COVID 19 and Hemodialysis Anxiety

Dear Sir,

The initial outbreak of coronavirus disease (COVID 19) was started in Wuhan, China, in December 2019 but rapidly spread worldwide to become pandemic causing grave threat to human race. Currently, number of COVID 19 cases has risen significantly in the United States, most of the Europe, Middle East, Asia, and Australia.[1]

The critical presentations leading to fatality have been more frequently associated with preexisting comorbidities like diabetes mellitus, cardiovascular disease, elderly population, and probably due to fragile immune system.[1] Large number of chronic kidney disease (CKD) patients, already having these comorbidities, are more vulnerable for COVID 19 complications. As a pandemic response, most of people have been advised to “stay at home” by doing nationwide lockdown in many countries as per infection control policy, but CKD patients on in-center maintenance hemodialysis (MHD) are bound to come to hospitals for their treatment.[23] In addition to this, MHD patients are readily distinguishable by some unique features which make them at high risk in the current COVID 19 pandemic. These characteristics include potential close contact for significant duration to other patients, nurses, and dialysis staffs during dialysis; CKD patients undergo MHD treatments in a much-closed space putting them at high risk for exposure to COVID 19. Taking all these considerations into account, patients on MHD are be considered at risk population for COVID 19 pandemic.[34]

During this pandemic of COVID 19, fear and panic wave is advancing worldwide ahead of the virus, which is mostly being induced by misleading and biased information through unfiltered social networks. This has provoked significant stigma of disease and started discrimination amongst people with its ill effects on disease containment strategies.[12] Amidst these uncertainties, health-care workers are not only going through tremendous physical stress due to intense work load but also developed mental exhaustion due to loss of few of their patients and their workmates. Additionally, their continuous functionality in infectious environment along with shortage of personal protective equipment (PPE) initiated panics among them as well.[25]

CKD patients on MHD and their caregivers are already suffering from depression and anxiety, but mostly underestimated and neglected. This unrecognized issue may lead to poor quality of life among them and never been optimally treated.[6] On top of this, the current turmoil of fear and apprehension launched by COVID 19 may lead to fuelling of more psychological disturbances among the CKD patients and their caregivers leading to hospital-related anxiety, which may be more hazardous for these fragile patient populations. Interestingly during this pandemic, medical professionals have been more inclined to emphasize on the biological aspects of disease transmission and prevention for dialysis unit functionality but can misjudge the importance of impaired mental sphere of MHD patients and their caregivers.[67] In the ongoing unrest, whether patient is presenting with COVID 19 symptoms or non-COVID illness may be misleading many times in patients on MHD and they are being diverted for screening to COVID 19 designated facilities, which may further compromise already weaken health-care systems, especially in developing countries like India with its limited resources.[2]

Fear may have led to underestimation of non-COVID etiologies of fever and respiratory symptoms, which could lead to delay in management of other treatable ailments. Media reports from India say that many dialysis facilities are being shut down for few days, when a patient on MHD is affected with COVID 19, and the exposed staffs being quarantined, without making alternative arrangements, which is creating access to dialysis more difficult. Additionally, due to fear, many patients in areas with disease hotspots are denied of life-saving dialysis in the absence of laboratory report.[2] After completing quarantine period, many dialysis staff and doctors have anxiety to resume duties due to shortage of PPE in many hospital settings. Besides these, as dialysis workforces are distinctly skillful and specialized, it is difficult to substitute them in this pandemic situation.[5] Ultimately, this anxiety has initiated more frustration for these frail CKD patients and their caregivers including nephrologists. This collateral damage triggered by COVID 19 pandemic is myriad and mostly unnoticed, though actually may give rise more morbidity and mortality than COVID 19 itself for which we need more realization and vigilance.[2]

In the COVID 19 context, important hurdles for hemodialysis population include disruption of supply chain of dialysis consumables and imported equipment, logistical issues to reach hemodialysis center after suspension of public transport,[2] and added costs for PPE and COVID 19 test passed on to patients, which increases dialysis cost with reimbursement stress. Another major obstacle is shortfall of dedicated area for COVID 19 suspect and positive patients in many hospitals which cannot be resolved out immediately. These aftermaths of pandemic are still not addressed for which we have to take necessary steps at the earliest.

In the present scenario, many documents came up with preventive recommendations in dialysis population and for health-care workers safety,[34] but reports on the actual magnitude of fear and anxiety along with its impact on CKD patients and dialysis staff are immensely needed. In our opinion, we can overcome this common enemy with collective efforts.