The number of patients with coronavirus disease 2019 (COVID-19) in the United States is rapidly approaching one million and the pace of hospitalizations and deaths is increasing ([@R1]). In addition to the clinical care of COVID-19--related respiratory illness, there will be increasing stress on dialysis units. Approximately 80% of people with COVID-19 are asymptomatic ([@R2]); thus, there may be a long period of time, with potentially frequent visits, between diagnosis and hospitalization. Therefore, dialysis facilities will be expected to accommodate large numbers of patients over a period of weeks to months without the possibility of an influx of new admissions at a time of peak patient numbers. The objective of this report is to present information from a survey we developed and completed for all chronic kidney disease--mineral and bone disorder (CKD-MBD) management working groups within the US Renal Network and from those in two international working groups that we learned about from their websites. We sought to identify dialysis facility characteristics, and dialysis procedures that would likely be performed in the context of hospital-based dialysis unit care of COVID-19--positive patients, particularly compared with home-based dialysis unit care.
METHODS {#S6}
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A survey was developed and distributed to dialysis facility managers and directors who serve as members of working groups related to CKD-MBD within the US Renal Network and two international working groups. The International Working Group for Renal Bone Disease (Working Group \[WG\]), which consists of nephrologists from Europe, Japan, Canada, and Australia, surveyed members in March 2020 and the International Society for Peritoneal Dialysis (ISPD), which consists of dialysis professionals, dialysis patients, and patient and caregiver advocates from the ISPD region, surveyed members in April 2020.
Survey development began in March 2020 and all work was completed by April 20. We defined "COVID-19 unit" as a facility providing dialysis care to dialysis patients who are being hospitalized or had been hospitalized for confirmed COVID-19. We identified respondents through information posted on the ISPD and working group websites. We sought to achieve a good response rate from the ISPD since respondents of this survey are actively involved in patient-directed activities such as advocacy and health care policy. Because the first ISPD working group member survey was completed in March, there was overlap with the start of our survey. Survey invitations were sent via email. Respondents could complete a web link to an electronic survey, submit a paper survey, or use a text messaging program.
The survey included questions about dialysis facility demographics and organization, staffing, and patient volume. Data were analyzed using Excel. We performed descriptive statistics including means, medians, standard deviations, and ranges where appropriate. This study was considered to be exempt from IRB review.
RESULTS {#S7}
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We received responses from 18 of 22 persons in the ISPD and from 26 of 39 (67%) of all respondents in the working groups. Respondents from the ISPD were more likely to be nurses (87%) than clinicians (11%) whereas respondents from the working groups were evenly split between clinicians (43%) and nurses (50%). Forty-four respondents indicated they are from hospitals and seven respondents indicated that their dialysis unit cares for COVID-19--positive patients. The proportion of respondents who indicated their dialysis facility was planning to implement changes due to COVID-19 was similar in the working groups (80%) compared to the ISPD (67%).
The majority of respondents were from US dialysis facilities (83%) and about half (53%) had a COVID-19 unit ([Table 1](#T1){ref-type="table"}). All respondents indicated they were either providing ongoing dialysis in patients diagnosed with COVID-19 or their unit was planning to start performing dialysis in patients with COVID-19. Only the ISPD respondents indicated that their units planned to start performing dialysis for patients who were currently asymptomatic with COVID-19 (i.e., patients who had tested negative for the virus). There was no significant difference between respondent locations (hospital vs. nonhospital) in the proportion of respondents whose dialysis units had already begun to provide or planned to begin dialysis for COVID-19 patients or in the proportion of respondents who planned to increase staffing or space for additional patients. In contrast, there was a significant difference between locations in the likelihood that staff would begin working from home and only respondents from hospitals and dialysis centers that currently provided dialysis care for patients with COVID-19 were willing to increase dialysis to home-based units for patients with COVID-19. Nearly all (90%) respondents indicated that they could accommodate more patients if staff worked from home. Thirty-two of 40 (80%) respondents from the ISPD were actively engaging their patients through their renal councils to seek funding and resources to support their units.
The majority of respondents had 1,100--4,000 dialysis patients on average with only seven reporting less than 100 dialysis patients on average and one reporting more than 4,000 dialysis patients. Most respondents (71%) indicated they were operating a dialysis unit that provided only maintenance dialysis (i.e., not for acute renal replacement therapy); 7% indicated a unit providing only maintenance dialysis or acute renal replacement therapy. The smallest percentage of respondents indicated they operated a dialysis unit that provided both maintenance dialysis and acute renal replacement therapy. More than half of respondents indicated their dialysis units had not identified patients with COVID-19 to provide dialysis. Respondents from the ISPD indicated their units were not identifying or screening patients with COVID-19 for dialysis (see [Supplemental Appendix A](#SD1){ref-type="supplementary-material"}).
To date, most of the respondents were not performing dialysis at home for COVID-19 patients (78%) or had plans to perform some home-based dialysis for COVID-19 patients (63%). A few units, however, reported that their units planned to or had already started home-based dialysis (21%) and other units had plans to start it. Dialysis units were not planning to increase the number of dialysis machines they had in order to increase home-based dialysis, although respondents from the ISPD indicated they were willing to increase the number of dialysis machines to meet the needs of COVID-19 patients. There was little indication that dialysis units were planning to start performing peritoneal dialysis for patients with COVID-19.
Almost all respondents (98%) reported they were performing or planning to start performing dialysis in patients with COVID-19. Of these respondents, 88% indicated that their dialysis units had enough staff to care for all of the patients in their units. Thirty-four percent (20 of 58) of respondents from the ISPD and 34% (29 of 86) of respondents from the working groups indicated that dialysis units had experienced a shortage of staff due to COVID-19, specifically a shortage of nurses. Respondents from the ISPD indicated that their dialysis units would continue to perform dialysis for patients who are asymptomatic with COVID-19 (see [Supplemental Appendix B](#SD1){ref-type="supplementary-material"}). The respondents indicated that dialysis units were not allowing patients on dialysis who had not tested positive for COVID-19 to come to the unit (92%). The majority of respondents from the working groups indicated that there was limited or no shortage of dialysis filters, although more than half of respondents from the ISPD and working group respondents indicated there were limited or no supplies for dialysis filters.
Eighty-six percent of respondents indicated that staff were using personal protective equipment during patient care (i.e., gowns, face shields, goggles, and masks) but less than half of respondents (43%) indicated that staff were using a mask for procedures other than intubation. Only 10% of respondents indicated staff were using N95 masks. Respondents indicated the availability of personal protective equipment varied greatly by the number of patients treated per day. Fifty-six percent of respondents from the working groups and 62% from the ISPD stated staff members were not provided with personal protective equipment when caring for COVID-19 patients, particularly gloves and gowns. However, there was not a significant difference between locations in the proportion of respondents whose staff were provided or were not provided with protective equipment. Respondents from the working groups indicated that staff members reported a variety of shortages, including gowns, masks, and face shields (see [Supplemental Appendix C](#SD1){ref-type="supplementary-material"}).
DISCUSSION {#S8}
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We found that a small number of dialysis facilities have already been providing dialysis care to patients with COVID-19 and that dialysis units have been increasing the number of patients they care for with this disease. Fewer than 10% of respondents were not providing dialysis to patients with COVID-19, and the majority were providing care to COVID-19 patients. More than 70% of respondents indicated that there would not be a shortage of staff or other resources for the dialysis units they operated, and about three-quarters of respondents from the ISPD indicated they would provide dialysis for asymptomatic patients with COVID-19.
Based on our results, we can assume that in many countries where there are fewer dialysis facilities, there will be a very limited need to expand dialysis services due to COVID-19. One area where there may be a problem will be in recruiting experienced staff who will come back to work during the surge in COVID-19 cases. We believe that dialysis professionals will be able to recruit and retain staff in a pandemic similar to COVID-19. We found a significant difference in staff working from home with respondents from hospitals and nonhospital settings who had to provide care for COVID-19 patients.
There are several limitations to this study. We were unable to reach some dialysis units that did not have a Web-based email account, and we did not have the capacity to reach
