Inpatient Dialysis Planning During the COVID-19 Pandemic: A Single-Center Experience and Review of the Literature

Figures & data

Box 1 Algorithm/Criteria for CRRT in Intubated COVID-19 Patients

Hypotensive AKI on more than one vasopressor agent, intubated – CRRT with ultrafiltration as tolerated

Hemodynamics improved on one vasopressor agent, no improvement in renal function – continue CRRT on vasopressor to maximize ultrafiltration

Hemodynamics better off vasopressors, no improvement in renal function – switch to IHD with maximum ultrafiltration to extubate

Abbreviations: CRRT, continuous renal replacement therapy; IHD, intermittent hemodialysis.

Table 1 Tiered Algorithm for Limiting Dialysis Treatments to Increase Resources

Tier 1	Overall stress level increasing, inpatient dialysis census not stretched, running two shifts
	1. All non-unit ESRD/AKI SARS-CoV-2 patients treatment times 3 hours/treatment, 3 times a week 2. ICUs, SARS-CoV-2 positive patients CRRT preferred to preserve PPE 3. IHD time frequency depending on patient needs as agreed on by ICU, Nephrology, nursing collaborative discussion. 4. CRRT - maximize anticoagulation, pre-filter replacement fluid, UF. 5. HD Current nursing staffing would allow four 6 -hour treatments SARS-CoV-2 in 12-hour day. 6. Non-SARS-CoV-2 ICU patients HD consider 2 hours/treatment, travel to inpatient dialysis unit as soon as possible 7. No elective hospital IHD new starts for outpatients 8. Overnight emergency dialysis only patients who meet ICU level of care. 9. Chronic ESRD patients otherwise not ICU level of care, would be dialyzed the next day
Tier 2	Census, resources stretched/stressed, inpatient dialysis unit running 3 shifts
	1. All non-unit ESRD/AKI patients SARS-CoV-2 neg treatment times 2–3 hours (excluding setup/breakdown time), 2 times a week on APC 9 and in warm units on the floors 2. ICUs CRRT preferred to conserve PPE, treatments limited to 8–12 hours per patient every other day (total setup/treatment/breakdown time). This would increase the number of patients who could receive CRRT to 10–15/day. Maximize anti-coagulation, pre-filter replacement, UF 3. ICU intermittent HD treatment time, frequency based on collaborative discussion. 4. In ICU, increase patient: nurse ratio 2:1 for putting patients on taking off machines; add tech to rotation to allow 3 machines to run per shift, increasing number to six treatments in 12-hour day. 5. Limit time, frequency of treatments on SARS-CoV-2 neg patients in CCU, SICU, NICU
Tier 3	Crisis – not enough nurses, not enough beds, not enough machines
	1. All non-intensive care unit patients 2 hours weekly 2. CRRT 4–6 hours/every other day 3. ICU IHD 2 hours, 2 days per week; discuss withdrawing dialysis if overall prognosis poor for recovering from underlying illness. 4. Patient nurse ratio 2:1 in ICU for putting patients on taking off machines; will still need 1:1 observation while on the machine 5. Consider emergency PD for select patients

Abbreviations: ESRD, end-stage renal disease; AKI, acute kidney injury; PPE, personal protective equipment; ICU, intensive care unit; IHD, intermittent hemodialysis; PD, peritoneal dialysis;  CCU, coronary care unit; SICU, surgical intensive care unit; NICU, neuro intensive care unit.