key: cord-1018400-xx95c7c0 authors: Rizo-Topete, Lilia; Claure-Del Granado, Rolando; Ponce, Daniela; Lombardi, Raul title: Acute kidney injury requiring RRT during the COVID-19 pandemic: What are our options for treating it in Latin America? date: 2020-12-31 journal: Kidney Int DOI: 10.1016/j.kint.2020.12.021 sha: 4b5c56a34c9a724b1a14792a9a063a0554627ff5 doc_id: 1018400 cord_uid: xx95c7c0 nan Within a month after the first case was reported on February 2020 in Brazil, all countries in Latin America had reported cases of the novel coronavirus disease 2019 (COVID-19); Brazil, Argentine and Colombia were the most affected countries, with 9,467,320 cases among them reported by early December (1) . Increased poverty, limited water access, poor sanitation, and distrust in governments are important factors that have affected the transmission and have facilitated COVID-19 outbreaks in Latin America (2) . Acute kidney injury (AKI) is common among critically ill patients with COVID-19, affecting approximately 20-40% of patients admitted to intensive care units; unfortunately the overall burden of AKI in COVID-19 might be underestimated in Latin America. Available information on epidemiology and risk factors for AKI in the region is generally scarce, and this situation has not improved during the COVID-19 pandemic. A recent study from 15 countries in Latin America (EPILAT-IRA study) provided data on 905 patients with AKI; the median age was 64 (50-74) yrs, and 61% were male. AKI was community-acquired in 62% of patients, with dehydration, shock and nephrotoxic drugs being the most common causes. Renal replacement therapy (RRT) was performed in 29% of cases, and the incidence of all-cause in-hospital mortality was 26.5%(3). Preliminary and unpublished data from the Latin American Society of Nephrology and Hypertension (SLANH) AKI Committee registry of AKI in COVID-19 patients, which has enrolled 393 subjects so far, showed that more than 50% of patients were female, the median age was 60 (IQR 48-71), 36% of patients developed proteinuria and 17% presented with hematuria. Most of the AKI was hospital-acquired (66%), and 225 of the 393 patients (57.2%) had indications for starting RRT. In 27 of the 225 patients (12%) RRT was not initiated; unfortunately, the reasons why RRT was not initiated were not documented. and only 23%, mainly large units, provided CRRT which is mainly available in large units (4) . Preliminary data from the IRA-SLANH registry of AKI in COVID-19 patients show that HD was used in 48.8% of cases, PIRRT was used in 25.1% of cases, CRRT was used in 18.3% of cases, and PD was used in 2.3% of cases; in the remaining of 5.3% of cases different types of RRT were used (i.e., patients experiencing hemodynamic instability were placed on CRRT for 48 to 72 hours and once their condition improved they were placed on HD). During the COVID-19 pandemic, the proportion of patients needing RRT increased to 5.6-23% with severe infection (6) . Nephrologists in Latin America need to consider all the possible RRT options available in each center for treating severe AKI (Figure 1 ). Since some patients with COVID-19 pneumonia have lower lung compliance, higher right to left shunt, and higher lung recruitability, and symptoms that mimics acute respiratory distress syndrome; and because hemodynamic instability and fluid overload are frequent in COVID-19 patients, CRRT should be the first option of treatment if available (7) . However, CRRT capacity was overwhelmed during this pandemic with shortage of filters and solutions in some countries of the region such as Mexico, Colombia and Bolivia. In those scenarios, CRRT machines were used to administer long intermittent treatments; for example, 10 hours instead of continuous (24 hours) with higher effluent flow rates (40 to 50 ml/kg/h). This strategy, which is commonly used in many centers across Latin America, will allows the CRRT machine to more quickly become available earlier for the care of another patient after cleaning the terminal. In the case where no CRRT devices are available conventional HD machines could be used to provide PIRRT, which has been shown to have similar hemodynamic effects, and provides similar metabolic control as CRRT (8) . Nonetheless, there are specific issues of concern regarding PD in AKI from COVID-19. When acute distress respiratory syndrome (ARDS) occurs, PD should not be used as the first modality for providing RRT, except when other modalities of RRT are not available. When patients need to be prone, PD with a lower infusion volume (20-25 ml/kg) can be used; this low dwell volume will usually not cause mechanical or hemodynamic disturbances. A Brazilian review study reported that ventilated AKI patients with two liters of PD dwell exchange presented with slightly increased intra-abdominal pressure on the first dwell. However, this did not interfere with patients' ventilation and oxygenation (10) . The use of automated cycler PD (APD) reduces the contact with patients, PD fluid exchange occurs automatically, and the exchange of used PD bags with fresh bags are only performed once daily with APD. This minimization of contact with the patients reduces not only the risk of contagion, but also the need for PPE usage, especially in the times when resources are very limited, and there is thus far no evidence of virus spreading from PD effluent. However, in a case report of a patient with small bowel volvulus who required surgery SARS-CoV-2 was found in reactive peritoneal fluid at higher concentrations than in the respiratory tract (11) . PD is simple and efficient and requires less equipment and infrastructure than other RRTs and reduces the exposure of healthcare staff, which is a critical issue amidst the ongoing pandemic. The shortage of resources that is facing doctors is one of the most difficult dilemmas in our region as it can affect decision of who should and who should not receive lifesaving treatments. Selection criteria must be explicit, transparent and produced collectively by the staff and accessible. The "first come, first served" criteria are in fact a selection criteria since once the available places have been filled, the subsequent patients will not have access to them, without the distinction of priorities of any kind. For this reason, guidelines and recommendations have been proposed for a decision-making process (12) . Age (relevant to the probability of survival and the expected years of additional live), comorbidities, functional state and the related long-term prognosis, are the most frequently adopted criteria. Finally, those patients excluded or withdrawn from active treatment have the right to receive the standard of care at the end of life and the staff is ethically obliged to provide it; in these cases maximal medical management is attempted (i.e., appropriate doses of loop diuretics for fluid overload, use of potassium binders, and use of sodium bicarbonate). The decision-making process is a three-step process based on introducing choice, deliberating among options, and helping patients analyze preferences and make decisions; palliative care and transfer from the ICU to an isolated room, if possible, should be provided as the last action of the staff. In summary, all types of RRT are available in Latin America for treating COVID-19 patients with AKI. We have adapted therapies such as CRRT in order to provide adequate treatment with limited resources; when available HD or CRRT machines are scarce, PD can be used. A proposed approach for the early identification of AKI and for providing RRT for patients with COVID-19 is shown in Table 1 . COVID-19 in Latin America COVID-19 in Latin America: Novel transmission dynamics for a global pandemic EPILAT-IRA Study: A contribution to the understanding of the epidemiology of acute kidney injury in Latin America Acute kidney injury in Latin America: a view on renal replacement therapy resources Pneumonia and respiratory failure from swineorigin influenza A (H1N1) in Mexico COVID-19 and Renal Failure: Challenges in the Delivery of Renal Replacement Therapy COVID-19: Nephrology preparedness checklist Outcomes of sustained low efficiency dialysis versus continuous renal replacement therapy in critically ill adults with acute kidney injury: a cohort study Kidney involvement in COVID-19 and rationale for extracorporeal therapies Effect of peritoneal dialysis on respiratory mechanics in acute kidney injury patients SARS-CoV-2 is present in peritoneal fluid in COVID-19 patients Clinical ethics recommendations for the allocation of intensive care treatments in exceptional, resource-limited circumstances: the Italian perspective during the COVID-19 epidemic Identify risk factors for AKI (e.g., chronic kidney disease, heart failure, chronic liver disease, diabetes, age ≥65) Close and continuous communication between nephrologists and the rest of the COVID-19 health care team Early identification of patients with KDIGO AKI stage 1 or 2 is essential as it allows prompt interventions and better outcomes (i.e., achieving and maintaining optimal fluid status). This could reduce AKI progression and improve mortality If a patient presents with severe AKI but does not meet any absolute criteria for RRT initiation, we recommend optimizing medical management until kidney failure becomes life threatening Absolute indications for starting RRT are: * Life-threatening hyperkalemia * Refractory fluid overload * Severe metabolic acidosis For patients on chronic renal replacement therapy (i.e., CAPD, IHD, APD) the decision to continue or to change RRT should be made promptly and assessed daily For example: If a patient is treated with CAPD and requires better solute control, the patient will be switched from CAPD to APD, and the prescription will be modified. If solute and/or volume control is not achieved Renal replacement therapy selection will be based on several factors like patient's hemodynamic stability, local availability, equipment, supplies, staff and local expertise AKI, acute kidney injury RRT, renal replacement therapy; CAPD; continuous ambulatory peritoneal dialysis APD, automated peritoneal dialysis; CRRT, continuous renal replacement therapy, PIRRT, prolonged intermittent renal replacement therapy