2018 and Q1-2019 (71.6% Vs 78.9% Vs 84.7%, P < 0.001), accompanied by a significantly increased remote follow-up rate (28.4% Vs 21.1% Vs 15.3%, P < 0.001). Compared with Q1-2018 and Q1-2019, the hospitalization rate (27.7% Vs 30.9% Vs 15.7%, P < 0.001) and the incidence of peritonitis (0.162 Vs 0.186 Vs 0.08 per patient-year, P < 0.001) decreased significantly in Q1-2020. PD patients had a significant decline in the drop-out rate for Q1-2020 compared with Q1-2019 (4.4% Vs 7.3% Vs 2.2%, P < 0.001). No differences in the incidence of catheter-related infections were observed. No significant differences were observed for any peritoneal dialysis key performance indicators (KPIs) between outpatient follow-up and remote follow-up patients.

CONCLUSION

During the COVID-19 pandemic (Q1-2020), our center practiced more remote follow-up procedures in PD patients. The hospitalization rate and peritonitis incidence were significantly decreased compared with the same time in previous years. No statistical differences were observed in other KPIs for peritoneal dialysis. This study shows that telehealth methods are a reasonable alternative to in-person care in the care/management of PD patients.

The utility of remote patient management in peritoneal dialysis

Remote patient management (RPM) programs are one of the most crucial innovations in the peritoneal dialysis (PD) field that have been developed in the last decade. RPM programs are associated with favourable clinical outcomes by increasing the adherence of the patients to PD prescription. The literature supports that RPM is associated with increased blood pressure control and technique survival, and decreased hospitalization rate, length of hospital stay and health costs. RPM programs also facilitate patient follow-up during the coronavirus disease 2019 pandemic, increase treatment adherence and lead to better clinical outcomes. However, published data remain scarce and mainly consist of observational or retrospective studies with relatively low numbers of patients. Therefore, randomized controlled trial results will be more informative to demonstrate the effect of RPM programs on clinical outcomes.

Adverse factors on nonenhanced abdominal CT for long-term continuous ambulatory peritoneal dialysis: a comparative study between patients who withdraw from and maintain long-term peritoneal dialysis

Purpose

To investigate the imaging features of patients with long-term continuous ambulatory peritoneal dialysis (CAPD) on nonenhanced abdominal CT and to identify adverse factors for long-term CAPD.

Methods

A total of 109 patients with less than 5 years of CAPD for peritoneal ultrafiltration failure who switched to hemodialysis (withdrawal group) and 23 patients with more than 10 years of CAPD (long-term group) were retrospectively enrolled. Nonenhanced CT manifestations in both groups were compared, including thickening and calcification of the parietal peritoneum, calcification of the mesangial margin and free margin of the small intestine wall, and calcification of the mesentery and abdominal aorta. A risk stratification model was proposed based on CT manifestations with statistically significant differences.

Results

The presence of the following CT findings was significantly different between two groups: extensive thickening of the parietal peritoneum (78.9% vs. 21.7%, P < 0.01); severe calcification of the parietal peritoneum (60.6% vs. 8.7%, P < 0.01); calcification of the mesentery (32.1% vs. 4.3%, P < 0.05); and calcification of the free margin of the small intestine wall (49.5% vs. 13.0%, P < 0.05). However, there was no significant difference in calcification of the mesangial margin of the small intestine wall (40.3% vs. 30.4%) or in abdominal aortic calcification (56.9% vs. 61.1%) (P > 0.05). The area under the receiver operating characteristic curve (AUC) was 0.906 (sensitivity 87.6% and specificity 82.6%).

Conclusion

Extensive thickening of the parietal peritoneum, severe calcification of the parietal peritoneum, and calcification of the mesentery and the free margin of the small intestine wall are adverse factors for long-term CAPD.

Acute Kidney Injury and Advanced Kidney Disease in the COVID-19 Pandemic: Proceedings From a National Kidney Foundation Symposium

The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented and historic public health crisis that continues to expand and evolve. The National Kidney Foundation held a 2-part continuing medical education live virtual symposium on July 16 and July 24, 2020, to address the multiple challenges of COVID-19 in the context of advanced chronic kidney disease. Faculty addressed the pathophysiology, impact, risks, and management of COVID-19 as it relates to advanced kidney disease. Testing, risk mitigation, and inpatient and outpatient management were also addressed. This concise review addresses major findings of the symposium along with certain updates regarding vaccinations since then. These findings include: (1) severe COVID-19 infection has been associated with acute kidney injury, (2) it is essential to prevent and actively manage acute kidney injury to decrease mortality in these critically ill patients, (3) management of patients with advanced kidney disease should be geared toward minimizing their risk for exposure while making sure they are receiving adequate treatments, and (4) patients with kidney disease, especially ones in advanced stages, should be prioritized for vaccination.

COVID-19 incidence and outcomes in a home dialysis unit in Madrid (Spain) at the height of the pandemic

INTRODUCTION

The 2019 coronavirus (COVID-19) is a viral infection caused by a new coronavirus that is affecting the entire world. There have been studies of patients on in-center hemodialysis (HD), but home dialysis population data are scarce. Our objective is to study the incidence and course of COVID-19 in a home dialysis unit (HDU) at the height of the pandemic.

METHODS

an observational, retrospective study enrolling all patients diagnosed with COVID-19 from the HDU of Hospital Universitario La Paz [La Paz University Hospital] (Madrid, Spain) between March 10 and May 15, 2020. We collected clinical data from the HDU (57 patients on peritoneal dialysis [PD] and 22 patients on home hemodialysis [HHD]) and compared the clinical characteristics and course of patients with and without COVID-19 infection.

RESULTS

twelve patients were diagnosed with COVID-19 (9 PD; 3 HHD). There were no statistically significant differences in terms of clinical characteristics between patients with COVID-19 and the rest of the unit. The mean age was 62 ± 18.5 years; most were men (75%). All patients but one required hospitalization. Ten patients (83%) were discharged following a mean of 16.4 ± 9.7 days of hospitalization. Two patients were diagnosed while hospitalised for other conditions, and these were the only patients who died. Those who died were older than those who survived.

CONCLUSION

The incidence of COVID-19 in our HDU in Madrid at the height of the pandemic was high, especially in patients on PD. No potential benefit for preventing the infection in patients on home dialysis was observed. Advanced age and nosocomial transmission were the main factors linked to a worse prognosis.

Anemia management for home dialysis including the new US public policy initiative

Patients with end-stage kidney disease (ESKD) requiring kidney replacement therapy are often treated in conventional dialysis centers at substantial cost and patient inconvenience. The recent United States Executive Order on Advancing American Kidney Health, in addition to focusing on ESKD prevention and reforming the kidney transplantation system, focuses on providing financial incentives to promote a shift toward home dialysis. In accordance with this order, a goal was set to have 80% of incident dialysis patients receiving home dialysis or a kidney transplant by 2025. Compared with conventional in-center therapy, home dialysis modalities, including both home hemodialysis and peritoneal dialysis, appear to offer equivalent or improved mortality, clinical outcomes, hospitalization rates, and quality of life in patients with ESKD in addition to greater convenience, flexibility, and cost-effectiveness. Treatment of anemia, a common complication of chronic kidney disease, may be easier to manage at home with a new class of agents, hypoxia-inducible factor-prolyl hydroxylase inhibitors, which are orally administered in contrast to the current standard of care of i.v. iron and/or erythropoiesis-stimulating agents. This review evaluates the clinical, quality-of-life, economic, and social aspects of dialysis modalities in patients with ESKD, including during the coronavirus disease 2019 pandemic; explores new therapeutics for the management of anemia in chronic kidney disease; and highlights how the proposed changes in Advancing American Kidney Health provide an opportunity to improve kidney health in the United States.

Maintaining the Uptake of Peritoneal Dialysis During the COVID-19 Pandemic: A Research Letter

BACKGROUND

Due to inherent challenges in maintaining physical distancing in hemodialysis units, the Canadian Society of Nephrology has recommended peritoneal dialysis as the preferred modality for patients requiring maintenance dialysis during the coronavirus disease 19 (COVID-19) pandemic. However, pursuing peritoneal dialysis is not without risk due to the requirement for in-person contact during catheter insertion and training, and there is a paucity of data regarding the experience of peritoneal dialysis during the early phases of the pandemic.

OBJECTIVE

To examine the incidence and outcomes of peritoneal dialysis between March 17 and June 01, 2020 compared to the same time period in preceding years.

DESIGN

Retrospective observational study.

SETTING

British Columbia, Canada. After the pandemic was declared on March 17, 2020, patients continued to be trained in peritoneal dialysis. In an effort to limit time spent in hospital, patients were preferentially trained in continuous ambulatory peritoneal dialysis, training times were truncated for some patients, and peritoneal dialysis catheters were inserted by a physician at the bedside whenever feasible.

PATIENTS

All patients aged >18 years who started chronic maintenance dialysis during the period March 17 to June 01 in the years 2018 to 2020 inclusive. The time period was extended to include the years 2010 to 2020 inclusive to evaluate longer term trends in dialysis incidence.

MEASUREMENTS

A provincial clinical information system was used to capture the date of commencing dialysis, dialysis modality, and complications including peritonitis. Overall uptake of peritoneal dialysis included new starts and transitions to peritoneal dialysis from in-center hemodialysis during the observation period.

METHODS

The incidence of dialysis during the specified time period, overall and by modality, was calculated per million population using census figures for the population at risk. Patients were followed for a minimum of 30 days from the start of peritoneal dialysis to capture episodes of peritonitis and COVID-19.

RESULTS

A total of 211 patients started maintenance dialysis between March 17 and June 01, 2020. The incidence dialysis rate (41.3 per million population) was lower than that expected based on the 10-year trend from 2010 to 2019 inclusive (expected rate 45.7 per million population, 95% confidence interval 41.7 to 50.1). A total of 93 patients started peritoneal dialysis, including 32 patients who transitioned from in-center hemodialysis, contributing to a higher overall uptake of peritoneal dialysis compared to preceding years. The incidence rate for peritoneal dialysis of 18.2 per million population was higher than that expected (16.3 per million population, 95% confidence interval 14.0 to 19.0). Half of patients (48%) underwent a bedside peritoneal dialysis catheter insertion by a physician. During 30 days of follow-up, 2 (2.2%) patients experienced peritonitis and no patients were diagnosed with COVID-19.

LIMITATIONS

Results are short term and generalizable only to regions with similarly low community rates of transmission of severe acute respiratory syndrome coronavirus 2.

CONCLUSIONS

These preliminary findings indicate that peritoneal dialysis can be safely started and perhaps expanded as a means of mitigating the anticipated surge in in-center hemodialysis during the COVID-19 pandemic. Important contributors to the uptake of peritoneal dialysis in British Columbia were bedside catheter insertions and expediting transitions from in-center hemodialysis to peritoneal dialysis.

COVID-19 and Renal Diseases: An Update

BACKGROUND

It becomes increasingly evident that the SARS-CoV-2 infection is not limited to the respiratory system. In addition to being a target of the virus, the kidney also seems to have a substantial influence on the outcomes of the disease.

METHODS

Data was obtained by a comprehensive and non-systematic search in the PubMed, Cochrane, Scopus and SciELO databases, using mainly the terms "SARS-CoV-2", "COVID-19", "chronic kidney disease", "renal transplantation", acute kidney injury" and "renal dysfunction" Discussion: The membrane-bound angiotensin-converting enzyme 2 is the receptor for SARS-CoV- -2, and this interaction may lead to an imbalance of the Renin-Angiotensin System (RAS), associated with worse clinical presentations of COVID-19, including acute pulmonary injury, hyperinflammatory state and hematological alterations. In the framework of renal diseases, the development of acute kidney injury is associated mostly with immune alterations and direct cytopathic lesions by the virus, leading to higher mortality. As for chronic kidney disease, the patients at a non-terminal stage have a worse prognosis, while the hemodialysis patients appear to have mild courses of COVID-19, probably due to lower chances of being affected by the cytokine storm. Furthermore, the current scenario is unfavorable to kidney donation and transplantation. The relationship between COVID-19 and immunosuppression in kidney transplantation recipients has been greatly discussed to determine whether it increases mortality and how it interacts with immunosuppressive medications.

CONCLUSION

The kidney and the RAS exert fundamental roles in the SARS-CoV-2 infection, and more research is required to have a complete understanding of the repercussions caused by COVID-19 in renal diseases.

Lessons Learnt during the COVID-19 Pandemic: For Patients with End-Stage Renal Disease, We Should Prioritize Home-Based Treatment and Telemedicine

BACKGROUNDS

The recent coronavirus disease 2019 (CO-VID-19) pandemic has placed worldwide health systems and hospitals under pressure, and so are the renal care models. This may be a unique opportunity to promote and expand alternative models of health-care delivery in patients undergoing renal replacement therapies.

SUMMARY

Despite the high risk of acquiring communicable diseases when undergoing in-centre treatments, only a small proportion of patients are currently being treated with home therapies. Recent data provided by the Italian Society of Nephrology (SIN), the REIN French Registry and the Wuhan Hemodialysis Quality Control Center clearly show that patients receiving hospital-based treatment have a 3- to 4-fold greater risk of infection, and a subsequent fatality proportion between 21 and 34%. On the other hand, home-based therapy can be managed remotely, there is little or no need for transport to and from the hospital, and it is less expensive. Besides, the digital revolution in health care with the development of virtual care systems can make home dialysis with telehealth a cost-effective solution for both patients and health-care providers. Such a transition would require specific training for physicians and health-care professionals and a functional re-organization of dialysis centres to improve the skills and expertise in caring for patients at home.

CONCLUSION

The need for more widespread home treatment is the main lesson learnt by nephrologists by the COVID-19 pandemic.

Strategies for Management of Peritoneal Dialysis Patients in Singapore during COVID-19 Pandemic

Peritoneal dialysis (PD) is the only well-established home-based dialysis therapy in Singapore. As it is a home-based modality, PD should be considered as a preferred mode of kidney replacement therapy (KRT) for patients with kidney failure during this COVID-19 pandemic as it avoids frequent visits to hospitals and/or satellite dialysis centres. The highly infectious nature of this virus has led to the implementation of the Disease Outbreak Response System Condition orange status in Singapore since early February 2020. This paper summarises the strategies for management of several aspects of PD in Singapore during this COVID-19 pandemic, including PD catheter insertion, PD training, home visit and assisted PD, outpatient PD clinic, inpatient management of PD patients with or without COVID-19 infection, PD as KRT for COVID-19 patients with acute kidney injury, management of common complications in PD (peritonitis and fluid overload), and management of PD inventory.

COVID-19 in ESRD and Acute Kidney Injury

The COVID-19 pandemic has greatly affected nephrology. Firstly, dialysis patients appear to be at increased risk for infection due to viral transmission next to an enhanced risk for mortality as compared to the general population, even in the face of an often apparently mild clinical presentation. Derangements in the innate and adaptive immune systems may be responsible for a reduced antiviral response, whereas chronic activation of the innate immune system and endothelial dysfunction provide a background for a more severe course. The presence of severe comorbidity, older age, and a reduction of organ reserve may lead to a rapid deterioration of the clinical situation of the patients in case of severe infection. Secondly, patients with COVID-19 are at increased risk of acute kidney injury (AKI), which is related to the severity of the clinical disease. The presence of AKI, and especially the need for renal replacement therapy (RRT), is associated with an increased risk of mortality. AKI in COVID-19 has a multifactorial origin, in which direct viral invasion of kidney cells, activation of the renin-angiotensin aldosterone system, a hyperinflammatory response, hypercoagulability, and nonspecific factors such as hypotension and hypoxemia may be involved. Apart from logistic challenges and the need for strict hygiene within units, treatment of patients with ESRD and COVID-19 is not different from that of the general population. Extracorporeal treatment of patients with AKI with RRT can be complicated by frequent filter clotting due to the hypercoagulable state, for which regional citrate coagulation provides a reasonable solution. Also, acute peritoneal dialysis may be a reasonable option in these patients. Whether adjuncts to extracorporeal therapies, such as hemoadsorption, provide additional benefits in the case of severely ill COVID-19 patients needs to be addressed in controlled studies.

Barriers to home dialysis: Unraveling the tapestry of policy

Home dialysis use as a treatment for end-stage kidney disease varies locally, nationally, and internationally. There is a call to action in the United States to significantly increase access and uptake of home dialysis as the preferred dialysis treatment option. Although most do not object to patient choice in modality selection, the reality is that there are multilevel barriers both obvious and subtle that interfere with expanding home dialysis access. Financial barriers and how payment is structured continue to be key drivers, although new models of care are emerging that include for the first time incentives rather than penalties regarding home dialysis. Resources to support implementation include expert personnel requiring educational training. Policies requiring training curriculum content that is not only specified within nephrology but also for these multidisciplinary providers requisite for successful home dialysis to ensure professional expertise is ready and available, and also to cultivate champions of home modality within the broader nephrology community. Perhaps most importantly, innovation through expanded investment in research is necessary to advance practices, elevate quality, and improve outcomes. Policy in a variety of sectors at local, regional, national, and international levels has the potential to drastically drive expansion and increasing success of home dialysis.

The reliability and success of peritoneal dialysis during the COVID-19 pandemic

We evaluated the symptoms, changes in laboratory findings during the novel coronavirus disease (COVID-19) pandemic, and the effect of depression in patients with peritoneal dialysis (PD). This is an observational and cross-sectional study. All patients were asked to fill the clinical assessment form and Beck depression and anxiety inventory. Also, the last two laboratory evaluations during this period were examined. A total of 123 patients performing PD were included. None of the patients were diagnosed with COVID-19. In the total study population, parathyroid hormone (PTH), serum albumin, phosphorus and ferritin levels significantly elevated at the end of 97 ± 31 days. PTH and phosphorus levels remained stable in remote monitoring automated PD (RM-APD) group (p = 0.4 and p = 0.5), they tended to increase in continuous ambulatory PD group and significantly increased in automated PD group (p = 0.09 and p = 0.01 for PTH and p = 0.06 and p = 0.001 for phosphorus, respectively). Moderate to severe depression was associated with dyspnoea, weight gain more than 5 kg, fatigue, palpitation and increased anxiety. PD is a reliable and successful form of dialysis and can be safely administered even if hospital access is restricted. Also, RM-APD may be a better choice because of providing more stable bone-mineral metabolism. Moreover, evaluating depression and anxiety is essential for the accurate clinical assessment.

[COVID-19 incidence and outcomes in a home dialysis unit in Madrid (Spain) at the height of the pandemic]

Introducción

La enfermedad por coronavirus 2019 (COVID-19) es una infección viral causada por un nuevo coronavirus que está afectando a todo el mundo. Hay estudios previos de pacientes en hemodiálisis en centro, pero hay pocos datos sobre población en diálisis domiciliaria. Nuestro objetivo es estudiar la incidencia y evolución de la COVID-19 en una unidad de diálisis domiciliaria (UDD) durante el pico de la pandemia.

Métodos

Estudio observacional y retrospectivo que incluye todos los pacientes diagnosticados de COVID-19 de la UDD del Hospital Universitario La Paz (Madrid, España) entre el 10 de marzo y el 15 de mayo de 2020. Se recogieron los datos clínicos de la UDD (57 pacientes en diálisis peritoneal y 22 pacientes en hemodiálisis domiciliaria) y comparamos las características clínicas y la evolución de los pacientes con o sin infección por COVID-19.

Resultados

Doce pacientes fueron diagnosticados de COVID-19 (9 diálisis peritoneal, 3 hemodiálisis domiciliaria). No hubo diferencias estadísticamente significativas entre las características clínicas de los pacientes con COVID-19 y el resto de la unidad. La edad media fue 62 ± 18,5 años; la mayoría eran varones (75%). Todos los pacientes menos uno necesitaron hospitalización. Diez pacientes (83%) fueron dados de alta tras una media de 16,4 ± 9,7 días de hospitalización. Dos pacientes fueron diagnosticados durante su hospitalización por otro motivo y fueron los únicos que fallecieron. Los fallecidos eran de mayor edad que los supervivientes.

Conclusión

La incidencia de COVID-19 en nuestra UDD en Madrid durante el pico de la pandemia fue alto, especialmente en los pacientes en diálisis peritoneal, sin observarse un potencial beneficio para prevenir la infección en los pacientes en diálisis domiciliaria. La edad avanzada y la transmisión nosocomial fueron los principales factores relacionados con peor pronóstico.

COVID-19 Extrapulmonary illness - The Impact of COVID-19 on Nephrology care

Coronavirus disease-2019 (COVID-19) has caused a pandemic that has affected millions of people worldwide. COVID-19 is caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and is spread by close contact and by respiratory droplets. It has also impacted different aspects of caring for people with kidney disease, including those with acute kidney injury (AKI), chronic kidney disease (CKD), those requiring kidney replacement therapy (KRT), and those with a kidney transplant. All of these patients are considered high risk. The lessons learned from the COVID-19 pandemic will hopefully serve to protect patients with kidney disease in a similar situation in the future.

Absence of SARS-CoV-2 in the effluent of peritoneal dialysis patients

The pandemic of respiratory disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is life-threatening in peritoneal dialysis (PD) patients. In PD patients with systemic viral infections, peritoneal effluent may be theoretically contaminated. We searched for the presence of SARS-CoV-2 genetic material by real-time reverse transcriptase-polymerase chain reaction assays in serial PD effluents of three PD infected patients. Nasopharyngeal swabs obtained at admission showed high viral load in all three patients, whereas none of the PD effluent specimen tested positive, even after dialysate concentration. Those results support at most a very low SARS-CoV-2 dissemination risk by the peritoneal effluent of PD patients. Imposing special disposal procedures, such as the instillation of hypochlorite in the drainage bags to prevent viral spread to health-care workers, are probably not required.

Covid-19 epidemic in the dialysis units of the french speaking part of Belgium : special insight into patients on home dialysis

In the French-speaking part of Belgium, between march and end of may 2020, 284 patients have suffered a Covid-19 infection, 7,9% of the prevalent dialysis population. Some of them have been  diagnosed through rt-PCT as they were symptomatic, others, asymptomatic,  being diagnosed by swab viral culture. Fifty two patients died (18% of the positive patients). The vast majority of them were patients on hemodialysis, only ten cases have been observed in patients on home dialysis techniques. Primary renal disease were diabetes or renal hypertensive disease in more than 50% of the patients and the most important comorbidities were cardiac ischemic or congestive disease, autonomy problems, cancer and smoking habits.