key: cord-0814489-qf8zun2v authors: Neyra, Javier A.; Connor, Michael J.; Tolwani, Ashita title: Preparedness of Kidney Replacement Therapy in the Critically Ill During COVID-19 Surge date: 2020-06-07 journal: Kidney Int Rep DOI: 10.1016/j.ekir.2020.05.029 sha: aa6d71ca57d6d3153f0d7bcad5dd9643104e928d doc_id: 814489 cord_uid: qf8zun2v nan The devastating and rapidly spreading COVID19 pandemic has challenged the health care system worldwide. COVID19 primarily affects the lungs and is caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). However, multiple other organ systems may also be affected including kidneys, blood (hypercoagulability), brain and heart. The incidence of acute kidney injury (AKI) secondary to COVID19 is estimated ~15-25%, 1-3 while requirement of kidney replacement therapy (KRT) has been variably reported with many large centers describing an incidence of up to 30% in critically ill patients. [4] [5] [6] Further, emerging observations have described two phenotypes of COVID19 pneumonia which may require a more individualized approach of KRT. 7 One phenotype has higher lung compliance, ventilation perfusion mismatch and low lung recruitability (type-L) while the other has lower lung compliance, higher right to left shunt and higher lung recruitability, mimicking Acute Respiratory Distress Syndrome (type-H). Therefore, it is possible that type-L patients are more susceptible to hypovolemia due to dysregulation in pulmonary perfusion, while type-H patients may benefit from timely KRT for fluid management if severe AKI develops and there is lack of response to diuretics. In this Perspective piece, we complement prior contingency planning recommendations by Burgner et al. 8 with some specific considerations for KRT preparedness in the Intensive Care Unit (ICU) under a model including vulnerability assessment, crisis planning, and crisis challenges. It is critical to monitor surveillance models of COVID19 projections as well as sustain continuous communications with state and local leaders of the preparedness plan. A commonly used reference is from the Institute for Health Metrics and Evaluation at the University of Washington (https://covid19.healthdata.org). Relevant information for the nephrologists is the projection of total hospitalized COVID19 patients and, specifically, total patients in the ICU, therefore a projection of ~25% of critically ill patients needing KRT can be established. Step-wise operational approaches with fluent channels of communication are recommended (Figure 1) , starting with assembling a multidisciplinary team encompassing all stakeholders involved in KRT delivery in the ICU (e.g., ICU & dialysis nurses, technicians, pharmacists, clinicians, supply chain management, administrative leadership, etc.). It is also important to accommodate the preparedness plan to specific logistics and hindrances of each institution, including the provision of KRT to non-COVID19 patients with end-stage kidney disease or kidney transplant. Overall, we recommend consideration of activation of the contingency plan when KRT resource utilization exceeds 80% of available KRT supply continuously for a period of 7 days and activation of the crisis plan when KRT resource utilization exceeds 100% of available KRT supply continuously for a period of 7 days during a foreseeable COVID19 local surge. Continuous Renal Replacement Therapy (CRRT) is the most common modality of KRT utilized in critically ill patients. However, other KRT modalities such as Prolonged Intermittent Renal Replacement Therapy (PIRRT), hemodialysis (HD), or peritoneal dialysis (PD) can be also considered for critically ill patients, particularly in settings with limited availability of CRRT machines. When using PIRRT, duration of therapy is ~6-8 hours using blood flow rate ~200 ml/min, dialysate flow rate 200-300 ml/min and ultrafiltration rate limited to less than 1 liter per hour. Additional considerations for PIRRT and HD include low temperature (35.5 C) and high calcium bath (3mmol/L) to attenuate intradialytic hypotension. If acute PD is utilized, cycler use is recommended with each fill limited to 1 liter in cycles of 1.5 to 2 hours for total of 8-12 hours to minimize risk of catheter leak. Several variations to the outlined plan in Figure 1 should be contemplated. A few examples are: 1) the movement/rotation of CRRT or HD machines between network institutions may not be feasible due to logistic restrictions (e.g., geographic distance); 2) the combination of 24-hour CRRT and shift-based CRRT (<12 hours per patientday) in 24-hour KRT cycles may or may not require CRRT dose adjustments; 3) the provision of PIRRT using sequestered HD machines in isolated COVID19 ICUs can be done during daytime or nighttime according to availability of dialysis nurses; and 4) the utilization of the acute PD program can be expanded to non-COVID19 patients with advanced CKD or kidney transplant in need of chronic dialysis to spare HD machines being utilized in COVID19 ICUs. Important challenges to consider are: 1) the supply chain (filters/tubing, solutions, etc.); 2) shortage of staffing, specifically of dialysis nurses for HD and for PIRRT, as dialysis nurses are likely to be in charge of starting, monitoring and stopping PIRRT; 3) training of ICU nurses not familiarized with HD machines for the provision of PIRRT and cyclers for PD; 4) complex schedule/rotation for provision of mixed KRT with structured allocation of 2 or more patients to a single KRT machine during a 24-hour cycle; 5) availability of portable reverse osmosis systems and dialysis water supply in ICU rooms; and 6) local expertise by surgeons for placement of PD catheters at the bedside for acute PD start. Severe COVID19 induces a hypercoagulable state in many critically ill patients as evidenced by a markedly high rate of KRT blood circuit failures (clotting) and higher rates of venous thromboembolism. The pathophysiology of this hypercoagulable state is still unknown, but possible mechanisms include macrophage-activation with cytokine release, deficiencies in fibrinolytic pathways, and endothelial injury leading to platelet activation. In this context, regional citrate anticoagulation (RCA) 9 or systemic anticoagulation 10 is used exclusively or synergistically. Unfortunately, RCA has not proven to be nearly as effective in COVID19 as in other critically ill patients. Alternatives using direct thrombin inhibitors such as bivalirudin or argatroban can be also considered although data in the overall KRT population are limited. Importantly, some type of anticoagulation -regionally in the CRRT/PIRRT circuit or systemically -should be utilized in COVID19 patients on KRT unless there are contraindications, taking into consideration specific logistics available locally at each institution. Limiting direct exposure of health care professionals is pivotal to mitigate contamination and horizontal transmission. Therefore, placing CRRT machines outside the patient's airborneisolated room with extension tubing provides a way to do it. Careful consideration should be taken to verify tubing does not preclude airborne isolation when exiting the room and of the additional amount of blood in the extracorporeal circuit which could impair hemodynamics in some patients, particularly if frequent treatment interruptions occur. Some additional complications may arise, such as impairment of return/access pressure monitoring, lack of detection of return line disconnections or blood circuit pressure drops, and consequently inability to timely detect unintended severe blood loss. Therefore, vigilant monitoring is advised. Hypothermia is another potential complication which can be mitigated by wrapping a Bair Hugger blanket around the extension lines. Despite there are options to locally compound CRRT solutions, it is recommended to use commercially available solutions as much as possible to decrease the risk of nursing and compounding errors. This is particularly important in the context of COVID19 given the high volume of patients receiving KRT and the limited direct exposure. Meticulous disinfection of KRT machine surface is recommended using registered bleach wipes products against coronavirus. In isolated COVID19 units, machines will typically remain sequestered and disinfected there. If machines are to be transported back to dialysis unit or storage, disinfection should occur prior to mobilization and precautions during transport procedures should be taken. There are no conclusive data to support one mode of KRT is superior to another. When delivered to the right patient at the right time with the optimal KRT prescription, all KRT modalities are effective in achieving patient-centered goals of solute and volume control. Nonetheless, iterative assessment of goals of therapy is highly recommended. 11 In terms of resource allocation or priority setting, the goals are legitimacy, fairness, and equity. 12 Parameters acceptable to the public in resource allocation decisions are need, survivability (prognosis/life expectancy), and social value. There is no doubt that this pandemic has challenged our healthcare system, economy and society as a whole. Nonetheless, positive things arise from debilitating times: creativity to surpass the obstacles and meaningful connections to work as a team and dynamically learn together about a disease we have never faced before. We should leverage on this positive thinking and continue working on preparedness to what is here today and what is coming tomorrow. Finally, paraphrasing a vigorous quote of Napoleon Bonaparte, we should all dress slowly (carefully work on preparedness) because we are all in a hurry (to beat this invisible enemy). None. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Acute kidney injury in patients hospitalized with COVID-19 in Wuhan, China: A single-center retrospective observational study Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study Acute Kidney Injury Associated with Coronavirus Disease Acute Kidney Injury in Hospitalized Patients with COVID-19 Covid-19 Does Not Lead to a "Typical" Acute Respiratory Distress Syndrome COVID-19 and the Inpatient Dialysis Unit: Managing Resources During Contingency Planning Pre-Crisis A practical citrate anticoagulation continuous venovenous hemodiafiltration protocol for metabolic control and high solute clearance We Use Heparin as the Anticoagulant for CRRT Optimizing renal replacement therapy deliverables through multidisciplinary work in the intensive care unit Development of a triage protocol for critical care during an influenza pandemic The authors would like to thank all the health care professionals involved in the overall care and, in particular, the provision of KRT to patients with COVID19.