Image from Pixabay / Gerald

SARS-CoV2 is a virus that has shaken the scientific community to its core. As we struggle to catch up to a rapidly evolving global pandemic, it is of utmost importance that we understand and develop novel strategies to conserve the resources necessary for continuous kidney replacement therapy (CKRT). This current pandemic has unveiled unprecedented demands of CKRT machines and consumables that have been made worse by strained global supply chains.

A group of nephrologists and intensivists recently published a series of recommendations in AJKD to address sustainability of resources for CKRT in the ICU.

Overview of CKRT sustainability plan. Figure 1 from Chua et al, AJKD © National Kidney Foundation

1. Projecting Demand: Chua et al examined the annual consumption of CKRT fluids and estimated the current use based on routine rates and the total capacity of hospital beds. Incident COVID-19 cases per week were projected based on current epidemiology. The study inferred a corresponding CKRT incidence of 1% with an average of 6 days of CKRT to estimate the assets and consumables for standard CKRT support and to predict the threshold when capacity would be exceeded.
2. Diversifying Supply: The importance of diversifying sources of CKRT machines from multiple vendors to ensure a continuity of supply is highlighted. This also includes adequate stocks of both tunneled and non-tunneled vascular catheters and sizes in addition to filters and dialysate and replacement fluid options, Institutions are encouraged to work with the vendors to ensure a supply of filter sizes that correspond to the most common range of body weight encountered in their practice.
3. Reduce Unnecessary Consumption: To ensure service sustainability, several strategies were suggested for more efficient consumption of CKRT resources. This included optimizing vascular access, adopting measures to prolong filter life, optimizing circuit anticoagulation, lowering blood flows to reduce citrate consumption, and adopting measures to improve the efficiency of CKRT Fluid.
4. Ensure Sufficient Machines: Purchasing CKRT machines is limited by supplier inventory and the substantial cost. It may be necessary to use 1 machine to treat 2 patients within a 24-hour period by compressing the run of KRT to 10 to 12 hours at correspondingly higher clearance to compensate for efficacy (accelerated venovenous hemofiltration). Consideration of peritoneal dialysis as an alternative to CKRT should be made for select patients when possible due to technical simplicity, minimal infrastructural requirements, lack of requirement for anticoagulation, and less nursing time.
5. Workforce Training: Nursing staff is required to run and monitor a successful CKRT program. It is ideal to have a core group of nursing supervisors monitor the CKRT program by overseeing machine assignments, initial setup, and training of a larger pool of bedside nurses. Creating accessible and simplified protocols should be developed to improve efficiency.
6. Centralized Coordination and Distribution: This would provide a means for responsive allocation and redistribution of machines and consumables. Tracking usage of consumable allows for better predictability and anticipation of expected surges in patient load, thereby averting supply chain disruptions.

Citrate and CKRT fluid consumption under (A) standard conditions, with higher blood flow rate (Qb) and pre–blood pump (PBP) rate, versus (B) conditions designed to reduce consumption. Variations in PBP (citrate) flow rate based on Qb; a higher Qb may be more ideal for hemofiltration but results in greater citrate delivery. The paired bicarbonate-buffered solution that contains key electrolytes, for example, potassium and magnesium, is often maintained to achieve metabolic equilibrium, resulting in greater overall CKRT fluid consumption. Lower blood flow reduces citrate consumption by 30%; paired bicarbonate-based solution is reduced proportionally, and delivered as a dialysate to reduce the filtration fraction. Ultrafiltration (UF) rate augments the overall CKRT dose. Delivered dose calculated based on 75 kg of body weight with correction factor applied (due to PBP dilution). Figure 2 from Chua et al, AJKD © National Kidney Foundation

Chua et al provide efficient ways to optimize CKRT in the face of a pandemic to concomitantly maximize resources while minimizing potential exposure. One recognizes that the experience discussed herein may not be generalizable to all healthcare settings. Some rural facilities may not necessarily have a robust underlying healthcare infrastructure, thereby limiting their ability to adapt to this supply and demand issue, e.g., due to a small workforce and not enough nursing staff to be trained for the changes. A careful review of current practice patterns and adapting recommendations to sustain CKRT machines and consumables will better prepare our healthcare system and extend our critical limit for life-saving medical treatments throughout the pandemic.

– Post prepared by David Alter, Smit Mehta @SmitToMyLou, Sandra Pasiah (AJKDBlog Guest Contributors), and Edgar V. Lerma @edgarvlermamd, AJKD Social Media Advisory Board member. 

To view Chua et al (FREE), please visit AJKD.org.

Title: Ensuring Sustainability of Continuous Kidney Replacement Therapy in the Face of Extraordinary Demand: Lessons From the COVID-19 Pandemic
Authors: H.-R. Chua, G. MacLaren, L. H.-L. Choong, C.-Y. Chionh, B.Z.E. Khoo, S.-C. Yeo, D.-W. Sewa, S.-Y. Ng, J.C.-J. Choo, B.-W. Teo, H.-K. Tan, W.-T. Siow, R.V. Agrawal, C.-S. Tan, A. Vathsala, R. Tagore, T.Y.-Y. Seow, P. Khatri, W.-Z. Hong, and M. Kaushik
DOI: 10.1053/j.ajkd.2020.05.008

In the face of the unprecedented public health crisis posed by the current pandemic, this special collection gathers COVID-19–related publications from the NKF family of journals. All articles in the collection are freely available.