Evidence-Based Practices to Reduce COVID-19 Transmission in Dialysis Facilities.

Abstract

At the start of the coronavirus disease 2019 (COVID-19) pandemic, we needed to quickly develop and deploy strategies to protect patients on dialysis from acquiring and spreading infection.With little information coming from the original Chinese epicenter of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the Centers for Disease Control and Prevention (CDC) offered guidance on the basis of experience with previous respiratory viral epidemics, which was quickly disseminated in the kidney community (1). Outpatient hemodialysis facilities are particularly challenging; patients with advanced kidney disease and associated comorbiditieswere likely to bemore susceptible to infection and, if infected, suffer higher morbidity andmortality. In addition, social distancing is all but impossible in most hemodialysis facilities. Dialysis organizations in theUnited Stateswent into action early and forcefully. They created separate facilities or shifts for patients with proven SARS-CoV-2 infections or those patients under investigation for possible infection, screened all patients and staff entering facilities for signs or symptoms of infection, emphasized frequent hand hygiene, and deployed personal protective equipment including gowns, gloves, and eye protection. They emphasized the importance of surface cleaning, machine and dialysis station disinfection, and limited access to only patients and essential personnel. Early in the pandemic, the guidance from CDC was for all staff to use surgical masks or N95 masks if available and for symptomatic patients to use similar masks, but CDC did not recommend masks for asymptomatic patients. The dialysis organizations went beyond this initial CDC recommendation and mandated universal masking for all patients and staff,whether symptomatic of viral illness or not. Weeks later, when the extent of asymptomatic SARS-CoV-2 infection and spread became clear, CDC recommended universal face masks. Early evidence from some dialysis facilities suggested that spread of infections declined when these measures were adopted (2). Over several months, reports from individual centers appeared showing high mortality among SARS-CoV-2–infected patients on dialysis (3). Later in the pandemic, the severity and mortality of COVID-19 appeared to ameliorate (4), although the reason for this change is unclear. What factors are important to infection transmission and morbidity? The early months of this pandemic saw lots of educated guessing—in the absence of hard evidence, care practices were designed and deployed on the go—like the proverbial designing the aircraft asweflew it. Is there a better way? In this issue of CJASN, Caplin et al. (5) analyze all 5824 prevalent London-based patients on hemodialysis from seven facilities agreeing to participate onMarch 2, 2020. After exclusion of 69 patients with ambiguous data, information from the remaining 5755 (98.8%) patients was examined from March to May 2020, at the height of the pandemic in that city. Available databases were robust enough to record COVID-19 test positivity, hospital admission, demographic and clinical data, dialysis facility characteristics, community COVID-19 cases, and deprivation indices. The authors conclude that community levels of COVID-19, with a small contribution of unit factors and masking, determine how the infection burden evolves. Patient age, diabetes, the number of patients in the dialysis unit, and facility layout were associated with the risk of disease.Masking of asymptomatic patients was associated with fewer hospital admissions, and the number of facility side rooms per dialysis station was associated with outcomes (suggesting that the capacity to isolate patients protects onward transmission). None of the other varying isolation or deisolation strategies used by different kidney centers were associated with outcomes, nor were deprivation indices. Thus, in retrospect, a major intervention that correlated with outcome was the masking of asymptomatic patients, an intervention not initially endorsed by CDC. Had this evidence been available sooner, the importance of universal masking in dialysis facilities would have been clear, and the public confusion that followed changing CDC recommendations would have been avoided. More efficient universal real-time observations, data collection, and analysis can reduce infection transmission and improve other clinical practices. Although the evidence in this London-based study showed no definitive relationship between deprivation indices and infection or hospitalization rate, data from the United States suggest a disproportionate portion of COVID-19–related deaths among Hispanic and Black people, including patients on dialysis and transplant candidates (6,7). Owen et al. (8) propose the cause Department of Internal Medicine, Nephrology, Yale University, New Haven, Connecticut Medicine-Renal, New York Medical College, Valhalla, New York