key: cord-1017905-sr6qxltk
authors: Carrara, Camillo; Cappelletti, Laura; Portalupi, Valentina
title: A View From The Front-Line of the COVID-19 War
date: 2020-04-26
journal: Kidney Int
DOI: 10.1016/j.kint.2020.04.018
sha: 69d82232a0a57f4ca7fe68e771e904e983a8864d
doc_id: 1017905
cord_uid: sr6qxltk

nan

Just a few weeks ago, I was looking at kidney biopsy slides through the microscope. As a nephrologist with a special interest in renal histopathology, I never thought I would soon find myself at the front-line in the coronavirus disease 2019 pandemic.

I started my residency in 2011 at the Papa Giovanni XXIII Hospital in Bergamo, in Lombardy, a northern region of Italy, after having developed a strong interest in nephrology during medical school. I was excited when I managed to get into one of the top-ranked Italian postgraduate nephrology training programmes. I soon developed a special interest in renal pathology, which I pursued also by completing my training at the Department of Pathology of the University of Washington in Seattle, with Prof. Charles Alpers.

Then came the day when two Chinese tourists in Rome tested positive for a new form of coronavirus, the severe acute respiratory syndrome cornonavirus 2 (SARS-CoV-9). It was 31 January, 2020. A week later, an Italian man who had just returned from the city of Wuhan, China, was admitted to a hospital in Lombardy, because of severe interstitial pneumonia and found to be positive for coronavirus. A cluster of cases was soon detected, starting with 16 confirmed cases in Lombardy on 21 February, which increased to 60 cases, the next day. The first death were also reported. In few days an increasing number of cases were diagnosed in Bergamo area, which soon emerged as one of the worst affected areas in Europe. In those early days of the spreading pandemic, the hospital's emergency wards were quickly overflooded by incoming patients, most of whom required hospitalization because of respiratory insufficiency of various severity. It was mandatory to make room for all these patients, which meant to convert a large number of hospital beds to treat SARS-CoV-2 patients. Bergamo Hospital is a tertiary referral center, serving an area of approximately 1 million people, with 1080 beds -including 53 beds in the Intensive Care Unit (ICU) and 40 beds in sub-intensive areas -and 9 medical or surgical departments. At the outbreak of the epidemic, the number of ICU beds dedicated to COVID-19 patients increased to 88, with additional 418 beds in the other departments devoted to the treatment of mild to moderate acute respiratory failure secondary to interstitial pneumonia. One problem that soon emerged was the coverage of all shifts, which could not be managed with the staff that in routine practice takes care of pneumonia and respiratory insufficiency (i.e. pneumologists, internists, infectious disease specialists, intensive care doctors). An ad hoc task force was established, which proposed to involve a number of physicians of any medical subspeciality in the care of COVID-19 patients. Under the supervision of pneumologist and intensivists, physicians (and also the nurses) were trained to the correct use of Venturi masks, reservoir masks and continuous positive airway pressure (CPAP) devices. New protocols were established within days to standardise therapy for COVID-19 patients based on the available literature.

Along with two other colleagues in the Renal Division (the co-authors of this editorial), I volunteered to participate in the COVID-19 task force, after the above mentioned training. I will never forget my first night shift in the COVID-19 unit. I was on duty with two colleagues -a plastic surgeon and a senior infectious disease specialist -and we had to take care of 45 quite sick patients during those long hours: I felt like being in a war front-line. I was really impressed with everyone's ability to react quickly and effectively; this huge effort brought together nurses, doctors, biologists, technicians and all the remaining hospital staff. I cannot deny the fear I felt, of being infected and of bringing the disease home, to my family. No one can deny it.

But the desire to be there, to contribute, comes first.

In the meanwhile, usual activities of the Renal Department had to be adapted to this unprecedented emergency. Our main concern was how to deal with kidney transplant programme. When we soon realized the magnitude of COVID-19 outbreak in our area, we felt that newly transplanted patients -who require full immunosuppressive therapies -would have been exposed to an excessive risk. We therefore suspended the transplant programme. Among kidney transplant patients who are on long-term follow-up at our hospital (780 patients), we registered 50 cases of SARS-CoV-2, eight of whom died. Most of these patients could be managed successfully at home, and only a minority required hospitalization. The Renal Division has a huge outpatient clinic, where patients with chronic kidney diseases, of any stage, are routinely followed. This activity had to be drastically limited to urgent cases, with the aim to reduce the access to the hospital so heavily burdened with COVID-19 patients. A lot of patients were anyway assisted by phone calls and email.

The dialysis unit is strong of 54 dialysis stations and takes care of 211 patients. Overall, 22 SARS-CoV-2 positive cases and 12 deaths were recorded (during the same period of time in 2019, three patients on maintenance dialysis have died).

Beyond the shadows of this dramatic experience there could be a glimpse of light. SARS-CoV-2 triggers a multisystemic process whose understanding raises many scientific questions. This is not just a lung disease, but also an inflammatory, vascular and cardiocirculatory disorder (and probably even more). The scientific community is concentrated in the common effort to find effective therapies and a vaccine. On the other hand, during our shifts in the COVID-19 units, we're learning to be less organ-specific, trying to remove for a

the exoskeleton of our medical subspeciality. The virus is reminding us that everything is