What are the COVID-19 prevention and treatment guidelines for patients with End-Stage Renal Disease (ESRD) undergoing hemodialysis?

COVID-19 Prevention and Treatment Guidelines for Hemodialysis Patients with ESRD

Patients with end-stage renal disease on hemodialysis should receive early COVID-19 vaccination with mRNA vaccines (preferably mRNA-1273 over BNT162b2), followed by a third booster dose within 1-2 months of the primary series, and subsequent boosters every 4-6 months due to their impaired and rapidly waning immune responses. 1, 2

Vaccination Strategy

Primary Vaccination Series

• Prioritize mRNA vaccines over adenoviral vector vaccines for all hemodialysis patients, as mRNA vaccines demonstrate superior immunogenicity in this population 2
• mRNA-1273 (Moderna) is preferred over BNT162b2 (Pfizer) due to markedly better immune responses, likely attributable to higher mRNA content 3, 2
• Hemodialysis patients develop delayed and blunted antibody responses compared to the general population, with lower seroconversion rates after standard two-dose regimens 1, 4, 2

Booster Dose Recommendations

• Administer a third dose within 1-2 months after the primary two-dose series to significantly increase antibody levels, particularly in poor initial responders 2
• This third dose achieves seroconversion in three out of four patients who were non-responders or weak responders to the initial two doses 3
• Subsequent booster doses should be given every 4-6 months due to progressive waning of immunity and emergence of immune-escape variants 2
• 96.1% of hemodialysis patients either maintain upper-limit titers or generate higher antibody levels after the third dose compared to after the second dose 3

Special Populations Requiring Enhanced Monitoring

• Patients on immunosuppressive therapy (particularly anti-CD20 agents like rituximab) should ideally wait at least 6 months after the last rituximab dose before vaccination, or taper steroids below 20 mg prednisone daily 1
• Patients with active cancer demonstrate worse humoral responses and may benefit from more frequent vaccine boosters 3
• Older patients and those with lower serum albumin levels have unfavorable antibody formation 4
• Younger age, previous COVID-19 infection, and higher serum albumin are positively associated with antibody response 4

Infection Prevention in Dialysis Facilities

Screening and Monitoring

• Screen all hemodialysis patients regularly for COVID-19 symptoms, as these patients may present with atypical manifestations leading to delayed diagnosis 1
• Patients with ESRD are at increased risk due to regular dialysis sessions in densely populated environments with high SARS-CoV-2 transmission potential 1
• Maintain heightened vigilance for infection in patients with documented lymphopenia, as severity correlates with infection risk 5

Facility-Level Precautions

• Implement social distancing measures within dialysis units 6
• Maintain rigorous personal hygiene protocols and augmented cleaning procedures 6, 4
• Consider isolation protocols for suspected or confirmed COVID-19 cases 6
• Provide health education to patients regarding transmission prevention 6

Treatment Considerations for COVID-19 in Hemodialysis Patients

Acute Kidney Injury Management

• Assess fluid status meticulously on hospital admission, as maintaining euvolemia is critical in reducing AKI incidence but difficult to achieve in COVID-19 1
• Monitor for dehydration requiring intravenous fluid correction, as fever and increased respiratory rate increase insensible fluid loss 1
• Record fluid balance (intake, output, weight), serum urea, creatinine, electrolytes, and full blood count 1

Thromboprophylaxis

• Administer prophylactic anticoagulation to all hospitalized COVID-19 patients with ESRD unless contraindications exist, as these patients are at increased risk of venous thromboembolism 1
• Use low molecular weight heparin (LMWH) or unfractionated heparin (UFH) for thromboprophylaxis 1
• In patients with renal dysfunction, prefer UFH over LMWH for reversibility, or adjust LMWH dosing based on anti-Xa levels 7
• Prophylactic-dose heparin is recommended for critically ill patients without contraindications 7

Electrolyte Management

• Monitor for hyperkalaemia closely and manage according to local protocols 1
• Potassium binders (patiromer and sodium zirconium cyclosilicate) can be used alongside standard care for emergency management of acute life-threatening hyperkalaemia 1

Renal Replacement Therapy Considerations

• Be aware of increased RRT circuit clotting due to the prothrombotic state in COVID-19 patients 1
• Follow local protocols for RRT anticoagulation, though optimal strategies remain uncertain 1

Referral Criteria

Refer hemodialysis patients with COVID-19 for specialist advice if: 1

• Diagnostic uncertainty exists about AKI cause requiring further testing
• Abnormal urinalysis suggests COVID-19-induced kidney damage or intrinsic renal disease
• Fluid management needs are complex
• AKI worsens despite initial management or fails to resolve after 48 hours
• Usual indications for renal replacement therapy develop, particularly with anuria

Critical Pitfalls to Avoid

• Do not assume adequate protection after standard two-dose vaccination in hemodialysis patients—third and subsequent boosters are essential 2
• Do not delay vaccination in immunosuppressed patients indefinitely; if the underlying autoimmune kidney disease is active, immunosuppressive therapy takes priority, though disease activation post-vaccination is rare 1
• Do not withhold thromboprophylaxis based solely on abnormal coagulation tests without active bleeding 7
• Do not overlook atypical COVID-19 presentations in ESRD patients, which can lead to delayed diagnosis 1
• Do not use BNT162b2 when mRNA-1273 is available, as the latter provides superior immunogenicity 2

Patients with Poor Vaccine Response

• Consider primary prophylaxis strategies (such as neutralizing monoclonal antibodies) for patients with persistent poor vaccine responses after multiple doses 2
• Polyfunctional CD4+ T cell responses are critical for viral protection; patients with low responses despite vaccination remain at risk for severe COVID-19 8
• Four patients in one study suffered severe COVID-19 despite three-dose vaccination, all having low polyfunctional T-cell responses 8