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Patients receiving facility-based hemodialysis represent a unique and vulnerable population during the coronavirus disease 2019 (COVID-19) pandemic. These individuals require life-sustaining treatment on average 3 times weekly at a dialysis center and cannot remain isolated at home. For each treatment, patients regularly interact with transportation workers, other dialysis patients, and members of the health care team. This places them at heightened risk for acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Furthermore, potential shortages of hemodialysis staffing and/or supplies (ie, from illness, quarantine, and markedly increased numbers of patients requiring acute dialysis for acute kidney injury) have been acknowledged as a significant risk to continued adequate delivery of facility-based hemodialysis care during the pandemic.
As part of contingency planning for lowering coronavirus transmission and/or the potential scenario of fixed/reduced resources during the COVID-19 pandemic, the strategy of reducing hemodialysis treatments from 3 times weekly to twice weekly has received international attention.
These studies concluded a twice-weekly hemodialysis prescription as noninferior to thrice-weekly treatment in select patients with preserved residual kidney function, with minimal interdialytic weight gain, and without hyperkalemia or marked comorbidity.
In Nova Scotia, Canada, patients receiving facility-based hemodialysis in affiliation with the province’s largest tertiary-care center were assessed for candidacy for twice-weekly treatment as part of contingency planning for the potential scenario of fixed/reduced resources in accordance with national Canadian guidelines for the management of outpatient hemodialysis during the pandemic.
The Nova Scotia Health Authority Renal Program provides kidney replacement therapy to individuals from a catchment area of more than 750,000 individuals. In April 2020, a rapid systematic review of all prevalent patients receiving at least thrice-weekly hemodialysis was performed, using a stepwise approach to apply key selection criteria (adapted from previously studied criteria
) for twice-weekly hemodialysis eligibility (Fig 1; further details of the stepwise approach are available in Item S1). Characteristics of patients who fulfilled twice-weekly criteria were reported using univariable statistics.
Of 473 patients assessed in a 3-week period, only 18 (4%) fulfilled criteria for twice-weekly hemodialysis (Fig 1). Of these patients, average age was 63 ± 12 (SD) years, average body mass index was 29 ± 5 kg/m2, 61% had diabetes, 95% were White; and at least 67% were receiving dialysis for 6-plus months before assessment (Table 1). Fifteen (83%) eligible patients missed 0 treatment in the preceding month, and none missed more than 1 treatment. Average serum albumin level was 36 ± 4 g/L; urea reduction ratio, 72.7; and residual urea clearance, 5.7 ± 2.7 mL/min/1.73 m2 (no patient’s predialysis serum urea values demonstrated >10% variability in the preceding 3 months).
Table 1Characteristics of Patients Who Meet Criteria for Twice-Weekly Hemodialysis
Our stepwise approach for the assessment of twice-weekly hemodialysis eligibility permitted a rapid evidence-based assessment for contingency planning purposes. Although feasible, a twice-weekly hemodialysis strategy could be applied to only a small proportion of our patient population, a finding that coincides with similarly low reported rates of twice-weekly hemodialysis patients in the United States.
This common pattern reinforces the notion that a higher percentage of North Americans may be precluded from twice-weekly eligibility due to a concurrent higher burden of comorbid diseases as compared with patients from other countries (ie, China) in which twice-weekly hemodialysis is more common.
our findings suggest that alternative contingency strategies need to be explored, a conclusion that extends to other Canadian centers if results to our strategy are generalized nationally. Recognizing that the inclusion criteria for twice-weekly hemodialysis eligibility were adapted into our stepwise approach and repurposed for contingency planning, if criteria for residual kidney function were relaxed, eligibility for twice-weekly hemodialysis would be higher, approximating 40% of patients. Of note, these patients still met inclusion criteria addressing hypervolemia, hyperkalemia, and multimorbidity, all major issues of concern for patients reducing from thrice- to twice-weekly hemodialysis in a recently published counterpoint report arguing against the use of twice-weekly hemodialysis in times of dialysis unit stress.
Because future adversity resulting in dialysis unit stress is inevitable (ie, natural disasters), we suggest that our rapid assessment approach be validated across other centers to inform the applicability of this contingency option.
Authors’ Full Names and Academic Degrees
David A. Clark, MD, Kenneth A. West, MD, and Karthik K. Tennankore, MD, MSc.
All authors contributed equally to each of research idea, data acquisition, data analysis/interpretation, and statistical analysis. Each author contributed important intellectual content during manuscript drafting or revision and agrees to be personally accountable for the individual’s own contributions and to ensure that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved, including with documentation in the literature if appropriate.
The authors declare that they have no relevant financial interests.
Received July 8, 2020. Evaluated by 1 external peer reviewer, with direct editorial input from the Editor-in-Chief. Accepted in revised form December 20, 2020.
We read with interest the research letter by Clark et al1 examining the feasibility of twice-weekly hemodialysis (HD) during the COVID-19 pandemic. Using a stepwise approach, only 4% of the patients fulfilled their criteria for twice-weekly HD. Therefore, they concur that twice-weekly HD should be implemented only as a last resort.2