COVID-19 puts kidney patients at high risk as poor immunity, ill-equipped dialysis centres expose patients to infection
Experience of doctors, healthcare activists and patients suggest that the situation in smaller towns and villages due to hardships faced by patients with acute kidney complications could be much worse than cities because of COVID-19.
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.
Data from around the world have suggested that patients with Chronic Kidney Disease (CKD) are at an increased risk of contracting coronavirus and the overall mortality rate of this group of people is also higher. Statistics specific to the United Kingdom show that between 3 March and 30 April, one in 10 people dependent on in-centre hemodialysis tested positive for coronavirus .
No such comprehensive study on the impact of coronavirus on kidney patients is available in India. But a survey done on 19 major Indian hospitals suggests that the renal healthcare infrastructure was severely lagging on social distancing and other preventive measures to shield this vulnerable section of the population from the deadly contagion.
The survey, slated to be published in Kidney International Reports, suggested that in the first phase of the lockdown, only 66 percent hospitals had created a plan to segregate COVID-19 patients who needed dialysis. The remaining hospitals had no facility to treat coronavirus positive kidney patients or those who developed kidney problems as a result of COVID-19 related complications.
Out of the hospitals which did have separate plans to combat COVID-19 and CKD, 66.66 percent adopted isolation units and separate dialysis machines, 25 percent had dedicated machines but no facility for isolation and 8.33 percent had dedicated shifts to treat coronavirus positive patients.
“In many private hospitals, services were affected due to lockdown restrictions, lack of internal protocols to handle the pandemic, fear of infection to medical staff, and an unwillingness to risk the business from non-COVID patients,” the survey said.
The survey constituted of premier healthcare units (8 government and 11 private). Experience of doctors, healthcare activists and patients suggest that the situation in smaller towns and villages could have been much worse.
Kidney patients risk exposure to deadly coronavirus to access life-saving treatment
Doctors this reporter spoke to unanimously opined that kidney patients already have compromised immunity, and those in post-transplant care are on heavy doses of immunosuppressants making COVID-19 a lethal situation for them.
Dr Abhijit Taraphder, a senior nephrologist at Apollo Gleneagles Hospital, Kolkata says, “Patients with chronic kidney disease or end-stage renal disease are more susceptible to develop COVID-19 . And when a dialysis patient contracts COVID-19 then it tends to be more aggressive as the patient is already on a compromised immunity. And the mortality rate is also very high.”
Shruti, a Delhi based kidney patient who is also working with a patient advocacy group Kidney Warriors Foundation, states that the biggest challenge for those dependent on clinical hemodialysis is undergoing the mandatory coronavirus tests every week or every 10 days.
The test, while a necessary precaution to safeguard healthcare workers and other patients at dialysis centres, also risks putting a kidney patient in close proximity of other suspected COVID-19 cases who may be present at the testing centres. The facility to get the test done at home is extremely limited, and expensive even where it is available.
“It is a big challenge for patients to get these tests done, without themselves contracting the virus in the process,” says Shruti.
Furthermore, the patients also run the risk of contracting the virus at the dialysis centre itself.
Vasundhara Raghavan, CEO of patient advocacy group Kidney Warriors Foundation, says, “This is a complex and a very sad situation. When the pandemic struck, nobody was prepared. We can’t blame anybody. The doctors are overburdened with COVID-19 situation. The technicians and dialysis centres simply don’t have the wherewithal to have separate isolation units and dialysis machines for COVID-19 positive patients, and the kidney patients definitely have no fault for wanting to stay alive.
“A lot of dialysis centres had to shut down, and even now are not able to handle kidney patients, who a lot of times are on immunosuppressants. You see, Hepatitis A, B and C infections are quite common among kidney patients. Those suffering from A need a different machine, those who have hepatitis C need to use a separate machine. Normal patients need completely separate machines. Now COVID-19 has been introduced to this equation. Who is looking at the logistics of it, that whether all safety protocols are being followed or not, especially in standalone centres in small towns?”
Taraphder also raises the issue of safety and compliance at standalone dialysis centres, that mostly cater to patients in smaller towns.
“These centres don’t have the means to segregate COVID and non-COVID patients. They also do not have separate machines for dialysing these patients. Not only do they lack in taking the precautions, but they also don’t have the expertise. For example, in a COVID-19 patient the anti-coagulants will have to be adjusted. It is a tricky thing and only an experienced nephrologist can do that. Most centres only have technicians and just a visiting doctor,” he said, adding that initially when the test kits were inaccessible and testing was controlled by strict norms, it may have exposed many patients to the virus at the dialysis centre.
A Mumbai-based patient, says that even a large hospital KJ Somaiya Hospital can’t follow all the precautions.
“When we go in for dialysis, the technicians are protected with PPE kits and everything but there is no protection for patients. They change the bedsheets between two sessions but they leave the old blankets to be reused by other patients. We usually do feel cold during the dialysis and instinctively have to reach out for the same blanket. What if someone contracts virus through that,” he says.
Sandhya Fernandes, a Mumbai-based activist with SOSMumbai who helped out Kidney Warrior Foundation during the COVID-19 pandemic, says that obtaining test results in a timely manner is a problem in Mumbai despite the state government allowing removing all preconditions in getting COVID-19 tests.
She says that there is often a delay in getting these reports. This delays the dialysis schedule of these patients, which in turn further compromises their immunity and puts their lives at risk.
“There was one time when a COVID-19 test centre lost the sample of a dialysis patient. It usually takes 48 hours for a report to come, this patient had to wait an additional 48 hours to get his report and dialysis.”
She says that incorrect result in the first-time test reports is also not unheard of.
Narrating the experience of one of his patients, Taraphder said, “One of our patients developed respiratory distress and subsequently she was isolated in the COVID-19 ward. Later two of her reports came negative so she was shifted back to the general ward. Now once she was shifted to the COVID ward there was every chance that she could get infected from another COVID patient also.”
He says that this problem will remain as long as doctors operate from a blind-spot about which patient is coronavirus positive and which isn’t.
Taraphder suggests that free and easy access to coronavirus tests, especially antibody tests, and prompt reports are the only way to resolve this issue.
Is COVID-19 vaccine a solution?
Another challenge facing COVID-19 patients, who were already suffering from chronic kidney disease, is that not all medication is suitable for them that have shown positive results in other patients, says Dr AL Kriplani, former head of department, Nephrology at the Bombay Hospital.
“It has to be seen whether the vaccination under development is safe to use on patients with CKD. Any and every vaccination or medication approved for normal patients throws up very different challenges when administered to Kidney patients, who are commonly immunocompromised,” says Kriplani.
Hydroxychloriquine, for example, a drug whose use and efficacy on COVID-19 patients is a different debate altogether, may not be the best course of treatment for CKD patients who contract coronavirus .
An article in The Conversation, authored by Teguh Haryo Sasongko, Associate Professor, Medicine, Perdana University, suggests that impaired kidney function increases the risk of adverse effects of the antimalarial drug as the ability of the liver and kidneys to process and remove HCQ/CQ from the body becomes very limited, hence increasing the threat of poisoning.
Can peritoneal dialysis be a safer option for patients?
Patient experience suggests peritoneal dialysis can be a great substitute in a lot of cases, especially at a time when reporting to dialysis centre means increased risk of coronavirus infection for kidney patients. But it is not without its own set of challenges.
Peritoneal dialysis (PD) is a type of dialysis treatment in which a soft catheter is placed in the belly surgically, after which the patient can themselves dialyze the waste fluid at home two to three times a day, with each session lasting around 30 minutes.
Hemodialysis, in contrast, requires patients to report at a dialysis centre a minimum of three times a week, with each session taking around four hours. Patients this reporter spoke to reported extreme exhaustion after sessions, and the inability to find gainful employment due to the frequent and long dialysis sessions.
Patients on PD, however, confirmed they experience a better quality of life as this method allowed them to be closer to a normal diet. The risk of missing a dialysis session is minimized, and they also reported feeling better, with toxins removed from their body more frequently.
A 33-year-old kidney patient who has opted for PD, says she got the catheter inserted at the Madras Medical Mission Hospital and was required to stay hospitalised for three weeks. During this time, she was also trained to carry out her own dialysis using the PD equipment. She says it can be a great option, especially for younger patients who are capable of taking care of their own health with the right training.
However, despite the above benefits, Raghavan estimates that less than 2 percent of people are currently choosing PD over HD. And she also points out the risks and reasons behind the lack of popularity of this option.
“PD, first of all, doesn’t get promoted that much. Doctors do not introduce patients to it very often. Then there is also the increased risk of infection simply because with HD, trained technicians at dedicated centres are taking care of your health and hygiene. With PD, ensuring sanitation and minimizing the risk of infection is completely in the patient’s hands,” says Raghavan.
“If people have comfortable accommodation, a large house where they can store the boxes of cleansing fluid, have a dedicated space that they can keep extremely clean then it becomes easier. Otherwise, it is very difficult. Patient education is also a key factor. They have to be trained properly to do it in a correct manner,” adds Raghavan.
Another factor that adds to the cons of PD is the initial high cost associated with it. HD is often free for the poor under various government schemes, and also insurance companies provide at least partial coverage against the costs. Some charitable trusts also run dialysis centres at a subsidised rate or provide financial assistance to the poor. But PD is not covered under insurance in India. The cost of buying the equipment in itself is discouraging for a lot of patients, who are started off on HD with a much simpler and cheaper process.
Peritoneal Dialysis is also not for everyone. The abdomen or belly of some people, particularly those who are morbidly obese or those with multiple prior abdominal surgeries, may make peritoneal dialysis treatments difficult or impossible.
Raghavan recognises the potential PD holds in evading the risk of contracting COVID-19 at the dialysis or COVID-19 test centres but is also vary of the risk of infections if it is not carried out with care.
She suggests opening small clinics and dedicated spaces in small towns, where people can visit and do their PD in a safe and clean environment. This can be beneficial for those who are unable to maintain this routine at their homes due to lack of space. These centres can also take away the hassle of procuring and storing the cleansing fluid, Raghavan says.
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