Human kidneys in hands isolated on blue background
COVID-19 has impacted the whole health system, but the renal service and patients have experienced a particularly turbulent year. Professor George Melotte talk Katherine Riley The impact of the pandemic and priorities for 2021 and beyond
According to Professor George Melotte, Clinical Lead for Renal Services, the COVID-19 pandemic has further highlighted the need to expand access to home dialysis therapy – a long-standing priority for the HSE's National Kidney Office (NRO). Figures at the end of 2020 show that there were 34 more patients accessing home therapy compared to the end of 2019 (six more home haemodialysis patients and 27 more peritoneal dialysis patients).
The NRO said the increase in provision was substantial, equating to an additional 9,000 treatments over the course of the year. At the end of 2020, there were a total of 58 patients receiving home hemodialysis and 238 patients receiving peritoneal dialysis.
However, these figures are small compared with the number of people receiving in-center hemodialysis, which also increased last year (from 1,933 in 2019 to 2,014 at the end of 2020).
“Currently around 12% of people are treated at home and 88% are treated in hospital. The NRO's aim is to increase that to 20%,” said Prof Mellotte, a consultant nephrologist at Tallaght University Hospital and St James's Hospital in Dublin.
he Medically Independent (MI) It is important to inform and educate patients about home therapy early on.
“I think we need to step up the nursing support for these patients,” Professor Melotte continued, noting that there are “relatively few” nurses allocated to providing home care. “We need pre-dialysis nurses. [and] We need home therapy care nurses to provide support to these patients. That's one of the barriers and we've been talking to the HSE about providing more support to these patients, because most people would agree that it would improve their quality of life if they could do this. But they need training.”
Professor Melotte said that most people “don't want to go back to the hospital” because home care not only reduces the risk of infection but also gives them more freedom and flexibility. It is noteworthy that as of March 19, 2021, there have been no COVID-19-related deaths among patients receiving home care.
Increasing the provision of home care would also save the health system money, but Prof Melotte acknowledged that patients may have to pay out-of-pocket costs such as electricity, so “we should consider encouraging more home care”.
According to the Irish Kidney Association (IKA), patients receiving home therapy are entitled to deduct some of the costs they incur from their tax, but they may not have a taxpayer in their household (the average age of people starting dialysis is over 60). Prof Melotte pointed to models in other countries, such as Australia, where costs such as training and electricity are subsidised.
“I think we should look to other countries' models for encouraging home-based treatment,” he said, confirming that proposals have been drawn up by the NRO and are under active discussion.
Patients in the Center
Dialysis center patients face a disproportionate risk of infection from COVID-19 due to their health vulnerability and the need to visit dialysis units three times a week. Internationally, the mortality rate after infection in this cohort has been reported to be over 20%. A study from the Beaumont Hospital Nephrology Department, reporting data from the early weeks of the pandemic (mid-March to mid-May 2020), provided grim insights into the level of threat for patients with end-stage kidney disease (ESKD).
During the study period, 20 of 296 hemodialysis patients in the hospital and two satellite units were infected with SARS-CoV-2, of which 10 (50%) died. According to a paper published in the Irish Medical Journal, the high mortality rate was mainly due to the early onset of hospital-acquired infections and frailty of underlying diseases, with 11 cases being hospital-acquired infections.
On April 7, 2020, the NRO introduced a policy requiring dialysis patients and healthcare workers to wear surgical masks during dialysis sessions. Later that month, the NRO recommended that patients not eat during dialysis. This guideline contributed to a significant reduction in COVID-19 infections among dialysis patients, Professor Melotte said.
He said that after the first wave of infections, there was a period of about four months when there were no cases in the dialysis unit.
I think we should follow the model of other countries that encourage home care.
Professor Melotte acknowledged that it was the prerogative of hospital administrators to implement the NRO guidance. But he insisted that the HSE was cooperating fully and was providing funding to provide surgical masks and thermometers for patients attending dialysis units across the country. He added that the self-drive allowance, approved by Liam Woods, HSE's director of acute operations, “has made a huge difference because patients no longer have to take a taxi, a family member can drive someone to them and there's no risk of infection in the taxi.” Additional isolation spaces have also been set up to allow Covid-19 positive patients to continue their dialysis treatment.
From the beginning of the pandemic through March 19, 2021, approximately 369 ESKD patients have been infected with COVID-19. Of these, 271 were hemodialysis patients, 14 were peritoneal dialysis patients, and 84 were kidney transplant patients. Sadly, there have been 76 COVID-19-related deaths, of which 64 were in-center hemodialysis patients and 12 were kidney transplant patients.
Transplantation
The increase in the number of patients undergoing in-center dialysis last year was double the average increase over the past decade, amounting to an additional 13,000 hemodialysis treatments. This increase is linked to a decrease in transplant activity and the aftereffects of COVID-19.
“The kidney transplant service was on hold for a while over the summer. It has now resumed, but activity is a little lower than usual due to a variety of complex medical reasons,” Professor Melotte said. Some 123 kidney transplants were performed in 2020, down from a five-year average of 167 in 2019.
“The number of people on dialysis has increased significantly over the past year, as people who couldn't get a transplant had to be kept alive by dialysis,” said Professor Melotte. In addition, there are people who have had severe COVID-19 and require long-term dialysis, and people with chronic kidney disease who have suffered further kidney damage after infection and now require dialysis. All these factors suggest that there will be major challenges ahead for kidney and transplant services.
Even before the pandemic, Ireland's kidney transplant rates were average compared to other European countries, and the IKA had requested the establishment of a second transplant hospital to complement Beaumont's program.
When asked MichiganProfessor Melotte said he is not in favour of two specialist kidney transplant hospitals, believing one would be enough for a population of just under five million. “I don't think it's a good idea to dilute the clinical expertise that's there in a second unit,” he said, describing the work at Beaumont as “fantastic.”
Professor Melotte said he would prefer to “consider initiatives such as protected admission spaces and protected operating theatres” to increase transplant numbers at Beaumont. He also cited promoting living organ donation as one of the NRO's priorities.
Kidney transplant waiting list data, published annually by the HSE Irish Organ Donation and Transplant Service, has remained within a certain range: 509 patients were on the list in 2019 (208 new listings, eight annual deaths), 462 in 2018 (178 new listings, 17 deaths) and 482 in 2017 (200 new listings, 15 deaths). However, Prof Melotte said there was no “cap” on the number of patients who would be considered eligible for a kidney transplant.
Eligibility for transplant is also assessed periodically, he added. “One year a patient may be medically eligible, but a few years later they may not be medically eligible due to other illnesses. All patients who are placed on the transplant list have been assessed as medically eligible for transplant.”
Meanwhile, the NRO is developing a treatment model for chronic kidney disease, but its work programme has been interrupted by COVID-19. The NRO aims to launch the treatment model later this year.
Professor Mellotte is a passionate advocate of “preventive nephrology”. He stressed the importance of early blood pressure testing and seeing a doctor for early detection of kidney failure or kidney disease. Early treatment has been shown to slow the progression of kidney disease, especially in high-risk groups such as those with diabetes and high blood pressure.
Furthermore, certain treatments and interventions may have adverse effects on patients with chronic kidney disease (e.g., pain medications and contrast agents for diagnostic procedures), so raising awareness of such issues is important in healthcare settings.
“So our long-term goal is to communicate more awareness to primary and secondary care providers about the impact of these treatments on the progression of chronic kidney disease.”
vaccination
when Michigan When I spoke to Prof Melotte in late March, COVID-19 vaccinations had been rolled out to most frontline health care workers, and had also begun for the “vast majority” of dialysis patients and a “significant number” of transplant patients. At the time, people with severe kidney failure who were not yet on dialysis “were not as easily identified”.
The NRO has been lobbying strongly to reprioritise ESKD patients in the original proposed vaccination ordering plan due to their increased medical vulnerability. Vaccination will significantly reduce the risk of infection for kidney disease patients, hopefully reducing the incidence of COVID-19 related kidney damage and resulting in more transplants compared to 2020. Professor Mellotte acknowledged that it has been an extremely challenging 13 months for kidney disease patients and staff.
“I would like to thank all the staff in the dialysis and home care units for providing excellent care to patients during the pandemic,” he stressed.
