- Unit Protocols – start here
- Information for patients
- Vaccination & shielding
- Treatment of COVID-19
- External links
- Downloadable files
The aim of this page is to provide links to reliable sources of information and to our local unit protocols. We have a separate page providing information about COVID-19 for patients with kidney disease.
Unit Protocols – start here
Almost all of the relevant guidance can be found here; much of it is specific for NHS Lothian.
- Intranet pages and guidance documents (only accessible within NHS Lothian)
- Anticipatory care planning (only accessible within NHS Lothian)
- Lothian & Borders COVID19 Haemodialysis Guidance
- Lothian & Borders COVID19 Information for Dialysis Patients
- Lothian “COVID Zone” induction pack
Information for patients
Having CKD – particularly CKD4/5 – or an organ transplant increases the risk of death from Covid-19. See OpenSAFELY, ISARIC and QCOVID studies (links below). Talking about risk in the context of “normal” annual risk of death may be helpful (see David Spiegelhalter’s BMJ paper).
When talking about masks, use this great visual representation of how effective masks are at preventing droplet spread.
Vaccination & shielding
The Renal Association have released a briefing document on Covid-19 vaccination for individuals with CKD. Vaccination is thought to be safe and effective in individuals with CKD.
The definition of “extremely clinically vulnerable” is given here.
How to add a patient to the “shielding list”: Clinicians can request that patients are added to high-risk groups (e.g. for new presentations of CKD5) by emailing firstname.lastname@example.org and providing: Forename, Surname, Address, Postcode and Shielding Category (and helpful to also give CHI).
How to expedite vaccination in exceptional circumstances: See the guidance and referral form (excel sheet) on the NHS Lothian intranet. Complete and e-mail the referral form to the address given within.
Treatment of COVID-19
General supportive care
The management of patients with COVID-19 is broadly the same as for any viral pneumonia / pneumonitis. Follow the usual principles of good supportive care. Avoid excessive fluid resuscitation. Avoid nebulisers and antibiotics unless there is an alternative indication for their use (e.g. asthma or superadded bacterial infection).
Early anticipatory care planning is vital for ALL patients. Complete NHS Lothian proforma. This should be completed on Trak [EPR > Overview / Progress > Hospital ACP (Cov 19)], but a paper version is also available. The ISARIC 4C score can be an adjunct in prognostication.
All patients should be given the opportunity to participate in RCTs (such as RECOVERY).
Dexamethasone (and other glucocorticoids) have been shown to reduce mortality in patients hospitalised with severe Covid-19. Patients with renal impairment were not analysed as a pre-specified subgroup in RECOVERY, but there is no good reason to think that this benefit should not extend to this patient group.
IL-6 antagonists (tocilizumab / sarilumab) improved survival in ICU patients on organ support in the REMAP-CAP trial (currently only reported in pre-print form – i.e. not yet peer-reviewed). In RECOVERY, Tocilizumab reduced mortality even in patients receiving ward-level care (currently published as pre-print).
There is no evidence base to support any other specific therapies. There are no high-quality data to suggest that we should be avoiding any particular class of medication. Note the following:
- remdesivir has not been shown to improve mortality in RCTs and WHO advise against its use in most cases; it is still used under expert (ID Consultant) supervision in selected cases – e.g. some organ transplant recipients with severe disease
- anticoagulation should be given only for standard indications (see MHRA alert)
- antibiotics should not be routinely prescribed in Covid-19 (see SAPG advice on management of Covid-19 in the community and in hospital)
- RASi should be used for their standard indications; therefore patients who currently take an ACEi or ARB should continue to do so
- analgesia; current UK advice is that there is no strong evidence that NSAIDs are detrimental in this context but that given a degree of uncertainty, paracetamol should be used first-line.
- National Infection Prevention Control Manual
- Health Protection Scotland guidance – Covid19 homepage
- Health Protection Scotland – guidance for health professionals in secondary care
- NHS Inform – information for health professionals
- NICE guidance on decisions around critical care
- BMA guidance on ethical issues
- Covid-19 Green book chapter (vaccination guidance)
- BMJ living guideline on drug therapies in Covid-19
- CMO Scotland letter on death certification (24th March 2020)
- Renal Association guidance for health professionals
- ODT guidance for health professionals
- Renal Association / BTS guidelines for management of transplant-recipients with Covid-19
- NICE guidelines on renal transplantation in Covid-19 pandemic
- NICE guidelines on AKI in Covid-19
- Covid-associated AKI ADQI consensus report
- National Inpatient Diabetes Covid-19 Response Group guideline on glycaemic control after dexamethasone
- RCOG guidelines on pregnancy
- Resus Council guidance on CPR
Education & further information
- BMJ Covid Hub
- NephJC pages – an ever-expanding resource with renal-specific information on Covid-19 and transplant, dialysis, AKI, ACEi / ARBs etc.
- RCPE weekly evening updates
- NHS Lothian Medical Education pages
- NHS Education for Scotland TURAS pages
- UoE / RCPE Critical Care course on FutureLearn
- online training for enrolling patients in the RECOVERY trial
- Internet Book of Critical Care – critical care textbook
- Coronavirus Tech Handbook – collaborative document with links to many other sources
- Wellcome timeline of developments in our understanding of Covid-19
Epidemiology and data visualisation
Core trials / papers
- OpenSAFELY: factors associated with mortality (large UK cohort)
- ISARIC WHO characterisation study (large UK cohort)
- ISARIC 4C mortality score: prediction of mortality in patients hospitalised with Covid-19
- QCOVID: prediction of Covid-19 mortality risk (large UK cohort)
- Scottish Renal Registry data on outcomes in patients on RRT or with a kidney transplant
- Outcomes in solid organ transplant recipients in England
- RECOVERY Dexamethasone arm
- WHO meta-analysis of glucocorticoids in Covid-19
- WHO SOLIDARITY: RCT of remdesivir, hydroxychloroquine, lopinavir, and interferon beta-1a
- BioNTechnPfizer RNA vaccine trial
- Oxford adenovirus vector vaccine trial
- REMAP-CAP IL-6 antagonist preprint
- RECOVERY Tocilizumab pre-print
Acknowledgements: The author of this page was Rob Hunter. It was first published 17 March 2020. The date it was last modified is shown in the footer.