Skip to main content

Main menu

  • Home
  • Content
    • Published Ahead of Print
    • Current Issue
    • Podcasts
    • Subject Collections
    • Archives
    • Kidney Week Abstracts
    • Saved Searches
  • Authors
    • Submit a Manuscript
    • Author Resources
  • Trainees
    • Peer Review Program
    • Prize Competition
  • About CJASN
    • About CJASN
    • Editorial Team
    • CJASN Impact
    • CJASN Recognitions
  • More
    • Alerts
    • Advertising
    • Feedback
    • Reprint Information
    • Subscriptions
  • ASN Kidney News
  • Other
    • ASN Publications
    • JASN
    • Kidney360
    • Kidney News Online
    • American Society of Nephrology

User menu

  • Subscribe
  • My alerts
  • Log in
  • My Cart

Search

  • Advanced search
American Society of Nephrology
  • Other
    • ASN Publications
    • JASN
    • Kidney360
    • Kidney News Online
    • American Society of Nephrology
  • Subscribe
  • My alerts
  • Log in
  • My Cart
Advertisement
American Society of Nephrology

Advanced Search

  • Home
  • Content
    • Published Ahead of Print
    • Current Issue
    • Podcasts
    • Subject Collections
    • Archives
    • Kidney Week Abstracts
    • Saved Searches
  • Authors
    • Submit a Manuscript
    • Author Resources
  • Trainees
    • Peer Review Program
    • Prize Competition
  • About CJASN
    • About CJASN
    • Editorial Team
    • CJASN Impact
    • CJASN Recognitions
  • More
    • Alerts
    • Advertising
    • Feedback
    • Reprint Information
    • Subscriptions
  • ASN Kidney News
  • Visit ASN on Facebook
  • Follow CJASN on Twitter
  • CJASN RSS
  • Community Forum
Perspectives
Open Access

Impending Shortages of Kidney Replacement Therapy for COVID-19 Patients

David S. Goldfarb, Judith A. Benstein, Olga Zhdanova, Elizabeth Hammer, Clay A. Block, Nina J. Caplin, Nathan Thompson and David M. Charytan
CJASN June 2020, 15 (6) 880-882; DOI: https://doi.org/10.2215/CJN.05180420
David S. Goldfarb
1Nephrology Section, New York Harbor Veterans Affairs Medical Center, New York, New York
2Division of Nephrology, New York University Langone Health, New York, New York
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for David S. Goldfarb
Judith A. Benstein
2Division of Nephrology, New York University Langone Health, New York, New York
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Olga Zhdanova
2Division of Nephrology, New York University Langone Health, New York, New York
3Nephrology Division, Bellevue Hospital Center, New York, New York
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Elizabeth Hammer
2Division of Nephrology, New York University Langone Health, New York, New York
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Clay A. Block
4Department of Nephrology, Hypertension and Transplantation, Dartmouth-Hitchcock Medical Center and Dartmouth Medical School, Lebanon, New Hampshire
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Nina J. Caplin
2Division of Nephrology, New York University Langone Health, New York, New York
3Nephrology Division, Bellevue Hospital Center, New York, New York
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Nathan Thompson
2Division of Nephrology, New York University Langone Health, New York, New York
3Nephrology Division, Bellevue Hospital Center, New York, New York
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
David M. Charytan
2Division of Nephrology, New York University Langone Health, New York, New York
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data Supps
  • Info & Metrics
  • View PDF
Loading
  • acute kidney injury
  • kidney replacement
  • hemodialysis
  • peritoneal dialysis
  • intensive care medicine
  • COVID-19
  • severe acute respiratory syndrome coronavirus 2
  • Renal Replacement Therapy

Practicing nephrology in New York City, at the epicenter of the novel coronavirus disease 2019 (COVID-19) pandemic in the United States, we have been struck by the continued focus on the concern that a critical deficiency of ventilators will occur. Our efforts in the past weeks have led us to fear that another critical shortage may occur before that of ventilators: our ability to deliver KRT for patients severely affected by COVID-19. We and other centers in New York are encountering significant challenges to delivering any form of KRT to the many patients with COVID-19 and AKI or kidney failure. To our knowledge, these challenges have been under-reported in the media and not acknowledged explicitly by public health officials or elected representatives.

The sparse data available on this subject suggest that the incidence of AKI in all people infected with SARS-CoV-2 is as low as 0.5% (1). This value belies what we observe in New York’s medical centers: the incidence of AKI in critically ill, hospitalized patients with COVID-19 is far higher. The possible causes of AKI in patients infected with COVID-19 have recently been reviewed (2). An informal survey of our intensive care units (ICUs) this week demonstrates that 20%–40% of intubated ICU patients have AKI that necessitates KRT. For example, to demonstrate the magnitude of our workload, Bellevue Hospital Center has 105 patients with COVID-19 in the ICUs, with 44 with AKI, 40 of whom required KRT; outside the ICUs, there are 276 patients with COVID-19, with 32 seen by the nephrology consult service, 22 of whom have kidney failure. The proportions are similar at Tisch Hospital and the New York campus of the New York Harbor VA, which have more and fewer total patients, respectively, in those categories. This high incidence of COVID-19–associated AKI is true for the full range of the demographically diverse patients we care for at New York University (NYU) Langone-Manhattan campus (the university hospital of NYU Langone Health), NYU Langone Hospital–Brooklyn, Bellevue Hospital Center (the largest of New York’s public hospitals), and the New York campus of the New York Harbor Veterans Affairs Health Care System. On the basis of exchanges with our nephrology colleagues, it also reflects what is being seen at all of the medical centers, big and small, in New York.

Our most acute problem, because of the surge of patients, is that capacity for delivering KRT is stretched to the point of nearly breaking. The possibility that this eventuality would occur in this pandemic was presciently foreseen in a recent article that described ways of mitigating the effects of the high incidence of AKI (3). On a normal day, our medical centers deliver many hemodialysis treatments and provide ample continuous KRT (CKRT) to meet the needs of hospitalized patients, but the needs have increased several-fold. In mid-March 2020, our contingency planning for COVID-19 did not foresee the increased extent to which these modalities would be needed, or the myriad hurdles to expanding capacity. Perhaps most important is the reduced numbers of trained staff available. Our hemodialysis nurses, like many health care workers in areas affected by the pandemic, became ill with COVID-19 and stayed home in isolation. Our contracted hemodialysis machine maintenance staff were also quarantined at times, preventing them from addressing machine dysfunction in a timely fashion. The skills required to perform hemodialysis are not readily acquired by previously untrained health care workers. Our hardworking nurses and technicians can provide only so many hemodialysis treatments per day in the ICUs of our hospitals, which have continually seen increasing numbers of admissions. The widespread geographic nature of the pandemic precludes hiring temporary hemodialysis staff. We reduced the frequency of hemodialysis for many patients with kidney failure treated in hospital-based dialysis facilities from three to two times per week, and the duration of therapy from 4 to 3 hours. These strategies were helpful, particularly as we acquired new patients with kidney failure—some with COVID-19—but they meant delivering a suboptimal prescription. We also experienced an at-least temporary loss of nephrologists to COVID-19 infection, increasing our own risk of burn-out, although the loss is less limiting than the loss of nurses and technicians.

Our utilization of CKRT in the ICUs has increased dramatically. We now have 11 machines at NYU Langone-Manhattan campus, six at Bellevue Hospital Center, and four at NYU Langone Hospital–Brooklyn. In these numbers of treatments, the modality places strains on ICU nurses. It constitutes a problem when the number of ICU beds and ventilated patients is expanded by decreasing nurse-to-patient staffing ratios. We also had to procure more machines. To provide KRT to two patients per day with each machine, we also instituted accelerated venovenous hemofiltration (4). Nationwide and regional increases in usage have caused unanticipated shortages for consumable CKRT supplies. Short-lived scarcity of continuous venovenous hemofiltration cartridges and fluid, and uncertain long-term prospects for maintaining supplies commensurate with anticipated needs, have occupied us on a daily basis.

We purchased three Tablo dialysis machines at VA, with more coming to NYU Langone-Manhattan Campus, hoping that their flexibility to provide conventional hemodialysis and CKRT, and their user-friendly interface, would augment our capacities. Training nondialysis staff and nephrologists to use them and getting preparatory water testing accomplished are modest impediments to their implementation, requiring at least 2 weeks. Modifications of facility plumbing allowed extension of dialysis modalities to additional sites and new ICUs.

We initiated the use of acute peritoneal dialysis, a modality rarely used in American ICUs in recent years, to remove pressures from our CKRT supply and hemodialysis staff. We were fortunate that our surgeons adapted quickly to our increased demand. At Bellevue Hospital Center, we had 22 patients on daily peritoneal dialysis, at New York Campus of the New York Harbor VA Healthcare System, we had six patients on daily peritoneal dialysis, and at NYU Langone-Manhattan Campus, we had four patients on daily peritoneal dialysis. The technique has had some success, but introduces many practical problems. As in many United States centers, few of our ICU nurses have experience performing peritoneal dialysis and understandably resist learning a new procedure under already trying circumstances. Adequate delivery of frequent manual exchanges of peritoneal dialysate has been intermittent, often reduced for long periods, especially at night when staffing is less abundant. Larger volumes of dialysate exchanges were not as adverse for ventilation as we initially feared. We have creatively resorted to training teams of non-ICU health care workers (including physicians from other specialties) to assist, but finding personnel to be present around the clock is currently difficult. As the number of patients receiving peritoneal dialysis has increased, supplies of dialysate have become uncertain. Pleas to our vendors have been successful thus far, but they, in turn, are limited by commitments to patients with kidney failure who dialyze with ambulatory peritoneal dialysis regimens. The long-term viability of this option is uncertain. Although we anticipate eventually using more peritoneal dialysis cyclers, we recognize that they will require additional training of various inexperienced staff. Currently we have two cyclers at NYU Hospital–Brooklyn, two at Bellevue Hospital Center (with a plan to lease 18 more), and none at Tisch Hospital or New York Campus of the New York Harbor VA Healthcare System.

The magnitude of this calamitous short-coming in KRT could not have been foreseen by the nephrology and ICU communities, as early and subsequent reports from China did not emphasize the problem. The result of our experience is that we must now highlight the possibility that before a deficiency of ventilators become an issue in caring for patients with COVID-19, provision of KRT may face critical shortages. This occurrence is particularly likely in the absence of national or regional efforts to increase supply and ensure that fluids and consumables are delivered to those centers with the most pressing needs. Contingency planning is appropriate and must be instituted now by medical centers that may soon face the full strength of this pandemic (3,5) (Table 1).

Guidance on the ethical principles used to allocate scarce resources focuses on the possible scarcity of ventilators, as promulgated by the New York State Task Force on Life & the Law (6). More recently, and in response to the current pandemic, a brief framework for allocation of ventilators and critical care beds has been introduced (7). Fortunately, as of the time of writing, such allocations of resources have not been required in New York at our institutions. Rather than provide recommendations regarding allocation of dialysis modalities should they be available in short supply, current guidelines tentatively suggest that patients with kidney failure be excluded from receiving ventilatory assistance because “renal failure increases morbidity and mortality in the ICU, and dialysis places increased demand on scarce nursing resources.” Our experience suggests that medical centers must actively consider how to balance the effort to provide KRT care for all comers without compromising the ability to deliver optimal or even adequate KRT to patients with survivable acute and CKD. We think it is time for medical authorities and ethicists to consider explicitly considering the possibility that KRT will have to be allocated at this time and in future public health disasters. Our ability to ration or triage medical resources is affected by local, hospital, and state policies, and laws. The complex assessments of the relevant guidelines will be made by practitioners, attorneys, administrators, and committees, which should include nephrologists as active participants. The Strategic National Stockpile has received attention regarding its ability to supply ventilators and personal protective equipment to America’s medical centers. It may be time now for it to consider stockpiling equipment for KRT. It may also be appropriate to train a larger segment of American health care workers to provide these potentially life-saving modalities in situations like the one we currently face.

View this table:
  • View inline
  • View popup
Table 1.

Impediments to delivery of adequate KRT

Disclosures

Dr. Charytan reports personal fees from AstraZeneca, grants from Bioporto, personal fees from Fresenius, grants and personal fees from Medtronic, and personal fees from PLC Medical, outside the submitted work. Dr. Benstein, Dr. Block, Dr. Caplin, Dr. Goldfarb, Dr. Hammer, Dr. Thompson, and Dr. Zhdanova have nothing to disclose.

Funding

None.

Acknowledgments

We are fortunate that our institutions have responded to this crisis in a timely, appropriate, and generous manner, with strong logistical and financial support.

The content of this article does not reflect the views or opinions of the American Society of Nephrology (ASN) or CJASN. Responsibility for the information and views expressed therein lies entirely with the author(s).

Footnotes

  • Published online ahead of print. Publication date available at www.cjasn.org.

  • Copyright © 2020 by the American Society of Nephrology

References

  1. ↵
    1. Guan WJ,
    2. Ni ZY,
    3. Hu Y,
    4. Liang WH,
    5. Ou CQ,
    6. He JX,
    7. Liu L,
    8. Shan H,
    9. Lei CL,
    10. Hui DSC,
    11. Du B,
    12. Li LJ,
    13. Zeng G,
    14. Yuen KY,
    15. Chen RC,
    16. Tang CL,
    17. Wang T,
    18. Chen PY,
    19. Xiang J,
    20. Li SY,
    21. Wang JL,
    22. Liang ZJ,
    23. Peng YX,
    24. Wei L,
    25. Liu Y,
    26. Hu YH,
    27. Peng P,
    28. Wang JM,
    29. Liu JY,
    30. Chen Z,
    31. Li G,
    32. Zheng ZJ,
    33. Qiu SQ,
    34. Luo J,
    35. Ye CJ,
    36. Zhu SY,
    37. Zhong NS; China Medical Treatment Expert Group for Covid-19
    : Clinical characteristics of coronavirus disease 2019 in China [published online ahead of print Feb 28, 2020]. N Engl J Med doi:10.1056/NEJMoa2002032 pmid:32109013
    OpenUrlCrossRefPubMed
  2. ↵
    1. Ronco C,
    2. Reis T
    : Kidney involvement in COVID-19 and rationale for extracorporeal therapies [published online ahead of print Apr 9, 2020]. Nat Rev Nephrol doi:10.1038/s41581-020-0284-7 pmid:32273593
    OpenUrlCrossRefPubMed
  3. ↵
    1. Burgner A,
    2. Ikizler TA,
    3. Dwyer JP
    : COVID-19 and the inpatient dialysis unit: Managing resources during contingency planning pre-crisis [published online ahead of print Apr 3, 2020]. Clin J Am Soc Nephrol doi:10.2215/CJN.03750320 pmid:32245780
    OpenUrlFREE Full Text
  4. ↵
    1. Gashti CN,
    2. Salcedo S,
    3. Robinson V,
    4. Rodby RA
    : Accelerated venovenous hemofiltration: Early technical and clinical experience. Am J Kidney Dis 51: 804–810, 2008 pmid:18436091
    OpenUrlCrossRefPubMed
  5. ↵
    1. Durvasula R,
    2. Wellington T,
    3. McNamara E,
    4. Watnick S
    : COVID-19 and kidney failure in the acute care setting: Our experience from Seattle [published online ahead of print Apr 7, 2020]. Am J Kidney Dis doi:10.1053/j.ajkd.2020.04.001 pmid:32276031
    OpenUrlCrossRefPubMed
  6. ↵
    1. Powell T,
    2. Christ KC,
    3. Birkhead GS
    : Allocation of ventilators in a public health disaster. Disaster Med Public Health Prep 2: 20–26, 2008 pmid:18388654
    OpenUrlCrossRefPubMed
  7. ↵
    1. White DB,
    2. Lo B
    : A framework for rationing ventilators and critical care beds during the COVID-19 pandemic [published online ahead of print Mar 27, 2020]. JAMA doi:10.1001/jama.2020.5046 pmid:32219367
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Clinical Journal of the American Society of Nephrology: 15 (6)
Clinical Journal of the American Society of Nephrology
Vol. 15, Issue 6
June 08, 2020
  • Table of Contents
  • Table of Contents (PDF)
  • About the Cover
  • Index by author
View Selected Citations (0)
Print
Download PDF
Sign up for Alerts
Email Article
Thank you for your help in sharing the high-quality science in CJASN.
Enter multiple addresses on separate lines or separate them with commas.
Impending Shortages of Kidney Replacement Therapy for COVID-19 Patients
(Your Name) has sent you a message from American Society of Nephrology
(Your Name) thought you would like to see the American Society of Nephrology web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Impending Shortages of Kidney Replacement Therapy for COVID-19 Patients
David S. Goldfarb, Judith A. Benstein, Olga Zhdanova, Elizabeth Hammer, Clay A. Block, Nina J. Caplin, Nathan Thompson, David M. Charytan
CJASN Jun 2020, 15 (6) 880-882; DOI: 10.2215/CJN.05180420

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Request Permissions
Share
Impending Shortages of Kidney Replacement Therapy for COVID-19 Patients
David S. Goldfarb, Judith A. Benstein, Olga Zhdanova, Elizabeth Hammer, Clay A. Block, Nina J. Caplin, Nathan Thompson, David M. Charytan
CJASN Jun 2020, 15 (6) 880-882; DOI: 10.2215/CJN.05180420
del.icio.us logo Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like

Jump to section

  • Article
    • Disclosures
    • Funding
    • Acknowledgments
    • Footnotes
    • References
  • Figures & Data Supps
  • Info & Metrics
  • View PDF

More in this TOC Section

  • A Body Size–Adjusted Maximum Ultrafiltration Rate Warning Level Is Not Equitable for Larger Patients
  • Food Insecurity and Kidney Disease
  • What Is the Best Maintenance Therapy for ANCA Vasculitis?
Show more Perspectives

Cited By...

  • Development of a federated learning approach to predict acute kidney injury in adult hospitalized patients with COVID-19 in New York City
  • Balancing the Needs of Acute and Maintenance Dialysis Patients during the COVID-19 Pandemic: A Proposed Ethical Framework for Dialysis Allocation
  • Mass Disasters and Burnout in Nephrology Personnel: From Earthquakes and Hurricanes to COVID-19 Pandemic
  • Impact of the COVID-19 Pandemic on Nephrology Fellow Training and Well-Being in the United States: A National Survey
  • Meeting the Demand for Renal Replacement Therapy during the COVID-19 Pandemic: A Manufacturers Perspective
  • Novel Use of Premixed Dialysate Bags during Water Supply Interruption in Acute Hospital Setting
  • Effect of COVID-19 on Kidney Disease Incidence and Management
  • Acute Peritoneal Dialysis During the COVID-19 Pandemic at Bellevue Hospital in New York City
  • Anticoagulation Strategies and Filter Life in COVID-19 Patients Receiving Continuous Renal Replacement Therapy: A Single-Center Experience
  • AKI in Hospitalized Patients with COVID-19
  • COVID-19-Associated Acute Kidney Injury: Learning from the First Wave
  • Acute Peritoneal Dialysis During the COVID-19 Pandemic at Bellevue Hospital in New York City
  • Peritoneal Dialysis for Acute Kidney Injury during the COVID-19 Pandemic
  • Google Scholar

Similar Articles

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Keywords

  • acute kidney injury
  • kidney replacement
  • hemodialysis
  • peritoneal dialysis
  • intensive care medicine
  • COVID-19
  • severe acute respiratory syndrome coronavirus 2
  • renal replacement therapy

Articles

  • Current Issue
  • Early Access
  • Subject Collections
  • Article Archive
  • ASN Meeting Abstracts

Information for Authors

  • Submit a Manuscript
  • Trainee of the Year
  • Author Resources
  • ASN Journal Policies
  • Reuse/Reprint Policy

About

  • CJASN
  • ASN
  • ASN Journals
  • ASN Kidney News

Journal Information

  • About CJASN
  • CJASN Email Alerts
  • CJASN Key Impact Information
  • CJASN Podcasts
  • CJASN RSS Feeds
  • Editorial Board

More Information

  • Advertise
  • ASN Podcasts
  • ASN Publications
  • Become an ASN Member
  • Feedback
  • Follow on Twitter
  • Password/Email Address Changes
  • Subscribe to ASN Journals

© 2022 American Society of Nephrology

Print ISSN - 1555-9041 Online ISSN - 1555-905X

Powered by HighWire