Thank you to everybody who took part in our recent webinar. Questions were submitted in advance, plus some further questions were addressed on the day. These were answered by kidney doctor Andrew Frankel from Imperial Healthcare in Hammersmith, and Nurse Consultant Karen Jenkins from Kent and Canterbury Hospital, supported by kidney doctor Rebecca Suckling from Epsom and St Helier Hospital.
Summary of the discussion
It was explained that although people on dialysis are at very high risk of becoming very ill if they contract Covid-19, there are many things that they can do to reduce their risk of catching the virus. These are generally the same things as for the whole population – reducing the number of people you meet up with, being really careful to keep 2m from people outside of your household/bubble and following very careful hygiene measures.
People’s level of individual risk will vary and it is best to speak to your kidney doctor to understand your own risk. There are a range of factors which increase risk, but having one or two of those risks does not mean you will definitely be at higher risk overall. It is important to note that although being from a Black and Minority Ethnic community is a risk factor in itself, individuals from these communities who are otherwise lower risk (e.g. from a younger age group, no other illnesses) may not be at a higher risk overall.
When it comes to decisions about going back to work or sending children back to school, it’s best to speak to your care team about your individual level of risk and then to the school or employer about what can be done to reduce risk. If you can work from home, it may be best for you to do this. Your employer should carry out a risk assessment before you return, so you can understand what actions they are taking and what actions you can take. The same safety guidance applies at school or work, which means you should keep 2m from others, and you and others around you should follow careful hygiene measures e.g. hand washing, wiping surfaces. Your doctor can write a letter for you to give to your employer about your level of risk and advise of any safety measures they should adopt.
Dialysis units have been working hard to keep patients safe during the Covid-19 outbreak. Some things have changed, for example video/telephone instead of face-to-face consultations, some dialysis schedules and home visits. Only changes that are safe will have been implemented. Things are gradually returning to how they were prior to the pandemic, but staff still have to consider how to keep patients and staff safe. Some of the measures introduced may stay in place and it is likely you will be offered a choice between face to face, telephone or video consultations.
Once a vaccine for COVID-19 is developed, people having dialysis will be a priority group to receive it. However, to date dialysis patients have not been involved in the clinical trials testing the vaccine, so they will need to be carefully monitored after taking the vaccine to check their response to it.
The majority of transplant programmes came to a halt during the Covid-19 pandemic. However, almost all have now re-opened. If a transplant operation may be more complex for you, or you would need to take a higher level of immunosuppressant medication it may not be the right time for you to be active again on the transplant list. You should speak to your kidney doctor about this if you have any concerns.
How does Covid-19 affect the kidneys?
If you have kidney disease you are at higher risk of becoming more ill if you contract Covid-19 and this is particularly true if you are having haemodialysis. If you have no kidney disease, or stable kidney function, Covid-19 can cause deterioration in kidney function or contribute to Acute Kidney Injury.
There are a range of other factors associated with more severe infection with Covid-19. This includes being of the male sex, being from the BAME population (particularly Afro-Caribbean and Asian groups), diabetes, obesity, and an underlying health condition like kidney disease. But having one or two of those risks does not mean you will definitely be at higher risk overall. For example, if you are a younger male from an Afro-Carribbean background, you may be at lower risk than an older male from a white background. It is best to discuss your individual risk with your own doctor.
What can we do to keep safe in the community?
Key things that kidney patients should do are the same as for the general population, for example keeping at least 2m from other people, frequent hand washing, covering your face, using a lanyard or badge to encourage others to keep their distance from you. You should try to avoid being face to face with too many people from outside your own support bubble. In addition, you should keep your indoor environment well ventilated and wash your clothes regularly, particularly if you have been to dialysis.
When thinking about going out to socialise, you should think about whether the environment you are going to is Covid 19 -secure and if it is not, you should consider whether you really need to go there. You should carefully follow rules about socialising indoors and these vary between UK countries and in areas where there are local lockdowns. It is probably not a good idea to stay overnight with people from outside your bubble.
In terms of hugging other people, it is probably safe if they are in your bubble. If they are not then take care and make sure you follow hygiene measures and wash your hands. You should also think about the number of people they may have seen recently and where they have been, and whether this has increased their risk of transmitting the virus.
What are renal units doing to keep patients safe?
Units are putting lots of things in place and staff are working really hard to keep patients and themselves safe. National recommendations are in place to provide guidance for local units. Things that have been done include; enhanced cleaning; enforcing social distancing measures where possible; reducing traffic in waiting areas; staggering appointment times; moving dialysis machines to increase distance between patients. Regular testing is also being undertaken. Patients with suspected or confirmed Covid-19 are isolated in specific areas and staff wear additional Protective Personal Equipment when treating these patients.
It is important to remember some dialysis patients may not wear masks because they are not able to, so we all need to be understanding of this. People having dialysis should follow careful hygiene measures. People coming into dialysis units need to wash their hands before entering the unit and should sanitise their hands before and after eating. If you observe any behaviours that could potentially increase risk, for example staff not following social distancing or hygiene measures, then you should talk about this to your unit staff.
Would it be better for dialysis patients to wear FFP3/N95 masks?
The higher specification masks are for medical staff and are used in areas where aerosol generating procedures take place, for example, when a patient has a procedure in hospital. Fluid resistant surgical masks, such as those given out by dialysis units, are safe for patients in normal circumstances.
Is it safe to change dialysis schedules?
It was necessary to change dialysis sessions for many people and patients were incredible flexible about this, which was very helpful. One of the reasons was that many units had to create specific dialysis areas for patients who had tested positive for Covid-19. Schedules were also changed so that contact between patients could be reduced. Moving to twice-weekly dialysis was primarily for people with residual kidney function who had recently started dialysis, and for whom twice-weekly sessions were safe. Some units were already doing twice-weekly sessions for this group of people, with incremental increases as needed. All units have now reverted to normal sessions, unless they are adopting incremental sessions for people starting dialysis.
Impact on healthcare
During the Covid-19 outbreak, renal teams have looked at how to reduce face-to-face contact between patients to keep them safer. A key way to do this is by reducing face-to-face clinic appointments. Video consultations have some advantages for patients and for the health service. Therefore, this is likely to continue, where it is appropriate. Patients should have a choice between video or face to face consultations. Renal Units will take a few months to resume full services, but the new normal is likely to include more video consultations where appropriate. Patients must still get the attention that they need, whether that is face to face or over video.
Is it safe to have a transplant now or could it be safer to stay on dialysis?
Initially most transplants were halted as clinicians did not know how risky it would be during the Covid-19 outbreak. However, most units are now re-opening. You should discuss with your care team about whether it is appropriate for you to be reactivated on the transplant list and whether it would be safe for you to receive a donor organ tomorrow. If you are likely to need lots of immunosuppression or are likely to have a more complex operation (e.g. because of obesity or cardiovascular problems) it may still be too risky for you to have a transplant. But if you do not have these additional concerns it is likely to be safer for you to receive a transplant than stay on dialysis, if an organ became available.
Should community nurses still visit home haemodialysis patients to take blood?
Practise is likely to vary across the country. Some patients may take their own blood samples, which are collected by courier and taken to hospital. Others are visited by nurses. More remote monitoring of home dialysis patients was introduced during the Covid-19 outbreak, but it was still important that patients did not feel isolated. It is now important to try to return to usual practices, while balancing this with safety. If nurses have to visit a large number of patients this may increase the risk of transmitting the virus, so local teams may still need to adjust how they work to make sure they keep patients and staff safe.
Would you consider home dialysis at this time?
There may be benefit from not having to go into the unit, but starting home dialysis will require training which will require home visits from staff or trips to the hospital. Overall, the same options should be available as normal. The level of Covid-19 infection of people on home dialysis was significantly less than people receiving in unit dialysis, so you may like to consider this when making a choice about types of dialysis.
Is it safe for children of kidney patients to go back to school?
There is no clear-cut answer to this. One of the key things is that you need to have a discussion with the school to see what they are doing to reduce risk. This should be in line with the published government guidance. If there are any adjustments that you need to make, or you would like the school to make, then you can discuss with the school. Younger children will be in bubbles with a certain amount of pupils, which they stay in for lesson and for playtime. This will limit the number of children that interact together. Other measures that schools should put in place include staggered start and finish times to reduce number of people at drop off and pick up times. They should also make sure children are washing their hands regularly and implementing an enhanced cleaning regimen in the school. When children return from school they should shower and wash their clothes. When you are travelling to and from school you should be careful about taking measures such as wearing a face mask and keeping 2m away from others.
Returning to work
Everyone is entitled to a risk assessment with their employer. The advice is still that you should work from home if your workplace cannot be made Covid 19-safe.
Can dialysis patients go back to work before the UK is at phase-4?
Patients should consider how safe their specific job and the environment could be. They need to consider their individual risk. They should have a discussion with their kidney doctor to help their decision-making. Doctors will also be able to write a letter for their patients to show to employers, outlining their individual risk. More information on this is available from the Kidney Care UK website or directly via the Renal Association. Employers must take action to try to minimise direct contact with the public. This could be using things like screens and implementing careful cleaning.
Teachers need to have a very serious discussion with their occupational health department and their school, to try to minimise numbers of people they are seeing, they should be in well-ventilated room, wash hands regularly and be careful about meetings held outside of teaching time. If you can go to and from work by your own means that is likely to best. However, if you cannot you should try to travel outside of rush hour, so you can keep your distance. You should avoid touching anything if possible and sanitise your hands before and after travelling. It is best not to travel at rush hour when you cannot avoid contact with others.
Is the risk greater for haemodialysis (HD) than peritoneal dialysis (PD)?
PD patients got fewer infections because they could properly shield, because they didn’t have to go into dialysis units. However if PD patients acquired Covid-19 their risk of becoming more seriously ill is probably the same as for haemodialysis patients.
Vaccines and antibodies
Dialysis patients will be offered the COVID-19 vaccine, although to date they have not been included in the trials for the vaccine so we need to understand firstly whether dialysis patients will react in the same way. So once it comes out, it is recommended that you have the vaccine and then your doctors will monitor how you respond to it. You should get the annual flu vaccine early, to make sure you do not get seasonal flu.
Having a negative antibody test does not mean you have not had Covid-19, particularly because if you are having haemodialysis then you may be less likely to produce antibodies. Many people who contract Covid-19 do not get symptoms, or get a mild illness. However, we do not know why there are differences in the way people respond to a Covid-19 infection.
You need to think carefully about risk and whether the risk is higher in the country you are thinking of travelling to. You should also talk to your kidney doctor about your own individual risk. If you do dialyse in another unit, in the UK or abroad, you will have to be isolated within your own unit when you return home.
Exercise during dialysis
This depends on the type of exercise. Gentle cycling may be OK, rather than heavy exercise that promotes heavy breathing. It is best to talk to your local unit and see what they have in place.
Should I be shielding before a live donation?
Most units will have a policy for people who have a planned living donation, which they will share with their patients about before the transplant. You should be very careful to reduce contact with others, and should also be careful when coming in for dialysis. Your children should continue to go to school, but you need to be extremely careful about taking all the measures that can reduce risk – washing hands, changing clothes on return from school.
To keep up to date with Covid-19 please go to www.kidneycareuk.org/coronavirus
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