Adding insult to injury: kidney replacement therapy during COVID-19 in India

To the editor

The coronavirus disease 2019 (COVID-19) pandemic has challenged the resilience of health care systems worldwide. Governments have ordered nationwide lockdowns (often suddenly) in an attempt to contain the spread of infection. Such measures have posed unexpected challenges to patients with pre-existing diseases, especially in limited-resource settings. In the current report, we describe the unique hardships confronted by treatment of in-center hemodialysis patients and kidney transplant recipients in India during the current lockdown period.

With public transport shut down and movement of private vehicles severely restricted, patients were unable to reach the dialysis facilities, often located at considerable distances.1, 2, 3 Nongovernment organizations and self-help groups have stepped in to help these patients, but sometimes are stopped by the police enforcing the lockdown. The majority of dialysis units are located in private hospitals. As part of the COVID-19 response, governments have taken over management of a number of private hospitals⁴ and ordered the closure of dialysis units. In some instances, units were closed down and staff were placed in quarantine after a patient or health care worker was found to be COVID-19 positive.⁵ In all such instances, patients are asked to go to other dialysis facilities, which in many instances already are working to capacity. Moreover, dialysis centers are not willing to accept newly diagnosed end-stage renal disease patients or patients shifted from closed units as a result of panic and misinformation and insist that they produce a COVID-19 test result.⁶ These problems are getting compounded by the lack of a clear and rational guidance that balances the need to contain spread while maintaining essential lifesaving treatments like dialysis. Deaths have been reported as a result of such delays.⁷

A lack of appropriate education of the dialysis workforce, combined with stigma and misinformation on social media, has created apprehension among dialysis staff. Despite the general recommendation that any quarantine should not result in loss of pay, this remains a real risk to staff in private settings.

Operations have been impacted by interruptions in medication and dialysis disposable supply chains (dialysis tubings, catheters, fluids, and drugs and/or expendables). The sudden demand for personal protective equipment led to a surge in pricing of items such as surgical masks. Some private dialysis units ask patients to pay for personal protective equipment. All elective surgical procedures have been cancelled at most centers, leading to cessation or severe curtailment of arteriovenous fistula surgery, tunneled catheter insertion, or peritoneal dialysis catheter insertion.

Kidney transplant surgeries, including those involving living donors, have been stopped in most centers. In a country where high-quality dialysis is not universally available, delaying transplant increases the risk of adverse outcomes for those who are forced to wait, especially when access to dialysis also is uncertain. Kidney transplant recipients living in remote areas are unable to obtain life-saving immunosuppressive drugs, available only in specialized pharmacies, or undergo mandatory investigations such as monitoring of graft function or therapeutic drug levels.

COVID-19 is exposing the deficiencies in care delivery in countries with weak health systems. Although patients with all chronic conditions are disadvantaged, patients on dialysis and kidney transplant recipients need special attention. We report the situation from India but believe patients in other countries at a similar stage of development face similar problems.³ The COVID-19 pandemic should force the global health care community and policymakers to anticipate and address the unique needs of different patient groups such as those with kidney failure.