COVID-19 infection rates in haemodialysis (HD) facilities are extremely high and are attributed to the high burden of comorbidities of HD patients coupled with inability to self-isolate needing thrice weekly attendance for HD treatment. Healthcare workers (HCW) in HD facilities are at risk of occupational exposure to COVID-19. Infection prevention control (IPC) measures were introduced during the pandemic aiming at reducing transmission and occupational exposure risk of COVID-19. Here we describe the results of our baseline and follow up occupational exposure audit in a renal centre in the North West of England following the implementation of a multifaceted IPC bundle.

Background: Patients undergoing haemodialysis (HD) are at higher risk of developing worse outcomes if they contract COVID-19. In our renal service we reduced HD frequency from thrice to twice-weekly in selected patients with the primary aim of reducing COVID 19 exposure and transmission between HD patients.Methods: Dialysis unit nephrologists identified 166 suitable patients (38.4% of our HD population) to temporarily convert to twice-weekly haemodialysis immediately prior to the peak of the COVID-19 pandemic in our area. Changes in pre-dialysis weight, systolic blood pressure (SBP) and biochemistry were recorded weekly throughout the 4-week project. Hyperkalaemic patients (serum potassium > 6.0mmol/L) were treated with a potassium binder, sodium bicarbonate and received responsive dietary advice.Results: There were 12 deaths (5 due to COVID-19) in the HD population, 6 of which were in the twice weekly HD group; no deaths were associated with change of dialysis protocol. A further 19 patients were either hospitalised and/or developed COVID-19 and thus transferred back to thrice weekly dialysis as per protocol. Of 141 eligible patients 113 (80.1%) were still receiving twice-weekly HD by the end of the 4-week project. Indications for transfer back to thrice weekly were; fluid overload (19), persistent hyperkalaemia (4), patient request (4) and compliance (1). There were statistically significant increases in SBP and pre-dialysis potassium during the project. Conclusions: Short term conversion of a large but selected HD population to twice-weekly dialysis sessions was possible and safe. This approach could help mitigate COVID-19 transmission amongst dialysis patients in centres with similar organisational pressures.

Background Screening with cardiac non-invasive stress studies (NISS) prior to listing for kidney transplantation can help in identifying treatable coronary disease and is considered an integral part of pre-kidney transplant evaluation. However, few studies assessed their effectiveness in all patients evaluated for transplantation in clinical practice. To evaluate the role of NISS in pre-kidney transplant evaluation we analyzed their impact prior to waitlisting in 1053 adult CKD-5 patients consecutively evaluated in Greater Manchester, UK during a 6-year period. Methods 918 waitlisted patients were grouped based on presence or absence of Diabetes or Cardio-Vascular Disease (CVD): Group-1 (255 DM-/CVD-/NISS-), Group-2 (368 DM-/CVD-/NISS+) and Group-3 (295 with DM or CVD). Results Group-2 patients had longer ‘time-to-listing’ (5.5months in Group-1 vs 6.9months in ‘Normal-NISS’ vs 9.9months in ‘Abnormal-NISS’, p<0.01) but none with ‘Abnormal-NISS’ needed coronary revascularization before listing. NISS was followed by revascularization in 8 Group-3 patients (3%). In multi-variate analyses, there was no association of NISS on death or MACE in listed patients. During follow up, Transplantation was the most significant factor associated with improved outcomes in all subgroups (HR:0.97, p<0.001). 135 patients were considered unsuitable for waitlisting, with NISS influencing management in 11 of these patients (8%). Conclusions Pre-kidney transplant evaluation with NISS influenced clinical management in 19 of 1053 (2%) patients. Screening with NISS added limited benefit but contributes to significant delays in listing and adding resource implications. Further studies are needed to assess clinical and cost effectiveness of NISS in pretransplant evaluation to optimize outcomes and resources.

We have read with interest the manuscript by Montesinos et al. [[1]Martin C. Montesinos I. Dauby N. Gilles C. Dahma H. Van Den Wijngaert S. et al.Dynamic of SARS-CoV-2 RT-PCR positivity and seroprevalence among high-risk health care workers and hospital staff [published online ahead of print, 2020 Jun 25].J Hosp Infect. 2020; S0195–6701 (30313-3)https://doi.org/10.1016/j.jhin.2020.06.028Abstract Full Text Full Text PDF Scopus (77) Google Scholar] assessing SARS-CoV-2 positivity and seroprevalence in 532 healthcare workers (HCWs) working in a tertiary reference hospital for Infectious Diseases in Belgium. Their study showed that HCWs in direct contact with COVID-19-infected patients did not have increased risk of COVID-19 compared with other HCWs. Similarly, in a recent study in 583 HCWs from a large hospital in Spain, direct contact with COVID-19 cases was not associated with increased risk of COVID-19 [[2]Garcia-Basteiro A.L. Moncunill G. Tortajada M. Vidal M. Guinovart C. Jiménez A. et al.Seroprevalence of antibodies against SARS-CoV-2 among health care workers in a large Spanish reference hospital.Nat Commun. 2020; 11: 3500Crossref PubMed Scopus (250) Google Scholar]. Both studies offer reassurance that personal protective equipment (PPE) measures in accordance with European Centre for Disease Prevention and Control ECDC [[3]European Centre for Disease Prevention and ControlInfection prevention and control and preparedness for COVID-19 in healthcare settings – third update. Stockolm, 2020Google Scholar] provide the appropriate level of protection from COVID-19. Conversely, in an audit of occupational exposure in our haemodialysis (HD) services at a tertiary centre in the North West of England, we noticed increased risk of COVID-19 in HCWs in direct contact with COVID-19-infected patients. This observation highlights the need to evaluate the existing Public Health England PPE guidance [[4]Thomas J. Srinivasan A. Wickramarachchi C.S. Dhesi P.K. Hung Y.M.A. Kamath A.V. et al.Evaluating the National PPE Guidance for NHS Healthcare Workers During the COVID-19 Pandemic.Clin Med (Lond). 2020 May 1; (clinmed): 2020-2143https://doi.org/10.7861/clinmed.2020-0143Crossref Scopus (64) Google Scholar] in HD units that recommends fluid repellent surgical masks and plastic aprons in conjunction with bare below the elbows policy in HCWs treating COVID-19-suspected or -confirmed patients not involved in aerosol-generating procedures [[5]Public Health EnglandGuidance COVID-19 personal protective equipment (PPE) Updated 18 June 2020. Summary of PPE recommendations for health and social care workers.2020https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/886707/T1_poster_Recommended_PPE_for_healthcare_workers_by_secondary_care_clinical_context.pdfGoogle Scholar] instead of ECDC [[2]Garcia-Basteiro A.L. Moncunill G. Tortajada M. Vidal M. Guinovart C. Jiménez A. et al.Seroprevalence of antibodies against SARS-CoV-2 among health care workers in a large Spanish reference hospital.Nat Commun. 2020; 11: 3500Crossref PubMed Scopus (250) Google Scholar] and CDC [[6]Centers for Disease Control and PreventionRecommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection.2020https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.htmlGoogle Scholar] recommended FFP2/3 masks and long-sleeved gowns in similar clinical settings. Our regional renal service covers a population of 1.55 million people and provides in-centre HD for 432 patients in one main and four satellite HD units. At the beginning of the COVID-19 pandemic in the North West of England initially one shift (19th March 2020) and subsequently the whole main hospital HD unit (6th April 2020) was designated for treatment of suspected or confirmed COVID-19 patients receiving HD. HD patients were screened prior to attendance for HD treatment to the satellite units and those with symptoms or with previous contact with COVID-19 cases were transferred immediately to the main unit for COVID-19 nasopharyngeal swab testing, medical assessment and HD treatment. Symptom-free HD patients received HD treatment at COVID-19-negative satellite units. A nursing team of 26 HCWs was assigned to cover the main COVID-19 unit and 48 HCWs were assigned to cover the two of the four satellite units. For the remaining two satellite HD units, nursing workforce is provided and managed by our industry partner and we do not have access to occupational exposure data. The nursing staff was not allowed to move between COVID-19-positive and -negative units from 19th March until 29th June 2020 when our HD programme was reconfigured at the recovery phase of the pandemic. During this period, 58 COVID-19 patients were dialysed at the main unit (including patients on maintenance HD and with acute kidney injury) and 237 patients were dialysed in the two satellite units staffed by nursing HCWs from our department. Public Health England PPE guidance [[5]Public Health EnglandGuidance COVID-19 personal protective equipment (PPE) Updated 18 June 2020. Summary of PPE recommendations for health and social care workers.2020https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/886707/T1_poster_Recommended_PPE_for_healthcare_workers_by_secondary_care_clinical_context.pdfGoogle Scholar] was followed for staff caring for suspected and confirmed COVID-19 patients including surgical masks, plastic aprons, protective eyewear and gloves and there were no issues with PPE supplies. Since 5 April 2020, following UK Renal Association recommendations [[7]PPE and use of masks by dialysis patients. 2020https://renal.org/renal-association-statement-ppe-use-masks-dialysis-patients/Google Scholar], this level of PPE was extended to all staff caring for HD patients (irrespective of COVID-19 status of patients) and all HD patients were advised to wear surgical masks. Nasopharyngeal testing for symptomatic (new continuous cough, high temperature) HCWs was introduced on 30 March 2020. Prior to this date testing was prioritized for patients presenting to the healthcare system with symptoms compatible with COVID-19 infection and symptomatic HCWs were advised to stay at home for 7 days. Amongst the 26 HCWs assigned to work at COVID-19 HD unit, 15 (57.6%) became symptomatic, 6 (23%) were diagnosed with COVID-19 on nasopharyngeal swabs (2 of whom required hospitalization), 3 had negative nasopharyngeal swabs and 6 were not tested with nasopharyngeal swabs because HCW testing was not yet recommended at that period. The dates of symptom onset of the COVID-19 HCWs were 30th March (2 HCWs), 6th April (1 HCW), 8th April (1 HCW), 14th April (1 HCW) and 4th June (1 HCW). Amongst the 48 HCWs covering the two satellite units, 17 (35.4%) became symptomatic, none had positive nasopharyngeal swabs, 4 had negative nasopharyngeal swabs and the remaining symptomatic HCWs were not tested because HCW testing was not yet recommended during that period. Our observations suggest that HCWs caring for suspected or confirmed COVID-19 HD patients are at high risk of COVID-19 with the existing level of PPE. A precautionary approach with enhanced levels of PPE in line with European recommendations [[3]European Centre for Disease Prevention and ControlInfection prevention and control and preparedness for COVID-19 in healthcare settings – third update. Stockolm, 2020Google Scholar,[8]Basile C. Combe C. Pizzarelli F. Covic A. Davenport A. Kanbay M. et al.Recommendations for the prevention, mitigation and containment of the emerging SARS-CoV-2 (COVID-19) pandemic in haemodialysis centres.Nephrol Dial Transplant. 2020; 35: 737-741Crossref PubMed Scopus (215) Google Scholar] should be considered in HCWs caring for HD patients with suspected or confirmed COVID-19 before the emergence of a second wave of the pandemic. The authors have no conflicts of interest to declare. None.