Dialysis Filter Life in COVID-19: Early Lessons from the Pandemic

Nephrologists take pride in ensuring that kidney failure is not a life-limiting determinant of health in the intensive care unit (ICU). Although mortality is high in those with AKI, continuous RRT (CRRT) offers a means to support those who require time to recover from their primary insult (1,2). However, for centers hit with early surges from the coronavirus disease 2019 (COVID-19) pandemic, the inability to provide effective dialysis was both a fear and a reality (3,4). Hospitals faced unprecedented supply-chain resource limitations (at least for American medicine) and strains on nursing staff (4). In addition, these patients showed a degree of systemic hypercoagulability that was disproportionate to what was expected in critical illness, with unique features, including a consumptive disseminated intravascular coagulation coexisting with hyperfibrinolysis and increased bleeding risk (5). Maintaining circuit patency, a problem that nephrologists have faced in providing effective clearance and volume management since the origins of hemodialysis, became a common theme once again (3). A number of studies have documented the efficacy of regional citrate anticoagulation for the prevention of clotting (6), and this strategy has been adopted by many centers, including ours, for the delivery of CRRT in patients with increased clotting risk. It became readily apparent, however, that many patients with COVID-19 had a significant burden of filter clotting, despite the use of regional citrate, optimization of vascular access, and adjustments in the CRRT prescription to reduce intrafilter hemoconcentration. This generated shorter, suboptimal treatments for patients, and caused a higher burden for nurses who had to repeatedly attend to machine alarms inside patients’ rooms. The absence of peer-reviewed literature forced direct communications between colleagues in early COVID-19 “hot spots” and anecdotes from American Society of Nephrology message boards as the only means for early clinical guidance. Many centers trialed …