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Perspectives
Open Access

COVID-19 and the Inpatient Dialysis Unit

Managing Resources during Contingency Planning Pre-Crisis

Anna Burgner, T. Alp Ikizler and Jamie P. Dwyer
CJASN May 2020, 15 (5) 720-722; DOI: https://doi.org/10.2215/CJN.03750320
Anna Burgner
Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
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T. Alp Ikizler
Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
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Jamie P. Dwyer
Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
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    Table 1.

    Practical ideas for increasing dialysis surge capacity

    Fluid restriction500–750 ml/d (approximately 10 ml/kg per day)
    Potassium resinsSodium polystyrene sulfonate
    Patiromer:
    8.4 g daily; at weekly intervals can be increased or decreased by 8.4 g/d up to a maximum of 25.2 g/d
    Sodium zirconium cyclosilicate:
    10 g three times daily for 48 h
    Oral non–potassium-containing alkali therapiesOral sodium bicarbonate available as tablet or as baking soda:
    7.7 mEq HCO3 per 650 mg tablet
    29 mEq HCO3 per 1/2 teaspoon baking soda
    Sodium citrate-citric acid solution:
    5 mEq HCO3 per 5 ml solution
    Total nephron blockadeLoop diuretic + carbonic anhydrase inhibitor + thiazide diuretic + mineralocorticoid receptor inhibitor (other strategies exist)
    In the setting of significant kidney impairment, consider using:
    Furosemide 200 mg intravenously every 6 hours + acetazolamide 250 mg by mouth every 8 hours
    + metolazone 10 mg by mouth twice a day + spironolactone 100 mg by mouth twice a day
    Intermittent HDLimit dialysis treatment duration to 3 hours for most treatments
    Limit dialysate flow rate (daily) to 600 ml/min
    Use twice-weekly dialysis, with proposed schedules: Monday–Thursday; Tuesday–Friday; and Wednesday–Saturday
    CRRT replacement fluid recipe1 L 0.9% NaCl with KCl as needed
    +1 L D5W with 150 mEq NaHCO3
    +1 L 0.9% NaCl with 1 g MgCl2
    +1 L 0.9% NaCl with 1 g CaCl2
    =4 L (153 mEq/L Na, 37.5 mEq/L HCO3, 2.6 mmol/L Mg, and 2.25 mmol/L Ca)
    SLED technical and logistic considerationsDialysate flow rate (QD) 100–200 ml/min
    Blood flow rate (QB) 200 ml/min
    Treatment duration 8–12 h (evenings, using HD machines at night)
    Treatment delivered daily or alternate days depending on patient need
    ICU nurse monitors machine and records details of treatment like CRRT
    If no contraindications, systemic anticoagulation with unfractionated heparin to target activated partial thromboplastin time drawn peripherally to be 1.5 times control
    Dialysate jugs should last the entire treatment
    PIRRT technical and logistic considerationsEffluent rate of 40–50 ml/kg per hour
    Treatment duration 8–12 h
    Treatment delivered daily or alternate days depending on patient need
    ICU nurse monitors machine and records details of treatment like CRRT
    Traditionally, anticoagulation not required but given the reports of the procoagulant nature of the COVID-19 syndrome, systemic anticoagulation with heparin may be necessary
    Replacement fluid and/or dialysate used should be precisely calculated to not waste fluid
    • HD, hemodialysis; CRRT, continuous RRT; SLED, sustained, low-efficiency dialysis; PIRRT, prolonged intermittent RRT; ICU, intensive care unit; QD, dialysate flow rate; QB, blood flow rate; D5W, 5% dextrose in water.

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Clinical Journal of the American Society of Nephrology: 15 (5)
Clinical Journal of the American Society of Nephrology
Vol. 15, Issue 5
May 07, 2020
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COVID-19 and the Inpatient Dialysis Unit
Anna Burgner, T. Alp Ikizler, Jamie P. Dwyer
CJASN May 2020, 15 (5) 720-722; DOI: 10.2215/CJN.03750320

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COVID-19 and the Inpatient Dialysis Unit
Anna Burgner, T. Alp Ikizler, Jamie P. Dwyer
CJASN May 2020, 15 (5) 720-722; DOI: 10.2215/CJN.03750320
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More in this TOC Section

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  • Incorporating Patient Preferences via Bayesian Decision Analysis
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  • How To Build a Successful Urgent-Start Peritoneal Dialysis Program
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  • Presentation and Outcomes of Patients with ESKD and COVID-19
  • Providing Care to Patients with AKI and COVID-19 Infection: Experience of Front Line Nephrologists in New York
  • Impending Shortages of Kidney Replacement Therapy for COVID-19 Patients
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Keywords

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