The world is facing an escalating pandemic unlike anything we’ve seen in our lifetimes. Hospitals from Elmhurst, New York, to Albany, Georgia, are overflowing with coronavirus patients desperately gasping for breath, while the death rate soars in Italy, Spain, and other countries.
But the threats to health go far beyond the direct victims of the virus. Heart disease patients are having life-saving procedures postponed or canceled, while those injured in crashes face critical shortages of hospital beds and intensive care rooms. And perhaps no single group of Americans is larger or more dangerously at risk than the 500,000 people in the United States who depend on a treatment called dialysis.
With their kidneys failed, these patients typically must travel to dialysis centers several times a week to have their blood taken out, cleansed of the toxins normally removed by kidneys, and returned to the body. Already frail and usually elderly, they are especially vulnerable if they get the virus. Yet their potential exposure is also much greater than average, because they usually must sit for hours in groups of a dozen or more for dialysis center treatment. They are sitting ducks for the virus.
Moreover, dialysis requires more than just blood cleansing. Patients also need access points put in their bodies that allow blood to be withdrawn and replaced. This often entails placing a catheter in a vein or joining an artery and vein together in what’s known as a fistula, to create a blood vessel strong enough to be tapped every few days. Those access sites traditionally have required surgery, along with regular maintenance and replacement. This means more risky visits to overburdened medical facilities.
I’ve heard the fear in patients’ voices as they grapple with a stark no-win choice: Risk infection by continuing treatment, or stay sheltered at home and get sicker and sicker.
Dialysis, for these patients, is required for life. Yet already, many dialysis patients are skipping treatments in response to the advice from government leaders to stay home. The tragic example of Puerto Rico after Hurricane Maria, where dialysis services were both severely affected and given low priority in emergency plans, shows us that the lack of treatment quickly causes mortality to soar.
The threat to patients’ health from the current pandemic became even more dire in mid-March when the Centers for Medicaid and Medicare Services issued an otherwise well-intentioned guidance to hospitals to stop all “nonessential” procedures. Unfortunately, CMS lumped dialysis access care in with obviously elective surgeries like breast enlargement. That threw the whole field into chaos. I’ve been spending many hours trying to help frantic people get their catheter placements rescheduled after their hospitals dumped them. It’s been heart-rending.
Fortunately, the kidney care community quickly snared an emergency meeting with CMS Administrator Seema Verma and her staff to press the urgent case that procedures to access blood vessels are, in fact, essential. On March 26, CMS agreed. Now comes the hard work of convincing hundreds of hospitals and medical centers to follow that crucial clarification and to reopen for those in need.
My main message to kidney patients is to stay home as much as you can, but please, also continue your dialysis treatments. Your lives depend on it. The entire community, from dialysis centers and nephrologists to organizations such as the National Kidney Foundation, is working to make that possible by providing safe transportation to patients, offering childcare and more masks and protective gear so that staff can keep working, and much more.
We are also exploring procedures (placing catheters or creating fistulas) outside of hospitals, such as in ambulatory surgery centers or in office-based access centers. And we can speed the adoption of innovative new technologies and approaches. For example, instead of requiring surgery and a hospital setting, an artery and vein can now be fused into a fistula using a needle, catheter, and heat to open up and then merge the blood vessel walls in a simple 30-minute procedure that can be done outside of a hospital. Meanwhile, telemedicine and smartphones can enable doctors to check on those access sites.
I’m realistic about the enormous magnitude of the crisis we are facing. Patients with renal disease will die of the virus. Others will die prematurely because they can’t continue with their treatment. We may even need to make the agonizing choice of rationing dialysis here in the U.S., giving priority to those with longer life expectancy and better expected outcomes.
But as I see the kidney care community truly band together to face this crisis, I hold out hope that we’ll not only survive, but that the steps we take toward new technologies and more home care eventually will create a better, safer future for those suffering from end-stage renal disease.
Terry Litchfield has worked to improve outcomes and disease management for patients with renal disease for more than thirty years.
