This text has been prepared by the ERA-EDTA Immunosuppression Working Group (IWG)

To health care authorities
Kidney patients using immunosuppression should be regarded as a high-risk group. Many of them are elderly and many have impaired kidney function and other co-morbidities known that enhance risk of adverse outcome of the COVID-19 infection. They use drugs that suppress the natural immune system and many of them have impaired kidney that in itself decreases immune functions. Taken together it is likely that this group will have a higher risk to have a more severe disease course when infected with the new Coronavirus. Authorities on all levels need to facilitate for these patients to be home on sick leave as a preventive measure to reduce individual risks and on a population level the burden of hospitalizations. Patients with co-morbidities such as CKD requiring immunosuppression will most probably consume more health-care resources when infected.

To clinicians
Background: Cases with the Corona virus SARS CoV 2 infection that cause COVID-19 have been detected in all European countries. In many areas there is transmission in the community. Personal communications from China suggest that CKD-patients treated with immunosuppression (IS) have the same risk of infection as the background population. Most COVID-19 infections are mild and self-limited, however, a published report from the US suggest that patients on IS (mainly transplant recipients) have an increased risk of severe disease. However, one publication on liver transplant recipients, emanating from a pediatric hospital in Italy, did not report of an adverse outcome in their cohort. Preliminary data from the “Brescia Renal COVID Task Force” on 20 renal transplant patients admitted with pneumonitis are circulating: despite a short median follow-up (7 days) 5/20 patients died; of note immunosuppression of this cohort has been managed with withdrawn of MMF/AZA, CNIs and mTOR inhibitor to be replaced by methylprednisolone 16 mg according to a protocol recently presented to the European renal community (https://www.era-edta.org/en/wp-content/uploads/2020/03/COVID_guidelines_finale_eng-GB.pdf).
Very little is known about the effect of IS in glomerulonephritis (GN) / vasculitis (AAV) patients with COVID-19 infection. In Brescia, up to the 22 of March, no patients on immunosuppressive treatment due to primary or secondary glomerulonephritis have been admitted or known to have symptoms imputable to SARS-Cov-2 infection; these patients were advised to respect social distancing rules since early stages of the coronavirus crisis.

Regarding patients in areas with few cases and no known community transmission of the virus

• Inform patients to avoid travelling.
• Recommend patients to keep stocks of drugs at home.
• Make new individual risk-benefit assessments and consider for instance postponing cytotoxic drugs and rituximab (RTX) treatment given as maintenance therapy for AAV or GN, keeping in mind that relapses are detrimental.
• Reschedule visits for patients with mild renal disease to give room for consultations with patients on immunosuppressive drugs before there is community spread in your area.
• Prioritize among patients with indication for renal biopsy, and postpone biopsies that can wait.

Regarding patients in areas with many cases and/or community transmission of the virus, but without known exposure to the virus

• Stay updated and follow the scientific development in the field and be aware that clinical advice may change rapidly as experience grow.
• Recommend patients to practice physical distancing and follow region / country public regulations on quarantine. See recommendations for CKD patients in general.
• Reduce patient traveling by replacing office visits with video or telephone consultations. Recommend your patients to have drugs delivered to their home by relatives or courier service.
• Reschedule visits for patients with mild renal disease to give room to contact patients on immunosuppressive drugs over-phone that you would like to inform about the virus and to assure that they adhere to their treatment whether changed or not.
• Patients in high risk situations (medical staff, employees that encounter significant exposure to people) should be given a letter from their health care provider explaining why they require reassignment of duties or working from home.
• Kidney biopsies in general should only be performed in urgent cases.
• Patients with newly diagnosed GN or AAV need to have decisions made about IS treatment regimen based on disease progress, biopsy findings, kidney function, level of proteinuria and co-morbidities. In disease with slow progression rate, normal kidney function and asymptomatic proteinuria consider mitigation with ARBs, blood pressure control and salt restriction until worst epidemic phase has passed.
• Make a new individual risk-benefit assessment for all immunosuppressive therapies in CKD patients. The evidence for a positive effect of IS for any specific disease is very important for this assessment. Be restrictive in diseases such as IgAN and secondary FSGS; but keep in mind that relapse of vasculitis or nephrotic syndrome may impose a greater risk compared to the effect of maintenance therapy if infected. In general, most otherwise healthy patients should not discontinue immunosuppressive treatment. Patients who have been in sustained remission for some time, could begin decreasing IS. Current tapering of IS should continue at least as planned.
• The individual risk-benefit assessment should take into account the possibility for the patient to practice physical distancing.
• Nephrotic syndrome leads to an immunocompromised state, postponing treatment might increase risk more than IS; especially in cases with deteriorating filtration rates or significant dysfunction at diagnosis.
• Consider postponing RTX for maintenance therapy; although there is no evidence this makes a difference; this is an opinion-based suggestion based on the fact that a dose of RTX reduces the ability to mount a new antibody response for several months. In addition, postponing RTX infusions reduces patient travel, a protective measure in itself.
• Hydroxy chloroquine phosphate (HCQ), has been suggested as possible treatment for the SARS CoV-2. There is no reason to stop such therapy when ongoing (used in SLE or RA). Be aware of HCQ interaction with other drugs, dose adjustments of CNI (mainly ciclosporin), mTOR inhibitors and Tamoxifen are needed.
• Advise GFR correlated dosing. Awareness of possible adverse effects needed.
• HCQ is not yet approved for prophylaxis by CDC or WHO even though some local hospital protocol suggests it. Risk of depleting stocks and depriving patients on current medication with HCQ need to be taken into account.
• Steroid treatment in COVID-19 appears problematic. Steroids have been used widely in ICU-settings at severe virus infections /ARDS, but previous studies on SARS and influenza have shown no benefit and seem to prolong time to viral clearance at all stages of disease. There is possibly an indication of steroids to counteract the cytokine storm in severe cases.

Regarding CKD patients on IS exposed to SARS CoV 2 (no symptoms, infection not confirmed)

• Practice isolation at home.
• Test for the virus, patients on IS may shed virus longer and when asymptomatic.
• Reduce steroids to equivalent of a prednisolone dose of 0.2mg/kg/d if possible.
• If leukopenia / lymphopenia is detected reduce dose of cytotoxic drugs until WBC recovers. Lymphopenia could be a sign of active COVID-19.
• If patients have hypogammaglobulinemia, intravenous IgG (IVIg) can be considered since this might also protect from secondary infections.
• If apheresis is indicated use FFP not albumin for replacement.
• Based on current evidence do not stop ARBs or ACEIs.

Regarding CKD patients on IS with proven COVID 19 infection but no or only mild symptoms

• Communicate importance of physical distancing and hygiene advise.
• Consider stopping or reducing antimetabolites (MMF, AZA). Corticosteroids should never be stopped abruptly. Reduce prednisolone to 0.2mg/kg/d. CNI, or at least ciclosporin might reduce virus replication. Discuss with infection medicine specialist.
• Postpone planned CYC and RTX drug administrations.
• Hospitalization based on symptoms and risk factors. Most patients can remain at home as long as symptoms are mild to moderate. Consider to follow-up the development by phone every 24-48 hours. Inform patient to be observant of progressive symptoms with difficulties breathing or high temperatures not responding to antipyretic treatmen.
• Assess levels of immunosuppression (WBC, immunoglobulins, CD19 and T-cell counts).
• If patients have hypogammaglobulinemia, intravenous IgG (IVIg) can be considered since this might also protect from secondary infections. Keep the risk of transmission to others in mind.
• Based on current evidence do not stop ARBs or ACEIs.

Regarding CKD patients on IS with COVID-19 and overt symptoms.

• Contact infection medicine specialist and specialist on vasculitis/GN GN for discussion of IS adjustment and therapy regimen.
• Several new drugs are being tested. Anti-viral therapy can be given off-label depending on availability and local practices. Please assist your infection medicine specialist on pharmacokinetic considerations in patients with reduced GFR.

This text has been prepared by the ERA-EDTA Working Group EUDIAL for patients on dialysis

The information in this section of the ERA-EDTA Covid-19 webpage is for a large part derived from the website of the Center of Disease Control (CDC). The site’s specific webpage for nephrologists and other professionals working with people on dialysis is very helpful, and contains much practical information. We urge you therefore to consult this webpage:
https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/dialysis.html
Please note that information may change over time. Please check this CDC webpage therefore regularly

General considerations

• A working team consisting of dialysis physicians, nursing staff and technicians should receive training in updated clinical knowledge of epidemic COVID-19, epidemic prevention tools, and guidelines from the government, scientific societies and hospital authorities. Instructions should include how to use facemasks, how to use tissues to cover nose and mouth when coughing or sneezing, how to dispose of, preferably disposable paper, tissues and contaminated items in waste receptacles, and how and when to perform hand hygiene. Training can be done peer to peer or online.
• Latest care recommendations and epidemic information should be updated and delivered to all medical care personnel as needed.
• Staff members should self-monitor their symptoms (if any) and should inform the team leader in case they or their family members develop symptom(s) suggestive of COVID-19 infection. Sick members of the team should stay at home, and in any case should not be in contact with patients or other team members.
• Nurses should be trained to perform nasopharynx swab for COVID-19 PCR, with appropriate dressing (FFP2 mask, goggles, mobcap, disposable surgical blouse, gloves).
• Body temperature should be systematically measured before the start and at the end of the dialysis session in all patients.
• Early recognition and isolation of individuals with respiratory infection is mandatory: 1. dialysis facilities should identify patients with signs and symptoms of fever, cough, upper airway involvement or conjunctivitis before they enter the waiting room and treatment area; 2. instruct patients to call ahead to report fever or respiratory symptoms; thus, the facility can be prepared for their arrival (preferably they should be seen at a first aid department and not on a dialysis department) or triage them to a more appropriate setting (e.g., an acute care hospital); 3. patients must inform staff of fever or respiratory symptoms before arrival at the facility by phone or appropriate electronic means; 4. patients with respiratory symptoms should be brought to an appropriate treatment area as soon as possible in order to minimize time in waiting areas; 5. all patients who have fever, cough, upper airway involvement or conjunctivitis should be screened for novel Coronavirus infection. For sampling, patients should be either in a single-patient room, or in a room dedicated to sampling. Disinfection of the room after sampling is mandatory.
• Ideally, symptomatic patients should be dialyzed in a separate isolated room (if available), in which a negative pressure can be processed, with the door closed. Otherwise, they should wait in a separate isolated room and given dialysis in the last shift of the day until infection is excluded. He/she should wear a proper (surgical or N95) mask filtering 95% of the particulate matter smaller than 2.5 µm in the aerosol of exhaled air.
• Patients with confirmed COVID-19 infection should be admitted to an airborne infection isolation room and should not receive dialysis in an outpatient dialysis facility, unless an airborne infection isolation room is available. All personnel involved in the direct care of patients affected by COVID-19 must undertake full protection, including long-sleeved waterproof isolation clothing, hair caps, goggles, gloves and medical masks (FFP2 or FFP3 mask if available) filtering 95 to 99% of particulate matter and aerosols in inhaled air. Hand hygiene must be strictly implemented: carefully washing hands with soap and water and systematically using alcoholic solutions and disposable gloves.
• Consideration should be given to cohorting more than one patient with suspected or confirmed COVID-19 and the healthcare team caring for them together in the section of the unit and/or on the same shift (e.g., consider the last shift of the day). Avoid, however, mixing of suspected and confirmed cases.
• Healthcare team should be cohorted, i.e., separate teams for management of high-risk and low risk patients. Only the minimum number of assigned healthcare team should enter the isolation room/cohort area, all non-scheduled team-mates should be excluded at all times.
• If a newly confirmed or highly suspected case of novel Coronavirus infection in dialysis centres is identified, disinfection must be carried out immediately. Areas in close contact with these patients must not be used for other patients until cleared.
• The medical waste from confirmed or suspected patients with novel Coronavirus infection must be considered as infectious medical waste and disposed accordingly.

Duration of isolation precautions for patients under investigation for or with confirmed COVID-19

• Until information is available regarding viral shedding after clinical improvement, discontinuation of isolation precautions should be determined on a case-by-case basis, in conjunction with local, regionalstate, and national health authorities.
• Factors that should be considered include: presence of symptoms related to COVID-19 infection, date symptoms resolved, other conditions that would require specific precautions (e.g., tuberculosis, Clostridioides difficile), other laboratory information reflecting clinical status, alternatives to inpatient isolation, such as the possibility of safe recovery at home.

Operations

Patients who need vascular access surgery should be screened for COVID-19. Operations on patients with confirmed or suspected COVID-19 infection should be carried out in a designated room with necessary protection for medical staff.

Home haemodialysis and peritoneal dialysis

These patients should be assisted at home as far as is possible, using telereporting assistance or other electronic systems for clinical management and to supplement home visits by healthcare staff, as deemed necessary.

Considerations

It can be considered to decrease the frequency of hemodialysis sessions from three to two times per week in patients that tolerate such a regimen. This could be considered

• to decrease the need for travelling by taxi / ambulance in case of shortage of such transportation means
• to decrease the chance of dialysis patients getting infected by travelling back and forth to the dialysis unit
• to decrease the chance of dialysis patients spreading the infection to the dialysis unit or the hospital
• to decrease the need for supplies of which shortages are expected. Especially with factories closing down (temporarily) and supply problems, your unit may run into logistical problems with shortage of material needed for dialysis. An early change from three to two hemodialysis sessions per week in a large part of your dialysis population may help to save material, allowing you to run your dialysis unit as long as possible.

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ERA-EDTA sharing Milano experience on coronavirus management in dialysis centers

While considering that patients on dialysis treatment are undoubtedly more exposed to contracting infectious diseases and to have more severe manifestations than the non-dialysis population, nephrologists from the Milano dialysis unit argue that there is NO reason to adopt specific prophylactic measures for the entire dialysis population. In their opinion common sense and individual protection rules as for other high risk subjects should prevail.

Author: Professor Mario Cozzolino, MD, PhD, Renal Unit, San Paolo Hospital and San Carlo Hospital, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy

Read the complete text here: Milano experience on coronavirus management in dialysis centers by Prof. Mario Cozzolino, Milan, Italy

2020-04-06: ERA-EDTA WG Descartes expert opinion regarding the management of immunosuppressive medication for
kidney transplant patients during the COVID-19 pandemic.

https://www.era-edta.org/en/wp-content/uploads/2020/04/Expert-opinion-on-ISD-in-Covid-19.pdf

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This text has been prepared by the ERA-EDTA Working Group Descartes for patients living with a kidney transplant

There are several guidelines that are adapted frequently and may differ according to epidemiological characteristics of the specific country as well as availability of resources. Health care professionals are therefore advised to follow local / regional / national guidelines. In addition, the most recent information can be found on the websites of WHO and the Center for Disease Control and Prevention (see below, but see especially the section ‘Relevant websites’).

It can be considered to cancel living and/or deceased donor kidney transplantations. Although there are no general guidelines, the following arguments may help in making such difficult decisions:

• Kidney transplantation is not a live-saving procedure in the short term
• Withholding a dialysis patient a suitable transplant kidney will increase the time on dialysis with associated morbidity and mortality
• Patients requiring induction therapy with anti-T or anti-B cell antibodies may be at increased risk for a severe course of COVID-19
• A shortage of health care professionals and available resources (ICU beds, drugs, material for viral testing) will impede the quality of care after transplantation

Weblinks of interest:

https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/patient-management

https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html

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The American Society of Transplantation (AST) Infectious Disease Community of Practice (IDCOP) developed a frequently asked questions sheet to relay information on the current state of COVID-19 knowledge after receiving queries from transplant colleagues across the world. Please review this FAQ document for information: https://www.myast.org/sites/default/files/COVID19%20FAQ%20Tx%20Centers%202020.03.11_FINAL.pdf

ESTABLISHING THE ERA-EDTA COVID-19 KRT DATABASE 22 March 2020

MISSION
To achieve as soon as possible insight in which patient and center characteristics are related to outcome in patients on kidney replacement therapy with a COVID-19 infection across Europe, to improve prognosis in these patients by intervening on modifiable risk factors.

BACKGROUND
With the present spread of the COVID-19 pandemic, we face difficult times. It may well be that in the coming months 20% or even a higher percentage of the population with kidney replacement therapy will not survive. For this reason it is essential that very rapidly epidemiological data are collected of COVID-19 positive patients on kidney replacement therapy. AIMIdentification of risk factors for mortality of patients on various forms of KRT, and which clinical characteristics are associated with prognosis

SOLUTION
Establishing a database that collects granular individual patient level data of patients on dialysis and living with a kidney transplant across Europe that will allow detailed analysis.

PLAN
The ERA-EDTA Registry is not able to collect such granular individual patient level data. Kitty Jager, Director of the Registry, understands the need for granular data collection. Such knowledge may help save lives. Other solutions are therefore needed. Luuk Hilbrands (Nijmegen, The Netherlands) has established a dedicated COVID-19 Data Collection, and started the third week of March. The ERA-EDTA Council decided by unanimous vote March 21, 2020, hat a dedicated COVID-19 KRT Database will be established. The ERA-EDTA Registry is already based in the Netherlands (Amsterdam, Kitty) and the dedicated COVID-19 Transplantation Data Collection is now situated in the Netherlands (Nijmegen, The Netherlands). It is recommended to start a database that integrates information on patients who are living with a kidney transplant as well as on patients on dialysis. Because it will be easier for communication, designing and running such an integrated database, it has been decided that the dedicated COVID-19 Dialysis Data Collection will be located in the Netherlands, a country that has a strong track-record in epidemiological research. The ERA-EDTA has approached dr. Casper Franssen and prof. Stefan Berger of the department of Nephrology in Groningen to volunteer to take on this assignment. They have agreed. A team is made consisting of the Luuk Hilbrands (chair of the dedicated transplantation data colection), Casper Franssen (chair of the dedicated dialysis data collection), Kitty Jager (director of the ERA-EDTA renal registry), Marc Hemmelder (chair of the Dutch renal registry) and Ron Gansevoort (ERA-EDTA COVID-19 action team). There will be an international Advisory Board consisting of the Chair of the Renal Registry (Ziad Massy), the Chairs and an additional member of the Working Groups EUDIAL (for dialysis) and Descartes (for kidney transplantation). They will start this weekend to design an ERA-EDTA endorsed COVID-19 KRT Database that has an optimal structure to meet its aims. There will be a generic core dataset, and a specific transplantation and a specific dialysis subset that will be easy to combine. In the future additional data may be obtained by record linkage with existing registries/databases (for transplantation and for dialysis). The ERA-EDTA will ask its members to help fill this database via blast mails and Newsletters.

2020-04-24: Success of the ERACODA project on dialysis and transplant patients with COVID-19: The first results of a cohort of 300 https://www.era-edta.org/newsletter/ERACODA_results.html

2020-04-09: ERA-EDTA Press Release: ERA-EDTA launches European database https://www.era-edta.org/en/wp-content/uploads/2020/04/ERA-EDTA-launches-European-database.pdf

2020-04-09: First results of ERACODA, the ERA-EDTA Database on dialysis and transplant patients with COVID-19 – Newsletter to the Nephrology community https://www.era-edta.org/newsletter/covid19_database_first_results.html

2020-03-30: ERA-EDTA Database for COVID-19 infected kidney patients has gove live – Newsletter to the Nephrology community https://www.era-edta.org/newsletter/covid19_database_live.html

2020-03-30: ERA-EDTA Database for COVID-19 infected kidney patients has gove live – Newsletter to National Societies of Nephrology https://www.era-edta.org/en/wp-content/uploads/2020/03/national-society-e-newsletter-n-45_30-3-2020.pdf

2020-03-27: Invitation to participate to the ERA-EDTA COVID-19 Database – Newsletter to National Societies of Nephrology https://www.era-edta.org/en/wp-content/uploads/2020/03/national-society-e-newsletter-n-44_27-3-2020.pdf

http://www.era-edta.org/images/Example_KTX_patient-ICU_deceased.pdf

Which patients should be entered:
The database is meant for European patients living with a kidney transplant or on dialysis, who are COVID-19 infected, whether they are admitted to hospital or remained at home.

How to register as user:
Please send an e-mail to COVID.19.KRT@umcg.nl. This e-mail should contain:
Your first name and surname
Your e-mail address
Your institution (in English when possible) + country

For the collection of the data, the data platform REDCap is used. You will be added as a user to this project within 1 working day. When your account is ready, you will receive an automatically generated e-mail with your log in details and data entry instructions.

Please note:
Data ownership will remain with the data submitter. Data submitters are partners in the project and will be acknowledged appropriately as co-authors. Data will be stored pseudonymized. The database will never be handed to other parties. After ending of the inclusion period, data will be returned to the data submitter and the database will be destroyed.

We are aware that in some countries there may be initiatives to start a similar database. We would like to ask these countries ALSO to take part in the present initiative.  Taking part in a pan-European initiative will allow reaching firm conclusions on mortality risk and risk factors for mortality much faster than via individual country initiatives. We intend to send downloads of country-specific data regularly for local analysis.

The ERA-EDTA Council urgently asks the members of the Society to help fill this up-coming COVID-19 KRT Database as rapidly as possible. Please spread this news among your colleagues.

Data entry instructions

For the collection of the data, the data platform REDCap is used (link to the database is: https://redcap.umcg.nl/). You will be added as a user to this project when requested via e-mail. When your account is ready, you will receive an automatically generated e-mail with your log in details.

Which patients to add: The database is meant for European patients living with a kidney transplant or on dialysis, who are diagnosed with COVID-19 (by PCR,  CT-scan, or chest X-ray), and either are admitted to hospital or staying at home. To get good insight, it is important that all COVID-19 diagnosed KRT patients are entered, and not just a subset consisting of those with the worst prognosis.

Add a patient: In case you want to add a patient, please choose in the Data Collection menu on the left the option “Add/Edit Record”. Then you click on “Add new record”. A Record ID will be generated automatically and you can start your data entry.

Retrieve a patient: The Record ID will also contain your patient’s country and hospital code. When you want to retrieve your patient (for instance because you want to add new data), type the patient’s hospital code in the “Search Query” field on the Add/Edit Record Page and select your patient.

Enter data: Filling in this database will cost you less than 5 minutes per patient. All pages that need to be filled in show a video tutorial how to enter data. Please note that this video is not supported by older web browsers. For every patient entered in the database, there are 4 sections that should be completed:
1. At presentation: patient characteristics
2. At presentation: COVID-19 related characteristics
3. Follow-up
4. Outcome

Sections 1 and 2 should be completed at presentation in the hospital, out-patient clinic, or dialysis center. Sections 3 and 4 should be completed when your patient:
1) is not admitted to the hospital;
2) was admitted to the hospital and is discharged or transferred, or has deceased.
In case a patient was sent home after a first presentation and returns to the hospital later on, you should add a new record of the same patient.

Save data: To end your data entry for each form, click on ‘Save and Exit Form’ or ‘Save and Go to the Next Form’ at the bottom of the page. You can stop at any time with entering data, but make sure that you save your form first before you exit. In case you do not execute any action during 15 minutes or longer, your REDCap session will expire and any data not saved will be lost.

Follow-up: 28 days and three months after your patient’s presentation we ask you to report the vital status of the patient at the respective moments in section 4.

Institutional Review Board (IRB) approval

Because this initiative is meant to analyze and improve patient care, and is purely observational, the IRB of the University Medical Center Groningen in The Netherlands waived the approval in the context of the Medical Research Involving Human Subjects Act and confirmed this in writing. However, to use all data collected across Europe, a written approval of all participating countries / sites is needed. For this urgent situation, most IRBs currently have a fast track procedure.

To help you getting a declaration from your IRB that participating in this project is exempt IRB approval, you can find here a template letter. In addition, many centers have a procedure to check whether the collection of patient data is compliant with regulation regarding data protection (GDPR). You can find here a set of documents (study protocol, patient information letter, informed consent form, data transfer agreement etc.) that can be used for obtaining approval in your center. Please send us the response at: COVID.19.KRT@umcg.nl. In case you need assistance, please contact us.

Of note, for this project that is meant to analyze and improve patient care, data ownership will remain with the data submitter. Data submitters are partners in the project and will be acknowledged appropriately as collaborative author on any product to derive from it. Data will be stored pseudonymized. The database will never be handed to other parties. After ending of the project, data will be returned to the data submitter and the database will be destroyed.

We ask you to fill this database as rapidly as possible, in the hope that this effort will speed up the process to improve the prognosis of the patients we care for. Given the very exceptional circumstances we advise you to consider not to wait for formal IRB approval, and to start entering data as soon as possible. Getting IRB approval may cost a considerable amount of time, and our experience is that IRBs in general agree with initiatives like this one. In the hypothetical case your IRB does not, we will of course delete all data you have entered.

2020-05-06: ERACODA Study Report 5

2020-04-29: ERACODA Study Report 4

2020-04-22: ERACODA Study Report 3

2020-04-14: ERACODA Study Report 2

2020-04-08: ERACODA Study Report

2020-04-16: Carmine Zoccali, ERA-EDTA President

The experience in the treatment of severe COVID-19 patients in some health contexts is limited. Treatments applied to these cases are experimental and recent knowledge may be difficult to reach. To help clinicians, the European Commission has launched a Web Conferencing system aimed at allowing clinicians to communicate easily with colleagues across the European Union to exchange knowledge and to discuss cases. The system aims also to improve knowledge and training, by organising webinars. Read more here and here

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2020-04-06: ERA-EDTA Working Group DESCARTES

The ERA-EDTA Working Group DESCARTES has been established to promote education, science and care related to kidney transplant patients. This group has written an expert opinion regarding the management of immunosuppressive medication for kidney transplant patients during the COVID-19 pandemic. Please read this important document here

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2020-04-03: Kate Stevens (Nephrologist, Queen Elizabeth University Hospital, Glasgow, United Kingdom)

View the  webcast of the 2nd ERA-EDTA COVID-19 Q&A Webinar held on Friday April 3, 2020.
Featured Qs: Hong Kong, Singapore and Germany Experience.
View the webcast here

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2020-04-02: Casper Franssen (Nephrologist, University Medical Center Groningen, The Netherlands)

CVVH and frequent filter clotting in patients with COVID-19

We have received several personal communications on frequent clotting of the CVVH filter/ extracorporeal circuit in patients with COVID-19 (e.g. Maria Jose Soler (Spain), Mario Cozzolino (Italy), Henk van Hamersvelt, (The Netherlands)). Frequent clotting not only limits treatment efficacy but may also contribute to shortages of filters. In this communication we summarize the experiences and advises of several collogues intensivists and nephrologist.

Patients with COVID-19 are reported to have a high risk of thromboembolic events and, therefore, several centers use higher dosages of thrombosis prophylaxis than usual (often double-dose).

To reduce the risk of clotting of the extracorporeal CVVH circuit, the need of a good central venous access, permitting high blood flow, also when is the patient is in prone position, is emphasized. Centers that use heparin as anticoagulation reported that they increase blood flow and give most (80 tot 90%) of the substitution fluid as predilution and, additionally increase the heparin dose. Centers that use citrate as anticoagulation, mostly use a higher citrate dose but this may lead to (more pronounced) metabolic alkalosis and citrate toxicity. Several colleagues reported that citrate toxicity seems to more frequent in patients with COVID-19 in comparison with those without COVID-19.

Other options to reduce the risk of clotting in patients without increased risk of bleeding could be:

• Combine standard citrate anticoagulation with continuous administration of low-dose heparin.

• Use other anticoagulation like argatroban or other direct thrombin inhibitors.

We ask our colleagues to that have experience with any of these alternatives to comment and share their experience with anticoagulation for CVVH, whether positive or negative.

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2020-03-27: Kate Stevens (Nephrologist, Queen Elizabeth University Hospital, Glasgow, United Kingdom)

View the  webcast of the 1st ERA-EDTA COVID-19 Q&A Webinar held on Monday March 30, 2020 at 4 PM GMT/5 PM CET
Featured Qs: Italian & Spanish Experience, publications, ACEi/ARB debate
View the webcast here

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2020-03-26: Webinar “COVID-19 Experience from Italy and China -Strategies of Extracorporeal Organ Support”. March 31, 2020, 1 PM CET

Join the webinar here Webinar ID 848 699 486

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2020-03-25: During the COVID-19 (COVID-19) epidemic physicians in China have entered the stage of actively treating severe patients and trying to improve the success rate of treatment and reduce the fatality rate. The Chinese Medical Association has issued an Expert Consensus on the Application of Special Blood purification Technology in severe COVID-19 Pneumonia. In order to better guide and standardize the application of blood purification technology in severe COVID-1 9, the expert group of nephrology committee of Chinese medical association and Chinese research hospital society has fully discussed how to carry out blood purification technology treatment for severe COVID-19 patients proposed in the above diagnosis and treatment plan, and formulated a consensus statement, that can be read here

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2020-03-25: Profs. Perico, Benigni and Remuzzi, from Bergamo, Italy, reviewed the most recent findings on the effects of SARS-CoV-2 infection on kidney diseases, including acute kidney injury, and examine the potential effects of ARBs on the outcomes of patients with COVID-19. They also we discuss the clinical management of COVID-19 patients with existing chronic renal disorders, particularly those in dialysis and with kidney transplants. You can read this article of interest for nephrologists here

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2020-03-24 The editorial team of the ERA-EDTA COVID-19 webpage

Could there be some light in the darkness? In Italy there seem to be now for the second day in a row less daily new COVID-19 positive cases and less COVID-19 related deaths. Please have a look at: https://www.worldometers.info/coronavirus/country/italy/  A link to this website can also be found elsewhere at the ERA-EDTA webpage, among links to other interesting interactive maps. Let’s hope that this is not some temporary thing, but the start of a real trend. Let’s hope that this indicates that draconian measures help to fight the pandemic in Europe, as it did in China and Korea. Anyway, this should not lead to loosening the present isolation measures !

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2020-03-20 The evolving COVID-19 epidemic is certainly cause for concern. In a thought provoking editorial, published on-line in the Lancet today, prof. Ioannides (a well-known and respected epidemiologist from Stanford University (USA), discusses that proper communication and optimal decision-making is an ongoing challenge, as data evolve rapidly. The challenge is compounded by exaggerated information. This can lead to inappropriate actions. He provides several examples that it is important to differentiate promptly the true epidemic from an epidemic of false claims and potentially harmful actions. To read his interesting editorial, please click here

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2020-03-19  Antonio Santoro (Division of Nephrology, Dialysis and Hypertension, St. Orsola-Malpighi Hospital, Bologna, Italy)

On behalf of the Emilia Romagna section of the Italian Society of Nephrology, Dr. Antonio Santoro from the St. Orsola-Malpighi Hospital in Bologna submitted their local protocol on the measures that patients and medical and nursing staff should take to limit the spread of COVID-19 infection in patients who need dialytic treatment for chronic kidney disease or acute renal failure. Please click here

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2020-03-18  Federico Alberici (Nephrologist, ASST Spedali Civili di Brescia, Unità Operativa di Nefrologia, Brescia, Italy)

Brescia in Italy is at the moment heavily affected by the COVID-19 pandemic. Specialists from various disciplines working in this region established the “Brescia Renal COVID-19 Task Force”. Dr. Federico Alberici shares on behalf of this Task Force the initial experiences in treating 21 patients with a kidney transplant and 17 patients on hemodialysis that were infected. The disease course seems to be more severe than observed in China, especially in patients with a kidney transplant, whereas prognosis may be slightly better in dialysis patients. A pragmatic treatment protocol is provided, as well as logistical considerations resulting from the extensive experience in the management of infected patients by this Task Force. Please read their contribution here

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2020-03-18  Jordana Cohen (MD, MSCE, University of Pennsylvania, USA, on behalf of the NephJC Working Group)

“NephJC statement on SARS-CoV-2 virus, COVID-19, and ACEi/ARB treatment”

Several initial reports from China suggest that hypertension and CKD may be risk factors for adverse outcomes amongst individuals with COVID-19 disease. Several recent articles in the lay press and medical journals have speculated that patients may benefit from discontinuing ACE inhibitors and ARBs. However, experimental data are conflicting, and these medications may even be beneficial in patients with COVID-19. Experts developed a summary of the existing evidence that is updated in real time on the NephJC website. The overarching conclusion is as yet to recommend patients who are prescribed ACEi/ARB therapy to continue these medications unless there is a compelling, evidence-based indication to discontinue therapy. Read the complete statement here and read more on http://www.nephjc.com/news/covidace2.

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2020-03-16  Umberto Maggiore (Board Member of the ERA-EDTA Working Group Descartes. Head of the Transplant Unit, University Hospital Parma, Parma, Italy)

On the website of the American Society of Transplantation (ATS), prof. Umberto Maggiore, transplant-nephrologist working in Azienda Ospedaliera-Universitaria Parma, Italy, has answered some important questions in a web-forum. Working in the focus of the European epidemic, he has unique experience of which we may learn. His contribution can be found at the ATS Outstanding Questions in Transplantation Research Forum. Unfortunately, this site has no open access. For your convenience prof. Luuk Hilbrands (Chair of the ERA-EDTA WG Descartes, Radboud UMC Nijmegen, The Netherlands) has therefore made a summary of some of the most crucial questions and answers that prof. Maggiore addressed. Read it here

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2020-03-14 Francesca Mallamaci (Chair ERA-EDTA Working Group EURECA-m. Reggio Calabria, Italy)

In an elegant, brief contribution Prof. Francesca Mallamaci from Reggio Calabria, Italy, discusses on behalf of the ERA-EDTA Working Group EURECA-m some important renal aspects of COVID-19 infection. Read it here

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2020-03-12 Monica Fontana (ERA-EDTA Executive Director, ERA-EDTA Headquarters, Parma, Italy)

Notwithstanding the unfortunate cancellation of the WCN, the leaders of ASN, ERA-EDTA and ISN decided to organize a virtual leadership meeting instead of the face-to-face one scheduled to take place in Abu Dhabi to continue the excellent collaboration for the on-going joint projects. This meeting will be rescheduled within the next few weeks.

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2020-03-10 Mario Cozzolino (Renal Unit, San Paolo Hospital and San Carlo Hospital, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy)

Milano experience on coronavirus management in dialysis centers
While considering that patients on dialysis treatment are undoubtedly more exposed to contracting infectious diseases and to have more severe manifestations than the non-dialysis population, nephrologists from the Milano dialysis unit argue that there is NO reason to adopt specific prophylactic measures for the entire dialysis population. In their opinion common sense and individual protection rules as for other high risk subjects should prevail. Read the complete text here

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2020-03-10 Carmine Zoccali (ERA-EDTA President, Reggio Calabria, Italy)

“Under these exceptional circumstances, responsible attitudes are fundamental to protect human health. Also following instructions from health authorities, the timing of the ERA EDTA Congress planned in Milan on June 6-9, 2020 as a live event is of course being reconsidered. Presently our Association is considering the organization of a virtual version of the same Congress. The ERA EDTA is making major efforts to transform our normal live event into a rich, articulated and interactive virtual event that may ensure to its large membership the flow of scientific news, educational events and interaction which typically originate from the annual Congress.”

120320 Are kidneys targeted by the novel coronavirus?

110320  Management of dialysis patients during the current coronavirus outbreak

https://www.kidneyfund.org/kidney-today/coronavirus-and-kidney-patients.html

2020-04-16: Question/Comment by Suzanne H. (Speech Therapist)
I am a Speech Therapist who normally works with young children. I am 57 years old.
My employers wish to redeploy me to an assistant nursing role in hospital which will involve caring for patients with a diagnosis of Covid19.
I have one kidney. I lost the right kiidney in 1993 following an error during a Caesarean birth (the surgeon by mistake stitched up through the right ureter)
My question: Am I at higher risk regarding Covid19 infection due to having one kidney?

Answer by Ron Gansevoort (General Nephrologist, UMC Groningen, The Netherlands)
The risk to be infected with Corona virus is probably not dependent on kidney function, but there is a gradual increase in risk for more severe complications of the infection when kidney function is lower. Notwithstanding, we use an eGFR of 30 (in otherwise healthy subjects) as threshold to indicate high risk. You did not mention what exactly your kidney function is. However, with one kidney, and no other medical problems, in general kidney function is around 50 to 60%. In that case you would not be defined as a “high-risk subject”.

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2020-04-07: Question/Comment by Sammy S. (father of a son with nephrotic syndrome)

My son is 7 years old, he has minimal change nephrotic syndrom. Exactly 27 months ago, when he fell ill, he took Prednisone for 3 months. Until today, over 2 years, he did not have a relapse. Generally, he feels good, blood pressure is also ok. Should we be afraid that he has a higher chance to get sick, or gets a relapse when Corona infected? Is he at high risk group ? Of course, we try to adhere to healthy diet and lifestyle.

Answer by Dr Rukshana Shroff (Consultant Paediatric Nephrologist, Great Ormond Street Hospital for Children, London, UK)
Since steroids have been stopped over 2 years ago your child does not have a higher risk of COVID-19 infection than any other person.
Steroids do affect the immune system, but they do not have a long-lasting effect, in fact rarely beyond 3-months of stopping the medication.
Your child and family must of course follow all the national guidelines and precautions advised to prevent COVID-19 infections or its spread in the community.

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2020-04-07: Question/Comment by Manuela M . (mother of a son with TINU)

My son (15 years old) is diagnosed with TINU-Syndrome and receives Mycophenolat-Mofetil in a high dosage since a year. He has no symptoms regarding kidney failure at the moment.
1.Do you know the outcome of patients with this therapy and COVID-19?
2. I am a physician working in general practice and it could be possible that I cannot avoid having contact with patients being treated at home with COVID-19. Should I stop working?

Answer by Dr Rukshana Shroff (Consultant Paediatric Nephrologist, Great Ormond Street Hospital for Children, London, UK)
A reduction of MMF may be an important measure for your child BUT it must be weighed up against the risk of renal disease (or worsening of uveitis, if your child had ophthalmological signs as a prominent feature of TIN-U). Generally we try to reduce the MMF dosage (or even stop it, depending on patient specific characteristics) with other viral infections that we see in kidney patients. However, there is no know experience of MMF therapy in COVID-19 positive patients.
I urge you to contact your local doctor and discuss the pros and cons of reducing MMF.
In the UK where I work, the government regulations are that when there is an immunosuppressed person in the household all members must self-isolate and work from home. We certainly recommend this for our kidney transplant patients, and other kidney patients who are immunosuppressed.

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2020-04-07 : Question/comment by Sylvie Chauve (Nephrologist, France):
How to handle the dialysate of a peritoneal dialysis patient that has COVID-19?

Answer by Carlo Basile (Nephrologist, EUDIAL WG Chair, Division of Nephrology – Miulli General Hospital – Acquaviva delle Fonti, Italy)
Reviewing the available data on SARS-CoV-2, I did not find any report showing that the virus has been detected in peritoneal dialysate effluents. By taking into account the available literature I would suggest the following paper: Farzadegan H et al: HIV-1 survival kinetics in peritoneal dialysate effluent. Kidney Int 50: 1659 – 62, 1996. It shows that sodium hypochloride 50% (Amukin) and 10% household bleach, after 10 minutes of exposure, were effective viricidal agents in disinfecting peritoneal dialysate effluents.
Thus, until further data become available, I would suggest the following precautions in discarding the PD effluent in documented cases of COVID-19 positive patients: adding a cup of 10% household bleach to the toilet before emptying the PD fluid into it, then waiting 5 minutes before double flushing the toilet – to kill the virus. Used PD bags and tubing should be placed in a plastic bag, the bag sealed, then placed in another plastic bag (double-bagging), before being discarded with household waste (unless the community/dialysis unit has other directions). Any inadvertent spills or splashes on surfaces should be disinfected with 10% household bleach.
Obviously, the well-known general rules (rigorous hand hygiene and face mask) advised to avoid the contagion to the relatives of the PD patient must be recommended.
Finally, I would recommend to read the ISPD strategies regarding COVID-19 in PD patients adapted from Peking University First Hospital (released on March 28 th, 2020).

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2020-04-07 : Question/comment by Sylvie Chauve (Nephrologist, France):
How to handle the dialysate of a peritoneal dialysis patient that has COVID-19?

Answer by Alferso Abrahams (Nephrologist, Dept. Nephrology, University Medical Center Utrecht, The Netherlands)
The route of transmission of SARS-CoV2 occurs mainly via respiratory droplets. Therefore, persons caring for PD patients with confirmed COVID-19 should wear appropriate personal protective equipment, i.e. gown, gloves, eye protection, and an N95 respirator.
In a recent study performed in 3 Chinese hospitals, SARS-CoV2 RNA was detect in only 1% (3 of 307) of the blood specimens and in 29% (44 of 153) of the stool specimens (PMID: 32159775). In another small single center study, SARS-CoV2 RNA was detect in blood of 10% (6 of 57) of the patients (PMID: 32102625). It should be noted that all these patients had severe clinical symptoms. However, it is unknown whether SARS-CoV2 is present in dialysate of patients with confirmed COVID-19.
Although there is a variety of opinion for disposal of drained dialysate from PD patients with COVID-19, the most important advise is to prevent accidental splashing when disposing drained dialysate and to wear appropriate personal protective equipment.

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2020-03-23: Question/Comment by D.H. (patient)
I only have one kidney & adrenal gland due to a pheochromocytoma back in 2005. I have had no issues with my kidney function, but I’m I at a higher risk concern if I become infected with COVID-19?

Answer by Maria Jose Soler (Nephrologist, Hospital Universitari Vall d’Hebron, Barcelona, Spain)
Thank you for your interesting question. As you already now, COVID-19 is a really new disease. For that reason, currently there are not studies demonstrating that one-kidney patients with only one adrenal gland are at higher risk for concern in case of getting COVID infection. In a recent paper published in Lancet by Zhou F. and cols. (Lancet. 2020 Mar 11. pii: S0140-6736(20)30566-3. doi: 10.1016/S0140-6736(20)30566-3. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.), hypertension, current smoker, chronic obstructive lung disease, and diabetes among others have been identified as a risk factors for worse prognosis in COVID-19 infected patients.

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2020-03-20: Question/Comment by Catherine Mauriac (Employee BBraun, France)
Snacks should nowadays be avoided during dialysis sessions according to recommendations of the French nephrological society (because of the risk of infection). Is this a firm advice? If a snack is taken during dialysis, what precautions should be taken? Our warm support to all caregivers.

Answer by Carlo Basile (Nephrologist, EUDIAL WG Chair, Division of Nephrology – Miulli General Hospital – Acquaviva delle Fonti, Italy)
As a general rule it is advisable to eat before or after dialysis as eating during dialysis can cause some problems such as a drop in blood pressure (please read “Eating during Hemodialysis” developed by registered dietitians nutrition services of the Alberta Heath Services). The recommendation of the French Society of Nephrology sounds reasonable because of the risk of infection. If the snack during the dialysis session is unavoidable because of a strong request from the patient or for other reasons (i.e., diabetic patients) I would recommend to minimize the risks: 1. to have an accurate hand washing both before and after the snack by using, for example, dispensers of gel hydro-alcoholic solutions at rapid evaporation; 2. to eat pre-packed biscuits or similar pre-packed foods; to have soft drinks, such as tea, in sealed cans.

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2020-03-19: Question/Comment by Alex Wilson-Smith (Patient, The United Kingdom)
I am a renal transplant patient with residual function on dialysis. Is there any information on stopping mTOR inhibitors such as sirolimus for those who have tested positive?

Answer by Luuk Hildbrands (Nephrologist, ERA-EDTA WG Descartes Chair, Radboud University Medical Centre, Nijmegen, The Netherlands)
There are insufficient data on the effect of different immunosuppressive drugs on the chance to develop symptoms when you are tested positive or on the course of COVID-19. Although experiments on cell cultures have suggested that calcineurin inhibitors (cyclosporine, tacrolimus) may have a protective effect against the coronavirus, there are no data from studies in humans. We know that as compared to other immunosuppressive drugs, sirolimus (and everolimus, both mTOR inhibitors) can have a protective effect against certain Herpes viruses, e.g. cytomegalovirus. Based on these considerations, my personal opinion is that there is no reason to discontinue the use of sirolimus as long as you are not severely ill.

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2020-03-18: Question/Comment by the nephrological community across Europe
We wish you all strength and luck fighting the COVID-19 epidemic right in its heart. Can you share with us information how you are doing in your dialysis units. What is the situation?

Answer by Mario Cozzolino (Nephrologist, Renal Unit, San Paolo Hospital and San Carlo Hospital, University of Milan, Italy)
We have by now about 15 to 20 chronic HD patients that are COVID-19 positive, which represents likely a higher prevalence of COVID-19 than in the general population. The reason is unknown, but perhaps due to transmission in the hospital. Around 30% of them are admitted to hospitals because of pneumonia. There is an urgent need for separation rooms / separate dialysis units to prevent transmission of the infection to other dialysis patients. Of the patients in the ICU approximately 5 to 10% develop AKI with a need for renal replacement therapy, all of them treated by CCH because of hemodynamic instability. Our staff is still able and ready to treat patients with all special medical health care problems. A shortage of dialysis nurses / nephrologists threatens, because of the high workload and personnel being sick or in quarantine. Fortunately, we are still sufficiently covered for treating dialysis as well as COVID-19 problems.

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2020-03-17: Question/Comment by Mohamed Abdelbary (Nephrologist, Alexanderia Armed hospital, Alexandria, Egypt)
A patient on hemodialysis was infected with COVID-19. Where can we hemodialyes such patient? Isolated room inside or outside the unit or in separate hospital taking in consideration the availability?

Answer by Maria Jose Soler (Nephrologist, Hospital Universitari Vall d’Hebron, Barcelona, Spain)
As stated by the Eudial Working Group: Patients with confirmed COVID-19 infection should be admitted to an airborne infection isolation room and should not receive dialysis in an outpatient dialysis facility, unless an airborne infection isolation room is available. All personnel involved in the direct care of patients affected by COVID-19 must undertake full protection, including long-sleeved waterproof isolation clothing, hair caps, goggles, gloves and medical masks (FFP2 or FFP3 mask if available) filtering 95 to 99% of particulate matter and aerosols in inhaled air. Hand hygiene must be strictly implemented, carefully washing hands with soap and water and systematically using alcoholic solutions and disposable gloves (see ARTICLES ON COVID-19 IN PEER REVIEWED JOURNALS: 20-03-16:  Recommendations for the prevention, mitigation and containment of the emerging SARS-CoV-2 (COVID-19) pandemic in haemodialysis centres. Basile et al. on behalf of the Eudial Working Group of ERA-EDTA   https://www.era-edta.org/en/wp-content/uploads/2020/03/391-1_NDT.pdf).

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2020-03-17: Question/Comment by Maurizio Mazon (Nephrologist, Nephrology Department, Santa Chiara Hospital, Trento, Italy)
The mortality rate from the virus in the elderly is impressive.
This population is often on ACE inihibition for a number of medical conditions; that treatment upregulates ACE2 receptor, which is the entry site of the virus.
Could this be the reason?

Answer by Maria Jose Soler (Nephrologist, Hospital Universitari Vall d’Hebron, Barcelona, Spain)
This is a really interesting question that has been under discussion the last week for many of the well-known International Scientific Societies. Currently, there is a lack of evidence to support differential use and the discontinuation of ACEis/ARBs in COVID-19 patients. For this reason, to date the European Society of Hypertension, European Society of Cardiology Council on Hypertension, Hypertension Canada, Canadian Cardiovascular Society, The Renal Association, United Kingdom, and ERA-EDTA among others recommend continuing ACEis/ARBs in COVID-19 infection patients. For more information on this topic I recommend to visit “The Coronavirus Conundrum: ACE2 and Hypertension Edition” (updated in real time).

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2020-03-16: Question/Comment by Betty Blaauw-Tauran (Patient, Groningen, The Netherlands)
I have nephrotic syndrome with normal kidney function, but receive maintenance treatment with rituximab once every 6 months to keep my disease quite. Do I have a higher risk to attract the disease or to get complications because of rituximab? I work in the hospital as receptionist and travel to work using public transportation. Can I still do this?

Answer by prof. Coen Stegeman (Nephrologist-immunologist, UMC Groningen, The Netherlands)
Remarkably, previous studies have suggested that rituximab is not associated with a clearly higher risk to attract viral infections or to develop more severe disease to viral infections. Whether this holds true also for COVID-19 is likely, but not 100% sure. This is reassuring, but because of some level of uncertainty, it seems prudent to regard yourself still as a high risk patient. Please use therefore all preventive measures that are advocated by the health authorities in your specific region/country for high risk patients. An important part of these measures is to avoid social contacts as much as possible. Avoid therefore public places, including public transportation. In case you see people, keep a distance of at least 2 meters. Given these considerations it seems wise to temporarily stop working as a receptionist until the situation improves.

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2020-03-15: Question/Comment by Francesco Fontana (Nephrologist, S.C. Nefrologia e Dialisi, Azienda Ospedaliero-Universitaria Policlinico di Modena, Italy)
Is it advisable to consider temporary suspension of deceased donor kidney transplant program in areas severely affected by Covid-19 pandemia, as suggested by The Trasplantation Society (https://tts.org/23-tid/tid-news/657-tid-update-and-guidance-on-2019-novel-coronavirus-2019-ncov-for-transplant-id-clinicians)?

Answer by Luuk Hildbrands (Nephrologist, ERA-EDTA WG Descartes Chair, Radboud University Medical Centre, Nijmegen, The Netherlands)
This should certainly be considered because transplant patients are exposed to additional risks when they acquire COVID-19: 1. It appears that the course of COVID-19 is more severe when patients are immunosuppressed, 2. Treatment with antiviral drugs can be impeded by interaction with immunosuppressive drugs (especially ritonavir – calcineurin inhibitors), 3. A current or future shortage of resources (ICU-beds, health care personnel, drugs, test material) can hamper optimal care of complications after transplantation. On the other hand, performing a kidney transplantation can be very important for an immunized patient when there is a suitable offer or when there is an imminent lack of vascular access. In my country (The Netherlands) most centers have suspended the program, but consider exceptional cases acceptable after having discussed the pro’s and con’s with the patient.

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2020-03-15: Question/Comment by Sourabh Sharma (Nephrologist, Army Hospital Research & Referral, Sriganganagar, Rajasthan, India)
Just out of curiosity: if bats were the source of COVID19 Why not to look for antibodies to the virus in bat itself?

Answer by Coretta van Leer (Virologist, UMC Groningen, The Netherlands)
Surely bats from which the closest family member of the coronavirus family has been isolated, also have antibodies against the virus. These antibodies would also be active and some even protective against SARS-2. However, bat antibodies cannot be administered to people because this will cause hypersensitivity reactions. Human antibodies can be mass produced in other organisms such as tobacco, purified and given as IV treatment. This was successful in treating Ebola, so it is promising. (the first Ebola antibody produced in this way was ZMab).

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2020-03-15: Question/Comment by Lorraine Clohessy (Patient)
My 50yr old husband has only one kidney. Is he classified as high risk if contracts Covid19 and should extra precautionary steps be taken?

Answer by Ron Gansevoort (General Nephrologist, UMC Groningen, The Netherlands)
There is no strict cut-off value in kidney function below which risk starts to increase. In general it holds that the lower the kidney function, the higher the chance for complications. Although we do not know this exactly, we assume that risk starts to be relevantly increased only when kidney function becomes lower than 30%. When patients are living with a kidney transplant, and use medication to suppress their immune system, risk increases even further. Such patients should be more careful not to attract COVID-19. In case of your husband, when kidney function is normal for having 1 kidney (i.e. around 50 to 70%), he does not use medication and has no other chronic diseases, his risk to have more severe complications of a COVID-19 infection are NOT increased. General precautionary measures as advised for the general population are sufficient.

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2020-03-14: Question/Comment by Antonio Santoro (Nephrologist, Dipartimento Insufficienze d’Organo e Trapianti. University of Bologna, Italy)
My question is about the use of ACE inhibitors and sartans in COVID-19 patients.They really need to be suspended or reduced in dosage?

Question/Comment by Ita Heilberg (Nephrologist, Federal University of São Paulo (UNIFESP), São Paulo, Brazil)
The increased expression of ACE2 in patients treated with ACE inhibitors and angiotensin II type-I receptor blockers (ARBs) resulting in an upregulation of ACE2 has been indeed proved yet to facilitate infection with COVID-19?

Answer by Maria Jose Soler (Nephrologist, Hospital Universitari Vall d’Hebron, Barcelona, Spain) and Ron Gansevoort (General Nephrologist, UMC Groningen, The Netherlands)

In our opinion, ACE inhibitors and angiotensin II type-I receptor blockers (ARBs) should be prescribed according to current guidelines. COVID by now is not an indication for a change in the antihypertensive treatment strategy.

Please see: https://www.eshonline.org/spotlights/esh-statement-on-covid-19/

More and detailed information can also be found at: http://www.nephjc.com/news/covidace2

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2020-03-14: Question/Comment by Ahmed Abo Omar (Nephrologist, Internal medicine and nephrology Dept.,Tanta University, Cairo, Egypt)
Is this any plan for nasopharyngeal swab for HD units medical staff or patients as well? And patients with high suspicion, can have HD session in isolation places or in their usual H.D. units?

Answer by Maria Jose Soler (Nephrologist, Hospital Universitari Vall d’Hebron, Barcelona, Spain) and Ron Gansevoort (General Nephrologist, UMC Groningen, The Netherlands)
We assume that you mean a swab to diagnose COVID-19 infection. In many institutions there is at present a (threatening) shortage of test kits. In that case it seems prudent to perform a nasopharyngeal swab only in patients and medical staff under clinical COVID-19 suspicion, and not to perform routine swabs.

In our institution symptomatic patients would be dialyzed in a dedicated separate room (if available) with the door closed, with great care for infection prevention of personnel and other patients (e.g. symptomatic patients should wear masks). When a separated room is not available: treat at the corner or end of room station. Symptomatic patients should be separated at least 3 meters from the nearest one.

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2020-03-13: Question/Comment by Jordi Bover (Nephrologist, Fundacio Puigvert. Barcelona, Spain)
Is there a potential unsafety of ACE inhibitors or ARBs as risk factor for covid-19 complications? Nature Reviews Cardiology 2020 zheng Y-Y et al, and BMJ 2020; 368:m810 sommerstein R

Answer by Ron Gansevoort (General Nephrologist, UMC Groningen, The Netherlands)
Indeed some have suggested that the use of ACE inhibitors might be unsafe in COVID-19 positive patients. We thank you for asking this question and sharing these references. As yet there is no firm epidemiological evidence to support this hypothesis. The European Society of Hypertension therefore does not support differential use of ACE inhibitors and ARBs in COVID-19 positive patients at the moment: https://www.eshonline.org/spotlights/esh-statement-on-covid-19/

More and detailed information can also be found at: http://www.nephjc.com/news/covidace2

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2020-03-13: Question/Comment by Joachim Beige (Nephrologist, KfH Renal Unit and Dialysis Centre, Dept. Nephrology, Leipzig, Germany)
What is the advice of the expert group on professional activities of dialysis patients in occupations with relevant contact to the public (teacher, waiter, express delivery and so). Should they be motivated to interrupt their work or should even nephrologists provide sick leave formulars to take them out of their jobs ?

Answer by Ron Gansevoort (General Nephrologist, UMC Groningen, The Netherlands)
Patients on dialysis (but also patients living with a kidney transplantation) have a seriously higher risk for complications due to COVID-19. We advise therefore to be very cautious, and follow guidelines for disease prevention strictly. One of the most important advices is to avoid crowds and unnecessary social contacts to prevent getting infected. This includes for instance also the use of public transportation. It seems therefore wise that people in the jobs you are referring too temporarily interrupt their work. Please note that this may vary from country to country, and within a country from region to region depending on the spread of COVID-19, but also on local regulations. Employers will likely understand this, and it seems therefore unnecessary, especially in these hectic times, that doctors waste their time filling in sick leave forms.

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2020-03-13: Question/Comment by David Attaf (Nephrologist, Nephrocare, Paris, France)
I learn from Dr Quentin Meulders (Avignon, France) that authors (BMJ) suggest a linkk between Covid-19 and Renine-angiotensin axis (see paper attached) :
– The protein in charge of the fixation of COVID 19 on cells is an angiotensin conversion’s enzym,
– Heart Failure Patients are at risk of complications during COVID 19 infections,
– They are treated by ACE / sartans
– Expression of mARN and ACE2 activity increase in animals with ACE/sartan
Question : Is it needed to stop ACE/sartan in case of infection ?
On the other hand , the opposite is claimed in other publication where it’s suggested to treat patients with ARA2 :
Angiotensin receptor blockers as tentative SARS-CoV-2 therapeutics.Gurwitz D, Drug Dev Res. 2020 Mar 4. doi: 10.1002/ddr.21656.
What is your opinion?

Answer by Ron Gansevoort (General Nephrologist, UMC Groningen, The Netherlands)
Indeed some have suggested that the use of ACE inhibitors might be unsafe in COVID-19 positive patients, and that ARBs are to be preferred. We thank you for asking this question and sharing this reference.

As yet there is no firm epidemiological evidence to support this hypothesis. The European Society of Hypertension therefore does not support differential use of ACE inhibitors and ARBs in COVID-19 positive patients at the moment: https://www.eshonline.org/spotlights/esh-statement-on-covid-19/

More and detailed information can also be found at: http://www.nephjc.com/news/covidace2

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2020-03-13: Question/Comment by Edoardo Melilli (Nephrologist,  Bellvitge University Hospital, Barcelona, Spain)
Immunosuppression management in kidney transplant recipients with mild symptoms/fever but without respiratory failure and a positive PCR.Any recommendation?

Answer by Maria Jose Soler (Nephrologist, Hospital Universitari Vall d’Hebron, Barcelona, Spain) and Ron Gansevoort (General Nephrologist, UMC Groningen, The Netherlands)
Recommendation recipients: In case of diagnosis of COVID-19: In patients with no or only upper respiratory symptoms, no therapy is recommended. In patients with lower respiratory tract symptoms, some drugs have been suggested to be associated with better outcome. You could therefore consider the possibility of installing therapy such as Tocilizumab, Bevacizumab, Chloroquine and Remdesivir (https://clinicaltrials.gov/ct2/results?cond=COVID&term=&cntry=&state=&city=&dist=). This, however, SHOULD PREFERABLY BE DONE with participation in a clinical trial if possible.

2020-04-02: Casper Franssen (Nephrologist, University Medical Center Groningen, The Netherlands)

CVVH and frequent filter clotting in patients with COVID-19

We have received several personal communications on frequent clotting of the CVVH filter/ extracorporeal circuit in patients with COVID-19 (e.g. Maria Jose Soler (Spain), Mario Cozzolino (Italy), Henk van Hamersvelt, (The Netherlands)). Frequent clotting not only limits treatment efficacy but may also contribute to shortages of filters. In this communication we summarize the experiences and advises of several collogues intensivists and nephrologist.

Patients with COVID-19 are reported to have a high risk of thromboembolic events and, therefore, several centers use higher dosages of thrombosis prophylaxis than usual (often double-dose).

To reduce the risk of clotting of the extracorporeal CVVH circuit, the need of a good central venous access, permitting high blood flow, also when is the patient is in prone position, is emphasized. Centers that use heparin as anticoagulation reported that they increase blood flow and give most (80 tot 90%) of the substitution fluid as predilution and, additionally increase the heparin dose. Centers that use citrate as anticoagulation, mostly use a higher citrate dose but this may lead to (more pronounced) metabolic alkalosis and citrate toxicity. Several colleagues reported that citrate toxicity seems to more frequent in patients with COVID-19 in comparison with those without COVID-19.

Other options to reduce the risk of clotting in patients without increased risk of bleeding could be:

• Combine standard citrate anticoagulation with continuous administration of low-dose heparin.

• Use other anticoagulation like argatroban or other direct thrombin inhibitors.

We ask our colleagues to that have experience with any of these alternatives to comment and share their experience with anticoagulation for CVVH, whether positive or negative.

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2020-03-31: Communication from Ron Gansevoort (General Nephrologist, UMC Groningen, The Netherlands)

The ERA-EDTA database for COVID-19 infected kidney patients has gone live. Read the newsletter here

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2020-03-15: Communication from Francesca Trebelli, ERA-EDTA Electronic Communication Committee (ECC) Coordinator, Parma, Italy

Austrian Professor Dr Josef Penninger is one of the world’s leading molecular immunologists. APEIRON Biologics AG a company Penninger founded, is currently tackling the ongoing outbreak of COVID-19 and is scheduled to start a pilot clinical trial for their newly developed drug that is supposed to decrease mortality in those affected by the virus. This webcast aims to shed light on the discovery and function of ACE2 – angiotensin converting enzyme 2. Furthermore, the lecture highlights the predisposition of ACE2 as a SARS-CoV and SARS-CoV-2 receptor.

https://connect.myesr.org/course/novel-coronavirus-outbreak-experience-and-challenges-in-imaging-and-beyond/

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2020-03-14: Communication from Francesca Mallamaci, ERA-EDTA WG EURECA-m Chair, Reggio Calabria, Italy:

In an elegant, brief contribution Prof. Francesca Mallamaci from Reggio Calabria, Italy, discusses on behalf of the ERA-EDTA Working Group EURECA-m some important renal aspects of COVID-19 infection. Read it here

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2020-03-13: Communication from Jörg Vienken, Nephrologist, Vienken Consultants, Aachen, Germany:

In the situation of highly infectious corona virudiae, surface cleansing of medical devices, such as dialysis monitors, tablest etc is of high importance. Please find attached two recent publications which adress both, surface clenasing and half life of Corona viruses attached at artificial surfaces.

Read the publications

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2020-03-13: Communication from Licia Peruzzi, Nephrology Department, Pediatric Hospital Regina Margherita, Turin, Italy:

As Italian Society of Pediatric Nephrology we are constantly monitoring the Italian situation of children affected by kidney diseases and until today March 13 we have NO CASES OF COVID INFECTION IN UNDER 18 PATIENTS WITH CHRONIC KIDNEY DISEASE. Our society https://www.sinepe.it/ daily publishes on update on cases and swabs performed in children

This information is for a large part derived from the webpages of the Center of Disease Control (CDC). This information may change over time. Please check the CDC website therefore regularly: https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html

General Introduction

Some people are at higher risk of getting very sick from this illness.

This includes:

• Older adults
• People who have serious chronic medical conditions like:
  • Chronic kidney disease, either having decreased kidney function, being on dialysis or living with a kidney transplant
  • Heart disease
  • Diabetes
  • Lung disease

If a COVID-19 outbreak happens in your community, it could last for a long time. (An outbreak is when a large number of people suddenly get sick.) Depending on how severe the outbreak is, public health officials may recommend community actions to reduce people’s risk of being exposed to COVID-19. These actions can slow the spread and reduce the impact of disease.

If you are at higher risk for serious illness from COVID-19 because of your age or because you have a serious long-term health problem such as chronic kidney disease, it is extra important for you to take actions to reduce your risk of getting sick with COVID-19. Some of these are summarized below.

Get Ready for COVID-19

• Have supplies on hand
  • Contact your healthcare provider to ask about obtaining extra necessary medications to have on hand in case there is an outbreak of COVID-19 in your community and you need to stay home for a prolonged period of time.
  • If you cannot get extra medications, consider using mail-order for medications.
  • Be sure you have over-the-counter medicines and medical supplies (tissues, etc.) to treat fever and other symptoms. Most people will be able to recover from COVID-19 at home.
  • Have enough household items and groceries on hand so that you will be prepared to stay at home for a period of time.
• Take everyday precautions
  • Avoid close contact with people who are sick
  • Take everyday preventive actions
    • Clean your hands often
    • Wash your hands often with soap and water for at least 20 seconds, especially after blowing your nose, coughing, or sneezing, or having been in a public place.
    • If soap and water are not available, use a hand sanitizer that contains at least 60% alcohol.
    • To the extent possible, avoid touching high-touch surfaces in public places – elevator buttons, door handles, handrails, handshaking with people, etc. Use tissue or your sleeve to cover your hand or finger if you must touch something.
    • Wash your hands after touching surfaces in public places.
    • Avoid touching your face, nose, eyes, etc.
    • Clean and disinfect your home to remove germs: practice routine cleaning of frequently touched surfaces (for example: tables, doorknobs, light switches, handles, desks, toilets, faucets, sinks & cell phones)
    • Avoid crowds, especially in poorly ventilated spaces. Your risk of exposure to respiratory viruses like COVID-19 may increase in crowded, closed-in settings with little air circulation if there are people in the crowd who are sick.
    • Avoid all non-essential travel
• If COVID-19 is spreading in your community, take extra measures to put distance between yourself and other people to further reduce your risk of being exposed to this new virus.
  • Stay home as much as possible.
    • Consider ways of getting food brought to your house through family, social, or commercial networks
• Have a plan for if you get sick:
  • Consult with your health care provider for more information about monitoring your health for symptoms suggestive of COVID-19.
  • Stay in touch with others by phone or email. You may need to ask for help from friends, family, neighbors, community health workers, etc. if you become sick.
  • Determine who can provide you with care if your caregiver gets sick

Watch for symptoms and emergency warning signs

• Pay attention for potential COVID-19 symptoms including, fever, cough, and shortness of breath. If you feel like you are developing symptoms, call your doctor.
• If you develop emergency warning signs for COVID-19 get medical attention immediately. In adults, emergency warning signs*:
  • Difficulty breathing or shortness of breath
  • Persistent pain or pressure in the chest
  • New confusion or inability to arouse
  • Bluish lips or face

*This list is not all inclusive. Please consult your medical provider for any other symptoms that are severe or concerning.

What to Do if You Get Sick

• Stay home and call your doctor
• Call your healthcare provider and let them know about your symptoms. Tell them that you have or may have COVID-19. This will help them take care of you and keep other people from getting infected or exposed.
• If you are not sick enough to be hospitalized, you can recover at home. Follow Center of Disease Control instructions for how to take care of yourself at home: https://www.cdc.gov/coronavirus/2019-ncov/about/steps-when-sick.html
• Know when to get emergency help
• Get medical attention immediately if you have any of the emergency warning signs listed above.

What Others can do to Support High Risk Adults

Community Support for High Risk Adults

• Community preparedness planning for COVID-19 should include older adults and people with chronic diseases or disabilities, and the organizations that support them in their communities, to ensure their needs are taken into consideration.
  • Many of these individuals live in the community, and many depend on services and supports provided in their homes or in the community to maintain their health and independence.
• Hemodialysis and long-term care facilities should be vigilant to prevent the introduction and spread of COVID-19.

Family and Caregiver Support

• Know what medications your loved one is taking (especially immunosuppressants in case of living with a kidney transplant) and see if you can help them have sufficient on hand.
• Monitor food and other medical supplies (dialysis material, incontinence material, material for wound care) needed and create a back-up plan.
• Stock up on shelf-stable food to have on hand in your home to minimize trips to stores. Shelf stable means foods that last a long time without spoiling, such as canned foods.
• If you care for a loved one living in a care facility, monitor the situation, ask about the health of the other residents frequently and know the protocol if there is an outbreak.

This text has been prepared by the ERA-EDTA Immunosuppression Working Group (IWG)

• Limit contact with hospitals. Ask for telephone consultations instead of physical visits when no urgent need is present.
• Do not stop your medication. Some drugs you have may even have beneficial effects on a virus infection.
• Adapt to physical distancing and follow quarantine policies of your region/country. Physical distancing is not restricted to non-family members. Measures must take your individual risk factors into consideration. Some patients will be advised to adhere to very rigid isolation during this disease.
• Wash your hands often with soap and water for 20 sec, several times daily and always soon after stepping indoors. (Additional general recommendations listed in the CKD section)
• If drugs run out of stock contact your doctor and discuss alternative.

This text has been prepared by the ERA-EDTA Working Group EUDIAL for patients on dialysis

Coronavirus is spread mainly from person to person. Older adults and people on dialysis or other severe chronic medical conditions seem to be at higher risk for more serious Coronavirus illness.  Because of this increased risk for kidney patients, it is especially important for you to take actions to reduce your risk of exposure.

It’s important that everyone follow these preventative measures:

• Stay home on your non-dialysis days, use individual transport to and from dialysis facilities, avoid public transportation, abstain from travelling around the country, avoid personal contact and to abstain from public, private, or religious events (family reunions, marriages, funerals, etc.). You may want to abstain from personal contact especially with your children and grandchildren because the younger population can spread the disease often without showing symptoms.
• Stay home if you feel sick or have any symptoms such as fever, cough, sore throat, body aches, headache, chills. If you are a dialysis patient inform your dialysis centre that you are not well.
• Avoid others who are sick. Limiting face-to-face contact with others as much as possible.
• Cover coughs and sneezes with a tissue, then throw it in the trash can. If you don’t have a tissue, cough or sneeze into your upper sleeve, not your hands.
• Wash hands often with soap and water for at least 20 seconds (Sing “Happy Birthday” to yourself twice while washing your hands—that will ensure you’ve washed them long enough.); especially after going to the bathroom; before eating; and after blowing your nose, coughing, or sneezing. If you don’t have soap and water, use hand sanitizer with 60%-95% alcohol.
• Clean very often the things that get touched a lot, like door handles.
• Avoid touching your face, especially your eyes, nose and mouth with unwashed hands.
• Wear a facemask if your healthcare team or someone from the public health office says you should.
• Avoid greetings people with a handshake, hug or a kiss. A smile and a verbal greeting will be just fine.

If you are at higher risk of getting very sick from Coronavirus such as being on hemodialysis, you should:

• Stock up on supplies, including medication.
• Take everyday precautions (see below) to keep space between yourself and others.
• When you go out in public, keep away from others who are sick, limit close contact.
• Wash your hands often.
• Avoid public transportation.
• Avoid crowds as much as possible.
• During a Coronavirus outbreak in your area, stay home as much as possible.

Why do you need to prepare for the coronavirus outbreak?

If there is a virus outbreak in your area and you need to decrease your risk of getting sick, it’s important that you have shelf stable food in your home. Shelf stable means foods that last a long time without spoiling, such as canned foods. It’s important to prepare now by stocking up 2-3 weeks’ worth of healthy, kidney friendly foods, fresh water, and medicines. This will help reduce your risk of infection by allowing you to avoid crowded spaces like grocery stores and drug stores.

What about your dialysis treatments and/or medical appointments? 

IMPORTANT NOTE:  If you are on dialysis, you should NOT miss your treatments. Contact your clinic if you feel sick, had contact with a proven COVID-19 positive subject or have any other concerns, so that the dialysis centre can choose whether you should be tested first for the coronavirus and that the dialysis centre can be prepared for your arrival. Furthermore, you should inform staff of fever or respiratory symptoms immediately upon arrival at the dialysis centre.

General hygienic measures you can take yourself as hemodialysis patient:

(1) In patients’ waiting rooms, use alcohol dispensers.
(2) When you are a hemodialysis patient, please wash your hands and fistula arm before starting dialysis and thoroughly disinfect the puncture areas.

Please remember that there is no need or benefit to wear masks of any kind to move around the hospital wards, corridors, or avenues of the hospital. Inappropriate use of these devices is a waste of resources which, in case of real and justified necessity, could cause an important deficiency.

For HD patients that had contact with people who have a high chance of being infected, or with people who subsequently tested positive:

When you have had contact with people who have a high chance of being infected, or with people who subsequently tested positive, please contact your dialysis facility immediately. Staff of your dialysis facility may ask you to follow some rules. These may encompass among others:
(1) In case of absence of manifestations of disease: wear a surgical mask when arriving at the center until leaving, and during the entire duration of the dialysis session. When sneezing, use disposable handkerchiefs and throw them away after each single use. Rigorous application of disinfectants is also recommended.
(2) In case you have to go to dialysis, but have fever or infectious airways, you will probably be sent to the emergency unit or a special COVID-19 unit, where you will be assessed by emergency staff and infectious disease specialists.

If you are a home hemodialysis patient or a peritoneal dialysis patient, you should be assisted at home as far as is possible, using telereporting assistance or other electronic systems for clinical management and to supplement home visits by healthcare staff, as deemed necessary.

This text has been prepared by the ERA-EDTA Working Group Descartes for patients living with a kidney transplant

Patients living with a kidney transplant have the same risk to become infected as the general population. Safety measures to prevent transmission of the disease that are advised by national health authorities are also applicable for transplant patients (see section ). As an additional measure, transplant patients should avoid contacts with persons who have a cough or are sneezing as much as possible. Moreover, they are advised not to travel to areas with a higher prevalence of the disease. Other measures, like wearing masks are not advised.

Once infected, symptoms may be more severe in patients using immunosuppressive drugs, especially when they are older and have other chronic diseases as well. In case kidney transplant patients develop symptoms (fever, cough, sneezing, shortness of breath) they should contact their physician. The policy for screening and hospital admission can differ according to local protocols.

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The American Society of Transplantation (AST) developed a Frequently Asked Questions (FAQ) sheet regarding COVID-19. This FAQ sheet may be of help for you. Please note that the situation is changing rapidly. This document will therefore be updated regularly. Contact your transplant center with urgent specific concerns that are not addressed in this FAQ sheet. A PDF version of this information can be found by clicking here.

https://www.myast.org/coronavirus-disease-2019-covid-19-frequently-asked-questions

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General advices by courtesy of Dr. Riella

Of note, information on this web site applies to the situation in general. Different regions will have slightly different procedures and precautions.

PATIENTS WITH CHRONIC KIDNEY DISEASE

I have an appointment in the hospital. Can I still visit the hospital for this appointment?

In almost all hospitals (most of) the scheduled appointments at the outpatient clinic will be cancelled by the hospital. Reason for this is to limit the number of physical contacts in the hospital, both for your own safety as for the safety of the patients within the hospital. Most of the appointments will be postponed or replaced by phone calls. In case your appointment will still take place in the hospital, please contact the hospital when you experience complaints like fever, coughing, sore throat or a runny nose before your visit. Healthcare facilities are taking special precautions to protect the health and safety of patients during this time. (An increasing number of hospitals has different routes for suspected or proven corona patients).

What about my monitoring and blood tests?

The key goal of all these measures is to protect your safety, so you will still have all blood tests, medications and treatments that are necessary for monitoring your kidney disease. If it is safe to postpone your appointment, might your doctor might choose to do so.

Is the virus more dangerous for me because of my kidney disease?

Patients with kidney disease have the same risk as the general population to get infected with coronavirus. In general, because of your kidney disease, you are at higher risk of getting more gravely ill than the normal population. This risk is most likely not the same for all kidney patients, but depends on the severity of your kidney disease. In general, it is though that patients with CKD stage 4 and 5 have an increased risk. Other patients groups are: patients aged older than 70 and patients with a kidney disease caused by auto-immune inflammation who are using immune suppressant medication.

It is extra important for you to take actions to reduce your risk of getting the coronavirus disease (COVID-19). If you hesitate to do something or go somewhere because of safety concerns, our advice would be: better safe than sorry and opt for the most careful approach.

It is advised to take social distancing measures. What is social distancing?

Social distancing measures are steps you can take to reduce the social interaction between people. This will help reduce the transmission of coronavirus (COVID-19) and protect the vulnerable groups, such as older people and people with health conditions. It is possible that social distancing measures do vary between countries, but in general social distancing measures include:

1. Avoid contact with someone who is displaying symptoms of coronavirus (COVID-19), even if they are mild. These symptoms include a runny nose or a cough, a sore throat or a fever.
2. Avoid non-essential use of public transport
3. Work from home, where possible. Your employer should support you to do this if possible.
4. Avoid large gatherings, and gatherings in smaller public spaces such as pubs, cinemas, restaurants, theatres, bars, clubs.
5. Avoid gatherings with friends and family. Keep in touch using remote technology such as phone, internet, and social media.
6. Use telephone or online services to contact your GP or other essential services.

Everyone should be trying to follow these measures as much as possible. Remember that these rules vary per country, and might be more stringent in your own. In some countries, as the UK, self-isolation of kidney patients is recommended for a period of 12 weeks.

Can I go to the shop?

See if your friends or neighbors can help with the shopping but be pragmatic and if you need to go to buy food, try to choose a quiet time and don’t forget to wash your hands after returning home. In some countries, special opening hours in the early morning exist to protect people with increased risk of developing severe symptoms.

I often suffer from a common cold. When should I be worried about an infection with the coronavirus?

As kidney patient you are vulnerable. You can get very sick from an infection with coronavirus. It is important to pay attention for potential COVID-19 symptoms including fever, cough, and shortness of breath. If you feel like you are developing symptoms, call your physician. He or she will inform you whether you should get tested for coronavirus and give you further advice.

Will I be tested for COVID-19?

Generally if you have symptoms of COVID-19 and you are self-isolating at home, you will not be tested for the virus. If you have had contact with someone who has had COVID-19 you will not be tested for COVID-19 virus but will be asked to self-isolate if you have symptoms. If your symptoms are progressing and you are feeling increasingly ill, please seek advice from your doctor.

If you are a dialysis patient with symptoms of COVID-19 it is likely that the dialysis team will test you to see if you need to be isolated within the unit during your dialysis sessions. If you have symptoms and are admitted to hospital you are likely to be tested.

What should I do when I have coronavirus disease?

Your physician will inform you about this. Depending, among other things, on the severity of your symptoms, you may recover at home or you will be admitted to the hospital.

The current situation causes me to experience a lot of anxiety, for my health and those of my loved ones. What can I do?

It is very understandable to experience anxiety due to the uncertainties that arise with the current situation. There are varies information pages that aim to aid you with coping with stress in these difficult times, for example the page of UK kidney care, which is written especially for kidney disease patients: https://www.kidneycareuk.org/news-and-campaigns/coronavirus-advice/managing-anxiety-and-fear/

General tips can be found on the webpage of the Centers for Disease Control and Prevention: https://www.cdc.gov/coronavirus/2019-ncov/prepare/managing-stress-anxiety.html

Another website which offers a lot of reading and practical tips on the subject is that of the Canadian center for addiction and mental health affiliated with the university of Toronto : https://www.camh.ca/en/health-info/mental-health-and-covid-19

MEDICATION

Is there enough medication for kidney patients, such as blood lowering agents, available?

For now, there is enough medication available. In case there will be shortage, there are often alternatives to replace the medication you are using.

I read that the use of ACE inhibitors an angiotensin II receptor blockers (ARB) (for example lisinopril, enalapril, ramilpril, losartan, etc.) has a negative influence on getting infected with the coronavirus. I use losartan, should I stop with taking this drug?

No, the current advice is to continue taking these drugs. This is a theoretical issue and so far there is no firm evidence to support this theory. The use of ACE inhibitors or ARBs upregulate the ACE2-receptor, to which the coronavirus binds. Based on this knowledge, the theory is that patients who are using these drugs are more vulnerable for coronavirus. So far, there is no evidence to support this theory. Moreover, animal studies showed that these drugs could even protect against long damage. Please keep in mind, doctors prescribe these drugs for a reason: to lower blood pressure to prevent progression of kidney damage. Therefore, discontinuation might cause harm, while there is no evidence to support that withholding ACE inhibitors or ARBs will do any good .

More information can be found here: http://www.nephjc.com/news/covidace2 https://www.escardio.org/Councils/Council-on-Hypertension-(CHT)/News/position-statement-of-the-esc-council-on-hypertension-on-ace-inhibitors-and-ang

I use medication to suppress the immune system (immunosuppressive drugs). Should I stop taking these drugs?

No, it is very important that you continue taking these drugs. Your immune system will not improve directly when you stop taking these drugs, it will stay suppressed for a while. Moreover, you need these drugs to prevent rejection of the kidney transplant (patients living with a kidney transplant) or to prevent a kidney disease flare (patients with a kidney disease).

I received immunosuppressive therapy in the past and my kidney function is normal at the moment. I look after my grandchildren two days a week, can I still do this?

If your kidney function is normal and you are not currently using medication to suppress your immune system, this will probably not lead to a higher risk of infection or more severe complications of COVID-19 compared to the general population. If you do not have other chronic diseases, precautionary measures as advised for the general population are sufficient. However, if you are older than 70, you are at greater risk for serious complications. You should therefore use all preventive measures that are advised for high risk patients. An important part of these measures is to stay at home and avoid social contacts as much as possible. Given these considerations it seems wise to stop babysitting your grandchildren, until the situation improves.

For more information on what to do when you are a high-risk patient, see: https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html

I am recovering at home. Can I use paracetamol when I don’t feel well?

We advise to discuss this with your doctor. In general, the use of paracetamol is safe, as long as you do not take more than instructed on the package insert.

Although there is no evidence that non-steroidal anti-inflammatory drugs (NSAIDs) worsens COVID-19 disease (https://www.ema.europa.eu/en/news/ema-gives-advice-use-non-steroidal-anti-inflammatories-covid-19), they are generally not advised for CKD patients because they can be harmful for your kidneys.

Can I be treated with antiviral drugs?

At present, no drug has proven to cure a corona virus infection. There are various antiviral medicaments that might be effective against the virus, however none have been definitely proven to be effective. These medicaments are only prescribed in certain cases. In some countries, as for example The Netherlands, national protocols are drafted guiding the management of corona disease, including whether or not to prescribe these antiviral drugs.

The World Health Organization has provided a dedicated webpage with various documents with information on the ongoing trials for the discovery of vaccines and therapies for COVID-19: https://www.who.int/blueprint/priority-diseases/key-action/novel-coronavirus/en/

Are antibiotics effective in preventing or treating the COVID-19?

No. Antibiotics do not work against viruses, they only work on bacterial infections. COVID-19 is caused by a virus, so antibiotics do not work. Antibiotics should not be used as a means of prevention or treatment of COVID-19. Of note, there is no proven therapy for COVID. Trials are ongoing.

DIALYSIS PATIENTS

Can I still receive dialysis treatment when I am diagnosed with Coronavirus Disease (COVID-19)?

Yes, dialysis treatment will continue as usual. If you have light symptoms and are permitted to stay at home, you can receive treatment in your own dialysis center. It is advised to contact them in advance to give notice of your situation. Make sure to use private transportation to your clinic and not use a taxi service that is shared with other patients. If you do not have private transportation available to you, in some countries ambulance services (with the appropriate prevention measures) are offered. Upon arrival, you will be separated from other patients to limit the chances of spreading the virus to others. The medical professionals will wear protecting clothes and facemasks. These measures are called isolation measures.

In case you are experiencing severe symptoms due to the corona infection and have been admitted to a hospital, dialysis treatment will be done there.

More information on recommendations for preventive isolation measures by the ERA EDTA can be found here: https://www.era-edta.org/en/wp-content/uploads/2020/03/391-1_NDT.pdf

I am a dialysis patients without symptoms, are there any changes for me?

Ensure your dialysis clinic has your contact details. There may be some differences in the way that services are delivered during this time. It is very important to make sure that your unit has your current contact details (including mobile phone numbers, and email addresses where available). This applies to all dialysis, transplant, other immunosuppressed and low clearance patients. Also please check that you have your unit’s daytime and out of hours contact numbers

You may be asked to be flexible about your dialysis sessions. In some cases your renal team may suggest some changes to your dialysis schedule (either in terms of location or frequency). If this is the case they will discuss this with you.

Can I use my regular transport to the dialysis center when I am diagnosed with a corona virus infection?

In case you are diagnosed with the corona virus, you can no longer use shared transportation. During transportation special measures to prevent further spreading of the virus are required. Taxi operators are not properly equipped to take these measures. Therefore, in some countries, transportation is arranged per ambulance. Contact your dialysis center and health insurance company to inform after the details for your country.

Is there sufficient medical equipment in storage for hemodialysis / peritoneal dialysis?

There may come a time when a shortage of some articles might arise, for example of protective face masks. In preparation, many dialyses facilities have made an inventory of the amount supplies in storage and set up arrangements in case they run out of this stock. These arrangements include reserving supplies from other departments. Many elective (non-essential) procedures have been postponed, freeing these supplies to be put into use in essential parts of hospital care, such as dialysis.

KIDNEY TRANSPLANT RECIPIENTS AND DONORS

I am a 60 year old transplant recipient and have a full time job as cashier at a supermarket. Which measures should I take to watch my health?

In general, it is advised to work from home when possible. In your job, however, this is not an option. We encourage to discuss with your employer the possibilities for being charged with duties that involve less contact with other people than usual. It is important to realize that, although you are not more at risk to be infected with the virus than any other person, your risk of getting more gravely ill is higher.

The world health organization has published guidelines how to prepare a work environment to prevent spreading of the COVID-19: https://www.who.int/docs/default-source/coronaviruse/getting-workplace-ready-for-covid-19.pdf?sfvrsn=359a81e7_6

As kidney transplant recipient, can I still go outside for a walk?

In case no strict self-isolation recommended, please be aware of your surroundings and avoid crowded areas. Always keep 1.5 meters distance between you and others.

I have donated a kidney. Do I have to be extra careful?

Most likely not. The chance of being infected with the virus is the same as for every other person. Being a living kidney donors does not increase your risk of having more serious illness with COVID-19. This is because ability to fight infection is not affected by kidney donation itself. You may have subsequently developed other health reasons which make you high risk and if that is the case it is important to take the advice of the government to socially distance.

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The above listing is not extensive. More information can be found on internet sites. One that merits specific mentioning is the one from the patient organization in the United Kingdom (Kidney Care UK):  https://www.kidneycareuk.org/news-and-campaigns/coronavirus-advice/

2020-04-02: Casper Franssen (Nephrologist, University Medical Center Groningen, The Netherlands)

CVVH and frequent filter clotting in patients with COVID-19

We have received several personal communications on frequent clotting of the CVVH filter/ extracorporeal circuit in patients with COVID-19 (e.g. Maria Jose Soler (Spain), Mario Cozzolino (Italy), Henk van Hamersvelt, (The Netherlands)). Frequent clotting not only limits treatment efficacy but may also contribute to shortages of filters. In this communication we summarize the experiences and advises of several collogues intensivists and nephrologist.

Patients with COVID-19 are reported to have a high risk of thromboembolic events and, therefore, several centers use higher dosages of thrombosis prophylaxis than usual (often double-dose).

To reduce the risk of clotting of the extracorporeal CVVH circuit, the need of a good central venous access, permitting high blood flow, also when is the patient is in prone position, is emphasized. Centers that use heparin as anticoagulation reported that they increase blood flow and give most (80 tot 90%) of the substitution fluid as predilution and, additionally increase the heparin dose. Centers that use citrate as anticoagulation, mostly use a higher citrate dose but this may lead to (more pronounced) metabolic alkalosis and citrate toxicity. Several colleagues reported that citrate toxicity seems to more frequent in patients with COVID-19 in comparison with those without COVID-19.

Other options to reduce the risk of clotting in patients without increased risk of bleeding could be:

• Combine standard citrate anticoagulation with continuous administration of low-dose heparin.

• Use other anticoagulation like argatroban or other direct thrombin inhibitors.

We ask our colleagues to that have experience with any of these alternatives to comment and share their experience with anticoagulation for CVVH, whether positive or negative.

2020-03-25: During the COVID-19 (COVID-19) epidemic physicians in China have entered the stage of actively treating severe patients and trying to improve the success rate of treatment and reduce the fatality rate. The Chinese Medical Association has issued an Expert Consensus on the Application of Special Blood purification Technology in severe COVID-19 Pneumonia. In order to better guide and standardize the application of blood purification technology in severe COVID-1 9, the expert group of nephrology committee of Chinese medical association and Chinese research hospital society has fully discussed how to carry out blood purification technology treatment for severe COVID-19 patients proposed in the above diagnosis and treatment plan, and formulated a consensus statement, that can be read here

2020-03-23: Organizational models in the management of COVID-19 in hemodialysis patients: the Genoa Experience – Nephrology and Dialysis Unit, S. Martino Hospital, Genoa, Italy  https://www.era-edta.org/en/wp-content/uploads/2020/04/Organizational-models-in-the-management-of-COVID-19.pdf

2020-03-19: Management of kidney transplant immunosuppression in positive coronavirus infection requiring hospital admission. By the department of Nephrology, Hospital Universitario La Paz, Madrid, Spain

https://www.era-edta.org/en/wp-content/uploads/2020/03/Management_of_kidney_transplant_immunosuppression_LaPaz.pdf

2020-03-19: Recommendations for treatment of patients on HD or with acute renal failure. By the Emilia Romagna section of the Italian Society of Nephrology.

https://www.era-edta.org/en/wp-content/uploads/2020/03/Recommendations-for-Dialysis.COVID-19-SIN-ER.pdf

2020-03-18: Management of patients on dialysis or with a kidney transplant during COVID-19 infection. By the Brescia Renal COVID-19 Task Force

https://www.era-edta.org/en/wp-content/uploads/2020/03/COVID_guidelines_finale_eng-GB.pdf

2020-03-10: The Milano experience on COVID-19 management in dialysis centers. By Mario Cozzolino, Renal Unit, San Paolo Hospital and San Carlo Hospital, Milan, Italy

https://www.era-edta.org/en/wp-content/uploads/2020/03/200310_Milano_Experience_Covid19_dialysis.pdf

View the Webcast here https://youtu.be/8q_CsvzNMRg

View the Webcast here https://youtu.be/Bny-yvJ0HBk

View the Webcast here https://youtu.be/HLu1jXAyu6A

View the Webcast here https://www.youtube.com/watch?v=658bIDclBZY&feature=youtu.be

https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd

https://www.healthmap.org/covid-19/

https://www.worldometers.info/coronavirus/

https://interaktiv.morgenpost.de/corona-virus-karte-infektionen-deutschland-weltweit/

2020-03-20: COVID-19 rapid guideline: dialysis service delivery https://www.nice.org.uk/guidance/ng160

https://www.who.int/emergencies/diseases/novel-coronavirus-2019

https://www.who.int/gpsc/clean_hands_protection/en/

Information on ongoing trials for the discovery of diagnostics, vaccines and therapies for COVID-19 https://www.who.int/blueprint/priority-diseases/key-action/novel-coronavirus/en/

Daily updated: https://www.ecdc.europa.eu/en

2020-03-24: Situation update worldwide https://www.ecdc.europa.eu/en/geographical-distribution-2019-ncov-cases

Daily updated: General information https://www.cdc.gov/coronavirus/2019-ncov/index.html

Specific information:

2020-03-18: How to Protect Yourself  https://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html

2020-03-17: Steps to Prevent Getting Sick when you are a High-Risk Patient https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/get-ready.html

2020-03-10: Coronavirus Disease 2019 (COVID-19): Interim Additional Guidance for Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed COVID-19 in Outpatient Hemodialysis Facilities https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/dialysis.html

Daily updated: Coronavirus Disease 2019 (COVID-19): Information for Healthcare Professionals https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html

2020-03-10: Coronavirus Disease 2019 (COVID-19): Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html

COVID-19 Chinese Consultation Center Release https://covid-19.alibabacloud.com/

Daily updated: U.S. National Institutes of Health: News releases and updates about COVID-19 https://www.nih.gov/health-information/coronavirus

2020-03-20: COVID-19 rapid guideline: dialysis service delivery https://www.nice.org.uk/guidance/ng160

2020-04-03 2nd ERA-EDTA Webinar on COVID-19 https://youtu.be/HLu1jXAyu6A

2020-03-30 1st ERA-EDTA Webinar on COVID-19  https://youtu.be/658bIDclBZY

COVID-19 Open Forum https://www.esot.org/news/latest-news/join-our-dedicated-covid-19-open-forum

Statement on the COVID-19 Outbreak https://www.esot.org/news/latest-news/esot-statement-covid-19-outbreak

https://www.asn-online.org/ntds/

2020-03-17: COVID-19 Resources https://www.theisn.org/covid-19

2020-03-13: Eurotransplant. COVID-19 and organ donation. https://www.eurotransplant.org/2020/03/13/covid-19-and-organ-donation/

2020-03-14: Austrian Professor Dr Josef Penninger is one of the world’s leading molecular immunologists. APEIRON Biologics AG a company Penninger founded, is currently tackling the ongoing outbreak of COVID-19 and is scheduled to start a pilot clinical trial for their newly developed drug that is supposed to decrease mortality in those affected by the virus. This webcast aims to shed light on the discovery and function of ACE2 – angiotensin converting enzyme 2. Furthermore, the lecture highlights the predisposition of ACE2 as a SARS-CoV and SARS-CoV-2 receptor.

https://connect.myesr.org/course/novel-coronavirus-outbreak-experience-and-challenges-in-imaging-and-beyond/

2020-03-18: Guidance for patients with kidney disease related to COVID-19 https://www.kidneycareuk.org/news-and-campaigns/coronavirus-advice/

Daily updated: The Coronavirus Conundrum: ACE2 and Hypertension Edition http://www.nephjc.com/news/covidace2

2020-03-23: COVID-19 drug interactions. Detailed recommendations and at-glance summary of medication interactions with experimental agents in the treatment of COVID-19: http://www.covid19-druginteractions.org/

2020-03-18: GlomCon Webinar on “COVID19 – Mitigation & Support Strategies in Patients with GN or Transplant”

https://t.co/nIMVmisX1e?amp=1

2020-04-17: The aftermath of coronavirus disease of 2019: devastation or a new dawn for nephrology? Agarwal Rajiv, NDT https://academic.oup.com/ndt/article/doi/10.1093/ndt/gfaa094/5820264

2020-04-15: ADAM17 inhibition may exert a protective effect on COVID-19. Soler MJ et al, NDT https://academic.oup.com/ndt/article/doi/10.1093/ndt/gfaa093/5820263

2020-03-30: Sound Science before Quick Judgement Regarding RAS Blockade in COVID-19. Sparks MA et al, CJASN https://cjasn.asnjournals.org/content/early/2020/03/30/CJN.03530320

2020-03-25: Should COVID-19 Concern Nephrologists? Why and to What Extent? The Emerging Impasse of Angiotensin Blockade. Perico L. et al, https://www.karger.com/Article/FullText/507305

2020-03-19: Editorial, The burning building, Fiona Godlee, Editor in chief  https://doi.org/10.1136/bmj.m1101

2020-03-18: The resilience of the Spanish health system against the COVID-19 pandemic. Legido-Quigley H. et al. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30060-8/fulltext

2020-04-22: Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City Area. Richardson et al. JAMA. https://jamanetwork.com/journals/jama/fullarticle/2765184

2020-04-22: Obesity a risk factor for severe COVID-19 infection: multiple potential mechanisms. Sattar et al. Circulation. https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047659https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047659

2020-04-14: Spread of SARS0CoV-2 in the Icelandic population. Gudbjartsson et al. https://www.nejm.org/doi/full/10.1056/NEJMoa2006100?query=featured_coronavirus

2020-04-08: First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment. Leung et al. The Lancet. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30746-7/fulltext

2020-03-30 COVID-19 in critically ill patients in the seattle region – case series. Bhatraju et al. https://www.nejm.org/doi/full/10.1056/NEJMoa2004500?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed

2020-03-29: The correlation between viral clearance and biochemical outcomes of 94 COVID-19 infected dischargec patients. https://link.springer.com/article/10.1007%2Fs00011-020-01342-0

2020-03-18: SARS-CoV-2 Infection in Children. Lu X et al,, https://www.nejm.org/doi/full/10.1056/NEJMc2005073

2020-03-13: Risk Factors Associated with Acute Respiratory Distress Syndrome and Death in Patients with Coronavirus Disease 2019 Pneumonia in Wuhan, China. Chaomin et al. JAMA. doi:10.1001/jamainternmed.2020.0994

2020-03-12: Clinical course and risk factors for mortality with COVID-19 in Wuhan. Zhou et al. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext

2020-02-28 Clinical characteristics of coronavirus disease 2019 in China. Guan et al. https://www.nejm.org/doi/10.1056/NEJMoa2002032

2020-02-27: Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: retrospective case series. Xu et al, BMJ. https://www.bmj.com/content/368/bmj.m792

PRE-PRINT ARTICLES (not Peer Reviewed)

2020-04-01: Risk factors for severe corona virus disease 2019 (COVID-19) patients: a systematic review and meta analysis. Xu. https://connect.medrxiv.org/relate/content/181?page=3

2020-05-01: Renin-Angiotensin-Aldosterone System Inhibitors and Risk of COVID-19. Reynolds et al. NEJM. https://www.nejm.org/doi/full/10.1056/NEJMoa2008975

2020-4-29: Effects of ARBs and ACEIs On Virus Infection, Inflammatory Status and Clinical Outcomes in COVID-19 patients with hypertension, a Single Center Retrospective Study. Guang et al. Hypertension.  https://www.ahajournals.org/doi/abs/10.1161/HYPERTENSIONAHA.120.15143

2020-04-27: ACE inhibitors and COVID-19: We don’t know yet. Khashkhusha et al, Editorial, Journal of Cardiac Surgery. https://onlinelibrary.wiley.com/doi/full/10.1111/jocs.14582

2020-04-21 COVID-19 and the Heart. Akhmerov A. et al. https://www.ahajournals.org/doi/abs/10.1161/CIRCRESAHA.120.317055

2020-03-30 Renin-Angiotensin-Aldosterone system inhibitors in patients with COVID-19. Vaduganathan M et al. https://www.nejm.org/doi/full/10.1056/NEJMsr2005760?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed

2020-03-28 Chronic Kidney Disease is associated with severe coronavirus disease 2019 (COVID-19) infection. Hendry BM and Lippi G. https://link.springer.com/content/pdf/10.1007/s11255-020-02451-9.pdf

2020-03-25: Renin-Angiotensin System Blockers and the COVID-19 Pandemic. At Present There Is No Evidence to Abandon Renin-Angiotensin System Blockers.  Epstein M. et al, https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.120.15082

2020-03-19: Kidney disease is associated with in-hospital death of patients with COVID-19. Cheng et al https://www.kidney-international.org/article/S0085-2538(20)30255-6/fulltext

2020-03-11: Do ACE inhibitors and ARBs cause more serious COVID-19 disease? Fang et al. https://www.thelancet.com/action/showPdf?pii=S2213-2600%2820%2930116-8

2020-03-07: The Novel Coronavirus 2019 Epidemic and Kidneys. Saraladevi et al. https://www.kidney-international.org/article/S0085-2538(20)30251-9/fulltext

PRE-PRINT ARTICLES (not Peer Reviewed)

2020-03-27: Anti-hypertensive Angiotensin II receptor blockers associated to mitigation of disease severity in elderly COVID-19 patients. Lui X. et al, https://www.medrxiv.org/content/10.1101/2020.03.20.20039586v1

2020-02-13: ACE2 expression in the kidney and the risk for kidney damage. Fan et al., MedRxiv preprint https://www.medrxiv.org/content/10.1101/2020.02.12.20022418v1

2020-02-20: CKD increases mortality risk of Covid-19 patients. Cheng et al., MedRxiv preprint. https://doi.org/10.1101/2020.02.18.20023242

2020-03-28: A case of novel coronavirus disease 19 in a chronic hemodialysis patient presenting with gastroenteritis and developing severe pulmonary disease. https://www.karger.com/Article/Pdf/507417

2020-03-23: Practical indications for the prevention and management of SARS-CoV-2 in ambulatory dialysis patients: lessons from the first phase of the epidemics in Lombardy. Rombolà G. et al, https://link.springer.com/article/10.1007%2Fs40620-020-00727-y

2020-03-20: Mitigating Risk of COVID-19 in Dialysis Facilities. Kliger A.S. et al, https://cjasn.asnjournals.org/content/early/2020/03/20/CJN.03340320

20-03-16:  Recommendations for the prevention, mitigation and containment of the emerging SARS-CoV-2 (COVID-19) pandemic in haemodialysis centres. Basile et al. on behalf of the Eudial Working Group of ERA-EDTA   https://academic.oup.com/ndt/advance-article/doi/10.1093/ndt/gfaa069/5810637

2020-03-10: Milano experience on coronavirus management in dialysis centers. Cozzolino M. et al. https://academic.oup.com/ckj/advance-article/doi/10.1093/ckj/sfaa050/5810636

2020-03-12: COVID-19 pneumonia in hemodialysis patients. Tang et al. https://www.sciencedirect.com/science/article/pii/S2590059520300492

PRE-PRINT ARTICLES (Not Peer-Reviewd)

2020-02-27: HD epidemic in HD in Wuhan. Ma et al., MedRxiv preprint https://www.medrxiv.org/content/10.1101/2020.02.24.20027201v2

2020-05-02: Strategies to Halt COVID-19 Spread for Organ Transplantation Programs. Wang et al. Am J Transplant. https://onlinelibrary.wiley.com/doi/abs/10.1111/ajt.15972

2020-05-01: Strategies for Prevention and Control of COVID-19 in the Department of Kidney Transplantation. Yurong et al, Transplant Int. https://onlinelibrary.wiley.com/doi/abs/10.1111/tri.13634

2020-04-29: COVID-19 in Kidney Transplant Recipients. Nair et al. Am J Transplant. https://onlinelibrary.wiley.com/doi/abs/10.1111/ajt.15967

2020-04-21: Early description of coronavirus 2019 disease in kidney transplant recipients in New York. Colombia University Kidney Transplantation program. JASN. https://jasn.asnjournals.org/content/early/2020/04/21/ASN.2020030375

2020-04-13: Early impact of COVID-19 on Transplant Center Practices and Policies in the United States. Boyarsky et al. https://onlinelibrary.wiley.com/doi/10.1111/ajt.15915

2020-04-09: COVID-19 Infection in Kidney Transplant Recipients. Banerjee et al. Kidney Int. https://www.kidney-international.org/article/S0085-2538(20)30361-6/pdf

2020-02-20: Implications of COVID-19 for transplantation. Michaels M.G. et al, Am J Transpl. https://onlinelibrary.wiley.com/doi/epdf/10.1111/ajt.15832

2020-03-17: Transplantation during the COVID-19 pandemia, a view from a large Milan transplantation center. Gori A. et al, Am J Transpl. https://onlinelibrary.wiley.com/doi/epdf/10.1111/ajt.15853

2020-03-17: Succesfull recovery of COVID-19 pneumonia in renal transplant recipient with long term immunosuppresion. Zhu L et al, American Journal of Transplantation. https://onlinelibrary.wiley.com/doi/10.1111/ajt.15869

PRE-PRINT ARTICLES (Not Peer-Reviewd)

2020-02-23: Risk of AKI in COVID19 (low). Wang et al., MedRxiv preprint https://www.medrxiv.org/content/10.1101/2020.02.19.20025288v1.full.pdf+html

2020-02-12: Kidney damage and dysfunction in COVID-9 infection. Li et al., MedRxiv preprint https://www.medrxiv.org/content/10.1101/2020.02.08.20021212v1.full.pdf

2020-02-12: AKI incidence in Covid-19 patients. Li et al., MedRxiv preprint. https://doi.org/10.1101/2020.02.08.20021212

2020-03-17: SARS-CoV-2 is stable for hours on surfaces. Van Doremalen N. et al, NEJM. https://www.nejm.org/doi/full/10.1056/NEJMc2004973

2020-02-06: Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. Kampf et al. https://www.journalofhospitalinfection.com/article/S0195-6701(20)30046-3/fulltext

2020-03-14: Psychological impact of quarantine and how to reduce it. Brooks et al. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930460-8

2020-03-30: Developing Covid-19 Vaccines at pandamic spead. https://www.nejm.org/doi/full/10.1056/NEJMp2005630?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed

2020-03-20: Clinical trial: Hydroxychloroquine and azithromycin as a treatment of COVID-19. Gautret et al. International Journal of Antimicrobial Agents, https://www.sciencedirect.com/science/article/pii/S0924857920300996?via%3Dihub

2020-03-18: A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19. Cao B. et al. https://www.nejm.org/doi/full/10.1056/NEJMoa2001282

2020-03-12: COVID-19: consider cytokine storm syndromes and immunosuppression. Mehta et al. https://www.thelancet.com/pb-assets/Lancet/pdfs/S0140673620306280.pdf

2020-01-01: Influences of cyclosporin A and non-immunosuppressive derivatives on cellular cyclophilins and viral nucleocapsid protein during human coronavirus 229E replication. Ma-Lauer Y. et al, https://www.sciencedirect.com/science/article/pii/S0166354219303936?via%3Dihub

PRE-PRINT ARTICLES (not Peer-Reviewed)

2020-01-04 Analytical sensitivity and efficiency comparisons of SARS-COV-2 qRT-PCR assays. Vogels et al. https://www.medrxiv.org/content/10.1101/2020.03.30.20048108v1.full.pdf

2020-03-17 : Development of an ELISA to detect SARS-Cov-2 seroconversion in humans, Amanat et al, https://www.medrxiv.org/content/10.1101/2020.03.17.20037713v1

2020-03-1: Development of an ELISA tot dectect SARS-Cov-2, Xiang et al, https://doi.org/10.1101/2020.02.27.20028787

2020-03-21: Hospitals as health factories and the coronavirus epidemic. Piccoli G.B, https://link.springer.com/article/10.1007%2Fs40620-020-00719-y

2020-03-19: Coronavirus disease 2019: the harms of exaggerated information and non‐evidence‐based measures. Ioannidis JPA https://onlinelibrary.wiley.com/doi/abs/10.1111/eci.13222

2020-03-14: COVID-19 and Italy. What next? Remuzzi et al. https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)30627-9.pdf

2020-03-17: Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. Van Doremalen N. et al, https://www.nejm.org/doi/full/10.1056/NEJMc2004973

2020-02-06: Preparing for extracorporeal organ support in ICU. Ronco et al. https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30060-6/fulltext