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COVID-19: Issues related to end-stage kidney disease

COVID-19: Issues related to end-stage kidney disease
Literature review current through: Jan 2024.
This topic last updated: Aug 02, 2023.

INTRODUCTION — At the end of 2019, a novel coronavirus was identified as the cause of a cluster of pneumonia cases in Wuhan, China. Subsequently, the infection has spread throughout the world, resulting in a global pandemic. The coronavirus is designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the illness it causes is coronavirus disease 2019 (COVID-19).

Patients with end-stage kidney disease (ESKD) have been disproportionately impacted by the pandemic due in part to their burden of comorbidities, and a wide variety of strategies have been developed to mitigate the effect of COVID-19 on this vulnerable population. With the widespread use of vaccinations, availability of antiviral therapy, and the emergence of less pathogenic variants of SARS-CoV-2, many of these strategies are no longer needed. However, it is possible that virulent cases of COVID-19 may surge again in the future. In addition, the response to the COVID-19 pandemic will inform the management of future outbreaks of severe respiratory disease in patients with ESKD.

This topic will discuss issues related to COVID-19 and delivery of nephrology care to patients with ESKD. Issues related to care of other types of patients with kidney disease are discussed elsewhere. (See "COVID-19: Issues related to solid organ transplantation" and "COVID-19: Issues related to acute kidney injury, glomerular disease, and hypertension".)

Other important aspects of COVID-19 that may affect this population are discussed at length elsewhere:

(See "COVID-19: Epidemiology, virology, and prevention".)

(See "COVID-19: Clinical features" and "COVID-19: Diagnosis".)

(See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

(See "COVID-19: Management in hospitalized adults".)

(See "COVID-19: Management of the intubated adult".)

(See "COVID-19: Myocardial infarction and other coronary artery disease issues".)

EPIDEMIOLOGY

Vulnerability of patients with ESKD – Patients with end-stage kidney disease (ESKD) are particularly vulnerable to severe COVID-19 due to the older age and high frequency of comorbidity, such as diabetes and hypertension, in this population [1-6]. Of the patients with ESKD, patients who receive dialysis at home, either hemodialysis or peritoneal dialysis, may be at a lower risk of developing COVID-19 compared with patients receiving in-center hemodialysis [7-10]. This was demonstrated in one study in which patients receiving in-center dialysis had an approximately twofold greater risk of infection compared with patients receiving home dialysis [8]. In another study of 818 patients on peritoneal dialysis who were followed for four months, eight patients (0.9 percent) were diagnosed with COVID-19 after measures to limit exposure were instituted [9], a rate much lower than that reported among patients on in-center hemodialysis. In addition, in the United States, hospitalizations related to COVID-19 were three- to four-fold greater among patients receiving hemodialysis compared with patients receiving peritoneal dialysis [10,11].

Patients with ESKD may also be at an increased risk of dying from COVID-19. In one study, for example, nearly one-third of hospitalized patients on dialysis with COVID-19 died [4]. In another study, one-half of critically ill patients on dialysis died within 28 days of admission to the intensive care unit (ICU) [5]. The overall mortality among patients on dialysis with COVID-19 was 20 percent or greater in three large studies [7,8,12]. A mortality rate of up to 32 percent was reported in a study from an area where regional prevalence of COVID-19 was high [13]. Mortality rates among ESKD patients in 2020 exceeded the rates of these patients in prior years, presumably due to additional deaths related to COVID-19 [10,11,14]. In the United States, for example, between February and August 2020, an estimated excess of 9 to 13 deaths occurred per 1000 ESKD patients [14].

Prevalence – The reported prevalence of COVID-19 among patients receiving in-center hemodialysis is higher than but largely mirrors the general population within a given region [8,15-18].

Later stages of the pandemic – As the pandemic evolved, subsequent studies of COVID-19 in ESKD reported an overall decline in morbidity and mortality. For example, in one study of over 100 patients with ESKD who developed COVID-19 during the Omicron surge, 81 percent had been vaccinated, 78 percent had no or mild symptoms, 9 percent had moderate symptoms, and 12 percent had severe symptoms [19]. Six patients required intensive care admission, two of whom required mechanical ventilation. Five patients died; one was directly attributed to COVID-19 and four to preexisting comorbidities.

OUTPATIENTS — Issues and practices related to COVID-19 among patients with end-stage kidney disease (ESKD) differ depending upon where they receive dialysis (eg, in-center versus home dialysis) and have evolved over the course of the pandemic.

Patients receiving in-center hemodialysis — The American Society of Nephrology (ASN) and International Society of Nephrology (ISN) issued interim guidelines and a list of resources to guide nephrology clinicians providing life-sustaining dialysis care [20,21]. These resources continue to evolve and are frequently updated. At a minimum, all dialysis organizations are urged to follow the recommendations from these guidelines. Some dialysis organizations may choose to follow additional measures to protect the health care staff and patients, depending upon their access to personal protective equipment and other resources [6].

Early recognition/isolation of individuals with respiratory symptoms — Outpatient dialysis facilities should, at minimum, heed the following guidance [22,23]:

Implement nonpunitive and flexible sick leave policies that permit ill health care personnel to stay home. Health care personnel should be reminded to not report to work when they are ill.

Identify patients with signs and symptoms of respiratory infection (eg, fever, cough) before they enter the treatment area.

Instruct patients to call ahead to report fever or respiratory symptoms so the facility can be prepared for their arrival or triage them to a more appropriate setting (eg, an acute care hospital).

Patients should inform staff of fever or respiratory symptoms immediately upon arrival at the facility (eg, when they check in at the registration desk).

Patients with symptoms of a respiratory infection should put on a facemask at check-in and should wear it until they leave the facility.

Provide patients and health care personnel with instructions (in appropriate languages) regarding hand hygiene, respiratory hygiene, cough etiquette, and use of face coverings.

Instructions should include how to use facemasks, how to use tissues to cover the nose and mouth when coughing or sneezing, how to dispose of tissues and contaminated items in waste receptacles, and how and when to perform hand hygiene.

Signs should be posted at clinic entrances with instructions for patients to alert staff so appropriate precautions can be implemented for patients who have a fever or symptoms of a respiratory infection.

Position hygiene-related supplies in close proximity to dialysis chairs and nursing stations to enable adherence to hand and respiratory hygiene. These supplies include tissues and no-touch receptacles for disposal of tissues as well as hand hygiene supplies (eg, alcohol-based hand sanitizer).

Patient placement — During surges in cases of COVID-19, outpatient dialysis facilities should, at minimum, heed the following guidance:

Provide sufficient space in waiting areas for patients to sit separated from other patients by at least six feet. Medically stable patients might opt to wait in a personal vehicle or outside the health care facility where they can be contacted by mobile phone when it is their turn to be seen.

Patients with respiratory symptoms should be brought back to an appropriate treatment area as soon as possible in order to minimize time in waiting areas.

If possible, facilities should maintain at least six feet of separation between patients. If not possible, then six feet of separation should be maintained between masked, symptomatic patients and other patients during dialysis treatments. Ideally, symptomatic patients would be dialyzed in a separate room (if available) with the door closed.

-Hepatitis B isolation rooms should be used for patients on dialysis with symptoms of respiratory infection only if the room is not needed to dialyze a hepatitis B infected patient.

-If a separate room is not available, masked patients should be dialyzed in corner or end-of-row stations and be separated from other patients in all directions by at least six feet.

Personal protective equipment — In general, health care personnel caring for patients with undiagnosed respiratory infections should follow standard contact and droplet precautions with eye protection unless the suspected diagnosis requires airborne precautions (eg, tuberculosis). This includes the use of [23]:

Gloves.

Facemask.

Eye protection (eg, goggles, a disposable face shield that covers the front and sides of the face). Personal glasses and contact lenses are not considered adequate eye protection.

Isolation gown.

-The isolation gown should be worn over or instead of the cover gown (ie, laboratory coat, gown, or apron) that is normally worn by health care personnel. If the supply of such gowns is low, then they should be prioritized for the initiation and termination of the hemodialysis treatment, manipulation of access needles or catheters, and for aiding the patient into and out of the station. They should also be used for cleaning and disinfection of patient care equipment and the dialysis station.

-When gowns are removed, place the gown in a dedicated container for waste or linen before leaving the dialysis station. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use.

Testing for COVID-19 — Testing should be performed in patients who present with symptoms concerning for COVID-19 or at the discretion of the nephrologist. Outpatient dialysis facilities should incorporate on-site SARS-CoV-2 testing using approved nucleic acid or antigen detection assays, when possible. This can significantly aid rapid identification and isolation of cases, thereby reducing the transmission. If on-site testing is not feasible, dialysis units should identify a local laboratory to which patients can be referred should they need testing. Health care personnel caring for a patient being tested should use the same personal protective equipment and other precautions as they would for patients who are positive for SARS-CoV-2, until the results are confirmed to be negative. (See "COVID-19: Evaluation of adults with acute illness in the outpatient setting", section on 'Ensure early diagnostic testing'.)

Additional measures for COVID-19 — When COVID-19 is suspected or confirmed in a patient receiving hemodialysis at the facility, the following additional measures apply:

If a hemodialysis facility is dialyzing more than one patient with suspected or confirmed COVID-19, an attempt should be made to cohort these patients, as well as the health care personnel caring for them, together in the same section of the unit and/or on the same shift (eg, schedule all such patients for the last shift of the day). If the etiology of respiratory symptoms is known, patients with different etiologies should not be cohorted together; as an example, patients with confirmed influenza and COVID-19 should not be cohorted together.

The health department should be notified about the patient.

Health care personnel should follow the Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings. This includes recommendations on personal protective equipment. Routine cleaning and disinfection are appropriate for COVID-19 in dialysis settings. Any surface, supplies, or equipment (eg, dialysis machine) located within six feet of symptomatic patients should be disinfected or discarded.

Products with Environmental Protection Agency (EPA)-approved emerging viral pathogens claims are recommended for use against SARS-CoV-2. Refer to List N on the EPA website for EPA-registered disinfectants that have qualified under EPA's emerging viral pathogens program from use against SARS-CoV-2.

When using products from List N, facilities should ensure the products also have a bloodborne pathogen claim (eg, hepatitis B, HIV).

Patients receiving home hemodialysis or peritoneal dialysis — During surges in cases of COVID-19, our approach to patients receiving home dialysis is as follows:

In general, during surges of COVID-19, patients receiving dialysis at home (ie, home hemodialysis or peritoneal dialysis) should have their regular follow-up visits by telemedicine or in-person, depending upon their health, the regional prevalence of COVID-19, and their personal risk of acquiring COVID-19. In addition, home visits by health care professionals should be minimized. These practices may be modified once patients and health care professionals are vaccinated or when local disease prevalence is low.

Patients should have at least two weeks of dialysis supplies and sufficient medications in case they have to self-isolate, or in case there is a break in the supply chain (eg, due to delivery staff sickness).

Staff nurses should communicate with patients frequently to distinguish and handle the most dangerous and severe cases in a timely manner and by referring patients to the emergency department, when appropriate. Unexpected or emergency visits to the clinic should be avoided as much as possible. With widespread availability of SARS-CoV-2 testing sites, patients should be encouraged to undergo testing if they develop any symptoms suggestive of COVID-19.

However, patients occasionally may need to be seen in person for various issues (eg, home hemodialysis training, suspected exit-site infection, suspected peritonitis) during a surge of COVID-19 cases. If an in-person visit is clinically indicated in this setting:

Attempt to limit transmission of SARS-CoV-2 in patients with suspected or documented COVID-19. This includes early identification and isolation of patients with suspected disease, as well as the use of appropriate personal protective equipment. A detailed discussion of infection control practices for the health care setting is presented separately. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the health care setting'.)

Attempt to limit the number of patients seen in-person during a given day in order to avoid crowded waiting areas and to minimize contact.

Minimize nonessential procedures in order to reduce unnecessary patient contact. In the peritoneal dialysis unit, for example, procedures such as peritoneal equilibration test (PET) testing and clearance measurements may be performed depending upon the regional prevalence of COVID-19 and local institutional policies. Deferring such testing early in the course of the pandemic was common. However, due to the prolonged course of the pandemic, the risk of COVID-19 exposure needs to be weighed against the potential for inadequate treatment by continuing to defer such testing.

The procedures that are necessary for placement and maintenance of adequate dialysis access (eg, arteriovenous fistula procedures, placement of a peritoneal dialysis catheter) are considered essential and should not be deferred. (See "COVID-19: Issues related to acute kidney injury, glomerular disease, and hypertension", section on 'Dialysis access planning in advanced CKD'.)

INPATIENTS DURING A COVID-19 SURGE — The American Society of Nephrology has issued guidelines for nephrology clinicians caring for hospitalized patients who require dialysis for end-stage kidney disease (ESKD). Many of these practices are applicable only during a surge in COVID-19 cases. Understandably, the execution of some of these guidelines will be limited by policies enforced at the level of any institution. However, when possible, adherence to these guidelines is encouraged.

Patients with COVID-19 who are undergoing dialysis should be colocalized on a floor or intensive care unit (ICU), when possible. Colocalization within adjacent rooms can enable one dialysis nurse to simultaneously deliver dialysis for more than one patient.

When possible, patients with suspected or confirmed COVID-19 who are not critically ill should be dialyzed in their own isolation room rather than being transported to the inpatient dialysis unit.

Where available, telemedicine interfaces with a camera should be used to troubleshoot alarms from outside the room and to minimize the need for the dialysis nurse or the nephrologist to enter an isolation room.

Patients receiving intermittent peritoneal dialysis who have multiple organ dysfunction can be temporarily switched to automated peritoneal dialysis or continuous kidney replacement therapy (CKRT). As in patients on hemodialysis, it is advisable to prevent hypervolemia, so increased ultrafiltration may be needed if remaining on peritoneal dialysis. The care of ESKD patients with COVID-19 who require CKRT is similar to care of patients with acute kidney injury who require CKRT. (See "COVID-19: Issues related to acute kidney injury, glomerular disease, and hypertension", section on 'AKI requiring dialysis'.)

In the early part of the pandemic, there was concern about the presence of SARS-CoV-2 in the spent peritoneal dialysate of patients with COVID-19 and about the proper method of disposal of such dialysate. This was based on an early report of a patient who had SARS-CoV-2 detected in their peritoneal dialysate [24]. However, this finding was not replicated in other case reports and case series [25-28]. Thus, additional disinfection of the spent peritoneal dialysate with sodium hypochlorite or other measures is likely not necessary.

ANTIVIRAL THERAPY — We consider indications and precautions for the use of remdesivir and nirmatrelvir-ritonavir in patients on dialysis to be the same as those in the general population. (See "COVID-19: Evaluation of adults with acute illness in the outpatient setting" and "COVID-19: Management in hospitalized adults".)

Dosing information for remdesivir and nirmatrelvir-ritonavir is as follows:

Remdesivir Remdesivir dosing in patients on dialysis is the same as that for patients not on dialysis. Although remdesivir's cyclodextrin vehicle can accumulate in kidney function impairment, the risks in patients on dialysis have been deemed low [29], in part because of the limited duration of treatment and in part because the cyclodextrin vehicle is dialyzable. The dosing regimen for remdesivir is detailed elsewhere. (See "COVID-19: Management of adults with acute illness in the outpatient setting" and "COVID-19: Management in hospitalized adults".)

Nirmatrelvir-ritonavir – Because nirmatrelvir accumulates with declining kidney function, we use a reduced dose for patients on dialysis [30]. An appropriate five-day dosing regimen for a patient on hemodialysis who weighs ≥40 kg is 300 mg nirmatrelvir plus 100 mg ritonavir on the first day, followed by 150 mg nirmatrelvir plus 100 mg ritonavir once a day for four more days. Although hemodialysis should remove only a small amount of nirmatrelvir, doses should be administered after a dialysis session. For patients on hemodialysis who weigh <40 kg, we reduce the dose further: 150 mg nirmatrelvir plus 100 mg ritonavir is given on day 1, followed by 150 mg nirmatrelvir plus 100 mg ritonavir on day 3 and on day 5 (ie, three doses total over five days).

For patients on peritoneal dialysis, we use the same nirmatrelvir-ritonavir dosing regimen as above.

Studies examining the use of these agents for the treatment of COVID-19 have typically excluded patients with ESKD, and drug labelling for nirmatrelvir-ritonavir does not recommend use in patients with advanced CKD. However, given the high risk for COVID-19-associated morbidity and mortality in patients with ESKD, we believe use of these antiviral medications in patients on dialysis is warranted. Support for their use is based on clinical experience, small studies, and pharmacokinetic data [29-33].

USE OF ESAs IN SEVERE COVID-19 — The use of erythropoiesis-stimulating agents (ESAs) for the treatment of anemia in patients with end-stage kidney disease (ESKD) who have COVID-19 is controversial [34,35]. ESAs may theoretically increase the prothrombotic risk posed by COVID-19, whereas withholding ESAs may precipitate or worsen anemia. There are no rigorous studies to guide management of anemia in this setting.

In our personal practice, the indications and contraindications for ESAs are the same in patients with active COVID-19 as they are in patients without COVID-19. In addition, the route of administration and the starting dose of ESA are also the same. (See "Treatment of anemia in patients on dialysis", section on 'Initial dosing and titration of ESAs' and "Treatment of anemia in patients on dialysis", section on 'Route of administration' and "Treatment of anemia in patients on dialysis", section on 'Contraindications'.)

However, we attempt to minimize the use of ESAs among hospitalized patients on dialysis who have severe COVID-19 by modifying the threshold for treatment, the target hemoglobin range, and the dosing strategy as follows:

Among hospitalized patients who were not being treated with an ESA prior to developing severe COVID-19, we avoid initiating ESAs unless their hemoglobin falls below 8 g/dL, and then target a hemoglobin of 8 to 9 g/dL.

Among hospitalized patients who were being treated with an ESA prior to developing severe COVID-19, we hold ESAs unless the hemoglobin falls below 8 g/dL, and then resume it at one-half of the previous dose.

Once the patient has recovered, we resume our usual practice with regards to ESA. (See "Treatment of anemia in patients on dialysis", section on 'Erythropoiesis-stimulating agents (ESAs)'.)

Our practice of minimizing the use of ESAs among patients on dialysis who have severe COVID-19 is designed to balance the potential risk of thrombotic complications of ESAs and the ill-effects associated with untreated anemia (eg, disabling symptoms, need for blood transfusions). However, deviation from this approach based upon an individual patient's risk profile (ie, risk of thrombosis and of anemia, comorbidities) and symptoms is also reasonable.

VACCINATION IN PATIENTS ON DIALYSIS AND PROVIDERS — We recommend vaccination against COVID-19 for patients on dialysis. Patients on dialysis, especially those receiving in-center hemodialysis, represent a vulnerable population who are at high risk of death from COVID-19 [8,12]. Recommendations on vaccine selection and schedule are the same as in the general population; dialysis is not a condition that warrants adjustments to vaccine administration. Detailed information regarding vaccination against COVID-19 is presented separately. (See "COVID-19: Vaccines", section on 'Approach to vaccination in the United States'.)

To protect patients on dialysis, we also encourage vaccination among all health care staff who work in dialysis units.

Direct evidence for vaccine efficacy among patients on dialysis is primarily limited to observational data, which demonstrate benefit [36-41]. In a large cohort of more than 200,000 patients on hemodialysis, vaccination with either mRNA-1273 (Moderna COVID-19 vaccine) or BNT162b2 (Pfizer-BioNTech COVID-19 vaccine) was associated with a substantially lower risk of COVID-19; among those with breakthrough infection, hospitalization rates and mortality rates were also lower [37].

Other data have evaluated rates of seroconversion among patients on dialysis [36,42-51]. In general, seroconversion occurs in the majority of patients on dialysis, but rates may be lower compared with the general population:

In a study of 1583 patients on dialysis who received a primary vaccine series, rates of seroconversion (determined by the development of antibodies to the receptor binding domain) were 98 percent for mRNA-1273, 96 percent for BNT162b2, and 67 percent for Ad26.COV2.S (Janssen/Johnson and Johnson COVID-19 vaccine) [42]. Among those who seroconverted, antibody responses were more robust with the mRNA-1273 vaccine than with the BNT162b2 vaccine.

In another large cohort of 2563 patients on dialysis receiving a primary vaccine series (most with either the mRNA-1273 or BNT162b2 vaccine), the seroconversion rate was 93 percent after one month [36]. Antibody titers waned and, by six months, 20 percent had no detectable antibodies to the receptor binding domain.

Seroconversion is likely indicative of vaccine efficacy. In the study mentioned above, breakthrough infections among vaccinated patients were more common among those whose antibody titers substantially declined [36].

As in the general population, we recommend booster vaccination(s) for patients with kidney disease who received a primary series (see "COVID-19: Vaccines", section on 'Dose and interval (for immunocompetent individuals)'). Observational data suggest higher COVID-19 vaccine efficacy after a booster. In a study of 1121 patients on dialysis, booster vaccination was associated with a substantially lower risk of SARS-CoV-2 infection [52]. Other studies report that COVID-19 booster vaccinations in patients on dialysis increase antibody titers and can induce seroconversion in patients with an inadequate response to the primary series [53-56]. In 130 patients on dialysis who did not seroconvert after receiving two doses of an mRNA vaccine, 106 (82 percent) seroconverted after an mRNA vaccine booster [53].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: COVID-19 – Index of guideline topics".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: COVID-19 overview (The Basics)" and "Patient education: COVID-19 vaccines (The Basics)")

SUMMARY AND RECOMMENDATIONS

Vulnerability of patients with ESKD – Patients with end-stage kidney disease (ESKD) are particularly vulnerable to severe COVID-19 due to the older age and high frequency of comorbidity, such as diabetes and hypertension, in this population. Patients with ESKD, especially those receiving in-center hemodialysis, may have a higher risk of infection and of mortality compared with the general population. (See 'Epidemiology' above.)

COVID-19 guidelines – The American Society of Nephrology (ASN) and International Society of Nephrology (ISN) have issued interim guidelines and a list of resources to guide nephrology clinicians. (See 'Early recognition/isolation of individuals with respiratory symptoms' above and 'Patient placement' above and 'Personal protective equipment' above and 'Additional measures for COVID-19' above.)

Home dialysis – During surges in cases of COVID-19, patients receiving dialysis at home should have their regular follow-up visits by telemedicine or in person, depending upon their health, the regional prevalence of COVID-19, and their personal risk of acquiring COVID-19. (See 'Patients receiving home hemodialysis or peritoneal dialysis' above.)

Inpatient care during a COVID-19 surge – The ASN has issued guidelines for nephrology clinicians caring for hospitalized patients who require dialysis for ESKD. However, most clinicians follow local institutional guidelines to care for hospitalized patients, including those with ESKD. These guidelines continue to evolve and are frequently updated, and many of these practices are applicable only during a surge of COVID-19 cases. When possible, adherence to the ASN guidelines is encouraged (see 'Inpatients during a COVID-19 surge' above):

Patients with COVID-19 should be colocalized on a floor or intensive care unit, when possible. Colocalization within adjacent rooms can enable one dialysis nurse to simultaneously deliver dialysis for more than one patient.

When possible, patients with suspected or confirmed COVID-19 who are not critically ill should be dialyzed in their own isolation room rather than being transported to the inpatient dialysis unit.

Where available, telemedicine interfaces with a camera should be used to troubleshoot alarms from outside the room and to minimize the need for the dialysis nurse or the nephrologist to enter an isolation room.

Antiviral therapy – We consider indications and precautions for the use of remdesivir and nirmatrelvir-ritonavir in patients on dialysis to be the same as those in the general population. Because nirmatrelvir accumulates with declining kidney function, we use a reduced dose for patients on dialysis. (See 'Antiviral therapy' above.)

Use of ESAs in severe COVID-19 – There are no rigorous studies to guide use of erythropoiesis stimulating agents (ESAs) for management of anemia among ESKD patients who have COVID-19. In our personal practice, we minimize the use of ESAs among patients on dialysis who have severe COVID-19 as follows:

Among hospitalized patients who were not being treated with an ESA prior to developing severe COVID-19, we avoid initiating ESAs unless their hemoglobin falls below 8 g/dL, and then target a hemoglobin of 8 to 9 g/dL.

Among hospitalized patients who were being treated with an ESA prior to developing severe COVID-19, we hold ESAs unless the hemoglobin falls below 8 g/dL, and then resume it at one-half of the previous dose.

Vaccination – We encourage vaccination against COVID-19 among patients on dialysis. We also encourage vaccination of all health care staff who work in dialysis units. Recommendations on vaccine selection and schedule are the same as in the general population. (See 'Vaccination in patients on dialysis and providers' above.)

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Topic 130632 Version 29.0

References

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