COVID-19 Associated Acute Kidney Injury: Managing Pandemic Demand Surge for Kidney Replacement Therapy in the US

During the COVID-19 pandemic, 30 to 40 percent of COVID-19-infected patients admitted to hospitals developed acute kidney injury (AKI). The number of patients requiring kidney replacement therapy (KRT) increased dramatically, putting overburdened hospitals under even further strain. To help meet the needs of patients throughout the U.S., Fresenius Medical Care North America (FMCNA) deployed its Disaster Response Team, which included 600 volunteer staff members and contract nurses. In addition, FMCNA created a pool of dialysis equipment and supplies that could be quickly routed to hospitals around the country. FMCNA’s well-coordinated response underscores the need for a frequently updated surge plan that is always ready for the next healthcare emergency.

Kidney involvement in patients with COVID-19 infection has been commonly observed throughout the pandemic and varies from mild asymptomatic hematuria and proteinuria to AKI requiring KRT. Initial reports from Wuhan, China, indicated that AKI rates related to COVID-19 infection were insignificant.1,2 However, very soon, growing evidence from Europe and New York showed that AKI from COVID-19 developed in 30 to 40 percent of patients with COVID-19 admitted to the hospital, and is associated with a considerable number of in-hospital deaths.3,4

AKI associated with COVID-19 can result from intrinsic renal pathology — including vascular thrombosis, viral mediated renal tubular injury, and glomerulonephritis — and from acute tubular necrosis resulting from fluid depletion, cytokine mediated systemic inflammatory syndrome, multiorgan failure, and rhabdomyolysis. Kidney biopsies are essential in understanding the pathogenesis of COVID-19-associated AKI. However, there are only a few series of kidney biopsies reported in COVID-19-associated AKI patients, with the majority of them showing acute tubular injury. Risk factors for COVID-19-induced AKI are shown in Figure 1.

FIGURE 1  |  Risk factors for COVID-19-induced AKI

A meta-analysis showed that, among critically ill patients with COVID-19, the pooled prevalence of AKI was 46 percent and 19 percent of patients in the ICU requiring KRT.5 Patients with COVID-19-associated AKI have higher mortality rates than those with COVID-19 without AKI. The mortality rate increases with the severity of AKI and need for KRT.6,7 A retrospective study found that 68 percent of people with COVID-19 AKI requiring KRT died during hospitalization.8 

A different study came to similar conclusions. When compared to patients without COVID-19, AKI associated with COVID-19 was more severe, including necessitating KRT and being associated with lower in-hospital kidney recovery.9,10 In a single center experience in New York, there was a high incidence (23 percent) and peak prevalence (29 percent) of severe AKI requiring KRT among critically ill patients. Although half of these patients died, the majority (84 percent) of those who survived had sufficient recovery of kidney function to allow cessation of KRT.11

FRESENIUS MEDICAL CARE NORTH AMERICA’S RESPONSE TO AKI ASSOCIATED WITH COVID-19 

Over the past year, the COVID-19 pandemic was associated with regional surges and global hot spots worldwide; the U.S. saw at least three distinct waves of COVID-19 cases by June 2021. The pandemic’s ebbs and flows put severe strain on hospital resources, including staffing and availability of dialysis equipment and supplies (Figure 2).12 In New York City, the KRT demand for AKI patients was four to five times higher during the pandemic. FMCNA's vertically integrated network was extremely valuable in meeting the needs of patients throughout the U.S. FMCNA’s Disaster Response Team, which typically responds to natural disasters like earthquakes and hurricanes, played a critical role. Its relationships with emergency operation centers, federal and state governments, and hospital systems have been instrumental in the effective coordination and response to the pandemic. 

FIGURE 2  |  Special challenges and strategies for KRT delivery in patients with COVID-19-associated AKI

MANAGING KRT DEVICES, DISPOSABLES, AND SUPPLIES

Demand for dialysis machines needed to manage cases of AKI increased 279 percent over baseline during the spring of 2020 in New York City.13 Increased regional demand required the ability to deliver KRT equipment where it was needed while simultaneously avoiding a surplus of unused equipment elsewhere. To coordinate distribution of equipment in a fair and informed manner, a team was formed that included members of sales, operations, logistics, supply chain, customer service, and contracts departments. Additionally, an inventory tracking tool was created to provide real-time orders, demand, and machine availability.

To meet the increasing demand, several operational and manufacturing adaptations were implemented:

• Increased production of bagged dialysate solutions, including bicarbonate
• Expanded lactate-based home solutions for use in hospitals
• Received Emergency Use Authorization for Multifiltrate PRO device and MultiBic/MultiPlus Dialysis bagged solutions
• Doubled the manufacturing capacity for tubing sets and filters
• Increased the availability of supplies and expanded training to support acute peritoneal dialysis (PD)

FMCNA formed a National Intensive Renal Care reserve to provide dialysis machines and related equipment for U.S. hospitals that were reeling under the pressure of the pandemic. The team created a pool of more than 150 pieces of dialysis equipment that were ready for rapid deployment to hospitals to manage the three to five time increase in regional demand for KRT. This included partnering with the NxStage team to redeploy existing NxStage critical care machines to areas of need with one week’s notice, allocating a pool of NxStage® System One™ cyclers to provide additional capacity in ICUs, and increasing the premixed dialysate supply by 75 percent. The equipment and supplies were housed for rapid deployment and efficiently managed by the local Fresenius Kidney Care (FKC) Inpatient Services team, working closely with the NxStage team.

MANAGING STAFFING AND SERVICES DURING SURGE IN COVID-19 AKI CASES

Early in the pandemic, FKC mobilized over 600 staff members who volunteered to travel to hospitals and in-center programs across the country. Nurses and technicians were deployed to areas designated as hot spots. Additionally, contract nurses were deployed to acute dialysis programs in Tacoma, New York, Chicago, and other cities due to the significant increase in demand for dialysis staff. 

The FKC in-patient services team responded to the increased demand for KRT in the hospitals by: 

• Creating amendments to acute dialysis agreements with hospital systems to provide extended KRT — i.e., prolonged intermittent KRT, sustained low-efficiency dialysis, or continuous KRT — to critically ill patients in the ICU 
• In select markets, supporting acute PD in ICUs by providing supplies, equipment, and nursing assistance 
• Following state-specific executive orders and board of nursing guidance around licensure and emergency privilege for staff  
• Adjusting staffing ratios of patient care technicians and licensed practical nurses to manage surge-related staffing needs
• Creating various care delivery models specific to the pandemic to increase the registered nurses’ ability to safely oversee more patients receiving KRT
• Assisting nephrologists and dialysis administrators with triaging care and allocating valuable dialysis resources, which included expanding the options for KRT
• Working closely with hospital systems to manage the influx of patients in alternative locations across many hospital campuses and newly created COVID-19 units 
• Partnering with outpatient dialysis units to discharge stable patients into COVID-19-positive treatment shifts

COVID-19-ASSOCIATED AKI-D IN OUTPATIENT DIALYSIS FACILITIES

Many COVID-19 survivors with AKI do not recover baseline kidney function at the time of discharge from the hospital. A study from New York showed that 32% of all hospitalized patients had not recovered baseline kidney function at a median of 21 days after hospital discharge.14 Another cohort study of 1,612 patients with COVID-19-associated AKI found that these patients experienced greater decreases in estimated glomerular filtration rate independent of comorbidities and severity of the AKI episode compared with patients with AKI not associated with COVID-19. The subgroup of COVID-19-associated AKI patients who had not recovered baseline kidney function at discharge were less likely to achieve complete kidney recovery during outpatient follow-up.15

A substantial number of COVID-19-associated AKI patients requiring acute kidney injury dialysis (AKI-D) were discharged from the hospitals to Fresenius Kidney Care outpatient facilities. During the pandemic, the number of new patients with AKI-D receiving outpatient dialysis at Fresenius Kidney Care facilities increased from approximately 1,000 patients per month to 1,350 patients per month. Additionally, the total number of patients with AKI-D treated per month at Fresenius Kidney Care outpatient facilities increased from approximately 3,200 patients to 3,700 patients. This increase in AKI patient volume at outpatient dialysis facilities during the pandemic placed additional strain on the operations and management of the facilities, which were already stretched for resources. Importantly, approximately one-third of individuals with AKI-D following COVID-19 recovered enough kidney function to discontinue outpatient dialysis within 90 days of starting outpatient dialysis. 

PREPARING FOR FUTURE PANDEMICS

The COVID-19 pandemic provides an opportunity to prepare for the provision of KRT in future pandemics.16 To be better prepared, the healthcare system needs to develop a surge plan that is routinely updated. A coordinated response to an increase in KRT, at both the regional and national levels, is critical and must include expanding the options for KRT, including acute PD, intermittent HD, prolonged intermittent kidney replacement therapy (PIKRT), and continuous kidney replacement therapy (CKRT). In addition, the plan must address the potential for unforeseen shortages of KRT devices, disposables, and fluids, as well as manufacturing and supply chain issues. The lessons learned from managing COVID-19-associated AKI during the pandemic are shown in Figure 3.

ACKNOWLEDGMENTS

The authors thank Gina Sharkey, vice president for Inpatient Services, and Tana Waack, vice president for Inpatient Services at Fresenius Kidney Care, for their editorial assistance and for sharing their valuable experience during this unprecedented pandemic.

FIGURE 3  |  Lessons learned from managing COVID-19-associated AKI

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References

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