British Renal Society and Renal Association position statement on resumption of renal services during and after the COVID-19 pandemic
With rising rates of COVID-19, some hospitals are stopping all elective procedures and surgery in order to support emergency admissions. In other parts of the country, hospitals are prioritising a back log of surgical cases that accrued during the first COVID-19 wave.
Whilst we recognise the difficulty of these choices and the need to focus care, we are writing to emphasise that time-critical procedures and surgery for patients with kidney disease should continue.
Although some of these procedures are classified as elective, they are often urgent and have significant implications for patient survival if delayed. Guidance has been provided by NICE and this remains active.
We therefore propose the following best practice recommendations supported by the Renal Societies and the Clinical Reference Group:
Establishing definitive treatment for management of end-stage kidney disease by dialysis treatment
NICE recommends that organisations should maintain procedure lists for creating access sites for patients with advanced chronic kidney disease who need to start haemodialysis or peritoneal dialysis. This should include:
- Vascular access surgery to form an AV fistula or AV graft, to enable patients with advanced kidney disease to begin dialysis safely. The creation of this type of access is associated with lower rates of infection and hospital admissions and extended patient survival compared to the alternative placement of a semi-permanent dialysis line.
- Lifesaving placement of peritoneal dialysis catheters which allows patients to start dialysis and begin a home-based dialysis treatment sparing them the increased COVID-19 risk that can be associated with frequent visits to dialysis units.
Managing the complications of vascular access
Kidney services should have access to a 7-day a week interventional radiology service, with surgical support, for the urgent treatment of vascular access complications such as fistula or graft thrombosis, critical fistulas or graft stenosis. These are life-preserving treatments for the maintenance of vascular access in patients with end-stage kidney disease.
Ensuring the sustainability of kidney transplantation
All kidney transplant services were re-opened following the first wave of the COVID-19 pandemic. Kidney transplantation remains a time-critical and life-extending treatment for many patients with end-stage kidney disease. The impact of kidney transplantation on survival for patients who are medically fit for a kidney transplant is profound.
We recommend that all kidney transplant units are following the guidance provided in the COVID-19 NICE guidance with a focus on ensuring that all patients who are medically fit for transplantation are able to continue to access kidney transplantation as the preferred treatment for end-stage kidney disease.
This may require close working between transplant units and their provider organisations in centres with high COVID-19 rates through the winter of 20/21.
Investigation of kidney disease
Ensure access to time-critical diagnostic procedures for the investigation of high-risk kidney disease.
Renal services should continue to have access to and perform urgent kidney biopsies for conventional time-critical criteria; for example, diagnosis of causes of acute kidney injury, nephrotic syndrome, accelerated chronic kidney disease, kidney transplant dysfunction where knowledge of disease process is time-critical for the institution of a life-preserving treatment.
Life-changing diagnostic kidney biopsies allow reversible causes of kidney damage to be identified and treated promptly to enable preservation of kidney function and avoidance of end-stage renal failure.
Managing kidney disease
Kidney services should have 7-day access to time-critical interventions for the treatment of kidney disease including:
- Interventional radiology for the management of renal tract obstruction as a cause of acute kidney injury
- Plasma exchange for standard clinical indications (e.g. anti-GBM disease; antibody mediated kidney transplant rejection)
- Infusion services for the management of rapidly progressive glomerulonephritis by cyclophosphamide and biologics.
Visibility of the importance of services in COVID-19 surge and recovery planning within Trusts
- The importance of maintaining outpatient review (remote where possible but face to face in some cases) to identify patients who require these interventions.
- The importance of protecting skilled surgical and radiology staff against redeployment so that they are able to offer these procedures.
- The importance of maintaining inpatient capacity, theatre capacity and radiology capacity to support this group of patients. As many of these patients fall into the clinically extremely vulnerable groups, we highlight the need to provide green pathways for these patients, including by use of the private sector, where needed.
- The importance of recognising that emergency surgical and radiological interventions in some patients who are relatively well but are COVID-19 positive. Trusts should ensure the sustainability of pathways to support such patients so that vital procedures remain deliverable.