What is the cut-off point in kidney function below which the risk increases significantly?

There is no strict cut-off value in kidney function below which risk starts to increase. In general it holds that the lower the kidney function, the higher the chance for complications. Although we do not know this exactly, we assume that risk starts to be relevantly increased only when kidney function becomes lower than 30%. When patients are living with a kidney transplant, and use medication to suppress their immune system, risk increases even further. Such patients should be more careful not to attract COVID-19. In case for example of a patient with one kidney and normal kidney function with no other chronic diseases or specific medications the risk to have more severe complications of a COVID-19 infection are NOT increased. General precautionary measures as advised for the general population are sufficient.
https://www.era-edta.org/en/covid-19-news-and-information/#toggle-id-1

The increased expression of ACE2 in patients treated with ACE inhibitors and angiotensin II type-I receptor blockers (ARBs) resulting in an upregulation of ACE2 has been indeed proved yet to facilitate infection with COVID-19?

ACE inhibitors and angiotensin II type-I receptor blockers (ARBs) should be prescribed according to current guidelines. I ndeed some have suggested that the use of ACE inhibitors might be unsafe in COVID-19 positive patients. As yet there is no firm epidemiological evidence to support this hypothesis. The European Society of Hypertension therefore does not support differential use of ACE inhibitors and ARBs in COVID-19 positive patients at the moment. COVID by now is not an indication for a change in the antihypertensive treatment strategy.
https://www.eshonline.org/spotlights/esh-statement-on-covid-19/

Is this any plan for nasopharyngeal swab for HD units medical staff or patients as well? And patients with high suspicion, can have HD session in isolation places or in their usual H.D. units ?

In many institutions there is at present a (threatening) shortage of test kits. In that case it seems prudent to perform a nasopharyngeal swab only in patients and medical staff under clinical COVID-19 suspicion, and not to perform routine swabs.
In is suggested symptomatic patients would be dialyzed in a dedicated separate room (if available) with the door closed, with great care for infection prevention of personnel and other patients (e.g. symptomatic patients should wear masks). When a separated room is not available: treat at the corner or end of room station. Symptomatic patients should be separated at least 3 meters from the nearest one.
https://www.era-edta.org/en/covid-19-news-and-information/#toggle-id-1

What is the advice of the expert group on professional activities of dialysis patients in occupations with relevant contact to the public (teacher, waiter, express delivery and so). Should they be motivated to interrupt their work or should even nephrologists provide sick leave formulars to take them out of their jobs ?

Patients on dialysis (but also patients living with a kidney transplantation) have a seriously higher risk for complications due to COVID-19. We advise therefore to be very cautious, and follow guidelines for disease prevention strictly. One of the most important advices is to avoid crowds and unnecessary social contacts to prevent getting infected. This includes for instance also the use of public transportation. It seems therefore wise that people in the jobs you are referring too temporarily interrupt their work. Please note that this may vary from country to country, and within a country from region to region depending on the spread of COVID-19, but also on local regulations. Employers will likely understand this, and it seems therefore unnecessary, especially in these hectic times, that doctors waste their time filling in sick leave forms.
https://www.era-edta.org/en/covid-19-news-and-information/#toggle-id-1

GENERAL INFORMATION FOR PATIENTS WITH CHRONIC KIDNEY DISEASE

This information is for a large part derived from the webpages of the Center of Disease Control (CDC). This information may change over time. Please check the CDC website therefore regularly:
https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html

General Introduction

Some people are at higher risk of getting very sick from this illness. This includes:

• Older adults
• People who have serious chronic medical conditions like:
  • Chronic kidney disease, either having decreased kidney function, being on dialysis or living with a kidney transplant
  • Heart disease
  • Diabetes
  • Lung disease

If a COVID-19 outbreak happens in your community, it could last for a long time. (An outbreak is when a large number of people suddenly get sick.) Depending on how severe the outbreak is, public health officials may recommend community actions to reduce people’s risk of being exposed to COVID-19. These actions can slow the spread and reduce the impact of disease.
If you are at higher risk for serious illness from COVID-19 because of your age or because you have a serious long-term health problem such as chronic kidney disease, it is extra important for you to take actions to reduce your risk of getting sick with COVID-19. Some of these are summarized below.

Get Ready for COVID-19

• Have supplies on hand
• Contact your healthcare provider to ask about obtaining extra necessary medications to have on hand in case there is an outbreak of COVID-19 in your community and you need to stay home for a prolonged period of time.
• If you cannot get extra medications, consider using mail-order for medications.
• Be sure you have over-the-counter medicines and medical supplies (tissues, etc.) to treat fever and other symptoms. Most people will be able to recover from COVID-19 at home.
• Have enough household items and groceries on hand so that you will be prepared to stay at home for a period of time.
• Take everyday precautions
• Avoid close contact with people who are sick
• Take everyday preventive actions
• Clean your hands often
• Wash your hands often with soap and water for at least 20 seconds, especially after blowing your nose, coughing, or sneezing, or having been in a public place.
• If soap and water are not available, use a hand sanitizer that contains at least 60% alcohol.
• To the extent possible, avoid touching high-touch surfaces in public places – elevator buttons, door handles, handrails, handshaking with people, etc. Use tissue or your sleeve to cover your hand or finger if you must touch something.
• Wash your hands after touching surfaces in public places.
• Avoid touching your face, nose, eyes, etc.
• Clean and disinfect your home to remove germs: practice routine cleaning of frequently touched surfaces (for example: tables, doorknobs, light switches, handles, desks, toilets, faucets, sinks & cell phones)
• Avoid crowds, especially in poorly ventilated spaces. Your risk of exposure to respiratory viruses like COVID-19 may increase in crowded, closed-in settings with little air circulation if there are people in the crowd who are sick.
• Avoid all non-essential travel
• If COVID-19 is spreading in your community, take extra measures to put distance between yourself and other people to further reduce your risk of being exposed to this new virus.
• Stay home as much as possible.
• Consider ways of getting food brought to your house through family, social, or commercial networks

Have a plan for if you get sick:

• Consult with your health care provider for more information about monitoring your health for symptoms suggestive of COVID-19.
• Stay in touch with others by phone or email. You may need to ask for help from friends, family, neighbors, community health workers, etc. if you become sick.
• Determine who can provide you with care if your caregiver gets sick

Watch for symptoms and emergency warning signs

• Pay attention for potential COVID-19 symptoms including, fever, cough, and shortness of breath. If you feel like you are developing symptoms, call your doctor.
• If you develop emergency warning signs for COVID-19 get medical attention immediately. In adults, emergency warning signs*:
• Difficulty breathing or shortness of breath
• Persistent pain or pressure in the chest
• New confusion or inability to arouse
• Bluish lips or face
* This list is not all inclusive. Please consult your medical provider for any other symptoms that are severe or concerning.

What to Do if You Get Sick

• Stay home and call your doctor
• Call your healthcare provider and let them know about your symptoms. Tell them that you have or may have COVID-19. This will help them take care of you and keep other people from getting infected or exposed.
• If you are not sick enough to be hospitalized, you can recover at home. Follow Center of Disease Control instructions for how to take care of yourself at home: https://www.cdc.gov/coronavirus/2019-ncov/about/steps-when-sick.html
• Know when to get emergency helpς
• Get medical attention immediately if you have any of the emergency warning signs listed above.

What Others can do to Support High Risk Adults

Community Support for High Risk Adults

• Community preparedness planning for COVID-19 should include older adults and people with chronic diseases or disabilities, and the organizations that support them in their communities, to ensure their needs are taken into consideration.
• Many of these individuals live in the community, and many depend on services and supports provided in their homes or in the community to maintain their health and independence.

Hemodialysis and long-term care facilities should be vigilant to prevent the introduction and spread of COVID-19.

Family and Caregiver Support

• Know what medications your loved one is taking (especially immunosuppressants in case of living with a kidney transplant) and see if you can help them have sufficient on hand.
• Monitor food and other medical supplies (dialysis material, incontinence material, material for wound care) needed and create a back-up plan.
• Stock up on shelf-stable food to have on hand in your home to minimize trips to stores. Shelf stable means foods that last a long time without spoiling, such as canned foods.
• If you care for a loved one living in a care facility, monitor the situation, ask about the health of the other residents frequently and know the protocol if there is an outbreak.

This text has been prepared by the ERA-EDTA Working Group EUDIAL for patients on dialysis

Coronavirus is spread mainly from person to person. Older adults and people on dialysis or other severe chronic medical conditions seem to be at higher risk for more serious Coronavirus illness. Because of this increased risk for kidney patients, it is especially important for you to take actions to reduce your risk of exposure.

It’s important that everyone follow these preventative measures:

• Stay home on your non-dialysis days, use individual transport to and from dialysis facilities, avoid public transportation, abstain from travelling around the country, avoid personal contact and to abstain from public, private, or religious events (family reunions, marriages, funerals, etc.). You may want to abstain from personal contact especially with your children and grandchildren because the younger population can spread the disease often without showing symptoms.
• Stay home if you feel sick or have any symptoms such as fever, cough, sore throat, body aches, headache, chills. If you are a dialysis patient inform your dialysis centre that you are not well.
• Avoid others who are sick. Limiting face-to-face contact with others as much as possible.
• Cover coughs and sneezes with a tissue, then throw it in the trash can. If you don’t have a tissue, cough or sneeze into your upper sleeve, not your hands.
• Wash hands often with soap and water for at least 20 seconds (Sing “Happy Birthday” to yourself twice while washing your hands—that will ensure you’ve washed them long enough.); especially after going to the bathroom; before eating; and after blowing your nose, coughing, or sneezing. If you don’t have soap and water, use hand sanitizer with 60%-95% alcohol.
• Clean very often the things that get touched a lot, like door handles.
• Avoid touching your face, especially your eyes, nose and mouth with unwashed hands.
• Wear a facemask if your healthcare team or someone from the public health office says you should.
• Avoid greetings people with a handshake, hug or a kiss. A smile and a verbal greeting will be just fine.

If you are at higher risk of getting very sick from Coronavirus such as being on hemodialysis, you should:

• Stock up on supplies, including medication.
• Take everyday precautions (see below) to keep space between yourself and others.
• When you go out in public, keep away from others who are sick, limit close contact.
• Wash your hands often.
• Avoid public transportation.
• Avoid crowds as much as possible.
• During a Coronavirus outbreak in your area, stay home as much as possible.

Why do you need to prepare for the coronavirus outbreak?

If there is a virus outbreak in your area and you need to decrease your risk of getting sick, it’s important that you have shelf stable food in your home. Shelf stable means foods that last a long time without spoiling, such as canned foods. It’s important to prepare now by stocking up 2-3 weeks’ worth of healthy, kidney friendly foods, fresh water, and medicines. This will help reduce your risk of infection by allowing you to avoid crowded spaces like grocery stores and drug stores.

What about your dialysis treatments and/or medical appointments?

IMPORTANT NOTE: If you are on dialysis, you should NOT miss your treatments. Contact your clinic if you feel sick, had contact with a proven COVID-19 positive subject or have any other concerns, so that the dialysis centre can choose whether you should be tested first for the coronavirus and that the dialysis centre can be prepared for your arrival. Furthermore, you should inform staff of fever or respiratory symptoms immediately upon arrival at the dialysis centre.

General hygienic measures you can take yourself as hemodialysis patient:

1. In patients’ waiting rooms, use alcohol dispensers.
2. ) When you are a hemodialysis patient, please wash your hands and fistula arm before starting dialysis and thoroughly disinfect the puncture areas.

Please remember that there is no need or benefit to wear masks of any kind to move around the hospital wards, corridors, or avenues of the hospital. Inappropriate use of these devices is a waste of resources which, in case of real and justified necessity, could cause an important deficiency.

For HD patients that had contact with people who have a high chance of being infected, or with people who subsequently tested positive:

When you have had contact with people who have a high chance of being infected, or with people who subsequently tested positive, please contact your dialysis facility immediately. Staff of your dialysis facility may ask you to follow some rules. These may encompass among others:

1. In case of absence of manifestations of disease: wear a surgical mask when arriving at the center until leaving, and during the entire duration of the dialysis session. When sneezing, use disposable handkerchiefs and throw them away after each single use. Rigorous application of disinfectants is also recommended.
2. In case you have to go to dialysis, but have fever or infectious airways, you will probably be sent to the emergency unit or a special COVID-19 unit, where you will be assessed by emergency staff and infectious disease specialists.

If you are a home hemodialysis patient or a peritoneal dialysis patient, you should be assisted at home as far as is possible, using telereporting assistance or other electronic systems for clinical management and to supplement home visits by healthcare staff, as deemed necessary.