Dialysis centers around the Denver area are setting aside certain hours or even entire facilities for patients who could have the new coronavirus, but it’s not guaranteed to protect their vulnerable patients.
Patients with end-stage kidney disease are caught in a cruel bind as COVID-19 continues to spread: many have to risk death from infection multiple times a week to get a treatment that keeps them alive.
Dr. Michel Chonchol, a nephrologist at University of Colorado Hospital, said kidney disease interferes with the immune system, making patients on dialysis more vulnerable to all types of infections. At the same time, potassium levels in the blood can quickly build up to unsafe levels if patients miss a dialysis appointment, putting them at risk for cardiac arrest, he said.
Most patients go to a dialysis center three times a week, for multiple hours at a time, with about 10% getting their treatment at home as of 2017. Kidney transplants also are a solution to end-stage disease, but there aren’t as many donated organs available as patients who need them.
University of Colorado Hospital set up a unit for patients with respiratory illnesses, Chonchol said. Patients who have been tested but don’t have results come in for one shift, and those with confirmed COVID-19 infections get treatment at a different time, he said. Certain chairs are designated for patients with COVID-19, though they could sanitize them for patients who might not be infected.
Grant Hindsley, The New York Times
Mat Risher sits for one of three weekly, four-hour dialysis sessions at the Northwest Kidney Centers in Kirkland, Wash., on April 1, 2020. As the pandemic sweeps the United States, patients needing kidney dialysis and employees of the clinics worry about keeping the virus at bay in such tight spaces. (Grant Hindsley/The New York Times)“We’re very good at decontaminating,” he said.
DaVita, one of two large companies that dominate the American dialysis market, also set up a “handful” of facilities in the Denver area to treat patients who have COVID-19, chief medical officer Dr. Jeff Guillian said. Some harder-hit areas have more designated centers to keep infected patients separate from others, he said.
Guillian said the company started stockpiling medications and equipment like surgical masks in January, as it became clear the virus could present a serious threat. In March, clinics started checking everyone who enters for fevers and asking about possible symptoms, and having everyone wear surgical masks. They’re gradually adding tests to figure out if patients should get treatment in a separate facility, he said.
“We want to make sure that we’re not overly conservative… but also that we’re being conservative enough,” he said.
Fresenius Kidney Care, the other major player in the dialysis market, released a statement saying its clinics had been screening patients and employees for COVID-19 since February, and those who test positive are sent to separate clinics or rescheduled for a time when uninfected patients aren’t present. Representatives declined to elaborate on whether Fresenius’ Denver-area clinics were using one or both of those strategies.
While testing can help identify some people who have the new virus, it sometimes produces a false negative, meaning a person shows up as uninfected but could still spread the virus. That’s one reason it’s important for everyone in a dialysis clinic to have a mask, and to check for signs of fever each time, Chonchol said. Newer units generally have chairs spaced about six feet apart, though some older ones are more densely packed, he said.
“The asymptomatic patients are really difficult to identify,” he said.
Since dialysis patients are at a high risk of serious infections, centers are required to follow strict criteria around hand-washing, equipment cleaning and use of gloves and masks even in normal times. DaVita and Fresenius centers in other states have been cited repeatedly for infection control failures, according to The New York Times, but Denver facilities have relatively clear records. Since 2015, the 35 centers in the metro area that have inspection reports have been cited for a combined 56 violations, with only eight noted in the most recent year, according to a search of state records.
Handwashing and sterilizing surfaces already were important, but they have an even greater emphasis now, Guillian said.
“Infection control has always been something we do as part of caring for patients,” he said.
Denver Post file
A dialysis machine is pictured at a Denver-based DaVita clinic in this file photo.Dr. Andrew Brookens, a Denver nephrologist, said he thinks the precautions centers are using will be helpful, but they’re also a “band-aid” solution on the overall problem of infection control. Patients generally prefer home dialysis and it produces equivalent results while more effectively distancing them from other people’s germs, but dialysis centers are reluctant to give up a lucrative market, he said.
“The true solution is to implement the change… of moving as aggressively as possible to home dialysis and transplant,” he said.
Most people who do dialysis at home have catheters in their abdomens, allowing them to put in and drain fluids to remove waste products from the body, Chonchol said. It’s not possible to do those surgeries now, and dialysis through a patient’s arm requires someone to watch constantly, which may not be possible in all homes, he said.
“To do this during an epidemic is very difficult,” he said.
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