There are 3 key patient issues that I need to bring to your urgent attention.
Kidney patient shielding status (see letter)
Deadline 5pm Monday 13th. All dialysis and transplant recipients and those receiving IS for immunological kidney disease (IKD) can benefit from this (some have included those in advanced kidney care). The central approach has missed many of our patients (circa 50%). Your Trust has a list of those patients on the central list. Your Trust lead for COVID19 needs to send a list of ALL RENAL TRANSPLANT, DIALYSIS & THOSE ON IS FOR IMMUNOLOGICAL KD to ensure none are missed. The lists will likely be on hand to you of your patients-please forward to your Trust COVID lead. I recognise the ridiculous deadline – hope a day later will still be accepted
Acute kidney injury – COVID19
Modelling of peak ITU activity indicates around 1200-1500 patients at same time across England (AKI in 26% ventilated and 3% non-ventilated ITU patients). Estimates of peak ITU activity has been lowered. The RA has worked with NHSE to develop COVID19 AKI prevention guidance for physicians and ITU management which will publish within 2 days. The key message is to maintain euvolaemic NOT overly dry. The latter approach will increase AKI further and severely challenge available capacity. Even at current prediction patient numbers are challenging to machine availability and consumables. Renal services are an important part of this working with ICU partners-will circulate links to guidance ASAP.
- Talk now to your ITU leads to plan for peak AKI capacity
- CVVH protocols to enable minimum 3 patients/machine over 48h
- Review CVVH anticoagulation protocol to address with pro-thrombotic state and save filters
- Link to Regional Renal Emergency ODN leads who will discuss with ITU ODN on regional basis
- Where appropriate and renal nurse staffing allows, consider Int HD support to ITU and allow early discharge. Renal advice and nursing and technical support will be required
Equitable access to ITU for patients with ESKD (dialysis and transplant)
The early phase has created a battle mentality in ITUs. We are aware of several patients declined for ventilation across the UK purely on the basis of ESKD co-morbidity which of course is inappropriate and not evidence based. NICE has produced urgent guidance on critical care admission criteria based on CFS. ESKD survival in general on ITU is similar to the general population. The RA has produced ethical guidance to compliment RCP and NICE . ESKD and COVID19 alone is NOT A CONTRAINDICATION TO ITU admission. Please challenge where appropriate and refer to local Trust Ethics Groups where needed.
We are proud to be part of our renal community who have already taken such a proactive approach and key leadership roles across many Trusts and nationally in this crisis.
Dr Graham Lipkin, President, The Renal Association
Prof Paul Cockwell, Clinical Vice President, The Renal Association
Dr Katie Vinen, Chair, Clinical Services Committee