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For weeks, US government officials and hospital officials have been warning about the looming shortage of ventilators as the coronavirus pandemic descends. But now, doctors are warning about unexpected, perhaps overlooked crises. The surge in Covid-19 patients with renal failure has led to a shortage of machinery, supplies and staff needed for emergency dialysis.
In recent weeks, frontline doctors in intensive care units in New York and other hard-hit cities have learned that the coronavirus is not just respiratory illnesses that have created overwhelming demand for ventilators. The disease also leads to yet another series of life and death calculations for doctors who have closed the kidneys of some patients and must ferry a limited supply of specialized dialysis machines from patients with renal failure to the next patient.
It remains to be seen whether the kidneys are the main target of the virus, or whether they are victims who fall into another organ as the patient's devastated body is surrendering.
Dialysis plays an important role in the kidneys, cleans the blood of toxins, balances essential components, including electrolytes, reduces blood pressure and removes excess fluid. It can be used for a temporary measurement while the kidneys are recovering, or for a long period of time if not. Another unknown is whether the kidney damage caused by the virus is permanent.
“Neurologists in New York City are getting a little crazy, making sure everyone with kidney failure gets treatment. “We don't want people to die from inadequate dialysis.
“We've never seen anything like this before in terms of the number of people who need kidney replacement therapy,” he said.
“Sufficient”
Outside of New York, the growing national demand for kidney treatment hints at the most advanced care units in hospitals in emerging hot spots such as Boston, Chicago, New Orleans and Detroit. Kidney experts estimate that between 20% and 40% of coronavirus patients suffer from kidney failure and require emergency dialysis, according to Dr. Alan Kliger, co-chair of the Nephrology Society, co-chair of Yale School of Medicine, Yale School of Medicine.
“Normal supplies are exhausted very quickly,” he said.
One New York City doctor was not allowed to speak publicly, recalling a difficult exchange with another doctor last week. “You're screaming at them. You're telling them you don't have a dialysis machine to give them. You hear the strength of other people's voices and despair,” the doctor said. “My job was hell.”
As the coronavirus spread rapidly in New York and other cities, the governor and mayor have sought thousands more ventilators. However, doctors are surprised by the lack of dialysis machines and supplies, especially specialized equipment for continuous dialysis. The treatment is often used to replace injured kidney work in critically ill patients.
The shortage was related not only to the machinery, but also to the supply of liquids and other necessary for dialysis regimens. Having a nurse trained enough to provide treatment was also a bottleneck. The hospital said it had asked the federal government to help prioritize equipment, supply and personnel in the countries that need it most, adding that manufacturers were not fully meeting higher demand.
The liquid needed to operate the dialysis machine is not on the Food and Drug Administration's monitoring list for potential drug shortages, but the agency says it is closely monitoring its supply.
The Federal Emergency Management Agency described the shortage of supplies and equipment as “unprecedented” and said it is working with manufacturers and hospitals to identify additional supplies both in the US and overseas.
“Everyone thought it was a respiratory illness,” said Dr. David Carlitan, dean of the nephrology department at NYU Langone Medical Center. “I don't think this was on people's radar screens.”
Early reports from China
Dr. Kalitan said the consumables allocated by the manufacturer were insufficient, adding that the hospital switched to a different type of machinery when it was unable to obtain the additional equipment needed. “It's not coming close to just meeting the needs,” he said.
Early reports from China suggested a lower incidence of kidney damage from Covid-19, but there were some indications that the virus could directly affect the kidneys. More data emerged from there, and as the pandemic began to take hold in Italy, it began to rule out the language to the broader kidney community, where many of the most severely ill patients, and those on ventilators, also need dialysis.
It remains to be seen whether organ damage is caused by a virus that infects kidney cells, or is it a secondary effect of a serious illness, or whether the tendency for blood clots to form in people with disease is increasing.
The amount of patients required to dialysis is “large or larger than the number of patients who normally dialyze,” said Dr. Barbara Murphy, chairman of the Medical School at Mount Sinai Health System. She said the number of patients requiring dialysis has tripled in her hospital alone.
The US shortage “emphasizes the lack of planning among state and federal officials to ensure priority access is given given hotspots like New York,” Dr. Murphy said.
Dr. Murphy also said that “we need to think about dialysis” with the region of the country that is planning a surge in ventilator demand. Hospitals are now appealing to major manufacturers to send more supplies.
Once the coronavirus reaches the US, Frecenius-owned Baxter and NXStage have set limits on what hospitals can order to prevent hoarding. Dr. Michael Ross, director of kidney disease at the Montefiore Health System in New York, spoke on the phone with the leader of a dialysis product production company last Sunday, saying, “We are expressing how important this is to patients.” The call was to get more machines, filters, predicted fluids, and tubes for continuous dialysis, he said.
5x orders
The lack of dialysate supplies at New York City hospitals was first reported by Politico. Two major manufacturers of equipment and supply for dialysis say that orders are increasing five times, sending manufacturing growth and equipment and nursing staff to the New York area. Illinois-based Baxter said demand from China and Europe is rising and is flying extra products from Europe this weekend.
“The surge in demand was very fast and very high,” said Baxter spokesman Lauren Russ. “We're doing everything we can.”
On Friday, Frecenius announced that he would create a nationwide supply of machines that can be moved from place to place. “We are committed to supporting hospitals with continuous supply, especially in the markets that have been affected the most, so patients can get the care they need,” Bill Barre, CEO of North America in Massachusetts, said in a statement.
New York Gov. Andrew Cuomo was asked at his briefing Thursday about a hospital report showing a lack of dialysis machines. “There's no complete shortage,” state health commissioner Dr. Howard Zucker said there's “no shortage on the whole,” while Cuomo said hospitals that need the equipment will get it.
In a statement, Baxter CEO Jose Almeida said the company is trying to prioritize delivery to “where it is most needed: hospitals that are overwhelmed by the influx of seriously ill patients from Covid-19.”
At Columbia University Irving Medical Center, Dr. Donald Landry, chairman of medicine, contacted Frecenius' Valle directly when other efforts failed and the situation became desperate. Dr. Landry said he appreciated the company responding by sending more machines, supplies and dialysis nurses, but he described the experience as a warning to better preparation. “New York City has given us a glimpse into when the system is coming towards the edge,” he said.
Acute kidney damage
Dr. Joshua Rosenberg, the primary care physician in the Brooklyn Hospital Center's intensive care unit, said Thursday that he was seeing acute kidney damage in patients who suffer from hypertension or diabetes, which exceeded those who were predisposed to kidney disease.
Miriam Figueroa, a dialysis nurse at the hospital, went from patient to patient on Thursday to provide three hours of dialysis treatment in the COVID-19 intensive care unit installed in a former chemotherapy injection unit. Some patients in the ICU had developed acute kidney damage. They were on emergency dialysis via a vein in the neck, including one hospital staff member. Ms Figueroa said as the need for dialysis for critically ill patients increased, dialysis services dealt with machines and supplies moving from outpatient clinics to inpatient wards. “We have to pull machines to get the bedside,” she said, “So there are few patients that can be done as outpatients.”
About 240 patients at the outpatient dialysis clinic hospital have died of Covid-19, according to Dr. Priyanka Singh, one of the nephrologists. People with chronic kidney disease may be particularly vulnerable.
Doctors also employ alternative types of dialysis. Some New York hospitals, including NYU, Montefiore and Weill Cornell, have turned more specialized dialysis devices (required for what is known as continuous renal replacement therapy) into peritoneal dialysis. It is usually used in patients with chronic kidney disease who want to treat themselves at home. This treatment is not always optimal, especially in patients who are not stable in their patients, but “we're trying to give something to the patient,” said Dr. Charitan.
wrestling
One problem with peritoneal dialysis in the Covid-19 context is the need to place a catheter in the abdomen of a patient. This makes it difficult to use in people with lung disorders, a technique in which patients roll over their stomachs to help them ingest oxygen, a technique in which patients roll over their stomachs to ingest their lungs, a technique in which they need to ingest their lungs, a technique in which they have to ingest their lungs, a technique in which they have pulmonary disorders. Some hospitals, including Montefiore, have catheters pointed towards the patient's side to assist with the problem.
Some hospitals struggle to find enough nurses and technicians to provide dialysis, especially after some of them are the most skilled at providing treatment. “We lost a nurse due to illness,” said Dr. Murphy of Mount Sinai. “We just got back some of those nurses, but that was a challenge. We've exhausted all the paths in the state when it comes to being able to increase nursing.”
Doctors say they are struggling with ways to ensure that patients who need care will receive it immediately, while assessing whether others can wait. “Now we have to think more about whether the patient really needs it, and we can provide dialysis to someone who needs dialysis more urgently, so that we can manage them medically without dialysis on another day,” Dr. Montefiore said. “These are not decisions we want to make.”
– The New York Times
