Faculty Bibliography

Background:The COVID-19 pandemic strained hospital resources in New York City, including those for providing dialysis. New York University Medical Center and affiliations, including New York City Health and Hospitals/Bellevue, developed a plan to offset the increased needs for KRT. We established acute peritoneal dialysis (PD) capability, as usual dialysis modalities were overwhelmed by COVID-19 AKI. Methods:Observational study of patients requiring KRT admitted to Bellevue Hospital during the COVID surge. Bellevue Hospital is one of the largest public hospitals in the United States, providing medical care to an underserved population. There were substantial staff, supplies, and equipment shortages. Adult patients admitted with AKI who required KRT were considered for PD. We rapidly established an acute PD program. A surgery team placed catheters at the bedside in the intensive care unit; a nephrology team delivered treatment. We provided an alternative to hemodialysis and continuous venovenous hemofiltration for treating patients in the intensive-care unit, demonstrating efficacy with outcomes comparable to standard care. Results:From April 8, 2020 to May 8, 2020, 39 catheters were placed into ten women and 29 men. By June 10, 39% of the patients started on PD recovered kidney function (average ages 56 years for men and 59.5 years for women); men and women who expired were an average 71.8 and 66.2 years old. No episodes of peritonitis were observed; there were nine incidents of minor leaking. Some patients were treated while ventilated in the prone position. Conclusions:Demand compelled us to utilize acute PD during the COVID-19 pandemic. Our experience is one of the largest recently reported in the United States of which we are aware. Acute PD provided lifesaving care to acutely ill patients when expanding current resources was impossible. Our experience may help other programs to avoid rationing dialysis treatments in health crises.

Kidney supportive care is the application of palliative medicine principles and practices to patients with kidney disease. The goal is alleviation of suffering through treatment of symptoms, empathic communication, and support for psychosocial distress. Kidney supportive care includes primary palliative care provided by nephrology teams, as well as referral of patients with complex distress for comanagement by an interprofessional specialty palliative care team, when available. The team may include physicians, nurses, social workers, chaplains, and dieticians. Comanagement with nephrologists offers an additional layer of support to patients and families as prognostic awareness, patient preferences, and care decisions are explored. Kidney supportive care can be offered to patients experiencing acute kidney injury or chronic kidney disease, including those with kidney failure treated by kidney replacement therapy (dialysis and transplantation). Kidney supportive care includes but is not limited to end-of-life care. This installment of the Core Curriculum in Nephrology outlines several practical applications of kidney supportive care, with a focus on the nephrologist's approach to symptom management, active medical management of kidney failure without dialysis (also known as comprehensive conservative care), acute kidney injury in seriously ill patients, and withdrawal from dialysis.