Across the globe, healthcare providers today have abandoned standard procedures in
order to address the immediate needs of the coronavirus disease 19 (COVID-19) pandemic,
which is spreading at an alarming rate. In spite of many challenges , the response
of the nephrology specialty to COVID-19 has been proactive, prompt, and widespread.
COVID-19 is highly contagious with the potential to affect a large number of individuals
especially those with comorbid conditions. Prior experience has demonstrated that
the 2003 severe acute respiratory syndrome-COV epidemic and the 2012 MERS-COV outbreak
had high mortality rates − approximating 75–92% − in patients developing AKI [2, 3].
In COVID-19 cases, preexisting chronic kidney disease or dialysis dependence is a
risk factor for poor prognosis. In a cohort of 21 patients admitted to the intensive
care unit, 47.6% had a preadmission comorbidity of chronic kidney disease and 9.5%
had preexisting dialysis dependence . Thus, it is critical to protect this vulnerable
population and a majority of these people need to congregate 3 times a week for going
through life-saving procedures.
Across the world, in-center hemodialysis (HD) units have scrambled to reduce potential
risks in the spreading of the infection to patients by creating new and working extra
shifts, reducing the number of HD patients dialyzing at the same time, allowing at
least 6 feet of space between HD chairs/stations, and even decreasing the duration
of patients' sessions. Despite these efforts, some patients in New York City are so
fearful of contracting COVID-19 and not showing up for in-center HD, because of which
there is an increase in the number of emergency room visits and hospital admissions
for fluid overload and electrolyte disturbances. The same scenario is seen in other
HD centers across the United States.
While home dialysis is the ideal option for social distancing during a pandemic, resource
constraints lead to the formation of barriers in converting in-center HD patients
to home HD or peritoneal dialysis (PD). For patients currently on PD, telemedicine
and advances in remote PD monitoring have been paramount in managing PD patients remotely.
Broadening Access to Telehealth
In March 2020, the Centers for Medicare and Medicaid Services broadened their access
to Medicare telehealth services following President Trump's emergency Declaration.
This new waiver (1,135) allows Medicare to pay for office, hospital, and other visits
furnished via telehealth. This is encouraging in the context of reimbursements, and
therefore, the use of telehealth has increased exponentially, and many centers are
working through logistical challenges.
In California's COVID-19 epicenter, some Silicon Valley hospitals place emphasis on
data privacy, maintaining strict policies with strong preference for providers and
patients to use hospital-approved technology. On the other hand, Mount Sinai Hospital
in New York City has taken a more patient-centric approach where nephrologists are
using all available technologies that the patient may be comfortable using including
FaceTime, Zoom, or WhatsApp. Since March 15, 2020, the Mount Sinai staff rescheduled
all routine monthly PD visits to virtual visits using whichever technology each patient
preferred. With limited staff in the clinic, the PD nurse inspects the exit site remotely,
the nephrologist virtually “sees” the patient, and PD logs are reviewed.
Remote Monitoring of Treatments
Performing monthly telehealth visits would not be possible for this patient population
without the ability to remotely monitor their treatments to assess the quality of
the home therapy delivered and troubleshoot any issues that may arise. Sharesouce,
a cloud-based connectivity platform that shares information from the patients' dialysis
cycler and enables nephrologists and clinical staff to remotely monitor each cycle's
information (fill volume and time, dwell time, drain volume and time, and ultrafiltration
volume) provides a solution to this problem.
The PD unit at Mount Sinai has approximately 80 patients and over 80% of patients
utilize Sharesource. It has been an invaluable resource to get patient's information
directly from home and has been a pivotal cog in facilitating the implementation of
telehealth. To date, over 90% of Mount Sinai's home dialysis patients have had their
monthly visits conducted through telehealth without having to come to the unit for
any of their needs.
The same holds true in Chicago, Illinois, a growing epicenter, where the Medical District
Home Dialysis staff are calling PD patients 2–3 times per week. Sharesource has become
key for handling this crisis, allowing them to track treatment and compliance. Patients
skipping treatments or who are not the most compliant are identified and educated
about the importance of their treatments. The risk of this behavior, which could bring
them up to the emergency room, where there is a high risk of COVID-19 exposure, is
In less urban areas not currently affected as much by COVID-19, such as at Baylor
Scott and White Healthcare in Temple, Texas, nephrologists are bracing for an onslaught
and have preemptively started using telemedicine for the monthly visits with their
home dialysis patients while utilizing the benefits of Sharesource to remotely monitor,
adjust, and troubleshoot their patients' dialysis treatments. One hundred percent
of their patients' data is on the Sharesource platform, and to date, over 80% of their
patients have had telehealth encounters. Patients have been more than willing to adopt
this technology and are appreciative of avoiding unnecessary exposure, further assisting
their providers' efforts to flatten the curve.
In other parts of the world, Italy and Spain, are weeks ahead of the United States
in the pandemic wave. In Vicenza Italy, one of the largest PD centers in Europe, remote
patient management has been utilized now in 100% of the 132 patients. All patients
receive virtual visits and communicate from home with the center. Fill volume and
time, dwell time, and general PD prescription are modified based on the collected
data such as drain volume and time, and overall ultrafiltration volume per session.
By implementing a complete telemonitoring of patients also using tablets and other
communication devices, in the middle of the epidemic peak, only 1 patient resulted
positive to COVID-19 due to a contact with his previously infected daughter. A special
protocol for remote management of peritonitis was also implemented with home delivery
of antibiotics. One patient had to have the catheter removed for omentum trapping
and no other complications were observed in the time span of the epidemic.
While the world is adapting to telehealth and managing patients remotely, Renal Therapy
Services (RTS), an independent entity owned by Baxter International, Inc., oversees
77 renal care centers with 4,500 PD patients worldwide. Back in 2016, RTS Colombia
implemented a Remote Patient Monitoring program for automated PD patients using Sharesource,
starting with a standardized training with structured follow-up using Key Performance
Indicators. Education and a well-structured plan were crucial for successful implementation.
It has been demonstrated that the use of standardized remote patient monitoring program
for the management of automated PD patients was associated with lower hospitalization
rates and decreased hospital length of stay . Having a well-established home dialysis
program where 40% of the RTS dialysis population utilizing PD as their dialysis modality
has allowed RTS Colombia dialysis facilities to adapt quickly during the pandemic.
While most patients are unable to switch to home dialysis currently, experts expect
the COVID-19 pandemic to act as a catalyst for a surge in this modality for the future.
The utilization of telehealth rebukes the perception that care is substandard to in-center
dialysis and also allays the fear of receiving care without medical oversight. Telenephrology
fosters the patient-clinician relationship and allows for substantial medical oversight
as clinicians can observe (via video) a patient's dialysis environment in their home,
providing feedback and recommendations. When the curve starts to flatten, social distancing
will still need to be maintained. The continued ability to provide clinical staff
with detailed, real-time information about PD patients' treatments and prescriptions
protects this vulnerable patient population and healthcare providers from unnecessary
potential exposure to COVID-19.
H.T. is an employee of Baxter International and owns stock in the company. In the
last 3 years, C.R. has been consulting or part of advisory boards for ASAHI, Astute,
Baxter, Biomerieux, B. Braun, Cytosorbents, ESTOR, FMC, GE, Jafron, Medtronic, and
Toray. O.E.S., S.S., J.U., and M.N. have no conflicts of interest or disclosures.
No funding was provided for this manuscript.
Drs. Osama El Shamy, Ha Tran, Jaime Uribarri, Shuchita Sharma, Mohanram Narayanan
and Claudio Ronco all contributed substantial contributions to the conception and
design of the work and drafting the work or revising it critically for important intellectual
content, as well as the final approval of the version to be published. Finally they
all agree to be accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are appropriately investigated