Coronavirus lockdown compounds kidney patients' woes; 28% skip dialysis, outpatient attendance falls 92%: survey

Millions suffering from chronic kidney disease could be at risk of cardiac arrest due to missed dialysis sessions and shortage of equipment.

Ananya Srivastava July 22, 2020 17:49:54 IST
Coronavirus lockdown compounds kidney patients' woes; 28% skip dialysis, outpatient attendance falls 92%: survey

Editor's Note: In a first-of-its-kind study, doctors and academicians surveyed 19 large urban hospitals to assess the impact of coronavirus pandemic in India on kidney patients. The report revealed a massive drop in patients reporting for checkup and dialysis. In this two-part series, Firstpost spoke to doctors, patients, and activists to understand how COVID-19 impacted patients. Part I is the direct impact of lockdown on access to healthcare; Part II explores how compromised immunity puts kidney patients at risk.

Over 28 percent of kidney patients missed one or more dialysis sessions and over four percent stopped reporting for dialysis during the first three weeks of the coronavirus lockdown, a new study has revealed.

The pre-proof version of a survey of 19 large hospitals across urban India, conducted by nearly two dozen scientists, slated to be published in Kidney International Reports, revealed a steep decline in kidney patients reporting for treatment and check-ups at nephrology units in these hospitals.

The attendance for outpatients (those not requiring hospitalisation) in the surveyed hospitals came down by an incredible 92.3 percent and inpatient service reduced by 61 percent during phase one of the lockdown.

The limitations of this first-of-its-kind survey, conducted at hospitals in major cities, are self-evident.

One can thus, in the absence of a national database of dialysis patients, only imagine the situation in smaller towns with limited infrastructure.

Millions suffering from chronic kidney disease could be at risk of cardiac arrest due to missed dialysis sessions and shortage of equipment.

Worse, since the outbreak of the pandemic, the conversation has been mainly focused on the ability of countries to address the needs of COVID-19 patients.

Little time and energy have been devoted to addressing the needs of those with non-communicable life-threatening diseases, including kidney ailments. For End Stage Kidney Disease (ESKD) patients, the schedule of dialysis treatment is pretty much set in stone: four-hour sessions, thrice a week.

Any change in this can have disastrous consequences. When a patient misses a dialysis session, toxic wastes and fluid begin to build up. This can make them feel more tired, cause difficulty breathing, nausea and swelling. A high level of potassium can also lead to cardiac arrest and ultimately death.

Every patient spoken to for this piece said they underwent two dialysis sessions per week in the early stages of lockdown. At least two patients said their usual four-hour sessions were cut in half as doctors with limited resources scrambled to accommodate more patients.

A patient based in Mumbai, speaking on condition of anonymity, said the local municipal hospital close to his home, where he received free dialysis under the Mahatma Jyotiba Phule Jan Arogya Yojna, was turned into a COVID-19-only healthcare centre without any prior information or alternative arrangements for patients.

He reached out to Kidney Warrior Foundation, a patient advocacy group, who helped him resume his sessions at the KJ Somaiya Hospital in Sion. However, the authorities requested him to not visit more than twice a week. Additionally, the sessions were only two hours long.

“After the dialysis I didn’t feel better at all. There was swelling and I still felt bloated. But when I questioned the technicians as to why they ended the session early, they said this much is enough to keep you alive,” he said.

The situation, however, has improved since the past 20 days, he admitted.

Another patient undergoing dialysis at KJ Somaiya Hospital narrated a similar ordeal, saying he faced backlash from staff for demanding an 'extra' dialysis session.

Dr Vijay Kher, chairman, Nephrology at Medanta Hospital in Gurugram, said that patients have had to miss dialysis and cut short sessions during the initial phases of the lockdown.

“I was working closely with the government in Delhi and Gurugram during the pandemic,” Kher said. “I am sure patients could not reach dialysis centres due to lack of transportation. Many small standalone centres shut down not because of government orders or unavailability of material, but because technicians would not report for duty. They were scared of coming to the centres.”

Kher also said that duration of dialysis and the frequency have had to be cut as just a few hospitals became responsible for administering life-saving treatment to a large population.

“In my dialysis unit we had patients arriving in shared rickshaws from far-off places,” Kher added. “So when the lockdown was imposed, they felt that coming thrice a week would not be possible. Then we had to cut sessions to twice a week. Some even insisted on once a week, but we had to tell them that was not advisable. We also had to cut down because there were other patients with  comorbidities. If we cut down their dialysis, they would die even without getting affected by the coronavirus.”

The lockdown also affected the availability of consumables for dialysis and essential medicines, at least initially, the survey reported. No light could be shed on the situation in small towns and villages as none of the activists, support groups or doctors spoken to for this piece were able to comment on the resumption of supply chains in remote areas.

Sejal P Jobanputra, a member of Kidney Warriors Foundation and an ESKD patient herself, said, “Dialysis consumables became a huge problem. Most consumables come from other countries. Dialysis centers had to reuse dialyzers and tubes to the max and cut down administering heparin, which is a blood thinner needed in dialysis to avoid blood clots and death by clots.”

COVID-19 patients become kidney patients

The problem compounded with the number of centres offering dialysis dwindling as the number of patients needing dialysis further increased. Renal failure increasingly became reported as a serious complication in COVID-19 patients who previously had no history of kidney disease.

Coronavirus lockdown compounds kidney patients woes 28 skip dialysis outpatient attendance falls 92 survey

This has emerged as a prominent trend in the US, where FAIR Healthcare (a non-profit healthcare cost transparency group), in a survey found chronic kidney disease and kidney failure as the most common comorbidities in hospitalised COVID-19 patients (accounting for 13 percent of all such patients in the period between January and May 2020).

The National Kidney Foundation also states that Acute Kidney Injury (AKI) is occurring in 15 percent of all hospitalised coronavirus patients in the US. Further, if a patient ends up in the ICU unit, their odds worsen. Reports indicate that more than 20 percent of ICU patients have lost kidney function.

A whole group of people with no previous history of kidney disease now face AKI, which brings an increased risk of developing chronic kidney disease.

However, the lack of a similar survey or database in India leaves us to rely on anecdotal experiences from doctors and activists working closely with COVID-19 patients.

Dr Abhijit Taraphder, senior nephrologist at Apollo Gleneagles Hospital, Kolkata, said kidney complications have been reported in several COVID-19 patients.

Dr AL Kripalani, senior nephrologist at the Bombay Hospital, also said he was aware of cases where COVID-19 related complications resulted in kidney injury.

This reporter also came across at least one such patient. She was undergoing treatment for COVID-19 at Lifeline Hospital in Mumbai. She is now cured of COVID-19 and discharged from hospital care, but will need dialysis for the rest of her life.

In another case, a suspected COVID-19 patient died due to kidney-related complications and non-availability of dialysis. She reported to the Bharat Ratna Pandit Bhimsen Joshi Hospital at Tembhe in Mira Bhayandar on 29 June with serious COVID-19 symptoms and was admitted the same day. She passed away on 2 July with kidney-related complications.

“My wife was admitted at the Tembhe hospital and we were told she needs dialysis, which would be given,” her husband Ardhendu Bhattacharya alleged. “The authorities kept mum for two days. Then, they told me the dialysis machine had not been functioning since the day she was admitted. I reached out for help on Twitter, but she passed away by the time we could arranged a bed at another hospital.”

Even after the patient’s demise, the family says they were never informed about the outcome of her coronavirus test.

Another person made a similar allegation against the same hospital on Twitter.

Increasing costs, increasing difficulties

Kidney patients without means are among the worst impacted. The life-long treatment, which is often not covered by insurance and often leads to a loss of employment for the patient, can be a financial nightmare.

Many depending on charitable trusts and NGOs have little choice but to bear the cost of treatment.

Dr Kripalani said, “Many have never had to pay for dialysis. They were under the care of charitable and government institutions. Now, with these places shut, they're suddenly left without cover.”

Vasundhara Raghavan, CEO of Kidney Warrior Foundation said, “One of the untold aspects of the crisis is that dialysis costs have increased. Patients with CKD were earlier spending between Rs 5,000 and 15,000 per week on dialysis. Now, technicians and nephrologists have to wear PPE kits. In Mumbai, they arranged ambulances to safely transport kidney patients. These are all additional costs for patients.”

Shruti, who is based in Delhi, said kidney patients like herself, who are  extremely vulnerable to contracting the infection, are also at risk of spreading it to healthcare workers.

“So, kidney patients are repeatedly asked to get the tests done,” Shruti said. “That can cost between Rs 2,000 and 4,000.” Not to mention the additional risk of going to a test centre and contracting COVID-19.

Sejal added, “Most dialysis centers want COVID-19 tests every 10 days. How can we pay for it? Rs 4,500 every 10 days... As if dialysis is cheap. We pay between Rs 20,000 and 50,000 per month for this life-saving treatment. Now, add this new expense. And since our regular centres are unable to treat us, we also have to shell out for transport.”

Amidst this pandemic, one thing has become exceedingly clear: kidney patients, and those suffering other non-communicable diseases, have been left out of the conversation for far too long.

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