COVID and kidney disease treatment: how kidney clinics have adapted

The coronavirus (COVID-19) has posed a new element of risk for kidney patients, but measures are being taken to maximise patient safety. Professor Liz Lightstone, a leading consultant nephrologist from London, has continued treating kidney patients throughout the pandemic. She shares her professional expertise with you on how COVID-19 can impact patients and how the management of kidney conditions has adapted to ensure that patients are safe.

Does COVID-19 cause severe illness in patients with existing kidney disease?

Results suggest that if you have certain conditions, you’re at higher risk of severe COVID symptoms. We believe that the coronavirus COVID-19 might cause severe illness in some patients with existing kidney disease. It’s important to remember that most people who contract COVID-19 have mild symptoms (or are asymptomatic) and do fine, but there are groups of patients that we think are particularly high risk for severe symptoms e.g. people with diabetes, many of whom will have kidney disease caused by their diabetes.

The biggest risk factor for a bad case of COVID is being older. The risk of having severe disease increases significantly over 60 years of age but particularly in the over 70s and over 80s. If you’re young, particularly less than 40 years old, you’re much more likely to have a mild course of the virus.

The majority of patients on dialysis come into their kidney centre three times a week for haemodialysis and in the UK, there has been a very high infection rate for patients in this group. This may be because whilst kidney patients on dialysis need to shield, they can’t because they must come to the kidney centre three times a week. Now, with social distancing and wearing PPE (personal protective equipment), in particular wearing masks on their journeys to and from the units and whilst on dialysis, the risk of infection in this group has fallen.

There is a large group of patients who have medicines, called immunosuppressants, that “squash” their immune system . Being on this type of medication might increase your risk of severe COVID symptoms. These medications are used for patients who have had a kidney transplant or who have certain forms of kidney disease e.g. lupus, vasculitis, nephrotic syndrome. It is not clear that all these drugs increase your risk of either getting the virus or having a worse course if you do. There does seem to be some consistent evidence that being on long term higher doses of steroids might predispose to worse infections.

Despite our concerns about risk, the data coming out so far suggest that relatively few of the patients we consider at increased risk i.e. those with transplants or kidney disease requiring immunosuppression, have had the virus or at least do not appear to have had severe disease. We think this might be because they have isolated at home. As a result, we don’t yet know what will happen when they stop shielding. Even when shielding is relieved, kidney patients need to maintain social distancing and avoid people who are known to be infected

So, while the short answer is that yes, COVID can cause severe symptoms in patients with existing kidney disease, it doesn’t affect all kidney patients this way. We’ve certainly had very vulnerable patients have proven but very mild disease e.g. a significant proportion of our dialysis patients who had proven Covid-19 did not require admission to hospital.

Can COVID-19 cause kidney disease in people with no underlying kidney problems?

Yes, COVID can cause kidney disease in people who previously had no kidney problems. What’s been shown in the UK and European patients is that there is quite a high rate of COVID patients in intensive care with acute kidney injury (AKI). Most seem to recover, but some might need dialysis. Whether these patients are left with long-term kidney problems is a subject of ongoing research, but the immediate result is that they get recover from AKI and other kidney problems caused by COVID.

How has the non-surgical management of kidney disease changed due to COVID-19?

Most units have moved away from face-to-face consultations and have moved to phone or video consultations. Despite this change, for most patients with kidney disease, it’s really important to follow up with blood tests and urine tests – whether these are taken at their local kidney unit or local GP practice.

We stress that we have set up safe systems and it’s safe for you to come to clinics for these tests. It’s very important that if your kidney team has asked for tests that you do have them: it’s more unsafe to ignore your scheduled or requested blood or urine test because if you do, we don’t know what’s going on with your condition.

Has the availability and frequency of kidney transplants changed?

Yes, the availability and frequency of transplants changed dramatically. Because of the pandemic, many units stopped performing transplants altogether. Partly because it just wasn’t considered safe, and partly because we didn’t have bed capacity to provide the care we thought necessary. Some units across the UK that had lower rates of COVID in their area have managed transplants throughout the pandemic. In London, live donor transplantation is restarting in private hospitals that have been commissioned by the NHS. These take place in COVID protected hospitals, meaning that they do not admit COVID patients so that they can absolutely minimise the risk of spreading the virus.

Patients and donors must self-isolate before live donor transplants and are required to shield after the operation for their safety. Most units are still trying to open deceased kidney donor pathways, but this needs a lot of planning and care to minimise the risk of patients catching COVID. In the UK, most units are already working to lower this risk and to open deceased kidney donor pathways. In London, deceased donor transplants aren’t yet open but this is under rapid review.

What care is there for people whose transplants have been delayed?

In this case, there are two types of patients:

• Patients not yet on dialysis but are waiting for a pre-emptive transplant (a transplant that occurs before the kidney function deteriorates so greatly that dialysis is necessary).
• Patients already on dialysis.

This long delay in transplants means that some kidney patients will have had to start dialysis. As for the ones already on it, they just need to continue until a transplant becomes available.

There have been patient surveys and results show that patients are very keen for transplants to restart. We will probably start with patients who are at lower risk of severe COVID and these are younger patients with fewer co-existent illnesses.

What measures are taken during treatment to lessen the risk of contracting the virus?

The measures have been a subject of a great amount of work and patient safety is at the centre of everything we do. Largely, we’re trying to make sure that patients without COVID don’t catch it. Patients who don’t have the virus will stay on a COVID protected pathway, meaning that they will not cross paths with patients at risk of the virus or those or who are confirmed to have it.

There is also a great focus on cleaning, particularly cleaning between each patient who has been seen. Also, staff and patients are expected to wear PPE and use hand sanitiser.

Despite patient fears of the virus, patients’ experiences at my hospital, the Hammersmith Hospital at Imperial College Healthcare NHS Trust, have been very good and there are far fewer patients waiting in outpatients. It’s not the same in every unit, but in ours, we meet and greet each patient at the door. After greeting them, their temperature is checked and a little medical history is taken to check that they have no COVID symptoms. They’re also given a mask to wear and overall, patients have found visiting the unit reassuring.

What happens if a patient is suspected of having COVID-19?

If a patient has the virus, we give them advice on self-care and we direct them to a different pathway (not the COVID protected one). No one should come to the kidney patient unit, or any medical unit, with symptoms of COVID but they should let us know they are unwell so we can advise them on what to do next.

Patients need to think about how they travel to their appointments for treatment and tests – it’s important they make sure they’re safe when they travel by always having a mask and hand gel available. Follow the government guidelines on safety measures outside.

Where can I get more information?

For more information, I recommend Kidney Care UK – nationally, we have agreed that all kidney patient advice is consistent and available centrally on Kidney Care UK’s website - https://www.kidneycareuk.org/news-and-campaigns/coronavirus-advice/; it is up to date and the information presented in a very accessible manner. The page is regularly updated and includes not just health advice but also advice about employment and rights.

To address concerns about your kidney health, don’t hesitate to get in touch with Professor Lightstone by visiting her profile – click here.