Need For Nephrology

As the presence of coronavirus lingers, some patients are experiencing sudden and severe kidney complications. One nursing organization is allocating additional specialists where needed.

Of the many adjectives that could be used to describe the path that the coronavirus (COVID-19) pandemic has taken this year, “predictable” is not one of them. From the casually contagious nature to the sudden severity of its various clinical complications, the virus has left many healthcare professionals baffled and concerned over its unpredictability. Although the disease’s impact on the respiratory system has garnered much of the industry’s attention, and for good reason, other life-threatening conditions continue to emerge. Earlier in May, officials with the World Health Organization alerted providers about an inflammatory syndrome in children and adolescents that’s believed to be closely connected to COVID-19.(1) The virus is also said to have serious effects on the cardiovascular system, nervous system, digestive system, and, in ways that continue to be more revealing, the renal system – particularly the kidneys. 

“The kidney failure is coming out of nowhere — it’s not a progression,” said Faith Lynch, MSN, RN, a nurse manager on the acute dialysis unit at NYU Winthrop Hospital, Mineola, NY. “They are having symptoms of volume depletion. They have severe, sudden acute kidney injury [AKI] with life-threatening hyperkalemia. Their potassium levels are going so high so fast, that we don’t even know what causes it. Many are developing acute tubular necrosis, and biopsies are showing that there are COVID particles appearing directly on the kidneys, which is proving that this virus is actively attacking the kidney cells. They are having cytokine storms, [which can destroy kidney tissue], and the kidney failure and hyperkalemia are occurring peri-intubation. I don’t think anyone knew that COVID was going to affect the kidneys in the way that it has.” Additionally, it is believed that blood clots that form due to the virus can clog blood vessels in the kidneys and impair function.(2)

As one who also serves as a chapter president for the American Nephrology Nurses Association (ANNA), Lynch has a unique perspective on the escalation that the virus has had on patients across the United States, primarily through her involvement in the ANNA’s Nephrology Surge Support Tool,(3) an initiative launched in April in response to a critical shortage of nephrology nurses in the U.S. that was occurring as kidney complications continued to spike. Through this tool, Lynch and her ANNA colleagues across the country are in a position to provide hands-on assistance where it is needed most and are collecting various types of insights from providers as they learn and attempt to manage the ongoing impact on this patient population.

A Timely Tool

Designed as an online interactive map, the ANNA surge tool is maintained by ANNA officials who track the need for nephrology staff members, including nurses, patient care technicians, and social workers through communications with health departments and other officials, and is accessible by providers throughout the U.S. who are free to monitor for areas of need and alert the organization about where and when they are available to assist these areas of need. To date, nurses have filled voids in seven participating states including New York, New Jersey, Pennsylvania, Massachusetts, Maryland, Illinois, and Louisiana, said Lillian Pryor, MSN, RN, CNN, president of ANNA. “COVID has created a need, and we were able to come up with a tool to connect the providers that have a need and the providers who are willing to travel to provide assistance. Our members are in contact with providers as to when and where they can be available, and we are able to offer certain travel resources, such as hotel discounts, that our members can rely on to assist in making accommodations.”

Specialty Services 

According to Pryor and Lynch, the severity of symptoms that patients are experiencing warrants the involvement of healthcare providers who are specially trained in nephrology to increase the chances of better outcomes. “Hemodynamic stability is seen completely different through the lens of a dialysis/nephrology nurse,” Lynch said. “It is what we deal with on a daily basis. We can see one set of vitals and look at a cardiac monitor and know if that patient will tolerate hemodialysis, and the ability of hemodialysis to impact a patient’s hemodynamic status is underappreciated. These patients have a higher rate of hypotension during dialysis and we’re dialyzing them on demand.”
One of the more prominent concerns among these patients is being able to determine how much fluid intake severely dehydrated patients can handle based on their kidney function—keeping patients euvolemic, i.e. a normal balance of body fluids. 

“You need to make sure that patients don’t go from dehydration to fluid overload,” Lynch said. “Because at that point you could get into congestive heart failure and other problems. In addition to possible respiratory issues, kidney problems can occur in patients due to abnormally low levels of oxygen in the blood. Our acute care nurses are able to troubleshoot and gauge the amount of fluid that patients need. Or we can give insight as to whether they should have continuous renal replacement therapies or intermittent treatment that could help maintain potassium levels as well as removing fluid. That’s where our skillset really comes in. We are astute at recognizing the best modalities that would provide the best results for patients.”

Pointers For Providers & Patients 

Upon hospital arrival, patients may display certain systems that should make providers curious about current or potential kidney issues say, Lynch and Pryor. “From what we’re hearing, most patients are coming in with depletion from nausea, vomiting, diarrhea, and running fevers,” Lynch said. “They’re not accepting a lot of food orally. In dialysis terms, they’re almost ‘dry’ because they don’t have a lot of volume.” 

Typically, kidney symptoms take a sudden turn between the 8-10 mark. “They seem to crash,” Lynch continued. “They have these cytokine storms, and that’s when the kidney failure and the hyperkalemia step in. And then when that occurs they’re being intubated within 24 hours.”

It’s true that some patients have pre-existing complications that contribute to the rapid decline, but not all, Pryor said. “Some patients are coming in with damage to the kidneys already,” she said. “Without COVID, nephrologists tell us they would expect about 15 percent of patients who come in to require some type of renal replacement therapy. But we’re seeing double that now due to COVID; it is affecting the kidneys that much, and the needed renal replacement therapy is what’s most unexpected. We’re running out of this type of equipment too.”

Of course, some patients may be isolating at home after a brief hospital stay or perhaps no hospital stay at all. Whether providers are discharging patients, or seeing them through tele-health services, or in communication with patients in other ways, Lynch and Pryor suggest that providers ask that patients be mindful of a few things. “Patients should be advised to stay hydrated and watch their urinary output,” Lynch said. “From my experience in the ICU with COVID patients, none of the Foleys have urine in them.”

Despite the unpredictability of the virus, there does not appear to be much reason to assume that the trend on impact to patients’ kidneys can be curbed any time soon. According to the ANNA, statistics show that as many as 6 in 10 COVID-19 patients can expect to experience some form of kidney involvement upon hospital admission. Other studies have indicated 20-40 percent of patients progress to develop kidney failure.

References

  1. Multisystem inflammatory syndrome in children and adolescents temporally related to COVID-19. WHO. 2020. Accessed online: www.who.int/news-room/commentaries/detail/multisystem-inflammatory-syndrome-in-children-and-adolescents-with-covid-19
  2. Sperati CJ. Coronavirus: kidney damage caused by covid-19. Johns Hopkins Medicine. 2020. Accessed online: www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-kidney-damage-caused-by-covid19
  3. Nephrology nurses needed for covid-19 hot spots across the U.S. ANNA. 2020. Accessed online: www.annanurse.org/covidhelp

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