5 Lessons Learned About COVID-19 and Kidney Replacement Therapy in the ICU

5 Lessons Learned About COVID-19 and Kidney Replacement Therapy in the ICU

Since the early days of the pandemic, COVID-19 infections have caused tremendous surges in ICU admissions, forcing healthcare providers and hospitals to change how they triage patients, handle staff scheduling, and allocate resources.1 Although difficult, these challenges together with the lessons and data they have generated can help ICU staff — and those who partner with them — prepare for the next widespread emergency.

While there are likely countless lessons to be learned and ways to apply them, we’ve identified five areas for consideration as we plan for future catastrophic events — whether another gloabal pandemic, a natural disaster, or another unforeseen crisis.

Lesson 1: An Unexpected Outcome — COVID-19 and Acute Kidney Injury

When sudden kidney failure emerged as a common risk associated with COVID-19 infections, nephrologists at many hospitals were confronted with challenges they had never faced before — including an alarming spike in the number of acute kidney injury (AKI) cases. According to a study in the Journal of the American Society of Nephrology, COVID-19 patients are nearly five times more likely to experience AKI than patients without COVID-19.2

In Spring 2020, Dr. Christopher Hebert* — an expert in ICU nephrology and founder of Kidney and Hypertension Associates of Dallas — was monitoring developments overseas with his team at Baylor University Medical Center (BUMC). As reports came in from Europe, they saw an unsettling trend.  

“In Italy, they were seeing about one-third of COVID-19 patients develop AKI for a multitude of reasons, including sepsis,” he said. “As the biggest hospital in Dallas/Fort Worth, we knew we were going to be hit.”

Dr. Hebert said that while COVID-19 patients with comorbidities like diabetes, high blood pressure, and obesity are typically more prone to AKI, the risk was more widespread in the Spring and Summer of 2020. About half of the COVID-19 cases admitted to BUMC developed AKI, many of whom required kidney replacement therapy (KRT).

Treating a novel disease led to some initial uncertainty about how to address AKI in COVID-19 patients. At first, there was no way of knowing whether dialysis would help them. But that quickly changed, as Dr. Hebert recalls.

“It became clear that not dialyzing was not helping,” said Dr. Hebert. “And then, almost overnight, we were doing up to 15 consults a day.”

At BUMC and in ICUs across the country, it was apparent that COVID-19 patients with AKI needed dialysis to survive and/or recover. In addition, based on their condition, nephrologists would need to identify the KRT option that would give them the best possible odds of survival.1

Lesson 2: Versatility Makes a Difference — Flexible KRT Options Proved Critical

While KRT is now considered a necessity for COVID-19 patients with AKI, the specific modality can differ depending on the patient’s condition:

• Continuous KRT (CKRT) is generally preferred for hemodynamically unstable patients because it delivers sustained therapy over a 24-hour period, giving patients more time to stabilize.
• Prolonged Intermittent KRT (PIKRT) is typically administered 4 to 6 (but up to 7) days per week for periods of 6 to 12 hours at a time. This option is often advantageous for patients who are still critical but no longer need CKRT.
• Intermittent hemodialysis (IHD) is primarily an option for more hemodynamically stable patients; often those who are ready to transition out of the ICU.

Whether initiated by a pandemic, a natural disaster, or another crisis, when ICUs become crowded, clinicians often need every available dialysis machine their facility can spare. If a machine can only provide one form of KRT, it is possible that only one patient can receive therapy from that unit each day. In these situations, a machine such as the NxStage® System One™ with NxView™ which can perform all three therapies mentioned above3 — can prove to be advantageous.

“It’s the flexibility that provides value,” said Dr. Hebert. “With the NxStage System One, we can do either CKRT or PIKRT. Because it supports intermittent therapy, we can run PIKRT in shifts and move machines from one patient to the next, and not have to lug additional machines from COVID-19 units to non-COVID-19 units. We can tailor therapies to the needs of the patients and the institution.”

Dr. Casey Gashti*, a board-certified nephrologist  at Rush University Medical Center in Chicago, points to anotherchallenge of treating COVID-19 — the severity of symptoms and resulting hospital stays, which can tie up beds and dialysis equipment for extended periods.

“In my experience, unlike some of the other patient populations that get better and then they leave the ICU, COVID-19 patients stay for 10, 14, or even 21 days,” Dr. Gashti points out. “Resource utilization becomes a very significant issue, and in these situations, PIKRT can help. If you run your treatment over 10 hours, you could use the same machine to dialyze two patients instead of one patient in a 24-hour period. That would address some of the surge in patients.”

Lesson 3: Together Ahead — The Critical Importance of Industry Partnerships

When resources run low and demand is high, hospitals must be able to count on partners in the healthcare industry to provide what is needed. Fortunately, there are several ways vendors and manufacturers can assist.

Equipment reserves

During COVID-19 spikes, demand for CKRT dialysis machines has increased nearly 300 percent, causing equipment shortages in some areas. Compounding this problem is the shifting location of COVID-19 “hot spots,” which can make it difficult to know when and where the need for these machines will become critical.1 Dr. Hebert recalled just how significant the need for CKRT machines has been at BUMC.

“Our hospital has 24 machines, and the ICU was using almost all of them to treat COVID patients with AKI,” he said. “Every machine was in use, and we had more patients who needed therapy.”

In these situations, hospitals must communicate specific needs to the companies that make and/or sell equipment. Industry partners may be able to locate additional machines in regions where the need is lower and deploy machines to places where the need is greatest.

Alternate solutions

Dialysis machine availability can be coupled with another supply challenge — in some areas, the need for bagged dialysate has risen nearly 40 percent when COVID-19 cases are at their highest.1

One solution to this problem is substituting lactate-based fluid4 (made for home hemodialysis) for the bicarbonate fluid normally used by hospitals. This requires some staff training but has shown no negative effects on the delivery of KRT.1

“Our ability to work with the NxStage Critical Care team has been very important during the surges,” said Dr. Hebert. “They’ve contacted us in advance, and we’ve had several conversations about the lactate-based fluid supply. Our department collaborated with their team to manage resources and utilize the alternate dialysate.”

Like lactate-based fluid, some dialysis machines and cartridges were originally designed for use in homes or skilled nursing facilities. However during the pandemic, they have been deployed where they were most needed, often to hospitals and ICUs. This repurposing of equipment and resources has helped make patient surges more manageable at several facilities throughout the country.5

Increasing access to supplies

Once industry partners are aware of supply shortages, whether existing or imminent, they may be able to increase production at manufacturing facilities to meet demand.

Hospitals should communicate early and often when critical supplies are getting low, and work with vendors to restore reserves before problems arise.

If vendors/suppliers don’t manufacture the supplies in question, they may have relationships with other companies, organizations, or agencies with the connections or capacity to assist.

The need for training

The more procedures and equipment that staff are trained on, the more versatile they can be. Healthcare industry partners can provide on-site or virtual clinical education to untrained staff, expanding capabilities for certain types of therapy and potentially freeing up personnel needed for specialty care.

For instance, nurses who are taught to administer PIKRT can fill in for dialysis nurses, who may need time for more critical patients requiring CKRT.1

Staff support and allocation

If industry partners employ clinicians, they may be able to send support staff to help with personnel shortages. These supplemental staff members may also be able to assist with training.

Lesson 4: Caring for Patients Means Caring for Staff (and Self)

With cases flooding ICUs, shifts getting longer, staff members in quarantine, and other complications, Dr. Hebert says there have been days when it felt like he and his team were “going to war with 47 fighter jets and only three pilots.”

“Personnel resources were down. Everyone was working harder and seeing death every day — it was demoralizing,” he said. “We were inundated physically and emotionally.”

Felicia Speed, LMSW, Vice President of Social Work Services at FMCNA, has worked with and advised healthcare professionals for years. She sees the pandemic as a potential contributor to various stages of physician burnout.

“Everyone is really looking to them for all the answers,” said Speed, of physicians in the field. “And the numbers keep changing, policies keep changing — so what you did two weeks ago may be different than what you do today, but you’re still trying to maintain that level of calmness and strength so that other people can feel more comfortable and secure. It is definitely a burden that physicians carry.”

Additional stressors have included being away from family and friends, concern about exposing loved ones, self-doubt, fear, and other emotions.

According to Speed, early signs of burnout could be increased cynicism or sarcasm and can escalate to “compassion fatigue” — meaning doctors and nurses are able to do their jobs but are emotionally checked out and lacking empathy. She said healthcare providers need to watch for these signs in themselves and their colleagues and take steps to counter the effects.

“Mentally and emotionally, we are not built to handle high levels of stress for long periods of time,” said Speed. “You have to give your body time to reset. You have to give your body time to replenish some of its energy.”

Healthcare workers need to “unplug,” said Speed, even if just for a few minutes at a time. She said breathing, meditation, listening to music, dancing, yoga, laughing, and other forms of relaxation can help provide a necessary break.

In addition, talking to others about common experiences can be therapeutic, she said, as can recognizing self and others for the work that’s being done.

“Take those opportunities and say, ‘Hey, I really did good today,’ but also show that appreciation to other people,” she advises. “I often tell people when you smile, the smile is not for you because you can't see it. It's really for other people.”

Lesson 5: The Importance of Preparing for the Future

The COVID-19 pandemic has disrupted millions of lives in unprecedented ways, and it’s far from the only catastrophic event of 2020 and 2021. The U.S. saw nearly $100 billion in damages due to wildfires, drought, tornadoes, hurricanes, floods, and other severe weather in 2020, and we’ve seen more of these disasters in 2021.6

These incidents — along with power outages and nearly a quarter-million water main breaks each year7 — cause injuries and deaths, displace people from their homes, and hinder patients from receiving medical care, including dialysis. Whether their condition is acute or chronic, patients with kidney failure need this life-sustaining therapy.

While it’s impossible to know when the next pandemic or natural disaster will occur, it is possible to prepare in ways that can help save lives and soften the impact. There are many ways for companies and care providers can be prepared and respond to emergencies in a more coordinated manner.

Make a plan

The most fundamental step organizations can take is to have a plan in place — before a disaster strikes. Tracking the successes and failures of previous emergency responses is one way for organizations to create more effective contingency plans.

As the COVID-19 pandemic began to take shape, FMCNA leveraged plans and lessons learned from previous natural disasters — including actions following the SARS and MERS outbreaks of 2003 and 2012, respectively. With a focus on protecting the most vulnerable and essential, our early, assertive approach to masking, social distancing, and sanitization exceeded initial government regulations and proved extremely effective at limiting exposure and infection rates among staff and patients.8

Coordinate with key organizations and agencies

Coordination with people and agencies that provide supplies, relief, and up-to-date information can help hospitals obtain the resources they need most during an emergency.

To keep our organization ready, the FMCNA Disaster Response Team maintains strong relationships with emergency operations centers, federal/state/local government officials, first responders, volunteer organizations, utilities, and businesses.

By keeping the lines of communication open and current, facilities can ensure that, when disaster strikes, fuel, water, transportation, and other supplies and services are prioritized for patients receiving dialysis treatment.

Consider emergency-ready KRT

In the congested and often hectic atmosphere of the ICU, flexible KRT solutions can be a true asset. Dialysis machines should be adaptable to changing priorities, able to move where they are needed most, and capable of fitting into tight spaces, such as hospital rooms already crowded with equipment and staff.

In the event of an emergency, these machines should remain operable even when access to power or clean water becomes problematic. With these scenarios in mind, a KRT machine for the emergent environment should be:

• Small and maneuverable
• Capable of performing multiple types of KRT (continuous, hybrid, and intermittent)
• Able to plug into a standard 110V outlet
• Generator-power compatible
• Able to use prepackaged dialysate, eliminating external water source reliance

Using Past and Present Experiences to Plan for the Future

Throughout the COVID-19 pandemic, hospitals have seen fluctuations in case numbers, severity and types of symptoms, demographics of the infected, death rates and more. To better prepare for the future, it’s important that we assess all the ways the pandemic impacts our healthcare system, the people who work in it, and the patients it serves.

Healthcare providers and companies must examine their response to these experiences — and other disasters — to identify new ways of working together to achieve our common goals.

* Paid speaker for NxStage Medical

INDICATIONS FOR USE:

The NxStage System One is indicated for the treatment of acute and chronic renal failure, or fluid overload using hemofiltration, hemodialysis, and/or ultrafiltration, in an acute or chronic care facility. The NxStage System One is also indicated for Therapeutic Plasma Exchange in a clinical environment. All treatments must be administered under a physician’s prescription, and must be observed by a trained and qualified person, considered to be competent in the use of this device by the prescribing physician. NxView is a computer-based touch screen user interface that provides online instructions for use, summarized system information, and remote access.

NxView is contraindicated as the sole method of monitoring a patient during treatment.3

RISK INFORMATION:
Kidney replacement therapy, as with any medical therapy, is not without risks. The decision of which therapy to use should be made by the physician, based on previous experience and on the individual facts and circumstances of the patient. There is no literature demonstrating one therapy is clinically better than another.9

1. Anger MS, Mullon C, Ficociello LH, et al. Meeting the Demand for Renal Replacement Therapy during the COVID-19 Pandemic: A Manufacturer’s Perspective. Kidney360 2021;2(2):350-4.
2. Fisher M, Neugarten J, Bellin E, et al. AKI in Hospitalized Patients with and without COVID-19: A Comparison Study. J Am Soc Nephrol 2020;31(9):2145-57.
3. NxStage System One User Guide, NC4921 Rev. K 2021-10.
4. NxStage PureFlow Solution IFU. NC45-1127 Rev B 2021-04.
5. “Fresenius Medical Care North America Unveils National Intensive Renal Care Reserve Unveiled in Response to COVID-19,” fmcna.com, last modified April 17, 2020, https://fmcna.com/company/our-company/news-releases/fresenius-medical-care-north-america-unveils-national-intensive-/.
6. Adam B. Smith, “2020 U.S. billion-dollar weather and climate disasters in historical context.” Climate.gov, last modified January 8, 2021, https://www.climate.gov/news-features/blogs/beyond-data/2020-us-billion-dollar-weather-and-climate-disasters-historical.
7. Jim Gebhardt, CFA, “The Time to Invest in America’s Water Infrastructure is Now,” blog.epa.gov, last modified July 12, 2016, https://blog.epa.gov/2016/07/12/the-time-to-invest-in-americas-water-infrastructure-is-now.
8. Franklin W. Maddux, MD, FACP, “Building on Lessons Learned: Activating a Global Pandemic Master Plan,” last modified September 21, 2020, https://fmcna.com/insights/annual-medical-report/annual-medical-report-2020/activating-global-pandemic-masterplan.
9. Nash DM, Przech S, Wald R, O'Reilly D. Systematic review and meta-analysis of renal replacement therapy modalities for acute kidney injury in the intensive care unit. J Crit Care. 2017 Oct;41:138-144.

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CAUTION: Federal law restricts this device to sale by or on the order of a physician.
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