Focus
- Provide guidance on the potential unique aspects of managing acute kidney injury (AKI) requiring renal replacement therapy (RRT) in the COVID-19 patient.
- Anticipate resource requirements and modify staffing, modality and supplies to reflect these changes.
General Considerations
- AKI is associated with increased in-hospital mortality in COVID-19 patients
- AKI requiring RRT in the ventilated critical care patient with COVID-19 related ARDS may be as high as 20-30% (limited data)
- Progression to oliguric AKI and a requirement for renal replacement is common in those who develop AKI in association with COVID-19 in the intensive care unit
- Mechanisms of AKI are poorly understood and may include (but are not limited to):
- Hypovolemia and under-resuscitation early in the disease course
- We recommend adequate initial fluid resuscitation to target euvolemia
- We recommend discontinuation of nephrotoxic medications on admission due to high rates of AKI regardless of admission creatinine levels
- Hemodynamic issues related to ARDS or COVID-19
- vasodilatory shock (sepsis, cytokine storm)
- cardiogenic shock (right heart, left heart, or biventricular failure)
- Thrombotic microangiopathy
- Rhabdomyolysis
- Hypovolemia and under-resuscitation early in the disease course
- Increased demand for acute RRT in critically ill COVID-19 patients is expected to strain dialysis resources and consideration of staffing models and supplies is recommended.
Modality of RRT
- For chronic dialysis patients, we recommend continuing the patient’s baseline modality
- For AKI, hemodialysis modalities are preferred over acute peritoneal dialysis
- Choice of renal replacement modality should be institution-specific based on experience and availability:
- SLED or CRRT may be preferred for hemodynamically unstable patients
- Patients should be transitioned to IHD once hemodynamics will tolerate
- If resource-limited by the availability of dialysis machines, consider acute peritoneal dialysis with catheter insertion at the bedside
Dialysis circuit clotting
- See ANTICOAGULATION
- Higher blood flow rates may also help reduce circuit clotting
- Saline flushes during dialysis may help reduce circuit clotting
- A citrate-based strategy for CRRT modalities in conjunction with therapeutic anticoagulation may also be helpful but requires institutional experience and protocols for safety
- We recommend close follow-up of evolving evidence and guidelines regarding this issue
PPE and Patient Isolation
- Droplet/contact precautions are required for all staff providing renal replacement therapy
- Airborne precautions and N95 masks are not required and should not be worn
- Special attention to hand hygiene is essential
- If available, extended dialysis tubing could permit the machine to sit outside the patient’s room to reduce direct contact with patient. This may only be possible for CRRT modalities and supplies are likely to be limited.