Doctors fear that if the covid-19 disease spreads in treatment centers, patients seeking dialysis will flood overburdened and under-equipped hospital emergency departments.
Some of the nation’s more than 5,000 private dialysis centers have begun handing out masks to stem the spread of the virus, but others are running short and rationing them.
Health-care providers, the Centers for Disease Control and Prevention, and the two companies that dominate private dialysis are developing ways to separate the well from the infected in dialysis centers. All expect that doing so will be necessary in coming weeks.
The plight of dialysis patients illustrates the larger difficulty of delivering medical care to huge numbers of people in a pandemic, when the single most important tactic is keeping them apart.
“Because patients need dialysis to live, self-quarantine at home is not an option,” said Nicole Lurie, a top preparedness official in the Obama administration and current co-chair of the emergency preparedness committee of the American Society of Nephrology. “Sending infected patients to the hospital only overwhelms the system even more, and introduces another source of infection. So the challenge of keeping staff from becoming infected and unable to work, and protecting non-infected patients from infected ones is huge.”
With their kidneys ineffective, most dialysis patients endure a difficult regimen of having their blood cleansed three days a week, four hours at a time. This is done mainly in privately-operated dialysis centers where eight to more than 30 chairs are arrayed in a large room. The patients’ blood runs through filters that remove toxins and waste before a machine circulates the blood back into them.
Most centers are operated by one of two companies, Fresenius Kidney Care and DaVita Kidney Care. A small percentage of patients receive their care at home, from centers affiliated with hospitals or from other organizations.
The nature of their kidney disease makes dialysis patients highly vulnerable to complications of infection and other health threats. Even a single missed session can cause life-threatening buildup of fluid in their lungs and hearts.
They “are older and by and large they have co-morbidities like diabetes and chronic heart disease and chronic lung disease,” said Alan Kliger, a nephrologist who is co-leading a task force that is trying to work out preparations for dialysis patients. “They are the primary at-risk group for covid-19.”
At Patty Danielson’s Fresenius dialysis clinic in Portland, Ore., about 25 chairs are grouped in “pods” of four about three or four feet apart — less than the minimum six feet recommended for effective social distancing during the pandemic. There is one enclosed chair for patients with infectious diseases who need to be isolated from the rest, she said.
Danielson, 61, who has been on dialysis for more than 12 years, leaves work as a psychiatric nurse manager precisely at 4 p.m. on Mondays, Wednesdays and Fridays so she can be in the chair at 4:45 and out by 9:15. Since the outbreak, staff members at the dialysis center have begun distributing surgical masks to each patient to prevent droplet transmission and are taking temperatures at the door. Patients with fevers above 100.4 degrees Fahrenheit are not allowed in.
With her immune system already compromised, “it was quite a sobering moment to think that if I get this virus I could die,” Danielson said. “It made me think about getting my funeral planned.” Which she did.
Planners are working on a variety of approaches, none of them ideal, for the time when the virus invades dialysis centers. Shannon Novosad, acting team lead for the CDC’s dialysis safety team, said that to accommodate patients infected with covid-19, centers may have to fill fewer seats to enforce six feet of distance between people receiving treatment. All may need masks to prevent infecting other patients.
Another possibility is to send all infected patients to one center or group them in one four-hour “shift” where they can’t harm one another, Kliger said.
But many dialysis patients depend on ride services or ambulettes to get to their facilities, and experts worry that drivers will not want to transport patients they know are infected, especially groups of them. In vans, infected patients may be sitting with uninfected people. Patients with jobs may have difficulty changing their shifts abruptly.
Already, some infected patients have been admitted to hospitals and must get their care there, Novosad said. “In some regions, capacity and hospital beds will definitely become an issue,” she said.
Dialysis centers also are suffering the same equipment shortages as other health-care facilities in places such as New York City, which has become the center of the U.S. outbreak.
Jeffrey Silberzweig, who runs eight nonprofit dialysis centers for the hospital-based Rogosin Institute, said he is stretching his mask supply beyond its limit. Each staff member is being asked to use a mask until it becomes too moist or tears.
“Our goal is make a mask last a week,” he said. “In some cases that will happen, but in many cases it won’t.”
Silberzweig doesn’t know when new supplies will arrive. “We reached out to the New York City Department of Health seeking more masks and we were told we are not a priority for the limited supply they have available,” he said.
Spokesmen for Fresenius and DaVita declined to answer questions about their efforts. In a prepared statement, DaVita said: “We are working in lockstep with the CDC and the kidney care community to protect our patient population and caregivers. Our proven expertise and international experience, coupled with our national footprint, allows us to roll out protocols quickly to avoid delicate and costly hospitalizations.”
In written answers to questions, Robert Kossmann, chief medical officer for Fresenius Medical Care North America, said the company has referred positive covid-19 cases to local health departments and hospitals where they can be treated and receive dialysis.
Kossmann said the company is trying to identify shifts and whole facilities where dialysis patients with covid-19 can be separated from uninfected patients. The company’s supply chain for protective equipment has not been disrupted, he said.