Middle East J Rehabil Health Stud
Middle East J Rehabil Health Stud

article information

Middle East Journal of Rehabilitation and Health Studies: Vol.10, issue 2; e133166
published online: March 6, 2023
article type: Letter
received: November 27, 2022
revised: January 23, 2023
accepted: January 25, 2023
DOI: https://doi.org/10.5812/mejrh-133166
Crossmark

Letter to the Editor: Lessons Learned from Exposure to COVID-19 in Hemodialysis Patients

authors:

avatar Ibtihale Boukhira ORCID 1 , 2 , * , avatar Said Jidane ORCID 1 , avatar Safiya Mahlaq 3 , 2 , avatar Aicha El Hanafi 4 , 2 , avatar Lahcen Belyamani ORCID 1

Research Team in Acute Medicine, Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Morocco
High Institute of Nursing Professions and Technical Health, Agadir, Morocco
Laboratory of Biostatistics, Clinical Research and Epidemiology (LBRCE), Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Morocco
Laboratory of Health Sciences Research, Ibn Zohr University, Agadir, Morocco

how to cite: Boukhira I, Jidane S, Mahlaq S, El Hanafi A, Belyamani L. Letter to the Editor: Lessons Learned from Exposure to COVID-19 in Hemodialysis Patients. Middle East J Rehabil Health Stud. 2023;10(2):e133166. https://doi.org/10.5812/mejrh-133166.

Dear Editor,

The COVID-19 pandemic, caused by a new coronavirus, is a major life-threatening health problem (1), especially for chronic dialysis patients (2). Somehow, mortality caused by SARS-CoV-2 infection was significantly higher in patients with renal failure on dialysis treatment than in the general population, with 10% to 41% on average (3, 4). This finding is due to the vulnerability of this population owing to immunosuppression and multiple comorbidities such as diabetes or cardiovascular disease. Globally, the number of people on dialysis is increasing, and approximately 89% of this vulnerable population is on hemodialysis (HD) (5). In high-income countries, the incidence of patients on dialysis is static or even declining (6), while it is dramatically increasing in low-income countries, both because of the increasing prevalence of non-communicable diseases leading to chronic kidney disease (CKD) and because of the growing affordability of kidney replacement therapy (7).

Kidney transplantation offers a better quality of life, longer survival, and lower costs than dialysis for this vulnerable population (8). However, in low- and middle-income countries, kidney transplantation is such rarely available that patients depend entirely on HD (7). In fact, during the COVID-19 pandemic, these patients faced complex problems and unforeseen challenges, including exposure to COVID-19 during transport to their hemodialysis centers and the risk of nosocomial transmission in these units given the need to travel frequently to care centers for treatment or the inability to maintain social distancing during transport and dialysis sessions (3, 9).

The exposure of these patients to COVID-19 poses a higher risk of serious complications and death (10, 11). In this regard, recommendations and strategies for prevention, mitigation, and containment have been implemented in hemodialysis centers.

Unfortunately, current recommendations for managing patients with COVID-19 and acute kidney injury (AKI) have been drawn largely from studies conducted in high-income countries (12). At the same time, in the health context of chronically underfunded healthcare systems, providing adequate resources for implementing these guidelines can be a significant challenge in many low- and middle-income countries (13). The results of several studies have shown that patients with the end-stage renal disease living in poor areas have a high risk of exposure to SARS-CoV-2 (14), and gross inequalities were found globally between the two shores in the management of chronic hemodialysis patients during the pandemic (15).

Inequality in Exposure to COVID-19 in Transport

Transportation can be a barrier to the accessibility of many healthcare services (16). Access to transport is a determinant of access to care for hemodialysis patients, given the frequency of their visits to dialysis centers (11). Most of these patients cannot get to dialysis independently, either by using public transport or taxis (17), which increases their exposure to COVID-19 and, thus, their fear. A recent study showed that the fear of contracting COVID-19 on the way to dialysis units is greater than during dialysis sessions (11). Another study showed that many people forgo transport public transport to avoid potential exposure to COVID-19, while the poor have compromised access to health care for fear of public transport (18). In this regard, several studies have proposed to use of private and individual vehicles as a measure to prevent the spread of COVID-19, instead of public transport (1, 19-21), which is not available for all patients in all countries, especially in low- and middle-income countries.

Indeed, during the pandemic, transport to and from the hemodialysis units was deemed more difficult for 31% of respondents in the hemodialysis units of low-income countries and 38% in low- and middle-income countries, compared to 16% and 19% in middle-income countries and high-income countries, respectively (15). Several studies have recommended applying infection control measures: physical distancing, hygiene, and hand washing before and after entering the vehicle and offering shuttles between trips (9, 22). These good practices are effective means of limiting the spread of the pandemic. In poorer societies, these simple measures may not be realized (23).

Inequality in the Exposure to COVID-19 in Dialysis Units

In this epidemic period, there is a high risk of nosocomial transmission that threatens hemodialysis units due to the high number of patients and visitors entering and leaving these units (2). Indeed, dialysis carries the risk of spreading COVID-19 among patients by medical means: Devices, beds, droplets, or aerosols (24), given that the main routes of transmission of COVID-19 are the inhalation of infectious droplets and close contact (2).

Hemodialysis patients should be considered infection carriers because of their frequent visits to hemodialysis centers (25). In fact, before arriving at the dialysis department, they may cross high-risk areas (1), which increases the risk of COVID-19 exposure (11). In this regard, several recommendations have been proposed, such as home dialysis (26) and monthly laboratory analysis (27), which might be an exciting solution. However, this remains difficult to achieve in low- and middle-income countries: Contexts with minimal resources and the inability to meet the requirements of this process.

Telemedicine and teleconsultation have also been implemented to reduce medical contact with patients (28). However, they require advanced digital technology and extensive training for healthcare professionals and patients to properly master these new skills (29), which is not the case in developing countries and remote areas (15). Unfortunately, there have been striking global inequalities in the care of chronic hemodialysis patients during the pandemic, which has disproportionately characterized low- and middle-income countries (15). The pandemic is a stark reminder of the gap between countries and between those who can afford health care and those who cannot (23).

Lessons Learned

Zoonosis continues to threaten humanity with imminent potential for panic and fear that affects and disrupts daily life (23). One of the lessons learned from the SARS-CoV-2 outbreak is how effectively well-resourced environments can respond to health crises (29). We believe that urgent action is needed to reduce the inequalities that glaringly exist between low- and middle-income countries, primarily addressing pre-existing vulnerabilities (15), and greater investment in public health, particularly in less developed countries where population density is high and the healthcare systems are the least developed (23). We have also learned that all nations must work together for the good of humanity and stop blaming each other in these uncertain times (23). Also, COVID-19 is an opportunity to reflect on how the world can center justice and equity in its efforts to universalize care. Governments should use this opportunity to invest in controlled changes to reduce persistent gaps in access to care, especially for vulnerable populations, such as hemodialysis patients, because these gross inequalities in health care are unacceptable in the era of globalization.

References

  • 1.

    Basile C, Combe C, Pizzarelli F, Covic A, Davenport A, Kanbay M, et al. Recommendations for the prevention, mitigation and containment of the emerging SARS-CoV-2 (COVID-19) pandemic in haemodialysis centres. Nephrol Dial Transplant. 2020;35(5):737-41. [PubMed ID: 32196116]. [PubMed Central ID: PMC7184437]. https://doi.org/10.1093/ndt/gfaa069.

  • 2.

    Lim MA, Pranata R. The Importance of COVID-19 Prevention and Containment in Hemodialysis Unit. Clin Med Insights Circ Respir Pulm Med. 2020;14:1179548420939260. [PubMed ID: 32699499]. [PubMed Central ID: PMC7345440]. https://doi.org/10.1177/1179548420939256.

  • 3.

    Hilbrands LB, Duivenvoorden R, Vart P, Franssen CFM, Hemmelder MH, Jager KJ, et al. COVID-19-related mortality in kidney transplant and dialysis patients: results of the ERACODA collaboration. Nephrol Dial Transplant. 2020;35(11):1973-83. [PubMed ID: 33151337]. [PubMed Central ID: PMC7665620]. https://doi.org/10.1093/ndt/gfaa261.

  • 4.

    Robinson BM, Guedes M, Alghonaim M, Cases A, Dasgupta I, Gan L, et al. Worldwide Early Impact of COVID-19 on Dialysis Patients and Staff and Lessons Learned: A DOPPS Roundtable Discussion. Kidney Med. 2021;3(4):619-34. [PubMed ID: 34007963]. [PubMed Central ID: PMC8120787]. https://doi.org/10.1016/j.xkme.2021.03.006.

  • 5.

    Moustakim R, El Ayachi M, Mziwira M, Belahsen R. Undiagnosed chronic kidney disease and its associated risk factors in an agricultural Moroccan adult's population. Nephrol Ther. 2020;16(3):147-52. [PubMed ID: 32278735]. https://doi.org/10.1016/j.nephro.2019.12.003.

  • 6.

    Pippias M, Jager KJ, Kramer A, Leivestad T, Sanchez MB, Caskey FJ, et al. The changing trends and outcomes in renal replacement therapy: data from the ERA-EDTA Registry. Nephrol Dial Transplant. 2016;31(5):831-41. [PubMed ID: 26361801]. https://doi.org/10.1093/ndt/gfv327.

  • 7.

    Liyanage T, Ninomiya T, Jha V, Neal B, Patrice HM, Okpechi I, et al. Worldwide access to treatment for end-stage kidney disease: A systematic review. Lancet. 2015;385(9981):1975-82. [PubMed ID: 25777665]. https://doi.org/10.1016/S0140-6736(14)61601-9.

  • 8.

    Wong G, Howard K, Chapman J, Chadban S, Cross N, Tong A, et al. Comparative survival and economic benefits of deceased donor kidney transplantation and dialysis in people with varying ages and co-morbidities. PLoS One. 2012;7(1). e29591. [PubMed ID: 22279541]. [PubMed Central ID: PMC3261160]. https://doi.org/10.1371/journal.pone.0029591.

  • 9.

    Adapa S, Aeddula NR, Konala VM, Chenna A, Naramala S, Madhira BR, et al. COVID-19 and Renal Failure: Challenges in the Delivery of Renal Replacement Therapy. J Clin Med Res. 2020;12(5):276-85. [PubMed ID: 32489502]. [PubMed Central ID: PMC7239583]. https://doi.org/10.14740/jocmr4160.

  • 10.

    Blake PG. Global Dialysis Perspective: Canada. Kidney360. 2020;1(2):115-8. [PubMed ID: 35372909]. [PubMed Central ID: PMC8809102]. https://doi.org/10.34067/KID.0000462019.

  • 11.

    Beaudet M, Ravensbergen L, DeWeese J, Beaubien-Souligny W, Nadeau-Fredette AC, Rios N, et al. Accessing hemodialysis clinics during the COVID-19 pandemic. Transp Res Interdiscip Perspect. 2022;13:100533. [PubMed ID: 35036907]. [PubMed Central ID: PMC8743465]. https://doi.org/10.1016/j.trip.2021.100533.

  • 12.

    Rudd KE, Cizmeci EA, Galli GM, Lundeg G, Schultz MJ, Papali A, et al. Pragmatic Recommendations for the Prevention and Treatment of Acute Kidney Injury in Patients with COVID-19 in Low- and Middle-Income Countries. Am J Trop Med Hyg. 2021;104(3_Suppl):87-98. [PubMed ID: 33432912]. [PubMed Central ID: PMC7957240]. https://doi.org/10.4269/ajtmh.20-1242.

  • 13.

    Hopman J, Allegranzi B, Mehtar S. Managing COVID-19 in Low- and Middle-Income Countries. JAMA. 2020;323(16):1549-50. [PubMed ID: 32176764]. https://doi.org/10.1001/jama.2020.4169.

  • 14.

    Bhayani S, Sengupta R, Markossian T, Tootooni S, Luke A, Shoham D, et al. Dialysis, COVID-19, Poverty, and Race in Greater Chicago: An Ecological Analysis. Kidney Med. 2020;2(5):552-558 e1. [PubMed ID: 32838290]. [PubMed Central ID: PMC7391019]. https://doi.org/10.1016/j.xkme.2020.06.005.

  • 15.

    Tannor EK, Bieber B, Aylward R, Luyckx V, Shah DS, Liew A, et al. The COVID-19 Pandemic Identifies Significant Global Inequities in Hemodialysis Care in Low and Lower-Middle Income Countries-An ISN/DOPPS Survey. Kidney Int Rep. 2022;7(5):971-82. [PubMed ID: 35291393]. [PubMed Central ID: PMC8912976]. https://doi.org/10.1016/j.ekir.2022.02.027.

  • 16.

    Cui B, Boisjoly G, Wasfi R, Orpana H, Manaugh K, Buliung R, et al. Spatial access by public transport and likelihood of healthcare consultations at hospitals. Transp Res Rec. 2020;2674(12):188-98.

  • 17.

    Yazawa M, Omae K, Shibagaki Y, Inaba M, Tsuruya K, Kurita N. The effect of transportation modality to dialysis facilities on health-related quality of life among hemodialysis patients: Results from the Japanese Dialysis Outcomes and Practice Pattern Study. Clin Kidney J. 2020;13(4):640-6. [PubMed ID: 32897276]. [PubMed Central ID: PMC7467582]. https://doi.org/10.1093/ckj/sfz110.

  • 18.

    Palm M, Sturrock SL, Howell NA, Farber S, Widener MJ. The uneven impacts of avoiding public transit on riders' access to healthcare during COVID-19. J Transp Health. 2021;22:101112. [PubMed ID: 36570715]. [PubMed Central ID: PMC9765222]. https://doi.org/10.1016/j.jth.2021.101112.

  • 19.

    Weiner DE, Watnick SG. Hemodialysis and COVID-19: An Achilles' Heel in the Pandemic Health Care Response in the United States. Kidney Med. 2020;2(3):227-30. [PubMed ID: 32363338]. [PubMed Central ID: PMC7195358]. https://doi.org/10.1016/j.xkme.2020.03.004.

  • 20.

    Meijers B, Messa P, Ronco C. Safeguarding the Maintenance Hemodialysis Patient Population during the Coronavirus Disease 19 Pandemic. Blood Purif. 2020;49(3):259-64. [PubMed ID: 32235119]. [PubMed Central ID: PMC7179526]. https://doi.org/10.1159/000507537.

  • 21.

    Manganaro M, Baldovino S, Working group of the P, Aosta Valley Section of the SIN. First considerations on the SARS-CoV-2 epidemic in the Dialysis Units of Piedmont and Aosta Valley, Northern Italy. J Nephrol. 2020;33(3):393-5. [PubMed ID: 32277423]. [PubMed Central ID: PMC7146073]. https://doi.org/10.1007/s40620-020-00732-1.

  • 22.

    Suri RS, Antonsen JE, Banks CA, Clark DA, Davison SN, Frenette CH, et al. Management of Outpatient Hemodialysis During the COVID-19 Pandemic: Recommendations From the Canadian Society of Nephrology COVID-19 Rapid Response Team. Can J Kidney Health Dis. 2020;7:2054358120938560. [PubMed ID: 32963790]. [PubMed Central ID: PMC7488889]. https://doi.org/10.1177/2054358120938564.

  • 23.

    Khoo EJ, Lantos JD. Lessons learned from the COVID-19 pandemic. Acta Paediatr. 2020;109(7):1323-5. [PubMed ID: 32289175]. [PubMed Central ID: PMC7262354]. https://doi.org/10.1111/apa.15307.

  • 24.

    Iio R, Kaneko T, Mizuno H, Isaka Y. Clinical characteristics of COVID-19 infection in a dialysis center during a nosocomial outbreak. Clin Exp Nephrol. 2021;25(6):652-9. [PubMed ID: 33555454]. [PubMed Central ID: PMC7869077]. https://doi.org/10.1007/s10157-021-02025-8.

  • 25.

    Tang Y, Xin Y, Deng F. Prevention and management of COVID-19 in hemodialysis centers. Am J Manag Care. 2020;26(8):e237-8. [PubMed ID: 32835464]. https://doi.org/10.37765/ajmc.2020.43887.

  • 26.

    Ferrey AJ, Choi G, Hanna RM, Chang Y, Tantisattamo E, Ivaturi K, et al. A Case of Novel Coronavirus Disease 19 in a Chronic Hemodialysis Patient Presenting with Gastroenteritis and Developing Severe Pulmonary Disease. Am J Nephrol. 2020;51(5):337-42. [PubMed ID: 32222713]. [PubMed Central ID: PMC7179539]. https://doi.org/10.1159/000507417.

  • 27.

    El Shamy O, Sharma S, Winston J, Uribarri J. Peritoneal Dialysis During the Coronavirus Disease-2019 (COVID-19) Pandemic: Acute Inpatient and Maintenance Outpatient Experiences. Kidney Med. 2020;2(4):377-80. [PubMed ID: 32337505]. [PubMed Central ID: PMC7179486]. https://doi.org/10.1016/j.xkme.2020.04.001.

  • 28.

    Singh T, Ngoh CL, Wong K, Khan BA. Impact of Telemedicine on Hospitalisation and Mortality Rates in Community-Based Haemodialysis Centres in Singapore during the COVID-19 Pandemic. Ann Acad Med Singap. 2020;49(10):756-63. [PubMed ID: 33283839].

  • 29.

    Rombola G, Heidempergher M, Pedrini L, Farina M, Aucella F, Messa P, et al. Practical indications for the prevention and management of SARS-CoV-2 in ambulatory dialysis patients: Lessons from the first phase of the epidemics in Lombardy. J Nephrol. 2020;33(2):193-6. [PubMed ID: 32207068]. [PubMed Central ID: PMC7095015]. https://doi.org/10.1007/s40620-020-00727-y.