“The peak of COVID-19 infections and hospitalizations for people on dialysis in Central Indiana is actually happening right now.”
As the COVID-19 pandemic has progressed, it has become increasingly clear that the novel coronavirus can take a serious toll on the kidneys—and on patients with kidney disease. According to the New York Times, some nephrologists estimate that 20 percent to 40 percent of ICU patients with COVID-19 suffer kidney failure and need emergency dialysis, and due to this unexpectedly high number, intensive care units in New York and other cities face a shortage of dialysis equipment. This has serious implications for COVID-19 patients, as well as for people who were on dialysis prior to the pandemic.
Brent Miller, MD, is Professor of Clinical Medicine at Indiana University School of Medicine in the Division of Nephrology, and Kidney Health Service Line Leader with Indiana University Health Physicians. I spoke with him to learn more about why the kidneys are so affected by COVID-19, and what this means for people with kidney disease in Indiana.
This interview has been condensed and edited.
Let’s talk first about COVID-19’s impact on people who already have kidney disease. What happens (or can happen) when someone with kidney disease contracts the novel coronavirus?
People with kidney disease are more susceptible to having a severe manifestation of COVID-19 for several reasons. One is because people with kidney disease tend to have more comorbidities, such as diabetes or high blood pressure, and they also tend to be older. All of those things make someone more susceptible to having a severe manifestation of the disease.
Additionally, just having kidney disease can make you more susceptible. We don’t have enough data on this yet, but if you’re a dialysis patient, and you get infected with the novel coronavirus and develop COVID, you have an approximately 1 in 4 chance of ending up in the hospital, and patients with kidney disease that are ill enough to be hospitalized have a high percentage of becoming very ill.
There have been reports of high mortality among transplant recipients with COVID-19. Part of the reason for that is because transplant patients must take immunosuppressant drugs so their body doesn’t reject the transplant. What additional factors are at play?
Really, the same factors as people who have kidney disease. It tends to be an older age group, and they are more likely to have comorbidities like diabetes or high blood pressure.
How is COVID-19 impacting kidney transplant surgeries at IU Health?
Transplant rates have dropped drastically here, as they have pretty much everywhere. Part of that is because of the risk to recipients, as we discussed, but bringing donors into the hospital potentially puts them at risk, too. Furthermore, there is a risk that a recipient could contract the virus through the transplant if the donor is infected, and in the early stages of the pandemic we did not have access to rapid accurate viral testing. Combined with a PPE shortage, the net effect was a large decline in all types of transplant operations. We’re starting to see that open back up a little bit here, though.
What about people who are several years post-transplant? Kidney transplant recipients have to take immunosuppressants for the rest of their lives, leaving them at high risk for severe manifestations of COVID-19 if they contract the virus. How are these patients coping?
They’re really anxious, and they’re taking shelter-in-place and social distancing orders super seriously. We’re approaching 60 days of this now, and that’s really taken a toll on people who can’t see their families or go out. I actually think some of my patients have taken it too far, and fear going outside for a walk around the block or working in the garden. So it’s a very high level of anxiety that’s impacting them. And that’s valid, because many in their position have gotten very sick and were hospitalized. So, there is a risk, but probably not from going walking around the block.
I imagine that COVID-19 is also really complicating the lives of people who were already on dialysis before the pandemic hit.
For those doing home dialysis, the pandemic has had a minimal impact—and, strangely, may actually make their lives better in the long run. I think this will lead to more widespread adoption of home dialysis among kidney disease patients. The pandemic has really emphasized to many people—including people at the Centers for Medicare and Medicaid, who decide which treatments to cover—all the reasons why we should expand the ability to perform dialysis at home. People on home dialysis have had minimal disruption to their dialysis treatment.
Yet, only 12% of dialysis patients in the country choose to do it at home. Most do it at a dialysis center, which means they have to transport themselves to an environment where they’ll be in close proximity to other people—patients and staff—several times a week for three to four hours. And they have to do it; it’s not elective. So, how to manage that?
One strategy that dialysis centers have implemented is using “cohorts” to minimize risk—they send people who are under investigation for COVID to one unit while they wait for their test results, and if positive, they’re moved to COVID-positive unit. That means that patients’ normal routines are disrupted, and that can be upsetting. They’re used to going to certain locations regularly, where they’ve formed bonds with the staff. That’s been really challenging for many.
It’s interesting—the peak of COVID-19 infections and hospitalizations for people on dialysis in Central Indiana is actually happening right now. For the general population here it was early- to mid-April, so there was a bit of a lag. We think that’s because dialysis patients were initially really strictly adhering to social distancing guidelines. Still, given how much they need to interact with other people in dialysis centers, the incidence is actually less than we expected.
Now, let’s talk about the high incidence of renal failure among COVID-19 patients who don’t have underlying kidney problems. Do these reports align with your own observations? How is COVID impacting people with healthy kidneys?
If you don’t have a severe manifestation of COVID, your risk of kidney disease is very low—probably so low it isn’t worth mentioning. But if you’re in the ICU with COVID, and especially if you’re on a ventilator, your risk is quite high—I’d say about 15%.
It’s being debated: is COVID’s impact on the kidneys about their reaction to the dysfunction of the other organ systems, or is it a direct effect of the virus on the kidneys? It’s probably both. We’re seeing that the virus can affect the respiratory system and the heart, which can lead to kidney failure; and then there’s also some evidence that it can directly affect the kidneys, too.
The New York Times recently reported that due to the unexpectedly high number of COVID-19 patients experiencing renal failure, we may face a shortage of dialysis equipment. Are you concerned about this happening in Indiana?
I’m less concerned about it than I was three weeks ago, but that’s because we were well-prepared here in Central Indiana. We paid close attention to what was happening in China, Italy, and New York, and met with hospital administration to share our predictions and estimate what our needs for dialysis fluids and equipment would be. And, subsequently, I think we’re going to make it through this without too much of a problem.
However, as time goes on, the disruption in manufacturing and global supply chains, as well as shortages in other locations, may have an impact on us. That’s something that we’ll have to change after this is over—our dependence on other places to manufacture dialysis fluid and supplies. We’re susceptible to a crisis situation here in Indiana because of that.
What do you want the general public to understand about kidney disease and COVID?
In the news media, you hear a lot about the big, dramatic stories, good and bad.
But underneath all that, you have so many people with vital roles that won’t be reported or talked about. For example, the people who figured out exactly how many days of dialysis supplies and fluid we needed in the warehouse so Methodist Hospital doesn’t run out. Or the people on outpatient dialysis teams, who make sure that patients don’t miss dialysis sessions, and keep the units open and the machines running.
We talk a lot about first responders and people working in the ICU, but we shouldn’t forget about the dialysis staff. They have been working at over-capacity in very stressful conditions, with a personal risk of acquiring the infection themselves and potentially transmitting it to their families. There is a whole unreported story about these staff members, who are working really hard to limit the impact of COVID-19 on this relatively small group of people with a chronic illness.
Also, like everything else in life, those who are well-prepared and have done the quiet, often-unappreciated drudgery of organizing and training tend to succeed, even when the unexpected occurs—like a pandemic. Overall, that is what I’m seeing in Indiana. We will learn from the areas where we’ve fallen short, and be even better prepared for the next crisis.