How Covid-19 is affecting dialysis patients

To help the people in Delhi get the life-saving procedure, the Delhi government ordered that no hospital shall refuse emergency care to any patients.

Kanchan Devi, 45, died last week after at least four hospitals were forced to refuse life-saving dialysis in the city. She had been on maintenance dialysis – a procedure to filter blood the way a healthy kidney does – twice a week for two-and-a-half years after she was diagnosed with chronic kidney disease.

To help people in Delhi get the procedure, the government ordered that no hospital shall refuse emergency care.(Bloomberg file photo)

“My mother got her last dialysis on April 7 and was to get the next one on April 11. The private hospital where she was undergoing treatment asked us to get a Covid-19 test done before the next visit. We got the test report on April 9 and I called the hospital. They said that they could not do the dialysis because the centre had to be shut down (as a patient there had died of Covid-19),” said her son Rishabh Soni.

The family then started calling all hospitals in east Delhi.

“We called up three private hospitals and one government hospital, but they all refused to taker her in. Finally, we had to take her to the emergency department of a private hospitals because her condition started deteriorating. She was given dialysis but it was too late, she died,” said Soni.

What is dialysis?

Dialysis is a medical procedure that removes excess water and toxins from the blood of the people with impaired kidney function.

Who needs dialysis?

Patients with acute kidney injury -- where the kidney is unable to perform its function suddenly -- need dialysis. This may be reversible if the underlying condition is healed.

Patients with end-stage kidney failure -- whose kidneys have lost 85 to 90% of their function -- need maintenance dialysis two to three times a week to take over the function of their kidney. This is not reversible and the patients need it till they get a kidney transplant.

Why are dialysis patients at a higher risk from Covid-19?

Patients undergoing dialysis usually have multiple co-morbid conditions like hypertension and diabetes

They are usually old

*They are also immunocompromised

*They visit hospitals often for dialysis

Her treatment was interrupted after east Delhi’s Shanti Mukund hospital had to shut its dialysis unit. At least three persons undergoing dialysis at the centre had tested positive for the infection, with one person succumbing to it.

Patients from at least two other private hospitals offering dialysis – south-east Delhi’s Moolchand hospital and east Delhi’s Ahimsa Dham – also had to scramble to get dialysis at other hospitals after their centres were shut down. In Ahimsa Dham, at least two people had tested positive of whom one had died of Covid-19, and at least six patients from Moolchand hospital’s dialysis unit had tested positive for the infection.

“When the cases were first reported, we immediately asked the centres to shut their services. All the patients who had undergone dialysis after the first person tested positive were put on surveillance and we are still in the process of testing them,” said an official from Delhi’s health department, on condition of anonymity.

To help the people in Delhi get the life-saving procedure, the Delhi government ordered that no hospital shall refuse emergency care to any patients. And, strict action, including cancellation of registration, maybe taken for denying care for not having a negative Covid-19 report.

Over-stretched dialysis centres

Besides hospitals unwilling to take in patients who might have the infection, over-stretched dialysis facilities are adding to the woes of those who have been displaced from these three hospitals.

“The hospitals do not want to take the chance of accepting a patient who might have the infection as it puts their other patients in jeopardy,” said the official from Delhi government.

“What will happen to the patients who have been undergoing regular treatment? Most dialysis centres in the city run at capacity and do not have space to accommodate the 50 to 100 patients,” said Akshat Garg, director, Deep Chand Dialysis Centre (DCDC), which runs around 60 dialysis machines in partnership with the Delhi government. “The government needs to earmark a separate facility for suspected or positive Covid-19 cases.”

Lok Nayak hospital, which is a dedicated Covid-19 faciltiy – on Sunday earmarked eight of its in-house dialysis machines for Covid-19 patients. The other machines run under public-private partnership (PPP) have been moved to other DCDC centres for now.

India currently has more than 1.5 million people suffering from end-stage renal disease, with about 200,000 being added to that total every year.

Why are dialysis patients at risk

Repeated exposure to the hospital environment coupled with lower immunity puts people requiring dialysis at a higher risk of getting the infection and developing severe symptoms.

“They usually also have additional comorbidities like diabetes and hypertension. Multiple hospital visits in a week also puts them at a risk of getting the infection,” said Dr RP Mathur, senior consultant of nephrology at Institute of Liver and Biliary Sciences (ILBS).

Mohin Khar, 78, has been going for dialysis sessions twice a week for two years now. She started wearing a mask two months ago when cases of Covid-19 first started being reported. She religiously washes her hand every 15 minutes.

“We also ensure that she takes a proper diet and maintains weight as prescribed by the doctor. We also try to keep her engaged and happy,” her son said.

And, hospitals are taking care to ensure that these vulnerable people do not get the infection.

At the hospital Khar goes to, Max hospital, Vaishali, everybody is checked for fever and other symptoms. They have to sanitise their hands once when they enter and then again when they enter the dialysis ward.

“To ensure ease of travel during the lockdown, the hospital had also issued us a letter that specifies the dialysis schedule and the name of the attendant. The police let us pass whenever we show the letter,” the son said.

The doctors have also created a WhatsApp group of the patients coming to the dialysis centre where they can check in on the patients.

“Inside the ward, we clean all the surfaces, change the sheets and seat the patients at a distance to minimise the risk of transmitting the infection. Anyone who had Covid-19 like symptoms is taken to a separate room for the dialysis and a test is done to check for the infection,” said Dr. Manoj K Singhal, director, nephrology and kidney transplant medicine, Max Hospital, Vaishali.

At ILBS, in addition to checking people for symptoms before entering the dialysis ward, washing hands and other precautions, screens have been placed between two patients to further minimise the risk of the infection being transmitted within the ward.

The asymptomatic Covid-19 patients have the dialysis centres worried as it is not possible to test everyone before each session.

“It is very difficult to manage dialysis patients in this scenario. All the staff members have to wear complete PPE in case there is even a slight possibility that someone might have the infection. If anyone does test positive that would mean the facility shutting down, the staff being quarantined. And, it is not possible to test these patients every time they come for dialysis, some people come thrice a week,” said Dr Suman Nayak, senior consultant of renal transplant.