COVID-19 Associated Acute Kidney Injury: Managing Pandemic Demand Surge For Kidney Replacement Therapy In The United States

FIGURE 1  |  Risk factors for COVID-19–associated AKI

The risk factors for COVID-19 associated acute kidney injury.

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

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%) and peak prevalence (29%) of severe AKI requiring KRT among critically ill patients. Although half of these patients died, the majority (84%) of those who survived had sufficient recovery of kidney function to allow cessation of KRT.11


Over the past year, the COVID-19 pandemic was associated with regional surges and global hot spots worldwide; the United States 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. Fresenius Medical Care North America’s (FMCNA) vertically integrated network was extremely valuable in meeting the needs of patients throughout the US. 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

 Special challenges and strategies for KRT delivery in patients with COVID-19 associated acute kidney injury.


Demand for dialysis machines needed to manage cases of AKI increased 279% 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 the bagged dialysate solutions, including increasing the production of 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 the US 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 times 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%. 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.


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 City, 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 RNs’ 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


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 dialysis (AKI-D) were discharged from the hospitals to FKC outpatient facilities. During the pandemic, the number of new patients with AKI-D receiving outpatient dialysis at FKC 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 FKC 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. 


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.

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

Challenges and lessons learned from managing COVID-19 associated acute kidney injury.

Meet The Experts


Dinesh Chatoth, MD
Associate Chief Medical Officer, Fresenius Kidney Care

Vice President and Medical Director, Critical Care, Fresenius Medical Care, Renal Therapies Group


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