VANCOUVER (NEWS 1130) — Between eight and 12 per cent of critical COVID-19 patients in Canada are experiencing serious acute kidney injuries as a result of the disease, says Canada’s leading nephrologist.
Doctors say the data on kidney failure in COVID-19 patients varies region to region, but the issue became clear after Italy, the United Kingdom, Washington state, and New York began flagging it.
The amount of damage to heart, kidney, liver, and blood clots in #COVID19 patients is extremely worrisome. This is why COVID is now become a chronic disease calamity not just a respiratory disease one. Suddenly strokes also incredibly dangerous too. https://t.co/RbUBxMT6W5
— Eric Feigl-Ding (@DrEricDing) April 27, 2020
Dr. Adeera Levin runs the BC Renal Agency and is the head of the University of British Columbia’s nephrology unit. She wants to reassure Canadians, especially the more than 25,000 receiving dialysis, that there are enough machines to meet demand.
“When we look at what is actually happening in Canada, even in the worst hit places like Ontario or Quebec, we’re not going to run out of machines,” says Levin.
However, she worries that because social and physical distancing is impossible for nurses administering dialysis, the disease could impact staffing levels.
Dr. Swapnil Hiremath, a nephrologist at Ottawa Hospital, has been tracking the data coming out of other jurisdictions. He says at any given time at any Canadian hospital, dialysis machines are already fully booked.
“Right now, we are lucky that the critical patient count hasn’t soared. If that happens we will be in deep trouble,” he warns, explaining units across the country are already running people on shifts from early morning until late at night to meet current demand.
“I don’t think there is a single program that has excess capacity lying around … all the units in the country are almost full at the best of times,” says Hiremath, adding it takes three shifts of nurses to keep each unit operating daily.
This letter reports that a cohort of kidney transplant patients had less fever, lower CD3, CD4 and CD8 counts, more rapid clinical deterioration, and increased mortality compared with the general population of Covid-19 patients. #COVID19
— NEJM (@NEJM) April 24, 2020
The head of the Canadian Nephrology Society, Dr. Deborah Zimmerman, says COVID-19 is causing damage in the kidneys for eight to 12 per cent of Canadians, but up to 20 per cent in harder hit regions such as New York and Italy.
“Much of it just looks like what we call acute tubular necrosis,” she explains. “The kidney ends up with areas that don’t seem to get enough oxygen or enough blood flow and they necrose … it’s very, very common in critically ill patients in the ICU and it looks like much of the kidney injury in COVID-19 is very similar.”
The good news, says Zimmerman, is the injury is potentially recoverable over time.
Meanwhile, American rapper Scarface has shared that he is on dialysis after testing positive for COVID-19 and beating the disease’s pneumonia symptoms last month.
Dialysis at home
Levin credits Canada’s health care system and the fact our country had more time to prepare for the disease for keeping the number of critical patients low.
She says it’s likely fewer Canadian COVID-19 patients are ending up in hospital, compared to the U.S. and Italy, in part because of our integrated public health care.
“[Canadians are] not waiting until the last minute to come and seek help … We do have a way to access care without putting your hand in your wallet,” says Levin.
Still, she warns cumulative impacts on dialysis capacity could become an issue as transplants have been put on hold, meaning people are not transitioning out of treatment as they would have if receiving new organs.
Dialysis patients typically visit the hospital three times a week, putting them at risk of infection. However, training those patients to do their own dialysis at home takes staffing that hasn’t been readily available everywhere.
“So we may have challenges with capacity just because people are not leaving the hemodialysis units the way they would normally,” says Zimmerman.
Something that is very worrisome, says Hiremath, is that between five and 15 percent of dialysis patients live in long term care facilities, where COVID-19 outbreaks have been concentrated and, in many cases, deadly.
“So a nursing home may be on lockdown, but if there is a patient there who requires hemodialysis, that patient will have to come from that lockdown facility to the hospital for dialysis three times a week so there’s a huge risk of bi-directional spread,” he says, meaning the kidney patient could bring the virus from the home to the other dialysis patients, or vice-versa.
Those with kidney diseases and injuries are at high risk of becoming critical if they contract COVID-19, so keeping chronic patients separate from COVID-19 patients receiving kidney care is a high priority.
One reason transplants are on hold is because patients receive around ten days of immunosuppressants to aid the body in accepting its new organ.
Provinces are prepared
Shortages of equipment in the United States has some Canadians wondering if we will face similar issues here.
Dr. Levin says provinces have been preparing and are ready to react and move resources around, if needed.
“We have ways to move things around so I think our biggest concern is trained personnel to do the dialysis if a lot of staff get sick,” says Levin, adding moving more people to home dialysis could help alleviate these pressures.
However, she says in the U.S. the number of black people dying of COVID-19 reveals how health outcomes are closely linked with underlying societal factors. She worries we may see similar outcomes in racialized populations here.
“We have not got any organized data that I’m aware of with respect to ethnic disparities in severity of illness in ICU’s in Canada, my guess is it is not only Indigenous people, I would imagine other ethnicities would also be more vulnerable for all the confounded socio-economic conditions, work conditions, etcetera,” says Levin.
Hiremath says provincial governments need to make sure there is a contingency plan in case of a surge or a second wave of COVID-19, and continue to fund more resources to transition kidney patients to homecare.
“It is true that people haven’t paid attention and I think this is sheer luck that we have gotten off like that, but that doesn’t mean we can let our guard down. We have to be better prepared than that.”
He is compiling resources online for both healthcare practitioners and patients, who have a lot of questions about how and when their lives may return to normal.
All #Covid_19 Kidney pages
& Hypertension/ACE2 https://t.co/vwnT0YMkQw
All #Nephrotwitter community pitching in
— Swapnil Hiremath, MD, MPH (@hswapnil) April 2, 2020
Hiremath says transplants are likely to resume before a vaccine is available, but the suppression of patients’ immune systems will make these procedures difficult.
B.C.’s Ministry of Health could not provide numbers on availability of dialysis machines in the province immediately, but did provide the following statement:
“Ministry of Health and BCCDC experts are reviewing reports and studies from around the world, not only on responses to COVID-19 but any subsequent issues recovered patients may be facing. We are learning many things about how this virus acts and how it affects people, and it continually informs our planning process for how we handle it. That is why we continue on our careful approach to this situation, using the best information available to us.”