Search

COVID-19, a disease caused by a novel coronavirus, is a major global human threat that has turned into a pandemic. This novel coronavirus has specifically high morbidity in the elderly and in comorbid populations. Uraemic patients on dialysis combine an intrinsic fragility and a very frequent burden of comorbidities with a specific setting in which many patients are repeatedly treated in the same area (haemodialysis centres). Moreover, if infected, the intensity of dialysis requiring specialized resources and staff is further complicated by requirements for isolation, control and prevention, putting healthcare systems under exceptional additional strain. Therefore, all measures to slow if not to eradicate the pandemic and to control unmanageably high incidence rates must be taken very seriously. The aim of the present review of the European Dialysis (EUDIAL) Working Group of ERA-EDTA is to provide recommendations for the prevention, mitigation and containment in haemodialysis centres of the emerging COVID-19 pandemic. The management of patients on dialysis affected by COVID-19 must be carried out according to strict protocols to minimize the risk for other patients and personnel taking care of these patients. Measures of prevention, protection, screening, isolation and distribution have been shown to be efficient in similar settings. They are essential in the management of the pandemic and should be taken in the early stages of the disease., Graphical Abstract Graphical Abstract

1. Evaluation of the patient1.1 Assessment of dry weight1.2 Measurement of blood pressure and heart rateduring dialysis1.3 Cardiac evaluation2. Lifestyle interventions2.1 Sodium restriction2.2 Food and caffeine intake during dialysis3. Factors relation to the dialysis treatment3.1 Manipulation of ultrafiltration3.1.1 Ultrafiltration profiling3.1.2 Blood volume controlled ultrafiltration3.2 Dialysate composition.3.2.1 High sodium dialysis and sodium profiling3.2.2 Dialysate buffer3.2.3 Dialysate calcium3.2.4 Other components of dialysate3.3 Dialysis membranes/contamination ofdialysate.3.4 Dialysate temperature.3.5 Convective techniques and isolatedultrafiltration.3.5.1 Convective techniques3.5.2 Isolated ultrafiltration3.6 Dialysis duration and frequency.3.7 Switch to peritoneal dialysis.4. Antihypertensive drugs and preventive medication4.1 Antihypertensive drugs4.2 Preventive vasoactive agents4.3 Carnitine5. Stratified approach to prevent IDH6. Treatment of IDH6.1 Trendelenburg position6.2 Stopping ultrafiltration6.3 Infusion fluids6.4 Protocol

Guideline 1. Prevalence of malnutrition and outcomeGuideline 2. Diagnosis and monitoring of malnutrition2.1. Diagnosis of malnutrition2.2. Monitoring and follow-up of nutritionalstatusGuideline 3. Recommendations for protein and energyintake3.1. Recommended protein intake3.2. Recommended energy intakeRecommendation 4. Recommendations for vitamins,minerals and trace elementsadministration in maintenancehaemodialysis patients.4.1. Vitamins4.2. Minerals4.3. Trace elementsGuideline 5. Treatment of malnutrition5.1. Dietary intervention5.2. Oral supplements and enteral feeding5.3. Intradialytic parenteral nutrition5.4. Anabolic agents5.5. Other interventions: daily dialysisGuideline 6. Metabolic acidosisAppendices

Department of Renal Medicine, St James’s University Hospital, Leeds, UK, Nephrology Department, Reina Sofia University Hospital, Cordoba, Spain, Division of Nephrology and Dialysis, Bolognini Hospital, Seriate, Italy, Department of Medicine, Division of Nephrology, Ege University Medical Faculty, Izmir, Turkey, Nephrology, Dialysis and Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France, Departement de Nephrologie JE 2411 Denutrition des Maladies Chroniques, Hopital E Herriot, France, Department of Diagnostic and Interventional Radiology, Helios Klinikum Wuppertal, University Hospital Witten/Herdecke, Germany, Medical Faculty University of Cologne, Medicine Clinic I, Hospital Merheim, Germany (retired), Department of Internal Medicine, Division of Nephrology, University Hospital Maastricht, The Netherlands, Nephrology Unit, SM Annunziata Hospital, Florence, Italy, Department of Surgery, University Hospital Maastricht, The Netherlands, Department of Nephrology, Nutrition and Dietetics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK (retired), Department of Medicine, Division of Nephrology, University Hospital, Wurzburg, Germany, Department of Nephrology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands and Nephrology Section, Department of Internal Medicine, University Hospital, Ghent, Belgium

Background. In patients on on-line convective treatments, given the considerable quantity of dialysis fluid re-infused, the small amount of acetate present in bicarbonate dialysis fluid as a pH stabilizing factor may allow a significant transfer of that anion to the patient, possibly inducing cytokine activation. Methods. To verify this hypothesis, we performed on-line haemodiafiltration (OL-HDF) with (3 mmol/l) and without acetate in dialysis fluid in a cross-over randomized order on 12 prevalent patients. Results. In comparison with the pre-treatment values, plasma acetate levels were unchanged during and after acetate-free OL-HDF, while they were 5–6 times higher in the course of OL-HDF containing acetate in dialysis fluid; plasma acetate levels returned to basal values 2 h after the end of the procedure. The total increase of bases in the patient attributable to acetate was 36%. Plasma bicarbonate values at the end of treatment were significantly lower in treatments without acetate, as compared to those with acetate. Interleukin-6 plasma levels were super-imposable at the beginning and in the course of the two methods compared, but there was a tendency towards a greater increase at an interval of 2 h following OL-HDF with acetate. Conclusions. Our preliminary results confirm the assumption that body gain of acetate is particularly high in convective treatments, while acetate-free OL-HDF slows down acetate burden. Clinical advantages due to these effects should be evaluated in properly designed prospective studies.