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New York hospital systems that have recently found themselves scrambling to get adequate supplies of ventilators for COVID-19 patients are now facing another urgent shortage, this time of equipment and staff required to treat patients suffering from acute kidney failure.
“I don’t think it’s widely known [in the public] that beyond the problem of respiratory failure requiring placement on a ventilator, close to a third of those patients who end up on a ventilator end up needing dialysis,” said Dr. Donald Landry, chairman of the Department of Medicine at Columbia University. “That turns out to be a rather gigantic dialysis need. So it’s placing a strain on resources.”
“We were [recently] over 200% of our typical operating volume” for dialysis patients, said Mount Sinai Hospital clinical director Joji Tokita, who oversees dialysis in the New York medical center. “It’s a huge statement that we were even able to accommodate that,” Tokita said. “As much dialysis as we would like to give under normal circumstances, it’s not possible. We can’t do that. I don’t think anyone can.”
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Last week, Dr. Jai Radhakrishnan, a Columbia University professor of medicine, tweeted out an urgent plea for volunteer dialysis nurses and Continues Renal Replacement Therapy dialysis machines, citing “Dire straits in NYC!!”
This means that while New York officials and hospitals have mobilized to address the shortage of ventilators needed to treat patients with coronavirus, facilities throughout the state may not be properly equipped to deal with kidney problems and renal failure, a critical component of treatment for many of the most severely afflicted patients.
In his news conference on Thursday morning, when asked about the concern over dialysis equipment, Gov. Andrew Cuomo said, “If any hospital has a shortage of anything on a daily basis, they let us know and we’ve been able to find that equipment for them, so that nobody has an actual shortfall.”
Treating kidney failure alongside COVID-19
Patients seriously ill with COVID-19 run a relatively high risk of developing kidney failure, part of a larger pattern of organ failure as the disease advances and deprives the body of oxygen.
“We have a large number of patients who have pretty advanced [COVID-19-related] kidney injury, and multi-organ failure,” Tokita said. “Patients come in with shortness of breath, become acutely hypoxic, and other organs start to fail. And a high number of patients, if they’re that sick, require some form of kidney replacement or dialysis.”
The level of treatment required for renal failure can quickly add an additional strain to hospital resources. “In order to do dialysis, you have to put a line in the patient, and put them on a machine,” Tokita said. “And that has to be done by a nurse that’s at the bedside for the duration of the treatment for safety reasons. That’s a bottleneck right there.”
And even as the number of coronavirus patients needing ventilators eases up, there could still be an increase in patients requiring dialysis.
“A lot of patients develop that need [for dialysis] a week or two into hospitalization,” said Dr. David Charytan, division director of Nephrology at NYU Langone Health.
“I think the number of patients and the need for ventilators will go down more quickly than the need for dialysis. And the need for dialysis may continue to grow for a little while.”
The upside is that by all indications, no patients in need of dialysis treatment in New York hospitals have been unable to receive it. “Everyone has gotten what they need and met the needs of their patients,” Landry said. “And yet we think that this is something that the powers that be should be aware of because we’re not out of it yet.”
Concern over not just shortage of equipment but also staff
In addition to being time intensive, treatment for renal failure requires specialized equipment with parts that aren’t necessarily compatible with every machine, making it potentially harder to source and produce than ventilators.
“You have just two major companies that provide [dialysis] machines for ICU patients, each with specific tubing and cartridges that are unique for each machine,” said National Kidney Foundation president Holly Kramer. “If they run out of tubing, it has to be the right type to fit the machine. And in patients with COVID-19, their blood clots very easily, and can clot the tubing when you’re doing dialysis. Then you have to get all new tubing and cartridges.”
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All of which means that an already tight supply of dialysis equipment in the medical system is facing enormous amounts of strain. “The Department of Health and Human Services is working on it, but it’s a complicated issue,” Kramer said. “It wasn’t like we had excess supplies across the country. It’s always been just enough, and even on a normal day you might be squeezed. So this is really stressing our supply of machines and personnel.”
As a stopgap, hospitals are finding ways to ration supplies and offer slightly shorter rounds of treatment. “A lot of global and national kidney authorities have endorsed things like shortening treatment a little bit,” Tokita said. “You have a small amount of time and want to take care of as many people as you possibly can. It’s understanding where we can optimize the therapy.”
While dialysis machines are badly needed, the more urgent shortage may be of the medical professionals who specialize in treatment for kidney-related ailments.
Staffing “is the biggest need, it’s probably a bigger issue than the equipment,” Kramer said. “You’re dialyzing more and more people with the same number of nursing staff. I think we really need more federal support and training of more dialysis nurses and professionals in nephrology.”
Tens of thousands of volunteer health-care workers have signed up to aid New York in its battle against the virus, but no data is publicly available on how many of those nurses or specialists are trained to work with dialysis machines or to treat patients suffering from renal failure.
With New York City hospitals still at the apex of the crisis and short-handed on both equipment and personnel, Tokita said, “even if a small fraction of patients are admitted to the ICU and a small fraction of those require kidney replacement, it’s still a high number, and multiple hospital systems across the Tri-State area are stretched beyond capacity.”
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The strain on the supply chain has already caused some hospitals to come close to running out—and in some cases, to temporarily run out—of dialysis supplies.
“All of us across the city are similarly constrained and have resorted to techniques we wouldn’t normally use to extend capacity, and have at times come close to running out, or run out for 12 hours or something like that,” Charytan said. “That, or they don’t have a long-range supply that’s guaranteed. And by ‘long range’ I mean a week or 10 days, not two months.”
