What are the recommended treatment guidelines for an adult patient with end‑stage renal disease on dialysis who tests positive for COVID‑19?

Treatment Guidelines for ESRD Patients with COVID-19

ESRD patients on dialysis who test positive for COVID-19 should continue their regular hemodialysis schedule in designated isolation areas with enhanced infection control measures, while receiving supportive care and considering corticosteroids if they require supplemental oxygen. 1

Dialysis Management

Continue regular hemodialysis sessions without delay, as interruption of dialysis can lead to life-threatening complications including hyperkalemia, uremic encephalopathy, and fluid overload that may worsen COVID-19 outcomes. 2

• Isolate COVID-19 positive patients in dedicated dialysis units or cohort areas, separate from COVID-19 negative patients, with dedicated staff and equipment. 3, 4
• Schedule infected patients at the end of the day or in separate shifts to minimize exposure to other patients. 3
• Maintain standard dialysis prescription (frequency and duration) unless clinical deterioration requires adjustment. 5
• Be aware of increased circuit clotting risk due to COVID-19-associated coagulopathy during renal replacement therapy sessions. 1

Pharmacological Treatment

Corticosteroids (Primary Recommendation)

Administer dexamethasone 6 mg daily (or equivalent corticosteroid) if the patient requires supplemental oxygen, noninvasive ventilation, or mechanical ventilation. 1

• Do NOT give corticosteroids to COVID-19 positive ESRD patients who do not require supplemental oxygen, as no mortality benefit exists in this group. 1
• This recommendation is based on the RECOVERY trial showing mortality reduction in oxygen-requiring patients (26.2% vs 23.3% with dexamethasone). 1

Anticoagulation

Provide prophylactic anticoagulation to all hospitalized COVID-19 patients with ESRD unless contraindicated. 1

• Adjust dosing based on renal function and bleeding risk, recognizing that ESRD patients have altered pharmacokinetics. 6

Antiviral Therapy

Remdesivir can be used without dose adjustment in ESRD patients, including those on hemodialysis, based on FDA labeling and safety data from Study GS-US-540-5912. 6

• The study evaluated 163 subjects with renal impairment (including 89 with ESRD on hemodialysis) receiving remdesivir 200 mg day 1, then 100 mg daily for 4 days. 6
• While metabolite exposures (GS-441524, GS-704277, and SBECD) are increased in ESRD, no dose adjustment is recommended. 6
• Safety profile in ESRD patients was consistent with the general COVID-19 population. 6

Medications to AVOID

Do NOT use the following medications as they lack efficacy and may cause harm:

• Hydroxychloroquine - strong recommendation against use. 1
• Azithromycin (unless bacterial co-infection documented). 1
• Lopinavir-ritonavir - strong recommendation against use. 1
• Interferon-β - insufficient evidence. 1

Fluid and Electrolyte Management

Maintain euvolemia through careful fluid balance assessment, as both volume depletion and overload worsen outcomes in COVID-19. 1

• Assess fluid status by clinical examination (peripheral perfusion, capillary refill, pulse rate, blood pressure, jugular venous pressure, pulmonary/peripheral edema) at each dialysis session. 1
• Monitor for dehydration from fever and increased respiratory rate, which increase insensible losses. 1
• Adjust ultrafiltration goals based on clinical status, recognizing that aggressive fluid removal may worsen hemodynamics in septic patients. 1

Hyperkalemia Management

Monitor potassium levels at least daily and manage according to local protocols. 1

• Consider potassium binders (patiromer or sodium zirconium cyclosilicate) alongside standard care for acute life-threatening hyperkalemia. 1
• Adjust dialysate potassium concentration based on serum levels and arrhythmia risk. 1

Monitoring and Laboratory Assessment

Perform the following assessments at hospital admission and regularly throughout treatment:

• Serum creatinine, urea, and electrolytes (sodium, potassium, bicarbonate) at least every 48 hours or more frequently if unstable. 1
• Full blood count to monitor for lymphopenia and other hematologic abnormalities. 1
• Inflammatory markers (CRP, IL-6, D-dimer) to assess disease severity and guide treatment decisions. 2
• Urinalysis for hematuria and proteinuria, which may indicate COVID-19-induced kidney damage. 1

Infection Control Measures

Healthcare workers performing aerosol-generating procedures (intubation, bronchoscopy, suctioning) on COVID-19 positive ESRD patients must use fitted N95 respirators (or FFP2 equivalent), plus gown, gloves, and eye protection. 1

• Standard dialysis procedures should follow institutional infection control policies with appropriate PPE. 1
• Minimize staff rotation between COVID-19 positive and negative patient areas. 3, 4

Indications for Nephrology Specialist Referral

Refer for specialist consultation if:

• Diagnostic uncertainty exists about acute kidney injury etiology superimposed on ESRD. 1
• Abnormal urinalysis suggests new intrinsic renal disease. 1
• Fluid management needs become complex beyond routine dialysis adjustments. 1
• Patient develops anuria or severe oliguria despite adequate dialysis. 1

Vaccination Considerations

ESRD patients should be prioritized for COVID-19 vaccination due to high risk of severe disease and mortality. 1

• Expect suboptimal antibody response compared to general population, with need for booster doses. 1
• No preference exists between mRNA vaccines (Pfizer/BioNTech, Moderna) and adenoviral vector vaccines (AstraZeneca) for ESRD patients. 1
• Seropositivity rates are similar between hemodialysis and peritoneal dialysis patients. 1

Common Pitfalls to Avoid

• Do NOT delay or skip dialysis sessions in COVID-19 positive patients, as this worsens both renal and respiratory outcomes. 2
• Do NOT use broad-spectrum antibiotics empirically unless bacterial co-infection is documented, as bacterial co-infection occurs in only 3.5% of hospitalized COVID-19 patients. 1
• Do NOT give corticosteroids to patients not requiring oxygen, as this provides no benefit and potential harm. 1
• Do NOT assume typical COVID-19 presentation, as ESRD patients may have atypical manifestations leading to delayed diagnosis. 1, 5