Impending Shortages of Kidney Replacement Therapy for COVID-19 Patients

Abstract

Practicing nephrology in New York City, at the epicenter of the novel coronavirus disease 2019 (COVID-19) pandemic in the United States, we have been struck by the continued focus on the concern that a critical deficiency of ventilators will occur. Our efforts in the past weeks have led us to fear that another critical shortage may occur before that of ventilators: our ability to deliver KRT for patients severely affected by COVID-19. We and other centers in New York are encountering significant challenges to delivering any form of KRT to the many patients with COVID-19 and AKI or kidney failure. To our knowledge, these challenges have been under-reported in the media and not acknowledged explicitly by public health officials or elected representatives. The sparse data available on this subject suggest that the incidence of AKI in all people infected with SARS-CoV-2 is as low as 0.5% (1). This value belies what we observe in New York’s medical centers: the incidence of AKI in critically ill, hospitalized patients with COVID-19 is far higher. The possible causes of AKI in patients infected with COVID-19 have recently been reviewed (2). An informal survey of our intensive care units (ICUs) this week demonstrates that 20%–40% of intubated ICU patients have AKI that necessitates KRT. For example, to demonstrate the magnitude of our workload, Bellevue Hospital Center has 105 patients with COVID-19 in the ICUs, with 44 with AKI, 40 of whom required KRT; outside the ICUs, there are 276 patients with COVID-19, with 32 seen by the nephrology consult service, 22 of whom have kidney failure. The proportions are similar at Tisch Hospital and the New York campus of the New York Harbor VA, which have more and fewer total patients, respectively, in those categories. This high incidence of COVID-19–associated AKI is true for the full range of the demographically diverse patients we care for at New York University (NYU) Langone-Manhattan campus (the university hospital of NYU Langone Health), NYU Langone Hospital–Brooklyn, Bellevue Hospital Center (the largest of New York’s public hospitals), and the New York campus of the New York Harbor Veterans Affairs Health Care System. On the basis of exchanges with our nephrology colleagues, it also reflects what is being seen at all of the medical centers, big and small, in New York. Our most acute problem, because of the surge of patients, is that capacity for delivering KRT is stretched to the point of nearly breaking. The possibility that this eventuality would occur in this pandemic was presciently foreseen in a recent article that described ways of mitigating the effects of the high incidence of AKI (3). On a normal day, our medical centers deliver many hemodialysis treatments and provide ample continuous KRT (CKRT) to meet the needs of hospitalized patients, but the needs have increased several-fold. In mid-March 2020, our contingency planning for COVID-19 did not foresee the increased extent to which these modalities would be needed, or the myriad hurdles to expanding capacity. Perhaps most important is the reduced numbers of trained staff available. Our hemodialysis nurses, like many health care workers in areas affected by the pandemic, became ill with COVID-19 and stayed home in isolation. Our contracted hemodialysis machine maintenance staff were also quarantined at times, preventing them from addressing machine dysfunction in a timely fashion. The skills required to perform hemodialysis are not readily acquired by previously untrained health care workers. Our hardworking nurses and technicians can provide only so many hemodialysis treatments per day in the ICUs of our hospitals, which have continually seen increasing numbers of admissions. The widespread geographic nature of the pandemic precludes hiring temporary hemodialysis staff. We reduced the frequency of hemodialysis for many patients with kidney failure treated in hospital-based dialysis facilities from three to two times per week, and the duration of therapy from 4 to 3 hours. These strategies were helpful, particularly as we acquired new patients with kidney failure—some with COVID-19—but they meant delivering a suboptimal prescription. We also experienced an at-least temporary loss of nephrologists to COVID-19 infection, increasing our own risk of burn-out, although the loss is less limiting than the loss of nurses and technicians. Our utilization of CKRT in the ICUs has increased dramatically. We now have 11 machines at NYU Langone-Manhattan campus, six at Bellevue Hospital Center, and four at NYU Langone Hospital–Brooklyn. In these numbers of treatments, the modality places strains on ICU nurses. It constitutes a problem when the number of ICU beds and ventilated patients is expanded by decreasing nurse-to-patient staffing ratios. We also had to procure more machines. To provide KRT to two patients per day with each machine, we also instituted accelerated venovenous hemofiltration (4). Nationwide and regiona