COVID-19

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Aims

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.

 

Information for patients

See our page on patient information about COVID-19 and the Kidney Care UK site.

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 JCVI priority groups for Covid vaccination are given here.

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 phs.healthdata@phs.scot 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).

 

Glucocorticoids

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.   

 

Other therapies

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.

 

External links

Core guidance

 

Society guidelines

 

Education & further information

 

Epidemiology and data visualisation

 

Core trials / papers

Observational:

Interventional:

 

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.

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