The COVID pandemic and how it is impacting dialysis care in India

1) Mayoor V Prabhu, MD,DNB(Neph), FASN
Associate Professor of Nephrology
Kasturba Medical College & KMC Hospital, Dr. Ambedkar Circle, Mangalore, India (Manipal Academy of Higher Education, Manipal, India)
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2) Sreedhar Reddy,DNB(Neph)
Consultant Nephrologist
Krishna Institute of Medical Sciences, Hyderabad, India

COVID-19, caused by the SARS-Coronavirus 2 has been sweeping across the globe since 2020 (it was declared a global pandemic by WHO in March 2020). No nation large or small, developed or underdeveloped, rich or poor has been spared from its relentless march. Ranging from an asymptomatic infection to severe respiratory distress, the infection is still a matter of much debate and research, as the medical profession toils day and night to contain it. One year down the line while the disease is still very much being understood and its long-term effects still a matter of conjecture, there is general agreement that patients with systemic illnesses and comorbidities are at higher risk of symptomatic and severe disease, and higher morbidity and mortality. In this regard, patients with kidney disease on dialysis pose a unique challenge to the medical teams. Dialysis requires frequent hospital visits, close interaction with several medical staff, frequent sampling and monitoring, prolonged in-hospital stay in case of Hemodialysis (HD), tend to have more frequent hospitalization, and this poses a high risk of COVID infection. Peritoneal Dialysis (PD) has the unique advantages of being a home-based therapy thereby obviating the need for hospital visits and automatically ensuring social distancing- the cornerstone of breaking the chain of spread of COVID-19. With many parts of the world including India witnessing travel bans and lockdowns, home-based therapies are definitely safer and convenient to the patients and their families. Patients on PD require less exposure to medical personnel, less travel to dialysis facilities thus less need to depend on public transportation, all decreasing the chance of being exposed to the disease. Further encouraging PD as a modality of Renal Replacement Therapy (RRT) in ESRD patients may help preserve supplies and manpower, for patients who require haemodialysis , as explained by Eapen JJ (1). Further, barring the most critically ill patients, PD is also a valid option for AKI in the setting of COVID-19. On 28 March 2020, the International Society of Peritoneal Dialysis published its strategy regarding COVID-19 prevention in PD patients. This statement endorses the strategy of keeping people on PD at home and suggests that hospital visits should be minimized for only urgent indications (such as suspected peritonitis or fluid overload), and that consultations should otherwise be conducted by telehealth (2). In the UK, by 29 April 2020, 2.9% of patients on PD were reported to have contracted COVID-19, compared with 9% of patients on HD (3). As more literature accumulates over time, we might be able to comment more conclusively on these issues.

India is one of the most severely affected countries in the world. Even though India rolled out the world’s largest COVID-19 vaccination programme and covered most of the healthcare workers in early 2020, it still saw a second wave of infections which peaked at more than 400,000 cases per day and a cumulative number of 28 million-plus at the time of writing. The number of daily cases is now around 120,000 per day. This crisis overwhelmed the healthcare system leading to increased mortality. There were infections in healthcare workers which stressed an already overburdened healthcare workforce. Without a doubt, kidney and dialysis care bore the brunt of hospital bed shortages, oxygen shortages, travel restrictions, supply chain interruption, and other logistical issues. Kidney care in India tends to be mostly available in the larger cities and in the private sector. Most patients (more than a quarter) requiring dialysis live as far as 100 km away, and up to 60% live more than 50 km from these centers according to a 2017 study. Prasad N. et al (4) published a paper in KI Reports, which attempted to
evaluate and quantify the morbidity and mortality in ESRD patients who were impacted by COVID-19 pandemic-related service disruptions in public and private hospitals in India. They found that 28% of patients missed one or more sessions of HD, many without informing the Unit. Some patients were advised by the treating nephrologists to reduce dialysis frequency because of accommodating potential dialysis required for the COVID-19–positive patients and curbs imposed by the hospitals. Complete drop-out was noted in up to 4% of patients. This drop-out was more in patients receiving dialysis at public sector hospitals. In some cases, large public sector hospitals were converted in their entirety into COVID care facilities, virtually shutting down long-running dialysis centers temporarily. It was a herculean task to overnight accommodate these patients into other dialysis centers, most of which were in the private sector. Impact on PD services was comparatively less, with very few centers reporting difficulties in procuring essential PD supplies. Unfortunately, PD penetrance in India remains very low compared to HD. India’s IT hubs Bangalore and Hyderabad were among the worst hit by the pandemic. Dr. P Vidyashankar, Head of Nephrology and Transplantation services at Bangalore’s Aster CMI hospital, has completed 150 CAPD catheter insertions under local anesthesia without complications and a cosmetically acceptable technique. He says during the pandemic period he found patients more willing to accept CAPD as therapy given its inherent advantage as a home-based treatment. Many patients (up to 20%) were in NYHA Class 4 and benefited from avoiding general anesthesia (in publication, personal communication). Kidney transplantation services, especially deceased donor transplants, came to a grinding halt in the early days of the pandemic, only to restart gradually over a few months. Many transplant recipients contracted COVID-19 over the past year, but data remains sparse as to the outcomes seen in this subset. Renal care teams including Nephrologists, postgraduates/fellows, dialysis and transplant unit staff also saw infections among themselves, fortunately with low morbidity and mortality.

The COVID-19 Working Group of the Indian Society of Nephrology came up with working guidelines to help PD practitioners in India to handle COVID-19 patients on PD. (5). This included guidelines for PD in AKI, in CKD, and comprehensive guidance for patients, caregivers, hospital visits, supplies, effluent disposal and treatment of COVID-19 in PD patients. As data and experience accumulate, these strategies might be refined further; however, this serves at present as an excellent tool to guide clinicians and patients alike. Going ahead, and with the hindsight gained from our experiences during this pandemic, encouraging PD as a modality of RRT should gain more traction. The inclusion of PD in the National Dialysis Programme is a welcome step in this direction. More public sector hospitals should be encouraged to set up PD programs to help cater to the ever-increasing case load. With the incorporation of remote monitoring technology, quality PD can be offered to patients at an affordable cost with Governmental/ NGO support. PD appears to be a therapy much more convenient and safe during a crisis like this and can help healthcare systems around the world deal better with patients needing RRT in these demanding times.

Competing Interests : None

(1)Eapen JJ. Peritoneal dialysis – ideal renal replacement therapy during coronavirus (COVID-19) pandemic. Indian J Perit Dial 2020;38:11-2.
(2) Cozzolino M,et al. COVID-19 pandemic era: is it time to promote home dialysis and peritoneal dialysis?, Clinical Kidney Journal, Volume 14, Issue Supplement_1, March 2021, Pages i6–i13,
(3) UK Renal Registry: Weekly COVID-19 Surveillance. Report for Renal Centres in the UK. Bristol: UK Renal Registry,2020
(4) Prasad N et al. The Adverse Effect of COVID Pandemic on the Care of Patients With Kidney Diseases in India .Kidney International Reports. Volume 5, Issue 9, September 2020, Pages 1545-1550
(5) Jeloka T, Gupta A, Prasad N, Varughese S, Mahajan S, Nayak K S, Agarwal SK, Abraham G, On behalf of COVID-19 Working Group of Indian Society of Nephrology. Peritoneal dialysis patients during COVID 19 pandemic. Indian J Nephrol 2020;30:171-3