"What is the latest on preventative treatments?" "What is the current level of risk from Covid-19 for people with kidney disease?" "What treatments are available should I contract Covid-19?"
As part of our series on Covid-19, Kidney Care UK held a webinar for patients, carers and healthcare professionals. Experts from renal medicine discussed Covid-19, chronic kidney disease and protective measures.
- The risk of people with kidney disease becoming very unwell with Covid-19 is now very much lower than earlier in the pandemic.
- The latest data for kidney patients showed:
- Less than 2 in 100 people who contracted Covid-19 had to be admitted to hospital.
- Of these very few people who were admitted to hospital less than 1 in 4 died.
- Four treatments are available this Winter to high-risk people who test positive for Covid-19. Sotrovimab is the treatment most likely to be prescribed for kidney patients.
- It is really important to take up all offers of vaccine boosters, as each dose can increase response even in immunosuppressed people. We also now have lots of data from their use across the world, which reassures us of their safety.
- Where we are now with Covid-19 means that people who have been shielding may decide to start building up their confidence and contact with others, while following precautions like wearing a mask and avoiding peak hour public transport. If there is another peak of Covid-19 cases, high risk people may like to reconsider their level of activity.
Thank you to all who attended and contributed to the webinar, the 11th in our series. It covered current risk from Covid-19, updates on Covid-19 treatments and vaccines, and things to consider to keep safe over Christmas.
We were joined by two kidney doctors, Laurie Tomlinson from Brighton and Sussex NHS Trust and Dr Michelle Willicombe from Imperial College, as well as Clare Morlidge, lead Renal Pharmacist at East and North Hertfordshire NHS Trust. David Hayward, Deputy Director - Therapeutics and Antivirals Taskforce at the Department of Health and Social Care, shared Government updates and plans on Covid-19 treatments.
The meeting was chaired by our Kidney Care UK policy director, Fiona Loud.
We would like to say a big thank you to our speakers for their advice and answering your questions.
Please do keep checking the Kidney Care UK Covid-19 guidance for updates.
What is the current risk of severe illness with Covid?
Laurie explained that the risk of people with kidney disease becoming very unwell with Covid-19 is now very much lower than earlier in the pandemic. Vaccines and community treatments, widespread natural immunity from having Covid-19 and increased knowledge about treating people who are very unwell with Covid-19 mean people are getting less severe infections and recover better.
However, the risk of people with kidney disease becoming very unwell from Covid-19 is still higher than in the general population. Therefore, it is important to follow sensible precautions, and for the medical community to keep working on effective protections and treatments and make sure these are available to vulnerable people.
The risk from Covid-19 increases with the severity of kidney disease. The risk to people with early CKD (stage 3) is now largely comparable to the general population. However, individual risk will also depend on other health conditions a person may have as well as their level of immunosuppression. You can speak to your kidney doctor about your individual risk.
Having a Covid-19 infection builds up a person’s immunity to the virus, meaning that subsequent infections are generally more mild. However, viruses like Covid-19 are always changing and a future variant of the virus may make a person more unwell.
Laurie shared data on Covid-19 infections and outcomes:
- The latest data (Nov 2022) from the Office of National Statistics (ONS) showed the number of cases is currently quite low, with around 1 in 60 people having an infection, although this looks to be increasing somewhat. This web page is updated every couple of weeks so you can see how the risk of being infected is changing.
The latest data for kidney patients showed how much the risk of hospitalisation and death from Covid-19 has fallen:
- Less than 2 in 100 people who contracted Covid-19 had to be admitted to hospital.
- Of these very few people who were admitted to hospital less than 1 in 4 died.
This data was collected from people with kidney disease who received a Covid-19 treatment (Sotrovimab or Monulpiravir). These treatments are for people at highest risk from Covid-19 (CKD 4 or 5, on dialysis or with a transplant) and are only given if symptoms are not resolving quickly by themselves. It is positive therefore to see that hospitalisation and death is very rare even in higher risk kidney patients who were feeling unwell with Covid-19.
Does Covid-19 reduce kidney function?
The panel explained that the risk of Covid-19 worsening kidney function and putting transplants at risk had significantly reduced. This is because, in general, people with kidney disease are not becoming as severely ill with Covid-19 as they were at the beginning of the pandemic.
All infections, including Covid-19, can reduce kidney function in people with CKD. Often it improves once the person gets better but for some people it will mean they reach dialysis slightly sooner than they otherwise would have. There is also a risk to transplants from any infection, but again if you’re fully vaccinated your chance of becoming severely unwell and your transplant being affected is now dramatically reduced
Early in the pandemic, Covid-19 did lead to poorer kidney function in people with no previous kidney problems, but this is rare now. It is more common that people may have slight dips in kidney function as they would with any infection but it improves with no lasting problems.
Update on Covid-19 Treatments
David Hayward spoke about the Government’s current work on Covid-19 treatments. He explained that four treatments are available this winter to high-risk people who test positive for Covid-19 and have not had to go into hospital. These are:
- Paxlovid and Monulpiravir – oral antiviral treatment (tablets you swallow)
- Remdesivir – intravenous antiviral treatment (given through a drip in your arm)
- Sotrovimab – intravenous antibody treatment (given through a drip in your arm)
David spoke about a recent change in national guidance for doctors deciding which Covid-19 treatment to use. It now advises Sotrovimab should be used in exceptional circumstances, for example if none of the other treatments are suitable. The change is based on new evidence from laboratory studies (in vitro research - in test tubes and petri dishes rather than in humans) that suggests Sotrovimab is less effective against the current variants of Covid-19.
However, Clare explained that Sotrovimab remains the treatment most likely to be prescribed this winter for kidney patients with CKD stage 4 or 5, on dialysis or with a transplant who test positive for Covid-19. This is because Paxlovid is not suitable for transplant patients and is unlikely to be suitable for high-risk kidney patients because of their poor kidney function. Remdesivir currently cannot be used by people with a reduced kidney function (eGFR less than 30) unless they are on dialysis and data suggests Sotrovimab works better than Monulpiravir for people with kidney disease. Remdesivir also requires 3 hospital visits and most Covid-19 Medicines Delivery Units (CMDUs) do not have the capacity to offer that.
Laurie highlighted her research group’s brand new data about what happens to kidney patients infected with Covid-19. It suggests Sotrovimab is still effective and better than Monulpiravir at reducing hospitalisations and deaths. Michelle explained that findings of real-life evidence like this may be different to the laboratory evidence because laboratory research can only look at one specific action of a drug. Drugs may act in lots of different ways on a virus. The reduction in hospitalisations and deaths among patients could be caused by an action that is not studied in the laboratory. However, as the virus is continually evolving new variants, effectiveness of these treatments will change.
David said that the Therapeutics Taskforce will continue to review all new evidence as it emerges, including this new study, and make any necessary changes to the guidance accordingly. He told the audience that NICE (National Institute for Health and Care Excellence) are doing a full appraisal of which drug treatments should be prescribed for Covid-19 which is likely to bring further changes to how the treatments are used once it is published in March 2023. Fiona highlighted that Kidney Care UK are concerned that NICE’s draft guidance only recommends Paxlovid for people in the community, which would leave most kidney patients without a treatment. She thanked the audience for sharing their views with us on that which we have passed on to NICE.
How can I access the treatments if I test positive for Covid-19?
Free lateral flow tests are still available for people at highest risk of severe illness with Covid-19. They can be ordered online.
If people have Covid-19 symptoms they should take a lateral flow test and record their result online or by calling 119. If it is positive they will be contacted by their local CMDU who will assess them to see if treatment is required. If people are getting better by themselves they will not be prescribed a treatment, so it is important not to underplay any symptoms you are experiencing.
This is the same process for all UK nations and it is possible to receive the drug treatments more than once, should you get Covid-19 again.
Evusheld and other protective treatments
There is a significant amount of interest and concern about the availability of protective treatments, including Evusheld.
David explained that the Department of Health (DHSC) has an active programme of work on the development of potential new medicines that could protect against Covid-19. They share the view of people with kidney disease that prevention is better than cure. Preventative treatments could be a complement to the vaccine programme and particularly important for people who may be less well protected by current vaccines.
David explained that DHSC had carefully assessed the evidence for Evusheld and concluded it may not be effective against current variants. It would therefore not be purchased at this time. Again, NICE are carrying out a full appraisal of Evusheld and this will be completed by April 2023. People with kidney disease can get involved in the consultation once the draft guidance is published early next year. Fiona shared how many people were very disappointed by this decision and emphasised that Kidney Care UK is feeding into the NICE review.
Laurie acknowledged that these are difficult decisions and the concerns of people with kidney disease were reflected in the many heartfelt comments in the webinar chat. She reflected on how this pandemic has really challenged the way that the Government and the NHS make decisions about which drug treatments to buy and the ongoing debates are a reflection of these challenges. Covid-19 is a rapidly changing virus, the drug treatments are expensive and its essential to make evidence-based decisions on how to use the already stretched NHS budget to best protect vulnerable people. But she reassured the audience that Government and NICE are being robustly challenged as to whether they have accepted the correct evidence by patient charities and kidney doctors alike.
Michelle explained that monoclonal antibodies do have a shelf life, which means they will become less effective as the virus changes. This makes it a challenge to produce up to date evidence for the treatments. But she felt it also means prolonged decision making about purchasing the drug is not a viable option. Faster review processes and using data from outside the UK are probably more appropriate and unfortunately it is likely that the NICE appraisal decision would be too late for Evusheld.
What new protective treatments are in the pipeline?
David described a research programme supported by the Government aimed at developing new protective treatments. PROTECT-V is looking at a nasal spray, Niclosamide, and has just started looking at whether a higher dose of Sotrovimab could offer protection. Michelle also highlighted the potential for convalescent plasma, collected from people recovering from the virus, to offer protection for people who do not respond to the vaccine. The Rapid Protection trial is looking at Evusheld and there is also work on how to adapt the vaccines to make sure they offer the most protection as the virus changes. There are no new protective treatments coming into use in the immediate future, but work is ongoing.
Buying Evusheld privately
There were many questions about buying Evusheld privately. Laurie and Michelle expressed their regret that this has been the only way to access this treatment. The panel did not know of any kidney doctors who may be able to assist with a private purchase, although it may be possible to identify an immunology specialist via a local private hospital. Laurie did advise caution before making a decision to buy the drug, because the evidence for the protection offered by Evusheld against current variants is very limited.
Michelle gave an update on the Melody study and thanked all of the patients who had taken part in this important study of vaccine response among people who are immunosuppressed. The study team are aiming to publish a paper on antibody response to vaccines before Christmas. A further paper before Spring will compare antibody test results with Covid-19 infection levels. Understanding how a person’s antibody response affects their chances of infection will be very helpful in future planning for how best to identify and protect the most vulnerable people.
What side effects do the vaccines have?
Clare explained that, like all vaccines, Covid-19 vaccines can have some side effects. The most common were headaches, soreness at injection site and aches and pains. You might like to take a paracetamol before your next vaccine to help with this. Rarely, people can have more serious side effects.
If you have had a more severe reaction to the Covid-19 vaccine you can speak to your GP about referral to a specialist vaccine clinic for subsequent doses, where they will assess whether an alternative vaccine should be used.
Covid-19 vaccines are not live vaccines, you cannot catch Covid-19 from a vaccine and they are safe for people with transplants. There is no evidence that the vaccines can lead to rejection of a kidney transplant.
The vaccines were tested thoroughly before they were licensed and because they followed processes in parallel rather than one after the other, the licensing process was comprehensive but quicker than normal. We also now have lots of data from their use across the world, which helps reassure us of their safety.
How effective are the vaccines?
Michelle explained that people whose immune systems are most suppressed will have less of a response to the vaccine. However, there is now good evidence that each booster dose improves the effectiveness of the vaccines for transplant patients. For most transplant patients, there is still a risk from Covid-19 after vaccination, but the risk of severe illness and hospitalisation is much less.
It is therefore really important to take up all offers of booster. We do not have any evidence yet regarding the new bivalent vaccines specifically and it’s recommended people take which ever vaccine is offered unless you have had a severe reaction to a particular one, in which case you should peak to your GP about referral to a specialist vaccine centre.
There is also good evidence that having a vaccine before immunosuppressant treatment begins is best in terms of protection. Recent transplant recipients who are due a booster should wait around 4 weeks after their transplant operation before having the vaccine.
Future plans for vaccines
There were questions about the future plans for vaccines. It is not possible to confirm what the vaccine schedule will be for 2023, but panellists said it would likely that the Covid-19 vaccine will eventually become an annual vaccine like flu. Multiple vaccines are needed because the immunity created by flu and Covid-19 type vaccines is fairly short-lived, so we have to have repeat vaccines to maintain the protection. This also means the vaccine can be adjusted each year in response to changes in the virus.
Developments in antibody testing were discussed. Michelle explained that the test results are a useful marker of how immunosuppressed a person is. This is important because we know that severely immunosuppressed people (who have not produced any antibodies in response to the vaccine) are at higher risk of becoming unwell with Covid-19. What we do not know is how well protected people who have produced antibodies after the Covid-19 vaccine are.
David gave an overview of government plans around antibody testing. They are keen to see how the tests can be used to support more individualised advice about protection. Test results could also help prioritise the most immunosuppressed patients for future treatments or other interventions. The Department of Health is aiming to launch a pilot study, involving experts from studies like Melody, to find out how NHS antibody testing can best support more individualised understanding of protection and provision of support. Depending on what is learnt from the pilot, the antibody testing programme will be extended during 2023.
Michelle recommended waiting until the next round of vaccines before seeking a test, as the work described above may have progressed, and asking your kidney doctor about testing rather than buying a private test.
What sort of precautions should we be taking now?
Clare explained that Covid-19 is transmitted by droplets, spread by coughing and sneezing, so hand washing and avoiding situations where you are likely to be exposed to these airborne droplets can reduce your risk of catching the virus. She advised you do not need to wipe down shopping.
Now the chances of getting very unwell with Covid-19 are much lower than earlier in the pandemic, we might want to make different decisions about the precautions we adopt. And it’s important to balance restricting our family and social lives, with maintaining our psychological wellbeing. Shielding took a huge toll on people’s mental health.
As Laurie’s data showed, very small numbers of people with kidney disease (including with CKD 4 or 5, on dialysis or with a transplant) who catch Covid-19 now go on to be hospitalised and fewer still are dying. The panel advised that it is the people who are most heavily immunosuppressed who are at most risk of becoming severely ill. People can talk to their kidney doctor about their likely level of immunosuppression. Michelle reminded the audience that people within the first year after transplantation have always been advised to be vigilant about infections and this also applied to Covid-19. Having other long-term conditions can also increase risk.
Reducing time spent in crowded indoor areas is sensible and, when you are inside public places, wearing masks (FFP2 if possible). If you have to travel on public transport, it's best to wear a mask and travel at quieter times.
The panel did not recommend that people lock themselves away, with no contact with others, not least because of the harm this can do to people’s mental health. Where we are now with Covid-19 means that people who have been shielding may decide to start building up their confidence and contact with others, while following some of the precautions described. If there is another peak of Covid-19 cases, high risk people may like to reconsider their level of activity.
Ultimately, what people feel comfortable with in terms of Covid-19 risk is an individual choice and also depends on things like financial and family situation. Laurie recommended the ‘risk budget’ approach, whereby people consider what is most important to them and what is less important. So they may want to attend a family Christmas event but not a work party. If an overseas holiday is really important to someone, they could put their ‘risk budget’ towards this while taking sensible precautions like masking during the flight. But then they could minimise other activities in the period before and after the holiday. Laurie also reminded people that they can consider asking visitors to take lateral flow tests before visiting and keeping away if they have coughs and colds.
Sources of further info:
Dr Michelle Willicombe is a Senior Clinical Lecturer and Honorary Consultant Nephrologist at Imperial College Healthcare NHS Trust, with clinical expertise in transplantation. Her research interest is in the prevention and treatment of antibody-mediated transplant rejection. She is the chair of the British Transplant Society Clinical Research and Trials Committee.
Dr Laurie Tomlinson is a Consultant Nephrologist in Brighton and an Associate Professor of Epidemiology at the London School of Hygiene and Tropical Medicine. Her academic work focuses on using ‘big-data’ to understand renal disease and drug effects. During the pandemic she has worked mainly on Covid-19 research using the OpenSAFELY platform.
Ms. Clare Morlidge is the lead Renal Pharmacist at East and North Hertfordshire NHS Trust. Clare is the President of the UK Kidney Association (UKKA) Multi-Professional Team (MPT) and immediate past Chair of the UK Renal Pharmacy Group (RPG) and was co-editor of their Introduction to Renal Therapeutics reference text. She is a member of the NHSE RSTP AKI workstream and currently sits on the UKKA Patient Information Group.
Fiona Loud has been Policy Director of Kidney Care UK since 2013 and was previously Director of the Kidney Alliance. Fiona is involved with numerous other groups, working to improve standards of care for kidney patients. She has been leading the charity’s policy and campaigning response to the Covid-19 pandemic. Fiona spent five years on dialysis after her kidneys failed, before receiving a transplant from her husband in late 2006.
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