Table 2.
Timeline and evolution of strategies for treating AKI in COVID-19-infected patients
| Strategy | Date |
| Formation of Nephrology Task Force | March 16 |
| Back-up schedules created | |
| High-risk staff shifted from inpatient services to lower-risk settings | |
| Purchase of additional CRRT and HD machines | March 17 |
| Installation of additional dialysis compatible plumbing for bedside dialysis | March 18 |
| Tubing extension for CRRT machine to place it outside the room | |
| NxStage Fresenius CAR 502–4.5 feet extension | |
| Reduction in HD frequency and treatment time in patients with ESKD who could tolerate that schedule | March 21 |
| Twice weekly HD for 2.5 h with low-potassium bath | |
| Typical schedule: Monday-Thursday, Tuesday-Friday, Wednesday-Saturday | |
| Potassium binders in patients with normokalemia (K>4 meq/L) but rising potassium level | |
| Sodium zirconium cyclosilicate 10 g daily | |
| Patiromer 8.4 g daily, uptitrated to 16.8 or 25.5 g as needed | |
| Diuretics to maintain euvolemia (furosemide 80 mg iv q 8–12 h or bumetanide 2–4 mg iv every 12 h with chlorthiazide 250 mg iv every 12 h in those with severe AKI and fluid overload) | |
| PIRRT treatments to allow treatment of 2–3 patients/d with one CRRT machine | |
| NxStage machine, CVVHD | |
| Blood flow rate: 250 ml/h for CVVHD and 300–350 ml/h for PIRRT | |
| Effluent flow rate: 25 ml/kg per h in CVVHD and 40–50 ml/kg per h in PIRRT | |
| Treatment time: 24 h for CVVHD and 6–12 h for PIRRT | |
| Dialysate fluid: RFP 400 (2 K bath), RFP 401 (4 K bath) | |
| Recovering patients with COVID-19 without a fever for at least 3 d started to be cohorted together on last inpatient HD shift followed by terminal disinfection | March 24 |
| Near capacity for inpatient HD due to majority requiring 1:1 nursing care | March 27 |
| Telemonitoring during HD treatments to minimize nurse exposure | |
| First patient started on acute PD | |
| Expanded inpatient nephrology services | |
| Inpatient HD unit started to open on Sundays | March 29 |
| Increased from 1 to 3 on call dialysis nurses | |
| Expansion and creation of 11 new COVID-19 intensive care units | |
| PD program initiated to increase capacity for acute dialysis | March 30 |
| Typical manual PD initial prescription: 1–2-L dwells every 2–4 h | |
| PD cyclers ordered to begin automated PD | |
| Inpatient E-consultations for nephrology went live | |
| Creation of acute PD service | April 1 |
| Nephrologist in-service training on performing PD exchanges to assist nursing staff | |
| Perfusionist reappointed to assist with PIRRT/CRRT | April 2 |
| Initiated bivalirudin anticoagulation protocol for PIRRT/CRRT clotting | |
| Bolus: 0.50 mg/kg bolus 1 h before PIRRT/CRRT | |
| Maintenance: 0.25 mg/kg per h 30 min before PIRRT/CRRT | |
| Stop 1 h before end of PIRRT | |
| Check activated clotting time 15 min into treatment and PTT 4 h into treatment | |
| Goal PTT 1.5–2× normal | |
| Nephrologists training nurses to perform PD | April 5 |
| Started to use PD cyclers (Baxter) (typical prescription: five exchanges of 1.8-L volume over 10 h with 1.5-h dwell time) | |
| Nephrologists began assisting in performing HD due to nursing staff shortage from illness (primed the machines, monitored patients on dialysis, applied pressure to the access at the end of treatment) | |
| Majority of both hospitals COVID-19 positive, all patients now being dialyzed in the inpatient HD unit | April 9 |
CRRT, continuous renal replacement therapy; HD, hemodialysis; CAR, cartridge; PIRRT, prolonged intermittent renal replacement therapy; RFP, replacement fluid pureflow; CVVHD, continuous venovenous hemodialysis; PD, peritoneal dialysis; COVID-19, severe acute respiratory syndrome coronavirus 2; PTT, partial thromboplastin time.