Nephrology and kidney care during the pandemic [PODCAST]

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“COVID-19 wreaks havoc on multiple areas of the body, and myself and my fellow frontline workers across the globe have been forced to quickly identify what tools work best in our quest to keep our patients alive.

While we’re working to identify which technologies can improve our patients’ outcomes, it’s encouraging that policy work is being done to ensure we can access the technology that allows us to provide life-saving care. We can’t do it alone.

As we anticipate a potential surge of cases in the coming months, we must be prepared with the proper PPE, medications, and medical technologies that will result in less devastation than what we experienced this spring. When it comes to pandemics, that means we’re intentional about establishing, nurturing, and supporting domestic manufacturers who can provide U.S. hospitals with the resources they need.”

Maria DeVita is a nephrologist.

She shares her story and discusses her KevinMD article, “The need for on-demand access to medical technologies when treating COVID-19 patients.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Maria DeVita. She is a nephrologist, and she wrote the KevinMD article “The need for on-demand access to medical technologies when treating COVID-19 patients.” Maria, welcome to the show.

Maria DeVita: Why, thank you very much, Kevin. It’s really a pleasure to be here today.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Maria DeVita: Sure. I like my story. I was a medical student down at Georgetown University in Washington, D.C. I came up to Lenox Hill Hospital after my training, after my graduation in 1984, did my residency and my fellowship at Lenox Hill Hospital in Manhattan, and I have been here ever since. So I basically have been in Washington, D.C., and New York City. And I went into nephrology three decades ago because I really wanted to become a better internist, and basically, the kidney’s job is to maintain homeostasis. So everything is happening all around, and the kidneys sort of keep your volume OK, keep your electrolytes OK, keep your blood pressure OK, and that really fascinated me.

So through all of that, you get involved with a lot of people whose kidneys aren’t working, so then they need dialysis. Dialysis cleans your blood. It also maintains your volume status. Then you extrapolate from that, and this newer equipment that we’ve been using, and sort of what we focused on a little bit with the article, was about pure ultrafiltration. So it’s not quite dialysis, because we’re not cleaning the blood, but we are removing fluid. For me, and getting back to the point on technology, it was really exciting to have at my fingertips different equipment that can do different things, and it was, what did I need at what moment, what resources did I have available, in the midst of all this COVID pandemic.

Kevin Pho: And speaking of that, we are talking in the middle of January. So describe what you’re seeing from a nephrology standpoint, either in a clinic or a hospital, during the pandemic.

Maria DeVita: Yeah, so if it’s OK, I’ll sort of go back to when it all started in March. As most of you will recall, New York City was sort of the initiation of the whole pandemic for the United States, and we were very much overwhelmed. It sort of was overnight. We had our first case the beginning of March. The city was closed down by St. Patrick’s Day. Streets were deserted. In March and April and May, we were overwhelmed with patients. Our hospital usually has about maybe 350, 400 patients regularly. Every day, we would have dozens of COVID admissions. At the peak number of COVID patients we were handling, and we’re sort of a smaller hospital in Manhattan, we had about 370 COVID patients. The thing that surprised us most was that about 20 to 25 percent of those patients went into kidney failure. So people hear about all the respiratory complications, some of the coagulation problems, but the kidney issues were sort of not really well understood or expected, so that was like a big deal.

We were able to get things under control. Everything was very quiet through the end of the summer into the fall, and now we’re sort of back up. The good news now, compared to the way it was back in March, was that all those patients in March were needing intensive care unit care, so they were very, very sick and needed ventilators. Now we only have one. We have about 60 or 70 patients or so in the hospital, which is hardly any compared to what we were doing, and most of those patients are not in the critical care unit. We have special COVID floors. So fortunately, we have a much smaller percentage of people needing the critical care, very few people needing intubation, and patients still needing some dialysis because they developed acute kidney failure, but overall much easier. We’re all exhausted, though, I mean, just emotionally more than physically, I think, as is, I think, every human being on the planet. So it’s a little bit harder in that regard, even though the patients are a little bit easier to handle.

Kevin Pho: And what specific impact on the kidney have you seen COVID have?

Maria DeVita: Yeah, it’s really remarkable. Basically, what happens when you get COVID and you get a severe COVID infection is that you get this huge immune response, and that immune cascade, cytokine storm, I think, is what it’s mostly referred to, will almost set off another set of reactions that then causes an acute tubular necrosis in the kidney. So that basically acutely damages the kidney so it can’t function, and that was happening, as I mentioned, to about 20 to 25 percent of our patients. And then they just become dialysis dependent for the time being. Unfortunately, back earlier in the start of the pandemic, a lot of those people didn’t survive. So we’ve learned a lot about how to manage them more on the respiratory side of it, and then therefore they aren’t getting such big reactions, so the kidney failure isn’t quite as common as it was before. But that was sort of unexpected, so we really had to think on our feet and sort of adjust to and adapt to the needs of the patients.

Kevin Pho: And from your experience over the past year or so, what percentage of the inpatients actually progressed to needing dialysis, of the COVID patients, that is?

Maria DeVita: Yeah, of the COVID inpatients, about 25 percent, which, at the onset, we were not expecting but a few. And it was mostly thought to be a respiratory problem. Get people intubated, treat their illness or support them, because there wasn’t any definitive treatment, and then they should recover. But what was happening is that they were going into this kidney failure due to this cytokine storm.

Kevin Pho: I know this is a little bit soon. Are you seeing any residual effects from those patients who recover from the acute tubular necrosis?

Maria DeVita: Yeah, so unfortunately, so acute tubular necrosis usually does get better. In this scenario, a lot of those patients didn’t survive. Of the patients that survived, and again, this is just in my population, which is smaller than other reports, maybe only 10 people recovered, and then they had no residual issues. And another four or five survived the whole intubation and recovered respiratory-wise and were better, but they became dialysis dependent. So, few patients got better. Some people got better from the COVID, but their kidneys didn’t regain function, which can happen with acute tubular necrosis.

Kevin Pho: All right, so let’s transition now into your KevinMD article, “The need for on-demand access to medical technologies when treating COVID-19 patients.” Now, for those who didn’t read that article, can you just walk my audience through it and share the story of why you decided to write it?

Maria DeVita: So basically, the pandemic overwhelmed us, and New York, as I mentioned, was overwhelmed, and we needed to provide a lot of dialysis to these patients. The main way to dialyze somebody, typically, is hemodialysis, where your blood is circulated through a filter. So we have what’s called intermittent acute hemodialysis, where we bring up a standard dialysis machine and dialyze somebody over three or four hours. Then we have, for people who cannot tolerate a shorter treatment, they get a slower form of dialysis that’s called CVVHD, continuous venovenous hemodialysis, and that’s a slow process. It’s usually going on for 12 to 24 to 72 to however long they need it, but it’s a nice, slow, methodical cleaning of the blood and removal of fluid. The hemodialysis is usually about three or four hours, and so everything’s more rapid, so rapid shifts versus shorter, longer shifts than what we were doing.

And what I sort of was commenting on is that there’s another piece of equipment called the Aquadex, and what it does, the medical term is called aquapheresis, and aquapheresis is just a way of pulling the fluid off, the ultrafiltration. So both the acute hemodialysis equipment and the CVVH do ultrafiltration. That’s sort of the mainstay of what dialysis does: removes fluid, cleans the blood. This latter technology just removes the fluid, and what’s nice about it is it’s very simple. The other pieces of equipment are more cumbersome, if you will. They do a great job. The standard hemodialysis is run by a hemodialysis nurse that sits at the bedside or in the unit and does one-to-one care with that patient while the patient’s getting dialysis. The CVVH is done by the critical care nurse, so the critical care nurse taking care of that patient will operate the machine, and that machine will run for hours to days, but it takes a while to set it up. The aquapheresis equipment is still run by the critical care nurse, but it’s a simpler machine to set up, because you don’t have to worry about the cleaning of the blood. You’re just ultrafiltrating, so it’s much simpler.

So the point there is that I had three technologies that I could use. Aquapheresis is sort of a newer technology, and it’s not really recognized among insurance companies and billers and most people, actually. So I was getting a little frustrated trying to use all my three tools, if you will. So what we would do is, in the moment, we would decide what patient needs hemodialysis, what patient needs the CVVH, and who just needs to have fluid removal, and we were just seeing the moment and just triaging it out, and it was very, very important. And that’s sort of what the article is referencing, how we just needed to flip between things, make quick decisions, and every day we would just come back and reprioritize our patients. And having that third piece of equipment was very useful, and I think that the fact that it isn’t so recognized was a little bit frustrating for me.

Kevin Pho: Now, when you talk about these three different technologies, and now we’re speaking in the middle of January, has the problem gotten any better? And are there still any non-clinical considerations that influence your decision among the three technologies you talked about?

Maria DeVita: Yes, there are still some barriers. The first two, the intermittent acute hemodialysis and the continuous form of renal replacement therapy, are both well-established modalities, and within the algorithm, I guess, of securing the equipment and using it and billing for it and having Medicare recognition for it, it is all standard. This aquapheresis is not quite dialysis, because it’s not cleaning the blood, but it is a procedure with no category yet. So I think that that still persists. I don’t think that persists now, still in January, and it may even persist moving forward, but I think it’s a really wonderful piece of technology that really needs a little bit more awareness.

The downside on aquapheresis is that it had initially come out to be used to decongest people with congestive heart failure. So the equipment came out, and it was mostly used by cardiologists in an outpatient setting. Most of the studies showed that it hasn’t been so helpful in regard to just standard diuretics. I sort of approach it as a nephrologist, and it’s somebody who’s not really making much urine, and if I have to get the fluid off but I don’t have to do the clearance, then it’s a great tool to sort of put in there. So I have sort of resurfaced it within our institution, and we just use it: What do we need to get done today? Do I have to clean? Can we do it quickly or slowly? Do I just have to get rid of fluid? And it’s been really a useful tool for that. And I think we’re still finding the niche for it, I guess, is what the issue is.

Kevin Pho: And across the country, how accessible is aquapheresis?

Maria DeVita: Yeah, I’ve talked to other people across the country during this pandemic, and it’s new, and I would say it’s not very accessible, and people aren’t sure really how to put it into the armamentarium of treating various patients. I think this is going to go way beyond COVID, and it’s just a way to pick the best technology for the problem or the condition that we need to solve for the patient right now, and that might change tomorrow. And for me, it’s very exciting to be able to have these different options, and we just sort of plug it into what we need to fix today.

Kevin Pho: And what are some of the barriers? Is it a cost issue? Is it a factor?

Maria DeVita: Yeah, I think it’s a cost issue. Sorry to interrupt you. I think it’s a cost issue, and it’s the fact that it hasn’t been well studied in controlled trials in the manner in which I want to use it, or I have been using it. I think it’s not really recognized yet within Medicare and other insurance companies for billing purposes. So those are the biggest barriers: just familiarity with it, to have more studies, and then just the economic repercussions with the insurance companies and Medicare.

Kevin Pho: We’re talking to Maria DeVita. She is a nephrologist, and she wrote the KevinMD article “The need for on-demand access to medical technologies when treating COVID-19 patients.” Maria, what do you anticipate to be the continuing nephrology challenges over the next three, six, nine months of the pandemic?

Maria DeVita: I think it’s just going to be more of the same, so that’s a little bit frustrating, but I think we’re better prepared than we were last March. And we just have to make sure that we get everybody to wear a mask and socially distance, so we don’t really have to take care of their kidneys. That would be the biggest thing. But we’re prepared. We would like to sort of be beyond it. And I think once people get sick, we’ll do the best we can for them. It’s best not to get sick. And then of course, my feeling is everybody should be vaccinated.

Kevin Pho: Any tips for us primary care doctors? For instance, if we see a previously hospitalized patient who may have been on dialysis, anything that we need to look out for and follow up?

Maria DeVita: Yeah, I think it’s important that most people, when they have an acute kidney injury, don’t really regain all their kidney function, so they will have some form of residual CKD, so chronic kidney disease. I think with those patients, you also have to be mindful that they can have elevated potassiums and low bicarbonates. They can also run a higher blood pressure. So it’s sort of the whole patient again, and sort of what my roots were for getting into nephrology. It’s the most general of all the subspecialties. But it’s monitoring their sodium and the potassium balance, their BUN and creatinine, and of course their volume status.

One of the exciting things that is happening is that there’s a lot of suggestion that the rate of fluid removal in people on dialysis, or in need of any form of renal replacement therapy, is the rate at which you remove fluid in people, and that’s a newer thing. So I think this equipment is going to be helpful, that we can sort of clean somebody pretty quickly and then sort of slowly pull off fluid, maybe switch between technologies, while we try to optimize patient outcomes.

Kevin Pho: And my final question: What’s your take-home message you want to leave with the KevinMD audience?

Maria DeVita: Well, thank you very much again, and I wanted to sort of let the audience know that they should be mindful of volume status and kidney issues. Chronic kidney disease and acute kidney injuries are very common, and if we’re aware of them, I think we can have better outcomes.

Kevin Pho: Maria, thank you so much for taking the time and for your insight, and thanks again for being on the show.

Maria DeVita: OK. It was great to be here. Thank you very much.

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