COVID-19 and Kidney Disease

[MUSIC PLAYING] Welcome, everyone. You're watching Coronavirus in Context. I'm Dr. John Whyte, Chief Medical Officer at WebMD. We've been talking about the impact of COVID on our bodies. We've been talking about it in our lungs, and our hearts, on our neurological system.

Well, one component we haven't talked about is the kidney. So today I've asked Dr. Adam Weinstein. He's the VP of Medical Affairs and Clinical IT Services at Davita. Dr. Weinstein, thanks for joining me.

Thanks for having me, John.

Let's start off with, what's the impact of COVID on the kidney? We heard a little bit about it in the beginning when we were talking about do antihypertensive medicines impact whether one might get COVID or, or actually protect against COVID. So tell us the latest thinking in terms of COVID in the kidney.

Well, I think I would put it into three buckets. COVID in patients who did not have kidney disease prior to being ill has led to numerous events of acute kidney injury, especially in the critically ill. And this is-- put some hospital systems and other places under duress as they've had to deliver dialysis services to critically ill patients and mass. For those that survive, there is significant kidney damage that they're left with.

Sadly, not many of them make it out of the hospital, if they have had acute kidney injury in a setting of chronic disease or-- sorry, acute illness like that. In terms of the other issues around COVID in the kidney, what we see is patients are at higher risk for having more severe illness if they have existing kidney disease. And so kidney disease is both the result of COVID as well as a risk factor for having a more severe course.

Now if you have chronic kidney disease, should you consider that as being at increased risk, as we do, say, with diabetes or heart disease or cancer?

Yes. Having chronic kidney disease often is not an isolated thing. It is most often the result of hypertension and diabetes. And, often-- as all those puts you at higher risk, certainly chronic kidney disease as well-- will as well.

Now, you deal, obviously, you know, at Davita with a lot of patients on dialysis. So how is COVID impacting the dialysis community, whether it's peritoneal dialysis or hemodialysis? Does it matter in terms of the impact?

Well, it certainly does matter quite a bit. You know, at Davita we focus greatly on patient safety at all times. And as the COVID ban tempen-- pandemic became clearer in its nature, we spun up a number of activities within the company and working with partners throughout the renal community to ensure that we consistently delivered high quality care.

We've altered various policies and procedures. We've altered how we've handled certain aspects of tracking patients, especially those that were under suspicion for COVID. And, of course, we've had to ensure that we've had the appropriate PPE throughout the entire continuum in center hemodialysis as well as acute dialysis services in the hospitals we work with.

You know, one of the things I was fascinated by that you and I chatted by email last night is exactly how we determine the prevalence of antibodies. We've been hearing a lot about that, that only 10% of people have been impacted by COVID and have antibodies, and they did it through looking at the blood of dialysis patients.

There was a journal article in Lancet in September that looked at the prevalence of SARS CoV 2 antibodies, looking at 28,000 randomly selected dialysis patients at 1,300 facilities, which is amazing when you think about how we extrapolate it, the data on dialysis patients, which we know typically are not representative demographically of the US population, and came up with these estimates. Really a contribution from the dialysis community in terms of our understanding of antibodies. Are you surprised by that at all?

No. You know, my colleagues and the various organizations that we work within in the renal community have been, I think, at the forefront of thinking through how to ensure we contribute to the overall scientific knowledge of COVID. And, certainly, we had grave concerns around the potential for the impact of COVID on our patients, and that article, in particular, is a great example of finding a way to contribute.

So as you probably know, a patient who completes their dialysis session often has a small amount of blood within the dialysis circuit, that is the tubing that hooks to the dialysis machine. That's a normal course of treatment. They utilize that remaining blood to identify these, these antibodies across numerous dialysis treatments. I thought it was quite an innovative and thoughtful way to approach the problem.

You know, one of the impact that we've talked about in the lungs and how COVID impacts the lungs is the issue of receptors, in [INAUDIBLE] receptors. And we know that, in terms of the kidney as well and we have a lot of physicians who watch this program as well as consumers, what's our latest understanding on [INAUDIBLE] receptors and in terms of patients that might be on certain antihypertensive medicines? Does it put them at risk of getting COVID? Does it actually protect them? What's the latest?

Yeah, there was a bit of controversy early on regarding the use of ACE inhibitors and, potentially, angiotensin receptor blockers in patients who may be at risk for COVID. And all of the data that I have seen to date has reinforced the fact that that's not the case, that those medicines on the whole are protective in a number of ways, and stopping them is bad. The most recent data I've seen does not indicate that it would confer any additional risk, to be on an ACE inhibitor or an ARB in terms of catching or the severity of COVID.

You mentioned a few minutes ago about protecting dialysis patients, protecting providers. You and I chatted before the show. I'm an internist by training, not a nephrologist. And we always like to show nephrologists like numbers.

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[INAUDIBLE] calculations. And the reason why I bring this up is, how is clinical data management changed in the setting of COVID? You really had to respond with new strategies and a new algorithms, in some ways, to address this, you know, pandemic.

John, you're absolutely right. And this is my area of both interest and expertise within Davita. So as the most clinically focused aspects of Davita were adjusting to ensuring that we had all the right protection in place for patients and staff within Davita. We also had a parallel program of ensuring that we could keep track of the patients, especially ones that were either diagnosed with COVID or were under suspicion.

We ended up having to ensure that those patients were cohorted, that is, put together on various shifts within our dialysis facilities and also ensure that their physicians and their care providers were able to keep track of them. As someone responsible for physician facing IT tools within Davita, we had a very rapid cycle time to make sure that that information was made available and ensure the continuity of care for the patients. In addition, like many organizations we went from a very nascent telehealth program to a full blown telehealth system that was applicable across both home and in center hemodialysis. And that happened in a matter of weeks, which is just amazing for large organizations.

And what are some of those technology shifts?

Yeah, I think the biggest technology shifts were really reworking, what would be called, the the plans for updates and changes. That is, in the IT world, something that happens months ahead of time and thinking about a year in advance.

And so we had to rapidly adapt our development schedules to adjust to the COVID crisis. In terms of-- in terms of telehealth, which has probably been the biggest front facing tool that our physicians and clinicians throughout the United States have seen a change in during COVID, that really was a matter of making sure we're working with the companies that we work with typically to ramp up the scaling of that and, in some instances, use our hardware in storage and got it-- getting it out to the field so that we could have iPads, for instance, within our dialysis facilities. And when you have, you know, 2,800 dialysis facilities, that's a lot of iPads to get out very quickly.

You've been a big proponent that there is many behind the scenes, non-clinical work that directly impacts clinical care. And you've been working with Medscape on-- on some ways that we can more effectively engage with physicians and other clinicians. Can you talk a little bit about that?

Sure, John. So at Davita, we have a number of physician facing IT tools, including one of our mobile applications designed to deliver clinical information to our physicians when and where they need it. As part of that mobile application, really a mobile platform, we've partnered with Medscape to deliver something called M.D. Loop, which provides a feed of nephrology-specific information and nephrology-specific resources to our physician users so that when they're engaging in whatever clinical activities go on within our application, they also have ready access to journal articles, information, and other potential useful resources for them.

You know, how hard is it to engage clinicians? We're always talking about ways to more effectively do that, and people like to say, you know, it's like herding cats. It's hard to get physicians on the same page. You know, what has been your experience and in terms of how do you effectively engage physicians when you have them across many facilities, you know, around the country?

Yeah, you know, I actually don't see it as herding cats. I see it more as earning their time. And to do that, you have to provide valuable tools that respect the workflow, that is, gives them what they need, where they need it, and when they need it, but also adds value to their day. And that's that's one of the reasons we've chosen to partner with Medscape, but more importantly, the philosophy that we use within our physician experience team at Davita starts with understanding our users, understanding their workflows, and then building around the use cases that we think would be most valuable. And so there's a lot of thought that goes into it, but you're absolutely right. Physician mindshare and physician time are highly valuable resources that we both respect and want to earn.

Does kidney care look very different two years from now because of COVID, whether it's management of chronic kidney disease or-- or even patients on dialysis?

So my prediction is that yes, it will look different. I don't know how very different. I mean, at the fundamental level, dialysis and the care of chronic kidney disease requires a certain base level of knowledge and treatments. However, I think we're going to see more remote access, that is, using telehealth, and as we evolve the various software products, we're going to have greater options in terms of understanding their patient. Nothing I think we'll ever truly replace a face-to-face encounter at a chair side or an encounter with one of your home dialysis patients in our facilities. But the fact is how we access data, what data is available, and, sort of, real time alerting and all that will continue to evolve.

Are digital tools going to become even more important in the management of disease?

Oh, totally. I mean, you know, I, I-- I speak often about how nephrology is a data-driven specialty that happens to care for kidneys. And that's not 100% accurate, but certainly from my vantage point, that's what I see. How do we get that information into the hands of clinicians in timely, useful, and concise ways?

I'm going to put you on the spot. Kidney more important than the heart?

[LAUGHTER] No comment. I love my cardiologists. They're wonderful people.

All right, Dr. Weinstein. I want to thank you for taking your time today helping us understand what the impact of COVID is on the kidney, something that we haven't been talking enough about, as well as the importance of, you know, clinical data management in terms of how we effectively manage disease.

My pleasure, John. Thanks for having me. This was fun.

And I want to thank you for watching Coronavirus in Context.

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