Dialysis in the Times of COVID!

Living with dialysis in the times of COVID is difficult, to say the least. The challenges of daily living have been altered to incorporate new safety measures to prevent infection from a highly contagious and deadly virus; social distancing, and masks. Various types of testing and vaccinations are now routine. For those with chronic kidney disease (CKD), on dialysis, or with a transplanted kidney, the world has suddenly become a frightening place to be.

Patients who deal with a chronic illness such as CKD and dialysis should become knowledgeable. One way to achieve this is by searching for and reading vetted journal articles directed at the medical community. By doing this, one can increase knowledge, better manage the disease and treatment, and even update clinicians, who rarely have the time to read newly published studies. An educated patient is a healthier patient.

When the pandemic first started to gain momentum, back in early 2020, I was overwhelmed with articles on a daily basis. I decided to keep a chronology of important information, particularly that which affected the dialysis community, on the Home Dialyzors United (HDU) website. It has been interesting to me to see how this pandemic has taken shape, transformed, grown, challenged and changed the scope of our health care system.

I have learned from these articles. End-stage kidney disease (ESKD) patients on chronic hemodialysis often have a high burden of comorbidities that place them at increased risk for adverse outcomes when hospitalized with COVID-19 and subsequent variants. I learned that, as a dialyzor, I am even more vulnerable to the devastating effects of COVID, and that frightens me. I want to understand everything I can about this virus because kidney patients are at higher risks of infection, complications, and death. Patients need to obtain factual information, and that is what I strive to provide, from reliable news sources known for their accuracy and unbiased reporting. I want information that is rooted in science and not speculation.

In 2022, we now have data that provides insight into the high death rates of CKD dialysis patients. The dialysis population actually shrank between 2019 and 2020, thanks to COVID, and its increase in mortality among dialyzors. This was the first time this has happened since widespread dialysis came into being in the 1970s! Death rates had been shrinking since the early 2000s until COVID.

The estimated number of excess deaths during COVID were also two to three times higher among dialysis patients than among kidney transplant patients. The reasons for excess deaths in the ESRD population might include the unmet need for in-person health services or SARS-CoV-2 transmission from other patients, staff members, or the wider community during the COVID-19 pandemic.

How scared would you feel if you were one of these dialysis patients? They are so vulnerable to the virus, yet must face greater exposure in the course of their weekly dialysis treatments in clinics.¹, ²

CMS has recently released preliminary Medicare claims data³ showing that patients with ESKD who are diagnosed with COVID-19 also had the highest rate of hospitalization among all Medicare beneficiaries. Hospitalization rates for dialysis patients are 40 times higher than for the general population.

Black patients have been hospitalized with COVID-19 at a rate nearly four times higher than white patients. “The disparities in the data reflect longstanding challenges facing minority communities and low-income older adults, many of whom face structural challenges to their health that go far beyond what is traditionally considered 'medical'.” ⁴

Then came the vaccines. Considered at high risk, dialysis clinics were among the first to offer the vaccine to its patients. These COVID-19 vaccines prove to be safe and effective. Since the advent of the Omicron variant, with its increasing incidence of infection and reinfection among those fully vaccinated and boosted, many have asked why they are now testing positive for COVID. While vaccines continue to significantly reduce the risk of severe illness, hospitalization, and death, they are no guarantee against infection.

Two years into this pandemic, some ask if vaccines have made a difference. That may be subject of another blog: to vax or not to vax? Vaccines have now been readily available, free to the public, since March of 2021, yet only 62% of the public have received the full dose of vaccinations, with another 24% having received a booster. ⁵

Omicron will give much of the population what some scientists call “superimmunity”—stronger protection against new variants and even future coronaviruses. Normal life will be possible even as the virus continues to spread and mutate. Superimmunity won't necessarily stop people from being infected or transmitting the virus. But most people who get infected—even with a more virulent variant—will experience milder or no symptoms.⁶

Those who are encouraging community-wide exposure with the intent of achieving "herd immunity" are pursuing an elusive and risky goal without any assurance of success—but with the certainty that many will die and countless others will suffer in the process.

Given the level of our knowledge, the current stage of the pandemic, the effectiveness of vaccines, new treatments, and the impact of the vaccine on immunocompromised populations such as dialysis and transplant patients, the only rational approach to public and individual health is to continue to minimize the number of people who become infected.

There are two ways of minimizing the spread of a highly infectious disease in populations of susceptible people.

• The first way. People can avoid all contact with other humans or anything that humans have recently touched. This is what social distancing attempts to approximate.

• The second way. Conceivably, we could avoid universal social distancing altogether if we could determine with reliability exactly whom we should be steering clear of. There is no need to avoid people who are not infected, and every reason to avoid people who are infected.

Thus, frequent testing, at home and in clinics, of the vulnerable dialysis population should be taking place. Fortunately, just last week, the government announced that on January 19, 2022 it would make four home test kits for COVID available to every household in the US, at no charge. Will this make a difference? Only time and data will tell.

America's hospitals and health systems are seeing rapid increases in inpatient and ICU admissions as the Omicron wave sweeps the nation. With more than 55 million total cases to date in our country and a heartbreaking 800,000 deaths and counting, hospital teams are pressed beyond belief. Many workers are simply exhausted and worn out after maintaining an unsustainable pace for almost 2 years on the frontlines battling COVID-19.

Not until frequent testing is administered routinely in the home and in dialysis clinics will COVID positive dialysis patients be diagnosed early enough to isolate and protect those around them from infection. COVID in the dialysis population has crippled the in-center model. Undiagnosed patients have infected clinic staff (and vice versa) to the point where some clinics have been forced to close their doors temporarily. In the early days of COVID-19, clinics set up independent cohorts for dialysis patients testing positive for COVID. Two years later, there is such a staffing shortage that this is no longer possible.

As a patient advocate, I would use the data from these studies to campaign for regular mandatory testing of all dialysis patients presenting for in-center treatments, or regular clinic visits. Merely testing for fever in the dialysis population is inadequate. Fatigue presents as the most common symptom of COVID in dialysis patients, which can be confused with the fatigue experienced with uremia. To protect dialyzors, regular testing for COVID in the clinic setting needs to be required.

People need to understand that the world can't be the same as it was before COVID and that we all need to support each other as we are all vulnerable. While many only want life to return to “normal,” in reality the only way forward is to accept the “new normal” of a life that includes regular testing (something we are already used to), masking (something else that is not new to us), and social distancing (something that was already occurring in clinics to some degree).

I can advocate strongly for mandatory testing for in-center dialyzors because I sit in the comfort of my home, doing my own dialysis treatments, without fear of infection. My concern is for the dialyzors transporting themselves to a clinic 3 days per week, for a treatment they must undergo to stay alive—yet knowing that going to that clinic may expose them to a virus that could kill them.