Mumbai: Some 30% of COVID-19 patients hospitalised in China and New York developed moderate or severe kidney injury, according to a report in the Johns Hopkins Medical Journal. Mumbai is facing an increased number of cases and pressure on hospitals--not just with the typical symptoms, but also complex cases that involve kidney complications. We speak to Siddhartha Lakhani, consultant nephrologist and transplant physician at the Fortis, Raheja and Global hospitals, and Gunjan Chanchalani, chief intensivist at Bhatia Hospital in Mumbai.
What symptoms are you seeing in patients in the last 45-60 days, and what’s been changing?
GC: We started planning [for COVID] early in March, when the first case was reported in Mumbai, when they were screening people who were travelling from abroad. We had multiple mock drills. It was around the second week of April that a surge in the number of patients began.
COVID is no different from any other illness. The mortality is not very high--if patients do reach [hospitals] on time, they do survive well. And many of them are asymptomatic or mildly symptomatic. The panic here is due to the infectivity. When the R factor [infectivity] of COVID is very high, a single patient can infect many patients. This is what is overwhelming our healthcare system, and this is where the problem is. The problem is not about the COVID disease per se.
People who are coming to you are largely recovering. Are you able to put an approximate number to that?
GC: In April, we were quite balanced with our resources--that is, we were able to take in every patient who came to our hospital. But from early May, since the number of cases has increased, we have had to turn away patients from our hospital. That is one sad part, because our resources--mainly the staff--are not able to match [the need]. When a staff [member] enters inside with that [personal protective equipment or PPE] kit, it is very difficult to function for more than six hours. To decrease the infectivity or risk to the staff, we have to give them a seven-day wean-off period. Our resources have actually come down to one-third of what they were. So, 50% of the staff is off on alternate weeks. We initially had three shifts of people working, and now we have four shifts working. So, you can imagine how much staff we are falling short of. So, this is the time when the cases have increased. We are falling short of staff more than the space.
But you are saying that for those who are turning up early, the ability to respond is almost like any other disease condition, almost like a flu--if I am not simplifying it too much.
The condition is definitely like a flu. But now, we are turning away people because we are falling short of [staff] to take care of those people. We have beds, but we don’t have people to work there.
How are you seeing the progression from your point of view as a nephrologist? Are you seeing similar trends that have been reported by this Johns Hopkins report amongst patients in New York or Italy and events in China?
SL: When we started in April, the cases were much fewer. [At] the time, the suspect load was much higher, and positive cases were much fewer because we didn’t have many patients with the COVID report. At the time, we were able to manage all suspects, and admit them--because the beds were sufficient. Even when the spread started, there were a lot of issues in Mumbai--a lot of dialysis patients were having problems because there were very few centres that were able to do COVID-positive dialysis. Gradually, we started realising--as a team, all over Mumbai--that we will probably need more [dialysis] machines. Slowly, with time, we are coping. Nair [hospital] itself has crossed 100 positive patients today. In Nair itself, [patients] who are newly diagnosed, or who are newly admitted with COVID, are getting dialysed. Seven Hills, definitely, has a significantly higher number. There were fewer machines at Seven Hills, Nair and KEM earlier; now, we are able to do it at multiple places.
Secondly, earlier, we were admitting all patients for dialysis. Now, we have isolation centres or dialysis centres--standalone centres that are catering to COVID-positive, asymptomatic patients. So definitely, the government has been realising with time that all COVID patients who are probably asymptomatic don’t need admission. Now, the guidelines have changed; and probably, still with time, we will realise that even mild symptomatic [patients] will have to be managed at home, if they really have to salvage others who are severe.
Are these patients who already had some kidney ailment, or have they developed a kidney ailment after contracting COVID?
SL: We have both [types of cases]. Definitely, more number of patients, at present, are [those who need] dialysis [and] are COVID-positive. They were already on dialysis; being immunocompromised and going out on a weekly basis for dialysis--whether it is twice or thrice a week, [increased their risk of exposure]. The number of critical patients is very low. Either they are coming with a severe cytokine storm, with severe DIC [disseminated intravascular coagulation] or probably landing up in severe multi-organ failure. We may be seeing them probably out of the admission; fewer than 5% of patients [are] having this type of picture. There are patients who already have some kidney ailment; and because of this excessive stress or probably because of this viral illness, some patients are landing up on dialysis because they were already probably a chronic kidney disease patient and because of this stress, they have landed up on dialysis.
Are you seeing cases testing COVID-19 positive, with only some sort of kidney damage or kidney failure as symptoms--in contrast to people who, maybe in the early days, were coming with lung infection and respiratory problems?
SL: The only thing we have seen is, a few patients have come with ‘protein urea’ to start with. Not all patients who are asymptomatic or mildly symptomatic have a rise in creatinine or poor kidney function. What we are seeing is, though they are pre-morbidly healthy--young patients also--we have found [a] few patients have protein urea on their routine urine reports. Definitely, with time, we will have to know whether this was a previous protein urea report which was positive, or [if] they are having persistent protein urea. Specifically, kidney infection or rise in creatinine with COVID illness is very less.
Does that mean that this virus is now attaching itself to receptors in the kidney, as they say it attaches itself to receptors in the lung?
SL: Probably, it is the effect of interleukins and cytokines affecting the endothelium [inner cellular lining of blood vessels], and that is how it is causing protein urea. It is the same pathophysiology that is affecting the lungs, or the myocardium [muscular tissue] of the heart. It is because of these inflammatory markers that are released because of the illness; not the virus specifically affecting the kidney. Foreign literature has shown some histopathology reports, but in India per se, we still don’t have any specific pathological report showing direct effect of the virus on the kidneys.
This is obviously a very difficult time for patients who are already suffering from some kidney ailments, and have to go through dialysis--in some cases every day, or every other day. So how are these patients managing?
SL: At present, as I said, we have around 12 centres that are managing in-house dialysis for COVID patients. We have come up with ‘Project Victory’ since the last five days. This includes a live count of machines available for these patients, where the hospital and the patient both are registered. The moment a hospital has a COVID-positive slot empty and you have a COVID-positive patient waiting for dialysis, they are directed there. Initially, this was a problem. A lot of patients were rejected. A lot of patients were running here and there; and they were not able to procure a bed for dialysis. But now, with this project, the patients are able to know where they have to go--because entering a casualty or ER [emergency response] department and running around for admission was a real difficult challenging task for these patients. Now, they know they have to go to this hospital and they have already registered. It becomes easy for them to get directly admitted.
What is the treatment path that you have been broadly following? Has that changed in the last 45 days? What are the kind of results that you have been seeing?
GC: COVID is still a puzzle, and there are still many pieces which are missing. Every day, we are learning a new treatment which may work. We have new studies coming [in] every day; so we are probably becoming wiser everyday. But, then there is no direct treatment to the virus. There is no antiviral which can actually kill the virus and turn things around.
The very fact that this pandemic has spread is because of the infectivity and because we can’t kill the virus early; so the patients do remain infectious for a long time and they continue infecting. That is the main worry. We are mainly doing symptomatic treatment. There are many vitamins/minerals that have been found to be effective. We use those for mild cases per se, as there is no antiviral. I would rather suggest that people could take that at home itself and not report to the hospital, so that we can save the resources for more deserving patients. And for sick patients again, we do not have anything. Oxygen is probably one thing that helps. Awake proning [placing a patient flat on their belly] is another factor that helps [with] oxygenation and opening up of the lungs.
We are giving more anticoagulants or blood thinners, which is also one factor in the pathophysiology of COVID disease. And another thing is we are using IL-6 inhibitors [to prevent a cytokine storm], which, when given on time, can turn things around.
This 80-year-old lady was not maintaining her oxygenation, and the family was not keen on [a] ventilator. We gave her the IL6 inhibitor and turned around things. What happens in COVID is, the virus goes and affects the system. There is a huge surge of inflammation or cytokines. We just cut off the cytokines. We are not per se killing the virus. So, when cytokines are cut, the body probably can heal itself in a better way, and so the oxygenation of this lady improved after the second dose and today she is sitting up, walking around in the ward and I am hoping that she will be discharged in a couple of days.
When a patient is suffering from both kidney failure or weak kidney, and showing slightly serious or moderate symptoms of COVID, are the treatments too strong? Are they able to manage both the problems at the same time?
SL: As discussed, the chronic kidney disease patients are already immunodeficient. So, milder patients are basically getting stabilised with just probably vitamin supplements or basic antibiotics. Of course, we are using drugs such as hydroxychloroquine, azithromycin, doxycycline, and ivermectin for many patients. So, there are definitely various temporary or short-term studies that have shown some benefits. We use these drugs, anyway, on day-to-day terms. So, they are not definitely significantly harmful to patients if given. We have specific drugs--except for IL6 inhibitors--which we use in our kidney patients also, but when we have either significantly higher count, which we document, or they are in cytokine-storm-like picture or multi-organ-failure-like picture.
The rest of the dialysis treatment per se remains the same; except in a case of acute kidney injury probably, which is specific to a multi-organ failure or a severe cytokine storm. We have used, [in] some patients, SLED [sustained low efficiency dialysis] or slow dialysis. These patients require a lot of anticoagulation. There are a lot of dialysis tubings, which are thrombosed or blocked because of blood clots. The requirement of anticoagulation is high in these patients, and there are studies which have shown that we can send them home on anticoagulation, which we have not yet started. With time, we will have to [consider] that also. At present, I think, most hospitals are using low-molecular-weight heparin [a blood thinner] or unsaturated heparin for these patients.
As cases rise--as they are predicted to, and we will have a lifting of the lockdown, which is expected to make them rise further--how are you gearing yourself? What do you see happening?
GC: We actually have our hospital quite prepared, but our main problem is human resources. So, if we can go up on that, the hospital is fully prepared. We have beds. In fact, even now, we are working on a good number of patients. Going ahead, small hospitals that are not treating COVID patients could lend their manpower resources to us, so that we could functionalise more beds. Maybe that is what I could expect from the government. We are trying to speak to smaller hospitals around, who are actually not very keen on having COVID [treatment] in their centre because COVID requires a lot of not just manpower but cleaning and resources as well; a lot more planning needs to be done. Not all hospitals are equipped with two entries--so that you can have a red entry and a green entry [for COVID and non-COVID patients]. So, you can’t make a clear corridor, give a lift to a COVID patient.
These smaller hospitals cannot really function with COVID and non-COVID [patients] at the same time. So, if they are not really functioning, they could lend their manpower resources to us so that we can function in a more stronger way and treat more patients. I think that would be the only thing which we can expect from the hospitals around. But overall, our management as I said has been quite supportive. We have mock drills. We have our whole contingency plan in place so that even if a [COVID] patient is transported, immediate cleaning is done. Within the next 20 minutes, anybody passing through the route will not be infected. So, all these plans are very much in place and we are quite prepared for that.
SL: There will have to be triage, which is already going on. Governments are making a lot of rules, but triage will be required. Probably severe patients going to bigger hospitals where there are more facilities; rather than just quarantine or oxygen centres. Milder or asymptomatic patients will have to be shifted to CCC [COVID-care centres]. They have already come up with the three-day rule. So probably three days will be ideal; you get admitted, [and] if there are no symptoms [for three days], then you can directly shift to a quarantine or a home-quarantine set-up. I think, with time, when the case numbers are going to increase, we will need more hospitals, definitely more beds, and manpower. Doctors or staff who are quarantined or sick, with time, will probably join us in the fight against COVID, and that is how we will be able to cope up with the limited resources we have at present.
What’s your advice to people who may be seeing the onset of COVID, or suspecting they have COVID, or maybe have even tested COVID+?
GC: I would just say, for the common man, please don’t panic. COVID is not dangerous. The only worry for a common man is, COVID has this terminology which is called ‘happy hypoxia’. What happens is, in patients who get COVID, it affects patients only who have comorbidities, or who are above the age of maybe 50 years--only those patients really worsen. Some young also do worsen. But obesity is also another factor. So young people with obesity are more at risk. People who are healthy should not bother. Probably just hydrating themselves well, eating well, and having good sleep are good ways to increase your immunity. So that is what they can continue.
With happy hypoxia, when COVID affects the lungs, the oxygenation of the body drops and the patient is not aware of it. The patient is happy still thinking that everything is normal with them. That is why it is called happy hypoxia. The point is to catch these patients at the right time, so that they can come to the hospital. My one advice to the common man is, when I fall sick, I have this tendency of lying on the bed. Instead, I would tell them to take out five to 10 minutes to walk around in their house in the normal way, and see if they are getting breathless. If they do, they should report to the hospital. Usually they can be treated at home itself. A fever of three to five days is normal in this COVID, and if your fever extends beyond that, then maybe you can come to the hospital. Otherwise, panicking at the first onset [of symptoms] and coming for the first fever probably limits our resources to take more deserving patients. Basically, [the test is if you are] breathless on exertion. If you are feeling breathless at rest, it's quite late.
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