The coronavirus disease 2019 (COVID-19) pandemic, technological advancements, regulatory waivers, and user acceptance have converged to boost telehealth activities. Due to the state of emergency, regulatory waivers in the United States have made it possible for providers to deliver and bill for services across state lines for new and established patients through Health Insurance Portability and Accountability Act (HIPAA)- and non–HIPAA-compliant platforms with home as the originating site and without geographic restrictions. Platforms have been developed or purchased to perform videoconferencing, and interdisciplinary dialysis teams have adapted to perform virtual visits. Telehealth experiences and challenges encountered by dialysis providers, clinicians, nurses, and patients have exposed health care disparities in areas such as access to care, bandwidth connectivity, availability of devices to perform telehealth, and socioeconomic and language barriers. Future directions in telehealth use, quality measures, and research in telehealth use need to be explored. Telehealth during the public health emergency has changed the practice of health care, with the post–COVID-19 world unlikely to resemble the prior era. The future impact of telehealth in patient care in the United States remains to be seen, especially in the context of the Advancing American Kidney Health Initiative. The coronavirus disease 2019 (COVID-19) pandemic, technological advancements, regulatory waivers, and user acceptance have converged to boost telehealth activities. Due to the state of emergency, regulatory waivers in the United States have made it possible for providers to deliver and bill for services across state lines for new and established patients through Health Insurance Portability and Accountability Act (HIPAA)- and non–HIPAA-compliant platforms with home as the originating site and without geographic restrictions. Platforms have been developed or purchased to perform videoconferencing, and interdisciplinary dialysis teams have adapted to perform virtual visits. Telehealth experiences and challenges encountered by dialysis providers, clinicians, nurses, and patients have exposed health care disparities in areas such as access to care, bandwidth connectivity, availability of devices to perform telehealth, and socioeconomic and language barriers. Future directions in telehealth use, quality measures, and research in telehealth use need to be explored. Telehealth during the public health emergency has changed the practice of health care, with the post–COVID-19 world unlikely to resemble the prior era. The future impact of telehealth in patient care in the United States remains to be seen, especially in the context of the Advancing American Kidney Health Initiative. The coronavirus disease 2019 (COVID-19) pandemic, new technologies, regulatory changes, and increased patient acceptance have led to accelerated evolution of telehealth in patient care settings. Telehealth delivers virtual patient care, addresses patient's medical concerns, and identifies issues that warrant in-person visits, while at the same time fostering social distancing in an effort to decrease COVID-19 transmission among health care workers and patients.1Chen J. Yin L. Chen X. et al.Management of peritoneal dialysis under COVID-19: the experience in Sichuan Province People's Hospital, China.Perit Dial Int. 2020; https://doi.org/10.1177/0896860820935298Crossref Scopus (6) Google Scholar,2Alfano G. Fontana F. Ferrari A. et al.Peritoneal dialysis in the time of coronavirus disease 2019.Clin Kidney J. 2020; 13: 265-268PubMed Google Scholar Telehealth has benefits for clinicians, the interdisciplinary team (IDT), and patients. Due to the complexity of patients receiving dialysis, telehealth may complement but not totally replace the in-person visit3Nakamoto H. Telemedicine system for patients on continuous ambulatory peritoneal dialysis.Perit Dial Int. 2007; 27: S21-S26Crossref PubMed Google Scholar, 4Brophy P.D. Overview on the challenges and benefits of using telehealth tools in a pediatric population.Adv Chronic Kidney Dis. 2017; 24: 17-21Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 5Krishna V.N. Managadi K. Smith M. et al.Telehealth in the delivery of home dialysis care: catching up with technology.Adv Chronic Kidney Dis. 2017; 24: 12-16Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar and provide better oversight of care with remote monitoring.6Nayak K.S. Ronco C. Karopadi A.N. et al.Telemedicine and remote monitoring: supporting the patient on peritoneal dialysis.Perit Dial Int. 2016; 36: 362-366Crossref PubMed Scopus (44) Google Scholar, 7Rosner M.H. Lew S.Q. Conway P. et al.Perspectives from the Kidney Health Initiative on advancing technologies to facilitate remote monitoring of patient self-care in RRT.Clin J Am Soc Nephrol. 2017; 12: 1900-1909Crossref PubMed Scopus (41) Google Scholar, 8Wallace E.L. Rosner M.H. Alscher M.D. et al.Remote patient management for home dialysis patients.Kidney Int Rep. 2017; 2: 1009-1017Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar It is not surprising then that patients receiving peritoneal dialysis (PD) have responded positively to telehealth.9Lew S.Q. Sikka N. Are patients prepared to use telemedicine in home peritoneal dialysis programs?.Perit Dial Int. 2013; 33: 714-715Crossref PubMed Scopus (21) Google Scholar, 10Lew S.Q. Sikka N. Thompson C. et al.Adoption of telehealth: remote biometric monitoring among peritoneal dialysis patients in the United States.Perit Dial Int. 2017; 37: 576-578Crossref PubMed Scopus (17) Google Scholar, 11Dey V. Jones A. Spalding E.M. Telehealth: acceptability, clinical interventions and quality of life in peritoneal dialysis.SAGE Open Med. 2016; 4https://doi.org/10.1177/2050312116670188Crossref PubMed Scopus (29) Google Scholar, 12Magnus M. Sikka N. Cherian T. et al.Satisfaction and improvements in peritoneal dialysis outcomes associated with telehealth.Appl Clin Inform. 2017; 8: 214-225PubMed Google Scholar, 13Gallar P. Gutierrez M. Ortega O. et al.[Telemedicine and follow up of peritoneal dialysis patients].Nefrologia. 2006; 26: 365-371PubMed Google Scholar, 14Nayak A. Antony S. Nayak K.S. Remote monitoring of peritoneal dialysis in special locations.Contrib Nephrol. 2012; 178: 79-82Crossref PubMed Scopus (12) Google Scholar, 15Lew S.Q. Sikka N. Operationalizing telehealth for home dialysis patients in the United States.Am J Kidney Dis. 2019; 74: 95-100Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar Telehealth and home dialysis both foster greater home-based care, less travel time, and fewer trips to the clinic and leverage the principles of patient and care partner autonomy and self-care. Telehealth may also help facilitate patient education about home dialysis modalities and self-care. Telehealth has been used to manage patients with chronic kidney disease (CKD) and demonstrated equal outcomes in CKD care by either in-person or virtual visits.16Tan J. Mehrotra A. Nadkarni G.N. et al.Telenephrology: providing healthcare to remotely located patients with chronic kidney disease.Am J Nephrol. 2018; 47: 200-207Crossref PubMed Scopus (33) Google Scholar,17Koraishy F.M. Rohatgi R. Telenephrology: an emerging platform for delivering renal health care.Am J Kidney Dis. 2020; 76: 417-426Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Although the opportunities for the application of technology to the betterment of the lives and care of our patients exist, implementation of these strategies continues to remain challenging. Here, members of the American Society of Nephrology COVID-19 Home Dialysis Committee review regulatory changes, use cases, implementation, and provider and patient perspectives on telehealth for home dialysis during the COVID-19 public health emergency. In the United States, the 2018 Bipartisan Budget Act extended telehealth access to home dialysis patients using home as the originating site beginning in 2019.18H.R. 1892 - Bipartisan Budget Act of 2018.https://www.congress.gov/bill/115th-congress/house-bill/1892/textDate accessed: August 15, 2020Google Scholar In a survey of 30 PD patients conducted in August 2018, none knew of the statute allowing them to opt for telehealth from their home.19Lew S.Q. Sikka N. Telehealth awareness in a US urban peritoneal dialysis clinic: from 2018 to 2019.Perit Dial Int. 2020; 40: 227-229Crossref PubMed Scopus (3) Google Scholar Since 2019, nephrology and telehealth journals have informed their readers about telehealth options for home dialysis patients and how to operationalize them with little effect.15Lew S.Q. Sikka N. Operationalizing telehealth for home dialysis patients in the United States.Am J Kidney Dis. 2019; 74: 95-100Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar,20Bieber S.D. Weiner D.E. Telehealth and home dialysis: a new option for patients in the United States.Clin J Am Soc Nephrol. 2018; 13: 1288-1290Crossref PubMed Scopus (26) Google Scholar,21Lew S.Q. Telehealth in peritoneal dialysis: review of patient management.Adv Perit Dial. 2018; 34: 32-37PubMed Google Scholar However, during the COVID-19 pandemic, interest and need for telehealth services have increased significantly, resulting in the rapid removal of prepandemic telehealth barriers.22Kacik A. Providence goes from 700 video visits a month to 70,000 a weekhttps://www.modernhealthcare.com/providers/providence-goes-700-video-visits-month-70000-weekDate accessed: July 9, 2020Google Scholar In addition to removing geographic restrictions and allowing for the home to serve as the originating site, the main regulatory changes pertinent to home dialysis patients now permit: (1) billing for services across state lines, (2) delivering care to both established and new patients through telehealth, (3) use of non–Health Insurance Portability and Accountability Act (HIPAA)–compliant platforms such as Skype and FaceTime, and (4) reimbursement for audio-only visits. An additional change broadened eligibility to provide telehealth services to all health care professionals who are eligible to bill Medicare for their professional services.23Centers for Medicaid & Medicare ServicesCoronavirus waivers & flexibilities.https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waiversDate accessed: August 15, 2020Google Scholar Furthermore, some but not all states have relaxed requirements for licensure as long as a provider holds a license in another state. Nephrology practices and dialysis providers have adopted telehealth platforms to deliver care for patients receiving dialysis. They may design platforms internally or purchase commercial products. Platforms can vary significantly in terms of cost, scalability, and technical support. Telehealth platforms range from videoconferencing alone to platforms that also allow for self-scheduling, payment collection, and physician notifications. Both providers and patients value ease of use when comparing videoconferencing platforms. Some videoconferencing platforms can only invite patients through text message, whereas others can only email invitations. Finally, one must consider security. Security encompasses both encryption standards and cybersecurity risk. HIPAA compliance requires data encryption, a Business Associates Agreement with the provider of the telecommunications, and the patient must be in a private physical environment. An information technology security specialist should evaluate cybersecurity and risks to network integrity to minimize potential susceptibilities of health care networks to viruses or cyber attacks. The clinician performing a telehealth encounter may require several systems to operate simultaneously. The clinician may therefore need simultaneous access to a HIPAA-compliant video platform (with a high-quality camera, concurrent audio, and secure communications) and an electronic health record (to check laboratory results, write a note contemporaneously, and prescribe medications electronically). However, the patient requires only 1 device. It must have a camera that can synchronize with the team's platform at the predetermined appointment time. Although patients mainly use their smartphone as the primary device, options for tablets and computers (laptop and desktop with webcam) should be considered, although the device choice remains highly dependent on the specific platform.9Lew S.Q. Sikka N. Are patients prepared to use telemedicine in home peritoneal dialysis programs?.Perit Dial Int. 2013; 33: 714-715Crossref PubMed Scopus (21) Google Scholar The staff may have to help the patient install the software application, provide instruction, test the linkage, and hold a practice session. Some patients may not have access to adequate hardware or access to technology, and this should be addressed to ensure equitable care for patients. A visit will proceed more efficiently if, in advance of the session, the team (usually the nurse) assembles and updates the medication list, dialysis prescription, vital signs, and laboratory results and collects remote data from PD or hemodialysis (HD) flow sheets. In this regard, the use of remote patient monitoring (RPM) may be particularly useful. RPM uses digital technologies to acquire home health data, transmitting the information to health care providers.6Nayak K.S. Ronco C. Karopadi A.N. et al.Telemedicine and remote monitoring: supporting the patient on peritoneal dialysis.Perit Dial Int. 2016; 36: 362-366Crossref PubMed Scopus (44) Google Scholar,8Wallace E.L. Rosner M.H. Alscher M.D. et al.Remote patient management for home dialysis patients.Kidney Int Rep. 2017; 2: 1009-1017Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar,10Lew S.Q. Sikka N. Thompson C. et al.Adoption of telehealth: remote biometric monitoring among peritoneal dialysis patients in the United States.Perit Dial Int. 2017; 37: 576-578Crossref PubMed Scopus (17) Google Scholar,24Rosner M.H. Ronco C. Remote monitoring for continuous peritoneal dialysis.Contrib Nephrol. 2012; 178: 68-73Crossref PubMed Scopus (22) Google Scholar,25Nayak A. Karopadi A. Antony S. et al.Use of a peritoneal dialysis remote monitoring system in India.Perit Dial Int. 2012; 32: 200-204Crossref PubMed Scopus (45) Google Scholar Existing home dialysis RPM platforms allow direct transmission of both biometric information (ie, blood pressure, blood glucose level, temperature, and weight) to providers and home HD and automated PD treatment parameters (ie, treatment completion, duration, interruptions, alarms, and ultrafiltration).26Drepper V.J. Martin P.Y. Chopard C.S. et al.Remote patient management in automated peritoneal dialysis: a promising new tool.Perit Dial Int. 2018; 38: 76-78Crossref PubMed Scopus (23) Google Scholar,27Remote Monitoring.https://www.amia.com/hcp/features/remote-monitoring BaxterDate accessed: August 15, 2020Google Scholar RPM obviates the need for paper dialysis treatment logs and provides information in key domains of dialysis access, blood pressure, target weight, and ultrafiltration management while identifying treatment adherence challenges and in some cases allowing remote changes to the prescription. Although the virtual visit lacks the traditional physical examination, a virtual "no touch" physical examination remains a possible alternative (Table 1). The absence of a satisfactory electronic stethoscope limits the appreciation of cardiac, pulmonary, and abdominal sounds. In a home HD patient, one cannot perceive the bruit in the arteriovenous access. Nevertheless, the no-touch examination still allows the clinician to evaluate volume status and dialysis access (catheter exit site or arteriovenous access). Volume status may be estimated by using weight, blood pressure, and ultrafiltration rate in addition to observable physical examination findings such as pedal edema. The exit site can be evaluated by electronic photograph or real-time observation.Table 1The "No Touch" Physical ExaminationParameterPossible FindingsGeneralWell vs ill appearingIn (no) acute distressEyes(Non)-icteric sclera(No) droopy eyelidsMouthDentation/oral cavity appears (ab)normal(No) thrush presentTongue (not) coatedCardiacHeart rate (ir)regular (based on patient counting the pulse out loud)Normo- vs hyper- vs hypotension (based on patient measurement of blood pressure)Tachycardia vs bradycardia vs normal pulse rate (based on patient measurement)PulmonaryWork of breathing with(out) effort(Not) speaking in full sentences(No) audible wheezingGastrointestinal(No) tenderness when the patient presses on the abdomenGenital-urologic(No) suprapubic tenderness when the patient presses in the area superior to the pubisMusculoskeletal(No) pedal edema(No) muscle tenderness when the patient squeezes the muscle in question(No) joint swelling(No) hand twitching(No) decreased ability to turn door knobNeurologic(Not) alert and oriented(Ab)normal gait(No) localized/focal weakness(No) tremor(No) asterixisTest functional status (functional status, gross vs fine examination)PsychologicalNormal vs anxious mood; normal vs flat affectGood vs poor memory (Not) anxiousHematologic(No) excessive bruising or bleedingPD specificExit site with(out) crust, drainage, or erythemaHD specificAV fistula or AV graft with(out) bruit and thrill (based on patient's assessment)(No) aneurysmal protrusion(No) purulent dischargeTunneled CVC exit site with(out) drainage or erythemaNote: Only items that can be and are actually visualized should be documented. Some findings require the patient to elicit by tapping, squeezing, or pressing.Abbreviations: AV, arteriovenous; CVC, central venous catheter; HD, hemodialysis; PD, peritoneal dialysis. Open table in a new tab Note: Only items that can be and are actually visualized should be documented. Some findings require the patient to elicit by tapping, squeezing, or pressing. Abbreviations: AV, arteriovenous; CVC, central venous catheter; HD, hemodialysis; PD, peritoneal dialysis. Other members of the IDT can perform assessments or counseling with the patient apart from the monthly visit. Studies have shown that dietitians using telemedicine platforms can successfully perform coaching programs for dietary counseling in patients with CKD, as well as diabetes management.28Kelly J.T. Conley M. Hoffmann T. et al.A coaching program to improve dietary intake of patients with CKD: ENTICE-CKD.Clin J Am Soc Nephrol. 2020; 15: 330-340Crossref PubMed Scopus (26) Google Scholar,29Benson G.A. Sidebottom A. Hayes J. et al.Impact of ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) telemedicine randomized controlled trial on diabetes optimal care outcomes in patients with type 2 diabetes.J Acad Nutr Diet. 2019; 119: 585-598Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar A regular virtual check-in with the social worker can permit discussions around emotional distress, caregiver burnout, and medical resource acquisition and management. These interdisciplinary visits performed virtually have been successfully performed in CKD programs and can be extended into PD programs.30Ishani A. Christopher J. Palmer D. et al.Telehealth by an interprofessional team in patients with CKD: a randomized controlled trial.Am J Kidney Dis. 2016; 68: 41-49Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar A clinical presenter may assist the patient with the telehealth visit. Family members (parents for minors or a spouse or sibling for adults), caregivers, friends, or nurses can gather vital signs, assist in the physical examination, help interpret and carry out changes in care plans or orders, and be an interpreter if a language barrier exists. As parties become facile with repeated practice and telehealth encounters, it may be possible to invite other health professionals in consultation. This act can increase patient access to care and reduce time to care, transportation time, and cost. These visits may include a virtual preoperative surgical assessment before PD catheter placement or a postoperative visit to evaluate wound healing. A PD nurse can also use telehealth to troubleshoot a PD catheter with the nephrologist or surgeon remotely. Likewise, fellows in nephrology training programs can be included in the care of these patients by using videoconferencing. This can simultaneously address training for the fellow in both PD and telehealth techniques. The impact of such broad use of telemedicine for home dialysis care on safe and effective care, infections, hospitalizations, technique failure, and patient-reported outcomes remains to be determined. Data collected during the COVID-19 pandemic may help inform the best use of telehealth among patients receiving dialysis. Stable home dialysis patients may be one group that could easily benefit from the regular use of telehealth. However, unstable patients who experience difficulty with travel plans may also benefit from telehealth because the alternative is not to be seen at all. The collective input from patients, nephrologists, and the IDT should determine a preferred approach to plan the follow-up visit. A previsit review of patient-maintained dialysis logs, remotely monitored data metrics, laboratory trends, and a screening telephone call for patient-reported symptoms by a nurse, along with specific decision support tools, can help in triaging patients (Box 1).Box 1High-Risk Factors That Might Trigger an In-person Visit Instead of a Telemedicine VisitRecent events•PD- or HHD-related infection within the last 1 mo•Hospitalization or emergency department visit within the last 1 mo•New home dialysis start within the last 1 moPatient factors•Inability to administer ESA at home•Does not have appropriate technology for telemedicine visit•New symptoms or medical issues needing attention, eg, abdominal pain•Access-related issuesPrevisit nurse, social worker, dietitian or nephrologist assessment•Concerns regarding adherence to the appropriate technique or prescribed prescription (ie, identified on remote patient monitoring)•Uncontrolled moderate-severe hypertension or significant hypotension•Patient-reported fluid imbalance not responding to prescription change or diuretics•Patient-reported new/worsening symptoms•Patient reports social isolation, severe depression, or anxietyAbbreviations: ESA, erythropoiesis-stimulating agent; HHD, home hemodialysis; PD, peritoneal dialysis. Recent events•PD- or HHD-related infection within the last 1 mo•Hospitalization or emergency department visit within the last 1 mo•New home dialysis start within the last 1 mo Patient factors•Inability to administer ESA at home•Does not have appropriate technology for telemedicine visit•New symptoms or medical issues needing attention, eg, abdominal pain•Access-related issues Previsit nurse, social worker, dietitian or nephrologist assessment•Concerns regarding adherence to the appropriate technique or prescribed prescription (ie, identified on remote patient monitoring)•Uncontrolled moderate-severe hypertension or significant hypotension•Patient-reported fluid imbalance not responding to prescription change or diuretics•Patient-reported new/worsening symptoms•Patient reports social isolation, severe depression, or anxiety Abbreviations: ESA, erythropoiesis-stimulating agent; HHD, home hemodialysis; PD, peritoneal dialysis. Approximately 45% of dialysis units are unable to provide home dialysis, especially in rural areas where there may be less access to a nearby home dialysis unit.31Prakash S. Coffin R. Schold J. et al.Travel distance and home dialysis rates in the United States.Perit Dial Int. 2014; 34: 24-32Crossref PubMed Scopus (30) Google Scholar Whereas urban communities are intuitively thought to have greater access to home dialysis, local traffic patterns may affect travel time as much as distance does in rural communities. In either case, telehealth presents a solution to accessing home dialysis facilities while safely isolating at home during the COVID-19 pandemic. Nevertheless, challenges remain in the implementation and widespread use of telehealth (Fig 1). Limited patient access to capable devices continues to be a known barrier. Because of this, patients may opt to use telehealth with a friend or family member assisting if they do not have a compatible device themselves. Changes that address regulatory barriers are needed for providers to assist patients by providing connectivity devices without "inducement" concerns.32HHS Office of Inspector General Fact SheetNotice of proposed rulemaking OIG-09336-AA10-P. October 2019.https://www.oig.hhs.gov/authorities/docs/2019/CoordinatedCare_FactSheet_October2019.pdfDate accessed: August 15, 2020Google Scholar The regulatory waivers provided during the COVID-19 pandemic demonstrate proof of concept that solutions and compromises can be found with the end goal of better care for home dialysis patients. However, even provision of the devices themselves may not be enough. Many patients do not have access to broadband internet speeds capable of videoconferencing; in turn, disparities will worsen should audio-only options be removed after the state of emergency has been lifted. Unfortunately, socioeconomic and language barriers persist. African Americans and Hispanics have been underrepresented in home dialysis nationwide and are underrepresented in video uptake in telehealth.33Wallace E.L. Lea J. Chaudhary N.S. et al.Home dialysis utilization among racial and ethnic minorities in the United States at the national, regional, and state level.Perit Dial Int. 2017; 37: 21-29Crossref PubMed Scopus (26) Google Scholar A recent report on the use of telemedicine for chronic disease management during the COVID-19 pandemic in the primary care setting has already reported a significant decrease in the number of visits by patients older than 65 years, non–native English speakers, Medicare/Medicaid-insured patients, or patients who self-identified as a racial/ethnic minority.34Nouri S. Khoong E.C. Lyles C.R. et al.Addressing equity in telemedicine for chronic disease management during the Covid-19 pandemic. NEJM Catalyst Innovations in Care Delivery. May 2020.https://catalyst.nejm.org/doi/full/10.1056/CAT.1020.0123#Google Scholar Overcoming limited access to devices and broadband internet is only the first step in addressing these challenges. Existing telemedicine platforms are unlikely to consider digital technology literacy, health literacy, age, or English language proficiency in their design.34Nouri S. Khoong E.C. Lyles C.R. et al.Addressing equity in telemedicine for chronic disease management during the Covid-19 pandemic. NEJM Catalyst Innovations in Care Delivery. May 2020.https://catalyst.nejm.org/doi/full/10.1056/CAT.1020.0123#Google Scholar Moreover, most nephrologists and dialysis providers do not have systems in place to provide training to patients on how to use these tools. There exists an opportunity for telehealth technology itself to provide solutions to ensure equitable access to care. As an example, interpreter services provided within telehealth visits could help bridge both language and cultural barriers to care. Increasing access to telehealth as described will require a concerted effort from government, regulators, payers, dialysis organizations, and nephrologists. As we move toward value-based care models, it stands to reason that removing barriers to telehealth will help increase minority representation and align with efforts to increase home dialysis use under the Advancing American Kidney Health Initiative.35Trump D. Executive Order on Advancing American Kidney Health.https://www.whitehouse.gov/presidential-actions/executive-order-advancing-american-kidney-health/Date accessed: August 15, 2020Google Scholar Nurses take leading roles in the startup and maintenance of many new technologies in home dialysis program while playing a primary role in coordinating all aspects of a telehealth visit to ensure optimally successful experiences for both the IDT and patient. Nurses facilitate telehealth by setting up the platform on the patient's device and teaching them how to use it. Nurses often take the lead in coordinating and setting the stage as patient visits get underway. Although many aspects of a visit include skills that are currently used in successful home dialysis programs, the nurse has taken on the responsibility for the technical aspect of telemedicine. Home dialysis nurse retention is a growing issue in the United States, a development that could adversely affect home growth. These telehealth-related care enhancements may provide home dialysis nursing a viable alternative career destination in a social distanced health care environment. Telehealth may overcome the challenges of creating workplaces that engage and retain nurses by incorporating flexible nurse schedules, enhancing communications with patients and colleagues, and developing collaborative relationships across the IDT. These strategic initiatives have been implemented in workplaces that have high staff engagement and retention36Koppel J. Deline M. Virkstis K. A two-pronged approach to retaining millennial nurses.J Nurs Adm. 2017; 47: 597-598Crossref PubMed Scopus (11) Google Scholar,37Scruth E.A. Garcia S. Buchner L. Work life quality, healthy work environments, and nurse retention.Clin Nurse Spec. 2018; 32: 111-113Crossref PubMed Scopus (17) Google Scholar and can now be experienced in the home dialysis setting. The success of these remote dialysis facilities relies on trained nurses to meet the care demands of this new and changing home dialysis experience. Patients have had different responses to telehealth. Many of the challenges could be mitigated and improved on by having patients be involved in both the design of the technology and crafting the patient experience for a telehealth visit. One author, C.W., appreciates telehealth and reports, "I use FaceTime to interact with the doctor and nurse at a specified time. My concerns are addressed. I don't have to travel to the dialysis unit or miss a prolonged period of time from work." However, not all patients participate in telehealth due to lack of internet service or device. Telehealth has also proved to be an extremely valuable resource for the pediatric dialysis community during the COVID-19 pandemic. Although 3% of all outpatient clinic visits at Children's Mercy Kansas City before the COVID-19 pandemic were conducted through telehealth, 70% of visits during the pandemic were telehealth based (B.A.W., unpublished observation). In addition, 35 of 38 pediatric dialysis programs participating in the Standardizing Care to Improve Outcomes in Pediatric End-Stage Renal Disease (SCOPE) Collaborative reported carrying out telehealth visits during this time. Before the COVID-19 pandemic, there was limited experience and a paucity of literature on the use of telehealth in pediatric nephrology. In a 10-year experience from Australia, telehealth was deemed to be a viable and cost-effective resource, saving an average $505 Australian dollars per consultation.38Trnka P. White M.M. Renton W.D. et al.A retrospective review of telehealth services for children referred to a paediatric nephrologist.BMC Nephrol. 2015; 16: 125Crossref PubMed Scopus (27) Google Scholar In a review of the use of telehealth tools in pediatrics, Brophy4Brophy P.D. Overview on the challenges and benefits of using telehealth tools in a pediatric population.Adv Chronic Kidney Dis. 2017; 24: 17-21Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar emphasized the important role that telehealth could play in improving access and reducing costs related to pediatric kidney care. The COVID-19 pandemic has stimulated an emphasis on telehealth and highlighted many of the benefits for pediatric dialysis patients and their families in terms of visit-related travel time, cost, and absence from school and work. The ability to visit with the IDT from home can also be comforting for the young child who may associate the hospital clinic with painful procedures. At the same time, ongoing challenges to be addressed include: (1) the need for accurate biometric measurements such as height and weight because growth represents a key pediatric-specific outcome parameter, and (2) the lack of privacy that may exist for a desired parentless portion of the clinic visit, particularly salient to the adolescent preparing for transfer to adult care or for a mandated routine suicide screen. The future landscape for advancing telehealth use in home dialysis depends on integrating technology with an efficient home program workflow, leveraging platforms that are user friendly, improving efficiency, and ensuring patient outcomes that surpass or are equal to in-person visits. Developing a balance between virtual and in-person visits for patients with high comorbidity will be critical. Change management initiatives should help the transition from traditional encounters to virtual care, especially as provider practices exit the COVID-19 pandemic. It remains unclear as to what regulations will return when the public health emergency ends. Box 2 includes considerations that must be accounted for in any long-term planning for ongoing telehealth coverage and expansion.Box 2Long-term Needs for Ongoing Telehealth Coverage•An alternative to monthly laboratory work for stable patients•Home must remain as the originating and distant sites•Allow health professional licensure across state lines•Allow health professionals to bill for services across state lines•Develop various media formats to educate patients and providers on telehealth•Formal adoption of telehealth as a preferred practice for stable home dialysis patients•Dissemination of online tools to promote modality education and training•Reduction in internet disparities•Creation of a national health information exchange •An alternative to monthly laboratory work for stable patients•Home must remain as the originating and distant sites•Allow health professional licensure across state lines•Allow health professionals to bill for services across state lines•Develop various media formats to educate patients and providers on telehealth•Formal adoption of telehealth as a preferred practice for stable home dialysis patients•Dissemination of online tools to promote modality education and training•Reduction in internet disparities•Creation of a national health information exchange Using technology and telemedicine to educate patients will be important in a connected world while trying to decrease face-to-face interactions. Future areas of study include virtual education about CKD and dialysis modalities, virtual transplantation evaluations, and virtual training for patients and caregivers as new starts to dialysis or retraining after a prolonged hospitalization. Measuring and conducting research on the delivered quality of care and patient outcomes and comparing telehealth and standard care along with patient and health care provider satisfaction (patient-reported outcome measures) with telehealth will be important determinants of whether the virtual practice continues to grow after the COVID-19 pandemic. A large-scale study from Canada may soon provide some answers (ClinicalTrials.gov identifier NCT02670512). If telehealth use can be captured during the COVID-19 pandemic using Medicare claims data, analysis of measured quality-of-care metrics for patients such as hospitalization, readmission, emergency department visits, and transplantation wait list rates may be important to help establish the role of telemedicine as part of routine care. COVID-19 has pushed telehealth to the forefront of all aspects of health care out of necessity to protect providers and patients while maintaining adequate care. Insurance coverage changes have aided in this transformation by allowing for a reasonable, sustainable, and efficient way to implement telehealth. It is reasonable to think that telehealth has reached its peak use during the pandemic and a subsequent decline may ensue when COVID-19–related waivers are lifted. However, an alternative future for telehealth could be the rapid development of supportive technologies that increase the number of patients who can be effectively cared for in their homes. Examples of such technologies include home-based point-of-care laboratory measurements based on finger sticks and home-based diagnostic tests that match accuracy with ease of use. However, it is clear that even in its current state, telehealth has forever changed the way we practice health care, and there will be no returning to a health care system devoid of it. As such, we must continue to make it better, we must continue to make it easier, and we must continue to make it available to anyone and everyone in need of care by addressing internet infrastructure, technology literacy, and socioeconomic determinants of health.
See Commentary on Page 1381 See Commentary on Page 1381 The coronavirus disease 2019 (COVID-19) pandemic resulted in extraordinary increase in the number of patients requiring renal replacement therapy (RRT), high rate of clotting in continuous RRT (CRRT) circuits, limited dialysis supplies and shortages of dialysis staff due to illness or quarantine.1Goldfarb D.S. Benstein J.A. Zhdanova O. et al.Impending shortages of kidney replacement therapy for COVID-19 patients.Clin J Am Soc Nephrol. 2020; 15: 880-882Crossref PubMed Scopus (92) Google Scholar, 2Goyal P. Choi J.J. Pinheiro L.C. et al.Clinical characteristics of Covid-19 in New York City.N Engl J Med. 2020; 382: 2372-2374Crossref PubMed Scopus (1602) Google Scholar, 3Hirsch J.S. Ng J.H. Ross D.W. et al.Acute kidney injury in patients hospitalized with Covid-19.Kidney Int. 2020; 98: 209-218Abstract Full Text Full Text PDF PubMed Scopus (1020) Google Scholar, 4Cummings M.J. Baldwin M.R. Abrams D. et al.Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study.Lancet. 2020; 395: 1763-1770Abstract Full Text Full Text PDF PubMed Scopus (1513) Google Scholar, 5Sise M.E. Baggett M.V. Shepard J.-A.O. et al.Case 17-2020: a 68-year-old man with covid-19 and acute kidney injury.N Engl J Med. 2020; 382: 2147-2156Crossref PubMed Scopus (59) Google Scholar This created an opportunity to use peritoneal dialysis (PD) for acute kidney injury (AKI). Patients treated with acute PD (AKI-PD) at our New York City hospital from April 1, 2020, to April 30, 2020, were retrospectively analyzed. Overall, 40 patients were screened and 11 were suitable for AKI-PD. AKI was defined as any patient with Acute Kidney Injury/Network (AKIN) stage 1 or greater; all patients in the cohort were AKIN stage 3. The nephrology consultant determined the need and timing for RRT initiation based on usual clinical indications. These patients were then referred to the AKI-PD team composed of an attending nephrologist and surgeon to determine candidacy for AKI-PD. Patients were excluded if they had significant abdominal surgical scars, uncorrected hernias, high likelihood of prone ventilation, active gastrointestinal issues such as ileus or small bowel obstruction, or were on dual antiplatelet therapy with aspirin and clopidogrel. Body mass index greater than 30 kg/m2 was a relative contraindication and candidacy discussed on a case-by-case basis. All 11 patients underwent bedside placement of a swan-neck double-cuff Tenckhoff tunneled PD catheter, with additional purse-string suture at the surgeon's discretion. Bedside placement of the catheters by a surgeon and an assistant alone was chosen to limit COVID-19 exposure of additional health care professionals. All patients received a bowel regimen to ensure 1 to 2 bowel movements daily, the choice of laxative was at the discretion of primary treating service. The median age of the cohort was 65 years (interquartile range [IQR]: 52–76); predominantly (91%) male (Table 1). Median body mass index was 26 kg/m2 (IQR: 23–30). Two patients had history of chronic kidney disease. One patient had a history of abdominal surgery. Median Sequential Organ Failure Assessment score was 9 (IQR: 6–10). All patients were on invasive mechanical ventilation and 45% required vasopressors. Acute respiratory distress syndrome, as defined by the Berlin criteria,6Ferguson N.D. Fan E. Camporota L. et al.The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material.Intensive Care Med. 2012; 38: 1573-1582Crossref PubMed Scopus (1062) Google Scholar was mild in 73% and moderate in 27%. Median baseline creatinine was 1 mg/dl (IQR: 0.9–1.44). Median time from admission to the development of AKI was 1 day (IQR: 0–3). Median peak creatinine was 6.6 mg/dl (IQR 5.6–8.15) and median daily urine output was 230 ml (IQR: 150–392) at initiation of RRT. In 73% of the patients, CRRT or intermittent hemodialysis was used as the initial RRT modality and switched to PD at a later date; time interval between discontinuation of CRRT/hemodialysis and initiating PD was less than 24 hours in these patients. CRRT circuit clotting was the primary reason for switching to PD in 2 patients.Table 1Baseline characteristics, PD prescription and outcomesTotal N = 11Baseline characteristics Age, median (IQR)65 (52–76) Male, n (%)10 (91) Race, n (%)Asian6 (55)White2 (18)Black1 (9)Declined2 (18) Ethnicity, n (%)Hispanic1 (9)Comorbidities, n (%) Hypertension7 (64) Diabetes mellitus5 (45) Chronic kidney disease2 (18) Coronary artery disease2 (18) History of abdominal surgery1 (9) Body mass index, kg/m2 median (IQR)26 (23–30)Clinical characteristics before PD initiation Severity of ARDS,aSeverity of ARDS defined per Berlin Criteria: mild (200 mm Hg < PaO2/FIO2 ≤ 300 mm Hg), moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg), and severe (PaO2/FIO2 ≤ 100 mm Hg). n (%)Mild8 (73)Moderate3 (27)Severe0 SOFAbSequential Organ Failure Assessment score. score, median (IQR)9 (6–10) Daily urine output, ml, median (IQR)230 (150–392) Blood urea nitrogen, mg/dl, median (IQR)99 (70–119) Creatinine, mg/dl, median (IQR)6 (4.7–6.4) Serum albumin, g/dl, median (IQR)1.6 (1.5–1.7)PD prescription Modality of PD, n (%)Manual PD6 (55)Automated PD5 (45) Time from PD catheter insertion to start of PD, h, n (%)<246 (55)24–485 (45) Dwell volume, ml, n (%)10005 (45)15001 (9)20005 (45) Therapy volume in liters per 24 hManual PD, median (IQR)8 (7–8)Automated PD, median (IQR)8 (8–9.9) Total therapy time in h,cTotal therapy time for all manual PD was 24 h. Four exchanges were performed in 24 h. median (IQR)24 (12–24) Daily urine output, ml, median (IQR)497 (137–1612) Daily ultrafiltration, ml, median (IQR)681 (262–1351)Laboratory values at 30-d follow-up, median (IQR) Blood urea nitrogen, mg/dl44 (24–61) Creatinine, mg/dl1.9 (1.3–3.1) Serum albumin, g/dl2.1 (1.4–2.6)PD catheter outcomes, n (%) Leak1 (9) Peritonitis0 (0)Patient outcomes, n (%) Renal recoverydRenal recovery was defined as no longer requiring renal replacement therapy.6 (55) Death4 (36) Alive on hemodialysis1 (9)ARDS, acute respiratory distress syndrome; IQR, interquartile range; PD, peritoneal dialysis.a Severity of ARDS defined per Berlin Criteria: mild (200 mm Hg < PaO2/FIO2 ≤ 300 mm Hg), moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg), and severe (PaO2/FIO2 ≤ 100 mm Hg).b Sequential Organ Failure Assessment score.c Total therapy time for all manual PD was 24 h. Four exchanges were performed in 24 h.d Renal recovery was defined as no longer requiring renal replacement therapy. Open table in a new tab ARDS, acute respiratory distress syndrome; IQR, interquartile range; PD, peritoneal dialysis. At the time of PD initiation, median blood urea nitrogen was 99 mg/dl (IQR: 70–118), creatinine 6 mg/dl (IQR: 4.7–6.4), and serum albumin 1.6 g/dl (IQR: 1.5–1.7). Six patients had serum potassium >5 mmol/dl and 1 had >6 mmol/dl. Median time for potassium levels to return to normal range was 2 days (IQR: 0–3) using PD combined with medical therapies, including oral potassium binder, insulin, and diuretics in these 7 patients. Median time for correction of metabolic acidosis was 3 days (IQR: 0–4). While on PD, the median daily urine output was 497 ml (IQR: 137–1612) and median daily ultrafiltration was 681 ml (IQR: 262–1351). Seven of the 11 patients were continued on diuretics. At 30 days, median blood urea nitrogen, creatinine, and albumin were 44 mg/dl (IQR: 24–61), 1.9 mg/dl (IQR: 1.3–3.1), and 2.1g/dl (IQR: 1.4–2.6), respectively. The median time from diagnosis of AKI to PD catheter insertion was 5 days (IQR: 2–14). The time from PD catheter placement to initiation of PD was less than 24 hours in 55% and between 24 to 48 hours in the remainder. The decision to start on continuous ambulatory PD or automated PD (APD) was based on the availability of cyclers and nursing familiarity with each modality. Five of the 6 patients who were started on continuous ambulatory PD tolerated an initial dwell volume of 2000 ml with no leaks; the sixth patient was switched to APD when a cycler was available. For those on continuous ambulatory PD, the initial prescription was 2000 ml every 6 hours. In the 5 patients initiated on APD, the initial dwell volume was between 1000 and 1500 ml and total therapy volume of 8000 ml to 10,500 ml over 12 hours total (1000 ml × 8 or 1500 ml × 7), which is in keeping with recently published acute PD protocols.7Srivatana V. Aggarwal V. Finkelstein F.O. et al.Peritoneal dialysis for acute kidney injury treatment in the United States: brought to you by the COVID-19 pandemic.Kidney360. 2020; 1: 410-415Crossref PubMed Scopus (32) Google Scholar In 4 patients the abdomen was empty while off APD; however, 1 patient was treated with consecutive 12-hour treatments due to hyperkalemia until the potassium normalized. In terms of ventilator parameters, plateau pressures were less than 30 cm H2O in all patients, except 1 patient with moderate-to-severe acute respiratory distress syndrome with plateau pressure of 33 to 38 cmH2O. No changes in plateau pressure were noted while on PD for any patients and none of the patients were in prone position while on PD. The median hospital length of stay was 42 days (IQR: 19–70). Four patients (36%) died and the median time from AKI to death was 17 days (IQR: 14–22). Six patients had renal recovery defined as dialysis independence as determined by the treating nephrologist. Median time from AKI to renal recovery was 37 days (IQR: 25–41). One patient was discharged and remained dialysis dependent. One patient who recovered renal function remains hospitalized at the time of writing. Regarding PD catheter outcomes, patients were treated with PD for a median duration of 14 days (IQR: 10–20). Ten catheters (91%) remained functional during the duration of the follow-up. One patient was switched to CRRT due to primary PD catheter nonfunction; this patient had a body mass index greater than 35 kg/m2 and a history of appendectomy. There was one episode of leak that was resolved with temporary reduction of dwell volume and the patient was able to continue PD. There were no episodes of peritonitis observed. One patient was switched to hemodialysis at the time of discharge to a skilled nursing facility that did not have PD available. One patient was converted to CRRT before death at the discretion of the intensivist, although the PD catheter was functional. Two patients required CRRT/hemodialysis supplementation for variable ultrafiltration and active gastrointestinal bleeding but were able to return to PD before renal recovery. In our cohort, 6 patients (54%) had renal recovery with a median follow-up of 35 days. Remarkably, these 6 patients survived their acute critical illness, and were all subsequently discharged. We hypothesize that preservation of residual renal function using PD may have contributed to the high rate of renal recovery observed.8Jansen M.A. Hart A.A. Korevaar J.C. et al.Predictors of the rate of decline of residual renal function in incident dialysis patients.Kidney Int. 2002; 62: 1046-1053Abstract Full Text Full Text PDF PubMed Scopus (456) Google Scholar Two of our patients converted from CRRT to PD due to repeated filter clotting. We did not observe any bleeding complications in our cohort, although we had the benefit of experienced operators. We hypothesize that hypercoagulable patients with COVID-19 may potentially have a lower risk of bleeding complications and consequently be excellent candidates for PD. The PD prescriptions used were variable, but each able to control metabolic parameters and provide adequate volume control. The primary limitation of our study was the small number of patients. However, this cohort represented approximately 20% of all patients requiring RRT in our hospital at the peak of the demand. Our report demonstrates the value of even a modest amount of PD in a time of crisis to be able to provide RRT for all patients who need it. In addition, although all patients were mechanically ventilated and critically ill, there is a potential for selection bias resulting in the high observed rate of renal recovery. Long-term outcome studies in a larger cohort are needed to confirm these findings. In summary, the practical utility and potential for a higher rate of renal recovery combines for an attractive and unique rationale for the use of AKI-PD in the critically ill COVID-19 population. VS reports speaker fees from Baxter International. All the other authors declared no competing interests. We acknowledge the extraordinary effort of our nurses and staff who are on the front lines of the COVID-19 crisis each day. Your patients and doctors thank you. Download .pdf (.03 MB) Help with pdf files Supplementary File (PDF) COVID-19 and ESRD: Entering a New Era of UncertaintyKidney International ReportsVol. 5Issue 9PreviewThe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; coronavirus disease 2019 [COVID-19]) pandemic has raised our awareness of the susceptibility of certain members of the population to this serious and often fatal infection. Across the globe, more than 5.8 million cases have been confirmed and more than 360,000 deaths reported as of the end of May 2020. Some areas have been particularly hard hit (the so-called epicenters of the pandemic) and certain populations within these epicenters have been particularly affected. Full-Text PDF Open Access
AKI is a recognized complication of coronavirus disease 2019 (COVID-19) (1). In this study, we characterized the AKI incidence and outcomes in patients with COVID-19 and AKI. We conducted a retrospective cohort study of 1002 patients admitted from March 1 to April 19, 2020 through the Emergency Department at NewYork-Presbyterian/Weill Cornell Medical Center. Patient follow-up was until at least June 20, 2020, at which time 22 patients were still hospitalized and nine were transferred to another hospital facility. Baseline creatinine was defined as the closest creatinine prior to March 1, 2020 or, if none was available, the creatinine at time of hospital presentation. The Weill Cornell Institutional Review Board approved this study. AKI, defined by the Kidney Disease Improving Global Outcomes criteria (2), occurred in 294 (29%) of the 1002 patients: stage 1 AKI (n=182, 18%); stage 2 AKI (n=29, 3%); and stage 3 AKI (n=83, 8%). KRT was performed in 59 patients (6%); 53 received hemodialysis and/or continuous venovenous hemodialysis, five received a combination of acute peritoneal dialysis and hemodialysis/continuous venovenous hemodialysis, and one received acute peritoneal dialysis. The time from hospitalization to AKI was a median of 2.2 days in stage 1 AKI, 2.4 days in stage 2 AKI, and 1.6 days in stage 3 AKI. We evaluated the urine electrolytes and microscopy associated with the AKI event within 3 days. Among those available, the fractional excretion of sodium (FENa) was <1% in 76%, and urine microscopy had granular casts in 21%. The presumed etiology of stage 3 AKI on the basis of manual chart review was acute tubular necrosis (ATN) in 28%, prerenal in 13%, prerenal/ATN in 11%, other causes in 4%, and unknown in 45% of patients. Granular casts were observed more frequently in stage 3 AKI than stage 1 AKI and stage 2 AKI (33% versus 16%, P=0.006). We compared clinical characteristics of the patients with AKI with those without AKI (Table 1). Patients who developed AKI were older and more frequently had a history of hypertension, diabetes mellitus, congestive heart failure, CKD, and kidney transplantation than patients without AKI (P<0.001). Proteinuria and hematuria were more frequent in patients with AKI than in patients without AKI (P<0.001). Baseline creatinine, admission creatinine, peak creatinine, white blood cells, procalcitonin, troponin I, C-reactive protein, d-dimer, ferritin, lactate dehydrogenase, lactate, and creatine kinase were significantly higher in patients with AKI than in patients without AKI (P<0.001), whereas hemoglobin and albumin levels were significantly lower in patients with AKI than in those without AKI (P<0.001). Patients with AKI were also more likely to have usage of nonsteroidal anti-inflammatory drugs, diuretics, and hydroxychloroquine during hospitalization; intensive care unit admission; mechanical ventilation; use of vasopressors; and longer hospital length of stay than patients without AKI (P<0.001). Table 1. - For continuous variable, the numbers of measurements are listed (n = number in total cohort/number in AKI group/number in the no AKI group) Characteristics Total Cohort, n=1002, No. (%) or Median (Interquartile Range) AKI Group, n=294, No. (%) or Median (Interquartile Range) No AKI Group, n=708, No. (%) or Median (Interquartile Range) Demographics and comorbidities Age, median, yr 66 (53–76) 69 (59–79) 63 (51–74) Men 619 (62%) 208 (71%) 411 (58%) Race White 354 (35%) 112 (38%) 242 (34%) Black 119 (12%) 41 (14%) 78 (11%) Other 272 (27%) 86 (29%) 186 (26%) Unknown/declined 257 (26%) 55 (19%) 202 (29%) Hypertensiona 597 (60%) 211 (72%) 386 (55%) Diabetes mellitusa 378 (38%) 138 (47%) 240 (34%) Congestive heart failurea 131 (13%) 67 (23%) 64 (9%) COPDa 81 (8%) 36 (12%) 45 (6%) Obesitya 184 (18%) 71 (24%) 113 (16%) CKDb 138 (14%) 66 (22%) 72 (10%) Kidney transplant recipient 33 (3%) 20 (7%) 13 (2%) Laboratory parametersc Baseline creatinine, mg/dl, n=1002/294/708 0.9 (0.8–1.2) 1.1 (0.9–1.4) 0.9 (0.8–1.1) Admission creatinine, mg/dl, n=1002/294/708 1.0 (0.8–1.3) 1.2 (0.9–1.9) 0.9 (0.8–1.1) Peak creatinine, mg/dl, n=1002/294/708 1.1 (0.8–1.8) 2.8 (1.8–5.0) 0.9 (0.8–1.2) WBC×103/μl, n=1002/294/708 6.9 (5.1–9.6) 7.6 (5.5–10.7) 6.7 (4.9–9.3) Hemoglobin, g/dl, n=1002/294/708 13.4 (12.2–14.8) 13.1 (11.5–14.5) 13.6 (12.4–14.8) Platelets ×103/μl, n=1000/294/706 207 (156–270) 200 (146–258) 213 (160–273) ALT, U/L, n=995/294/701 34 (22–57) 34 (21–54) 35 (23–59) AST, U/L, n=986/291/695 42 (28–65) 46 (30–70) 41 (27–63) Alkaline phosphatase, U/L, n=995/294/701 74 (59–100) 78 (59–105) 73 (58–99) Total bilirubin, mg/dl, n=995/294/701 0.6 (0.4–0.8) 0.6 (0.4–0.9) 0.6 (0.4–0.8) Albumin, g/dl, n=995/294/701 3.2 (2.8–3.5) 3.1 (2.7–3.4) 3.2 (2.9–3.6) Prothrombin time, s, n=878/284/594 13.3 (12.3–14.6) 13.4 (12.6–15) 13.2 (12.3–14.4) Procalcitonin, ng/ml, n=930/278/652 0.17 (0.09–0.42) 0.32 (0.16–0.69) 0.14 (0.08–0.30) Troponin I, ng/ml, n=845/262/583 0.03 (0.03–0.05) 0.04 (0.03–0.12) 0.03 (0.03–0.03) ESR, mm/h, n=716/216/500 73 (49–99) 76 (49–101) 72 (48–97) CRP, mg/dl, n=748/228/520 11 (6–19) 14 (7–22) 10 (5–17) d-dimer, ng/ml, n=686/211/475 442 (273–900) 636 (339–1845) 391 (248–772) Ferritin, ng/ml, n=784/240/544 732 (339–1392) 965 (500–1566) 611 (292–1278) IL-6, pg/ml, n=181/91/90 26 (10–58) 33 (14–63) 18 (9–50) LDH, U/L, n=866/263/603 417 (319–545) 478 (353–608) 399 (311–515) Lactate, mmol/L, n=619/197/422 1.6 (1.1–2.2) 1.9 (1.3–3) 1.5 (1.1–2.0) Creatine kinase, U/L, n=582/199/383 144 (76–308) 186 (86–409) 130 (71–255) Urine protein, 1+, 2+, 3+, n=748/269/479 505 (68%) 207 (77%) 298 (62%) Hematuria, 1+, 2+, 3+, n=748/269/479 362 (48%) 174 (65%) 188 (39%) Fractional excretion of sodium <1%, n=148 112 (76%) Urine granular casts >0/hpf, n=220 46 (21%) Hospital characteristics/outcomes NSAID usage in hospital 278 (28%) 104 (35%) 174 (25%) Diuretic usage in hospital 277 (28%) 178 (61%) 99 (14%) Anticoagulation usage in hospital 675 (67%) 201 (68%) 474 (67%) Hydroxychloroquine usage in hospital 695 (69%) 231 (79%) 464 (66%) ICU admission 274 (27%) 183 (62%) 91 (13%) Mechanical ventilation 261 (26%) 179 (61%) 82 (12%) Vasopressor usage 261 (26%) 183 (62%) 78 (11%) Length of stay, d, n=971/281/690 7 (3–17) 17 (7–39) 6 (3–12) Mortality 172 (17%) 118 (40%) 54 (8%) Among the laboratory parameters, WBCs, hemoglobin, platelets, ALT, AST, alkaline phosphatase, total bilirubin, albumin, procalcitonin, ESR, CRP, d-dimer, ferritin, and LDH were measured similarly in the AKI group and in the no AKI group (P>0.05), whereas prothrombin time, troponin I, IL-6, lactate, urine protein, and hematuria were measured more frequently in the AKI group than the no AKI group (P<0.05). P values were calculated using the Wilcoxon rank sum test for analysis of continuous variables and using the Fisher's exact test for analysis of dichotomous variables. All statistical analyses were performed using R 3.3.3. CKD indicates baseline creatinine of ≥1.5 mg/dl. COPD, chronic obstructive pulmonary disease; WBC, white blood cell; ALT, alanine aminotransferase; AST, aspartate aminotransferase; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; LDH, lactate dehydrogenase; hpf, high-power field; NSAID, nonsteroidal anti-inflammatory drug; ICU, intensive care unit.aObtained using International Classification of Diseases-9 and International Classification of Diseases-10 codes.bA baseline creatinine prior to Emergency Department presentation was used in 320 patients (32%).cAll laboratory values were the first values obtained after Emergency Department presentation except for the fractional excretion of sodium <1% and urine granular casts >0/hpf, which were obtained within 3 days of the AKI event. Urine granular casts were detected using an automated system (iRiCELL; Beckman Coulter, Brea, CA), and they were manually verified by laboratory technicians. Patients with AKI had higher mortality than patients without AKI (40% versus 8%, P<0.001). Among the patients with AKI, 140 (48%) recovered to their baseline kidney function. Among the 154 (52%) who did not recover to their baseline kidney function, 43 received dialysis, among which 34 were dialysis dependent and 26 died (60%), and 111 did not receive dialysis, among which 80 (72%) died (P=0.18). Patients with AKI who did not recover to their baseline kidney function were older; had more congestive heart failure; had less anticoagulation use; and had higher d-dimer, troponin I, and peak creatinine levels than patients with AKI who recovered to their baseline kidney function (P<0.001). Within the AKI group, we found that the FENa was <1% in a majority of patients, and granular casts were present in 21% of patients. However, another study found that FENa was <1% in 38% of cases of patients with AKI and COVID-19 (3), and therefore, FENa evaluation needs to be interpreted with due caution and may not reflect the AKI etiology. As for potential etiology for the AKI, limited data from patient series of kidney biopsies support ATN as the most common cause of AKI (4). Further studies are needed to better understand the basis for kidney dysfunction. In this study, we found several laboratory parameters that are significantly different between patients with AKI and patients without AKI. d-dimer level was significantly higher in patients with AKI without kidney function recovery than in patients with AKI and kidney function recovery. A recent study in patients with COVID-19 admitted to the intensive care unit reported d-dimer as predictive of the need for dialysis (5), and it is likely that d-dimer is a predictor of disease severity. We also found a higher IL-6 level in patients with AKI than in patients without AKI. Whether cytokine storm also played a role in kidney injury is unknown. Disease severity may also be linked to men, and further evaluation is needed to understand the relationship between sex and AKI. An important limitation of our study is that the incidence of community-acquired AKI may have been underestimated because only one-third of patients had a baseline creatinine prior to admission. In conclusion, our study identified a high incidence of AKI in hospitalized patients with COVID-19. We found that a significant proportion did not have complete kidney function recovery, supporting the importance of CKD follow-up in patients with COVID-19. Disclosures O. Akchurin reports receiving a grant from the National Institutes of Health and is a recipient of the Clinical Scholar Award from Weill Cornell Medicine. M. Choi reports receiving grants from the National Institutes of Health. D. Dadhania reports receiving advisory board fees from AlloVir Inc., CareDx, and Veloxis Pharm. D. Dadhania, J. Lee, and M. Suthanthiran have filed patent US-2020-0048713-A1 titled "Methods of detecting cell-free DNA in biological samples." J. Lee reports receiving a grant from BioFire Diagnostics LLC, grants from the National Institutes of Health, and a grant from the National Kidney Foundation. F. Liu reports receiving advisory board fees from Accordant and is on the speakers' bureau on Janssen Pharmaceuticals. V. Srivatana reports receiving speakers' fees from Baxter Healthcare. M. Suthanthiran reports receiving grants from CareDx, Inc. and the National Institutes of Health and consultant fees from CareDx, Inc. and Sparks Therapeutics. Y. Zhang reports other from Iris OB Health, Inc. and grants from the Agency for Healthcare Research and Quality, the National Institutes of Health, and the US Department of Transportation, outside the submitted work. All remaining authors have nothing to disclose. Funding This study received support from NewYork-Presbyterian Hospital and Weill Cornell Medical College, including the Clinical and Translational Science Center (National Center for Advancing Translational Sciences grant UL1 TR000457) and Joint Clinical Trials Office.
The nasal passages harbor both commensal and pathogenic bacteria. In this study, we sought to characterize the anterior nasal microbiota in PD patients using 16S rRNA gene sequencing.Cross-sectional.We recruited 32 PD patients, 37 kidney transplant (KTx) recipients, 22 living donor/healthy control (HC) participants and collected anterior nasal swabs at a single point in time.We performed 16S rRNA gene sequencing of the V4-V5 hypervariable region to determine the nasal microbiota.Nasal microbiota profiles were determined at the genus level as well as the amplicon sequencing variant level.We compared nasal abundance of common genera among the 3 groups using Wilcoxon rank sum testing with Benjamini-Hochberg adjustment. DESeq2 was also utilized to compare the groups at the ASV levels.In the entire cohort, the most abundant genera in the nasal microbiota included: Staphylococcus, Corynebacterium, Streptococcus , and Anaerococcus . Correlational analyses revealed a significant inverse relationship between the nasal abundance of Staphylococcus and that of Corynebacterium . PD patients have a higher nasal abundance of Streptococcus than KTx recipients and HC participants. PD patients have a more diverse representation of Staphylococcus and Streptococcus than KTx recipients and HC participants. PD patients who concurrently have or who developed future Staphylococcus peritonitis had a numerically higher nasal abundance of Staphylococcus than PD patients who did not develop Staphylococcus peritonitis.16S RNA gene sequencing provides taxonomic information to the genus level.We find a distinct nasal microbiota signature in PD patients compared to KTx recipients and HC participants. Given the potential relationship between the nasal pathogenic bacteria and infectious complications, further studies are needed to define the nasal microbiota associated with these infectious complications and to conduct studies on the manipulation of the nasal microbiota to prevent such complications.
