Dialysis practices during the COVID-19 pandemic: a survey from India

Introduction: We aimed to study the practices being followed in dialysis units across the country during the COVID-19 pandemic. Objectives: To study the dialysis practices being followed during the COVID-19 pandemic Patients and Methods: A questionnaire assessing treatment and preventive practices being followed in dialysis units during the COVID-19 pandemic was emailed to nephrologists and nephrology trainees practising in India. Responses were recorded electronically. Results: We received 173 valid responses. About 83.2% nephrologists were providing dialysis for COVID-19. Hemodialysis/slow low-efficient dialysis was the most common modality (65.2%) of renal replacement therapy (RRT) in COVID-19 acute kidney injury. In dialysis patients with suspicious symptoms, most common test to rule out COVID-19 was RTPCR (reverse transcriptase polymerase chain reaction) +chest imaging ( 42.2%)followed by RT-PCR alone (34.1%). Around 80.9% nephrologists sought a negative RT-PCR in patients who had recovered from COVID-19 before discontinuation of isolation measures. Adherence to COVID19 preventive measures varied between 15.2% (portable reverse osmosis disinfection) to 97.1% (mask wearing). Healthcare worker (HCW) training programme was present in 88.4% cases, paid leaves for COVID-19 in 89% and daily HCW symptom screen in 65.3%. The most frequently identified barrier to chronic kidney disease care was a delay in transplantation (66.5%).Accordingly, 20.8% reported a temporary closure of dialysis unit due to COVID-19 outbreak. Moreover, 63% of nephrologists counseled patients to choose peritoneal dialysis above hemodialysis as permanent RRT. Conclusion: Hemodialysis/SLED is the preferred modality of RRT in COVID 19-AKI. Many nephrologists are counseling for peritoneal dialysis as superior to hemodialysis during COVID19 for maintenance RRT. Preventive measure adherence is variable across centers. Healthcare w


Introduction
The COVID-19 pandemic has posed a special challenge to nephrologists where they have to provide essential life-saving dialysis to patients with COVID-19 on one hand and safeguard their dialysis patients and healthcare staff against it on the other hand. Almost 1.75 lakh people in India are on maintenance dialysis (1). Additionally, 11-37% of hospitalized patients of COVID-19 may develop AKI, 23% of whom may need renal replacement therapy (2). A number of extracorporeal non-renal therapies are also facilitated by the dialysis units in patients of COVID-19. Altogether, dialysis facilities have been catering to a large number of patients in this pandemic and dialysis units have the potential to become COVID-19 "hotspots" if adequate precautions are not taken.

Objectives
We aimed to describe the various treatment and preventive practices being followed in dialysis units across India during this pandemic.

Study design
We designed a survey consisting of 32 questions to assess dialysis practices being followed in various parts of the country during the COVID-19 pandemic. The questionnaire (supplementary file 1) was designed on Google forms. Apart from the personal details of the nephrologists and the type of facility they are working in, the questionnaire consisted of five parts; 1) Dialysis of COVID-19 patients 2) Management of suspicious and recovered cases of COVID-19 3) Measures to prevent spread of COVID-19 in hemodialysis unit -this included a set of measures derived by combining the guidelines developed by the Indian society of nephrology and the hemodialysis unit preparedness checklist as issued by the George Institute of Global Health (3,4) 4) Measures to ensure healthcare worker(HCW) safety 5) Barriers to ideal CKD care during the pandemic Respondents were given the option to reveal their identity/email ID or fill the form anonymously. All other questions were mandatory. Each respondent was given the option to fill multiple responses if associated with more than one dialysis center/hospital. The questionnaire was sent by email and through social media (Twitter) to nephrologists and nephrology trainees working in India. A reminder email was sent to non-respondents two weeks after the first email. Responses were accepted till one month after the initial email (18 th November to 18 th December 2020).

Data analysis
Results were expressed as percentages with the denominator being the total number of responses to the question. Data was managed on SPSS version 25.

Results
We received 176 responses overall (123 unique email addresses and 51 anonymous responses).
Two responders had filled the form twice (practice in two different centers). Three responses were excluded from the analysis since the location of current practice was not in India.
Nephrologists from 20 states of the country participated in the survey, maximum were from Tamil Nadu (n=32) followed by Maharashtra (n=27). The distribution of respondents from various states is shown in Figure 1. Around, 79.8% (n=138) respondents were practicing in private centers, 17.3% (n=30) in government centers and 2.90% (n=5) in others. About 56.1% were working in teaching hospitals, 39.8% in non-teaching hospitals and 4% stand-alone dialysis centers.
A separate COVID-19 designated dialysis unit was used by 43.4% of the nephrologists, while only ICU dialysis was available in 28.9% of cases.
Other modes of isolation were separate room with closed door 16.6%, separate room without door (1.3%), last shift of the day (9.6%). Furthermore, 77.2% of respondents providing dialysis to COVID-19 patients had a designated staff member per shift to perform dialysis only for COVID-19 cases.

Management of suspicious and recovered cases of COVID-19
For patients with clinical features suspicious of COVID-19, the most commonly done test to rule out COVID-19 was a combination of RT-PCR and chest imaging followed by RT-PCR alone (34.1%) and RT-PCR +antigen testing (8.9%). Only 27.1% respondents allowed suspected COVID -19 cases for dialysis in routine hemodialysis unit while awaiting test results, whereas 71.1% waited for confirmatory tests prior to dialysis (1.7% referred to other centers).
In case of a negative test in a suspicious patient, 82.6% continued isolation measures during dialysis whereas 14.4% dialyzed in the routine hemodialysis unit without isolation (2.8% referred to other center).
The protocol followed for discontinuation of isolation precautions for patients who had recovered from COVID-19 is illustrated in Figure 3. Accordingly, 80.9% of nephrologists asked for a nasopharyngeal swab testing for COVID-19 RT-PCR before allowing patients in routine HD unit.

Measures to prevent spread of COVID-19 in hemodialysis unit (for non-COVID patients)
Percentage adherence to measures to prevent COVID-19 in hemodialysis unit is illustrated in Although the dialysis unit staff members got a paid leave in 89% cases if they contracted COVID-19 or developed signs/symptoms consistent with it, only 62.4% were given a paid leave if they came in high-risk contact with a COVID-19 case (but were asymptomatic /tested negative).

Barriers to care
The most frequently identified barrier to CKD care was a delay in the transplantation of CKD patients (n=115, 66.5%), followed by missed dialysis sessions due to unavailability of transport (59.5%), delay in urgent dialysis due to suspicion of COVID-19(57.2%), decrease in the number of dialysis unit staff members ( 57.2%) and delay in creation of permanent arteriovenous (AV) access (n=94,54.3%). Accordingly, 20.8% respondents reported a temporary closure of their dialysis unit during the pandemic.

Discussion
The COVID-19 pandemic has brought about restrictions in almost every field of work, including non-essential medical care (5). Dialysis is a life-sustaining procedure for millions across the globe and most dialysis centers have been running throughout the pandemic, even with the strictest lockdowns.
We aimed to study dialysis practices being followed in the country during this pandemic.
Various countries have issued specific guidelines to be followed in hemodialysis units during this pandemic (3,6,7). Despite the guidelines by various societies and the surge of published data on COVID-19 , there are many unanswered questions regarding safe and ethical dialysis practices in this pandemic. Often physician judgement and logistics are the deciding factors when faced with such unaddressed issues.
At the time of the study, 83.8% of nephrologists were providing RRT to COVID-19 patients.
This included 86.7% government run centers and 84.1% of private centers. It is interesting to note that more nephrologists were providing hemodialysis to COVID-19 AKI patients than to maintenance hemodialysis COVID-19 patients and up to 30% had only ICU facility available for COVID-19 dialysis. This highlights the difficulty of isolating patients of COVID-19 in an outpatients based hemodialysis unit. Although the chronic peritoneal dialysis programme has not been widely practiced in India (8), it was noted that almost 15.2% of participating nephrologists were providing acute peritoneal dialysis in COVID-19 patients with AKI. This number being higher in government hospitals (26%) compared to private hospitals (10%). Besides, 63% of nephrologists counseled patients regarding benefit of peritoneal dialysis above hemodialysis as a permanent mode of RRT. Given the advantage of lesser contact with healthcare setup and lesser need to travel, peritoneal dialysis has been suggested as a safer option for maintenance therapy during the pandemic (9,10). Whether this pandemic will become the driving force for the much needed boost to peritoneal dialysis services in India is yet to be seen.
There are various areas of uncertainty as to how to manage patients with suspicious symptoms without proven COVID in dialysis units. Maintenance dialysis patients often present with cough or shortness of breath due to non-infective causes like fluid overload, cardiac complications or anemia. A combination of RT-PCR + imaging (CT chest/ X-ray) was the most commonly done investigation (42.2%) for allowing dialysis patients with suspicious symptoms in routine hemodialysis unit and almost 71.1% of nephrologists preferred to wait for the final results of the test before permission to get routine hemodialysis.
Keeping in mind the false negative rates of such testing, 82.6% of nephrologists continued dialysis in isolation for patients with suspected COVID-19 even if they tested negative by the unit protocol.
The time-period of isolation required for patients who have recovered from COVID-19 is not yet clear. Viral shedding may be prolonged in immunosuppressed patients (11) and in CKD (12,13).

The CDC (Centers for Disease Control and Prevention) advises to continue transmission based
precautions for patients with COVID-19 for 10 days (mild illness) to 20 days (severe illness) after symptom onset (14). The Canadian society of nephrology, on the other hand, recommends that isolation should be continued until the patient has been symptomatic for a minimum of 14 days along with two negative RTPCR tests separated by at least 24 hours (7). In our study, 80.9% of nephrologists asked for a retesting to exclude COVID-19 viral shedding before isolation discontinuation and 3.5% asked for two such negative tests. The time-period of isolation after a negative test varied between <7 days to >21 days.
Studies from renal registries show that between 10-20% patients getting in center hemodialysis may contract COVID-19 infection. Mortality rates are much higher in this population than in the general population (15)(16)(17). Therefore, measures to prevent spread of COVID-19 in hemodialysis units are of utmost importance. We found a high overall compliance rate for use of masks, surface disinfection and hand washing practices. However, compliance to disinfection of RO(reverse osmosis) units, bed sheets disinfection prior to laundry, having a separate designated entry/exit for social distancing, providing trash can/tissue at dialysis bed and adequate bed distancing protocols were followed by only a few nephrologists (15-43%). In addition, patient behaviors like not eating in dialysis unit and coming alone for hemodialysis when stable were often not being followed. These are small easily enforceable measures which may go a long way in preventing outbreaks in the HD unit. A study which assessed CKD care delivery in the first few weeks of lockdown in the country highlighted how 28.2% patients had missed their dialysis sessions at that time, some of whom subsequently required emergency dialysis and some died. Other issues identified at that time included almost complete discontinuation of kidney transplantation programmes and marked drop in the outpatient and inpatient attendance (18). The current study was conducted almost 8 months after this study and although restrictions have been eased, there continue to be several hurdles to CKD care. The delay in kidney transplantation was the most frequently recognized barrier to CKD care as per our survey (66%). A recent international survey from 16 countries showed that living kidney donation was on hold in 75% centers across five continents (19). Since live kidney donation is the backbone of transplantation programmes in India, this delay in transplantation together with a decrease in the dialysis unit HCW strength, increased the burden on dialysis units in the country manifold. The resumption of live kidney donor renal transplantation will probably help to ease this burden.

Conclusion
This was a survey-based study to analyze practice patterns during the COVID-19 pandemic. A large number of nephrologists are providing dialysis-based care to COVID-19 patients in India.
Although hemodialysis is the most favored mode of RRT in both COVID-19 positive patients, acute peritoneal dialysis has become an important option in COVID-19 cases and nephrologists are also counseling patients requiring maintenance dialysis for use of peritoneal dialysis over hemodialysis during these trying times. Compliance to measures to prevent COVID-19 has been overall fair and dialysis HCW safety has been addressed in most dialysis units.

Limitations of the study
This study has few limitations. Participation in the survey was voluntary and hence the study is liable to the limitations of sampling errors consistent with any survey-based study. Although we were able to capture data from nephrologists practicing in 20 states, there was an over representation of the southern and western states compared to the northern and eastern states.

Authors' contribution
PP was the principal investigator of the study. RE and MJK were included in preparing the concept and design. The manuscript draft was prepared by PP. Critical evaluation and revision was done by RE and MJK. All authors have approved the final manuscript.