The treatment of chronic dialysis patients always requires high demands on hygiene for several reasons. Renal insufficiency leads to immunodeficiency and increased susceptibility to infection10,11. Patients are regularly treated in dialysis centers in a coherent manner three times weekly while they are in a non-medical and therefore not hygienically controllable environment between treatments. In addition, many patients are transported to and from treatment-facilities by taxi, group transport or qualified ambulance services. This is a complex situation even when dealing with multi-resistant bacteria12, and it became a challenge in the context of the pandemic.
Experience from Italy13 and Spain14 indicates that dialysis patients have a particularly high mortality risk (approx. 30%) when infected with SARS-CoV-2. The German Society for Nephrology (DGfN) therefore made organizational and hygienic recommendations3 at an early stage to protect this vulnerable patient group. Persons under therapeutic immunosuppression are also at risk, including patients with a kidney transplant. Recommendations for dealing with immunosuppression were formulated by the European Renal Association4.
This survey shows that dialysis facilities in Germany felt well informed and prepared, and both staff and patients followed the hygiene measures well, according to the respondents. Thus, 81.9% of the facilities also felt able to continue treatment of dialysis patients when they got infected with SARS-CoV-2, although the separation or cohorting places high demands on premises and staff. Facilities that were unable to do this have made arrangements with other providers to ensure that patients are cared for in all cases. Dialysis care is secured - also through cooperation across the boundaries of different providers.
The pandemic has brought significant changes in patient transport management. Medically necessary journeys to dialysis are fully covered by the health care insurance system in Germany, accounting for up to 20% of the total costs of renal replacement therapy. For this reason, collective transports are often organized - unless there are medical reasons not to do so. In the pandemic situation group transports of dialysis patients in one vehicle are not recommended by the DGfN. The changeover to individual transport has taken place on a large scale, although not nationwide. This is associated with relevant additional costs, as is the expansion of the use of qualified patient transport. It will be challenging to find a balance between infection prevention and economy in the further course of the pandemic.
The deployment of staff in the dialysis center, especially the deployment of employees who belong to the risk group for severe COVID-19 courses, is also a burden for the facilities. According to the participating facilities, work related SARS-CoV-2 infections have already occurred. This constellation met the requirements for recognition as an occupational disease15.
Changes in the area of deployment of employees who belong to the risk group pressurize personnel situation in the dialysis facilities, as well as sickness-related absences or quarantine orders by the health authorities. Against the background of the highly specialized qualification requirements in dialysis care, it is remarkable that so far only 16% of the facilities have experienced severe staff shortage, which under a rule of exception allows the continued use of contact persons of COVID-19 patients in patient care16.
As in all areas of outpatient care, patient contacts have been significantly reduced in recent weeks. Patients under therapeutic immunosuppression, e.g. for glomerulonephritis or after kidney transplantation, are particularly at risk of infection. It is very comprehensible that the frequency of presentation of these patients in the outpatient clinics was deliberately reduced, but this is not without risks. Especially in the early stages of therapy, frequent corrections of the dosage of immunosuppressive drugs are necessary. After organ transplantation, some immunosuppressive drugs are adjusted according to plasma levels.
Immunosuppression is not reduced prophylactically after kidney transplantation. This procedure is in accordance with the recommendations of the ERA-EDTA4 ,according to which a reduction of immunosuppression in COVID-19 infection, graded according to the severity of the disease, is planned, but not as a prophylactic measure.
This survey was the first nationwide survey and analysis among nephrologist about the SARS-CoV-2 epidemic in Germany.
Through the different involved organisations (DGfN, DN, KfH) we could almost reach every nephrologist in Germany.This resulted in a good response rate, especially among medical directors who in general represent a dialysis facility and primarily influence the implementation of hygiene recommendation and care of dialysis and CKD-non-dialysis patients.
The distribution of provider (private, non-profit and others) in our survey reflects the current outpatient care of dialysis patients in Germany.
With our approach we achieved a good representativeness of dialysis facilities in Germany. General limitations of non-interventional and descriptive cross-sectional studies also apply to our survey.
In summary, the SARS-CoV-2 pandemic already has had a significant impact on the care of patients with chronic kidney disease in Germany, although infection numbers were lower than in several neighbouring countries. However, evident deficits in the treatment are not obvious.
This is due to the high degree of willingness to cooperate across different dialysis providers and the comprehensive formulation of practical recommendations by the professional associations.