A 49-year-old male had end-stage renal disease and secondary to diabetic nephropathy, and was undergoing maintenance HD. His general condition was stable. He was admitted to the hospital on January 31, 2020, with complaints of intermittent cough. However, he had no fever, chills, myalgia, or anorexia before admission. He had undergone chest computed tomography (CT) scan because of a history of contact with a COVID-19 patient (his mother) 5A days earlier. His CT scan showed a small cotton-wool spot in the right lobe of the right lung and he was suspected to have ACOVID-19 (Fig.A 1a). The reverse transcription polymerase chain reaction (RT-PCR) of the patienta$ s pharyngeal swab was positive for the COVID-19 nucleic acid 2 days after hospitalization. The patient was treated with lopinavir plus ritonavir combined with interferon alfa-2b inhalation as antiviral therapy, and continued on HD (see below). However, 5 days after admission, he began to develop fever and his condition worsened rapidly. A repeat chest CT showed scattered ground-glass opacities in both lungs 8 days after admission (Fig.A 1b). He was transferred to the intensive care unit and required endotracheal intubation and mechanical ventilation. At 14 days after admission, chest radiography showed several reticular shadows in both lung fields (Fig.A 1c). Unfortunately, after 15A days of admission, the patient developed multiple organ dysfunction syndrome and died.
Precautionary measures were applied in our HD center during the COVID-19 outbreak in late December 2019, a month before this patient was confirmed to have COVID-19. These included enhanced environmental cleaning, exclusion of visitors, and monitoring of hand hygiene. All patients undergoing HD had their body temperatures monitored and were asked to put on masks; patients with fever had to undergo chest CT and blood cell analysis. This allowed shifting of suspected patients into an isolated dialysis unit in isolated wards. Since an outbreak of the COVID-19 developed in Hubei, China, especially after presence of the first COVID-19 positive patient in our HD unit, some maintenance HD outpatients worried about becoming infected and prolonged their HD interval. The dialysis unit staff followed the recommendations of the WHO for infection control including the use of waterproof disposable gowns, gloves, caps, goggles, and N95 masks.
Once the diagnosis of COVID-19 was confirmed, the patient was kept in the COVID-19 isolation ward along with other non-dialysis COVID-19 patients; the dialysis machine was kept in the COVID-19 isolation ward between dialysis sessions and was used only for COVID-19 patients requiring HD. All staff involved in the direct care of patients affected by COVID-19 had to undertake full protection (see above) and strictly implemented hand hygiene. We performed continuous venovenous hemodiafiltration using the Fresenius multiFiltrate dialysis machine (Fresenius Medical Care, Bad Homburg, Germany). A commercial carbonate replacement fluid (QingShanLiKang, Chengdu, China) was used and Fresenius AV600S dialyzer (Fresenius Medical Care) was employed without reuse. After each HD session, the dialyzer, all blood tubing, and the spent dialysate were discarded as infectious waste and the dialysis machine was disinfected with sodium hypochlorite solution according to the manufacturera$ s instructions.
Radiographic images of the patient. b; An axial CT of the thorax recorded 8 days after admission showing diffuse large regions of ground-glass opacification with partial consolidation in the lower lobe of both lungs.