Protected: Preliminary report on the Covid-19 outbreak in Valle d’Aosta dialysis centers


Valle d’Aosta, Italy’s smallest region, faced a Covid-19 epidemic trend of absolute relevance. In line with data concerning the local general population, the predominance of the illness among uremic patients has been high. The authors report here preliminary data on the spread of this disease within the region and on the clinical trend of the infected patients who needed to be hospitalised.



Keywords: Covid-19, outbreak, dialysis

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Covid-19 in patients on dialysis: infection prevention and control strategies


Covid-19 is a disease caused by a new coronavirus presenting a variability of flu-like symptoms including fever, cough, myalgia and fatigue; in severe cases, patients develop pneumonia, acute respiratory distress syndrome, sepsis and septic shock, that can result in their death. This infection, which was declared a global epidemic by the World Health Organization, is particularly dangerous for dialysis patients, as they are frail and more vulnerable to infections due to the overlap of multiple pathologies. In patients with full-blown symptoms, there is a renal impairment of various degrees in 100% of the subjects observed. However, as Covid-19 is an emerging disease, more work is needed to improve prevention, diagnosis and treatment strategies. It is essential to avoid nosocomial spread; in order to control and reduce the rate of infections it is necessary to strengthen the management of medical and nursing personnel through the early diagnosis, isolation and treatment of patients undergoing dialysis treatment. We cover here a series of recommendations for the treatment of dialysis patients who are negative to the virus, and of those who are suspected or confirmed positive.

Keywords: Covid-19, hemodialysis, transmission, prevention

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La malattia da Coronavirus 2019 (Covid-19), appartiene alla grande famiglia di virus a RNA che possono essere isolati in diverse specie di animali [1] e che, per ragioni ancora sconosciute, possono attraversare le barriere della specie e possono causare nell’uomo malattie che vanno dal comune raffreddore a patologie più gravi come la SARSr-CoV1e la MERS. Il 30 gennaio 2020 l’Organizzazione Mondiale della Sanità ha dichiarato ufficialmente l’epidemia Covid-19 un’emergenza di sanità pubblica di interesse internazionale [2].

I sintomi clinici dei pazienti comprendono febbre (44%-98%), tosse secca (68%-76%), mialgia (18%) ed affaticamento (18%); i pazienti in gravi condizioni possono presentare respiro affannoso, rantoli umidi nei polmoni e suoni del respiro indeboliti fino alla polmonite bilaterale, sindrome da distress respiratorio acuto (ARDS), sepsi, shock settico e morte [3]. Sulla base dell’indagine epidemiologica attualmente in corso, il periodo di incubazione della malattia è generalmente compreso tra 3 e 7 giorni, con un massimo di 14 giorni [2] e la trasmissione da uomo a uomo avviene attraverso goccioline di saliva o con contatto diretto; a differenza della SARS, il Covid-2019 è responsabile dell’infezione anche se il paziente è asintomatico [2].


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Covid-19 and its impact on nephropathic patients: the experience at Ospedale “Guglielmo da Saliceto” in Piacenza


Roberto Scarpioni and colleagues recount their experience with the Covid-19 epidemic at the Nephrology and Dialysis Center of the “Guglielmo da Saliceto” Hospital in Piacenza, where everybody is still fighting to this moment to contain the spread of the disease and face an increasingly unsustainable clinical situation. Piacenza is only 15 km away from the main cluster of cases in the country (Codogno, in the Lodi province) and, after the closure of the Hospital in Codogno, saw an escalation in the number of patients testing positive to Covid-19.

The authors describe their efforts and the practices they adopted to contain the spread of the disease among inpatients visiting the hospital’s Hemodialysis Clinic. They also reflect on some of the data available on the 25/03/2020, such as the number of patients testing positive and the mortality rate, unfortunately very high. Their aim is to help all colleagues that have yet to face this epidemic in its full force.

Keywords: Covid-19, coronavirus, nephropatic patients, dialysis, kidneys, Piacenza, Emilia Romagna

A cluster of cases of a new unknown type of pneumonia was first signalled in Wuhan, China, on the 31st December. Chinese researchers later identified the cause of the infection as a novel coronavirus called SARS-CoV-2 o Covid-19 [1]. Exactly one month later, in Rome, two Chinese tourists from Wuhan were the first to test positive to the virus in Italy. The first Italian case of Covid-19 was hospitalised on the 21st February in Codogno (Lodi province), only 15 km away from Piacenza [2]. The following weeks saw an exponential increase in the number of infections, to the point that Italy is now the country that has been most heavily hit by the pandemic after China. We have more than 57.521 confirmed cases, with more than 8.256 in the Emilia Romagna region alone, where 1.077 patients have died and 721 have recovered [3].

Here we describe our own experience with the Covid-19 epidemic at the Nephrology and Dialysis Center of the “Guglielmo da Saliceto” Hospital in Piacenza, where everybody is still fighting to this moment to contain the spread of the disease and face an increasingly unsustainable clinical situation. We hope this will be useful to all colleagues that have yet to face this epidemic in its full force, as it has already happened in Emilia Romagna and Lombardia. Piacenza is only 15 km away from the main cluster of cases in Codogno and, after the closure of the Hospital there, saw an escalation in the number of patients presenting to the A&E testing positive to Covid-19 (see Fig. 1).


Fig. 1: Number of patients presenting to the A&E testing positive to Covid-19


The exponential growth in the number of nephropathic patients with a Covid-19 infection forced us straight away to adopt measures to contain the spread of the disease among inpatients visiting the hospital’s Hemodialysis Clinic. Starting from day 3 and 4 we adopted very strict measures, both when dealing with patients and between colleagues. Fortunately to date (25/03/2020) none of the doctors has been found positive to the virus, while three nurses have been found positive and have isolated at home, in good general conditions.

Inpatients’ body temperature was measured before they entered the ward; they were invited to wear face masks, wash their hands with an alcohol-based sanitizer and change their clothes and shoes. The personnel wore face masks, protective glasses and gloves, and disinfected rooms and machinery at the start of each shift [4].

At first, patients needing chronic hemodialysis were treated within the ward using CRRT (Continuous Renal Replacement Therapy) or high-volume hemofiltration (6 L/hr), with adsorbent membranes to remove inflammatory cytokines (IL-6) and endotoxins. In order to avoid contacts as much as possible, we treated two patients at a time, under the supervision of a single nurse and in the same room, separate from the rest and with its own transport system. Later, however, the high volume of patients forced us to move outside the ward to set up a new space devoted to quarantined patients. While waiting for the test results, all patients were treated as positive by medical personnel wearing face masks, goggles, gloves and overcoats. We insured a distance of at least 1-1,5 m between the beds by emptying the room of all that was not immediately necessary. One of the most difficult tasks was organising a separate transportation system, devoted solely to patients positive to Covid-19 and disinfected after each round. As for us, apart from wearing the protective gear describe above, we decided to avoid holding any staff meetings indoors.

As of today, it is extremely clear how dangerous Covid-19 is for fragile nephropathic patients: 41 of our patients on hemodialysis have been infected, 16% of the total (mean age 73±11, range 52-90 years, all white Caucasian, 31 men/10 women). The diagnosis was based on the results of the oro-rino-pharyngeal swab, wherever possible, or on the findings of the pulmonary CT. It is surprising to note that the rate of infection is the same recorded at the Renmin Hospital in Wuhan (16%) [5]; we have to consider, however, that over the first few says only symptomatic patients were tested for the virus.

Of these patients, those with a temperature and/or struggling to breathe were empirically treated with 5-OH-chloroquine and antiretroviral therapies, when considered appropriate by the infectologist. Due to the patients’ age and previous comorbidities, the mortality rate has unfortunately been very high: to date, half of the infected patients have died (18/41, 41% raw mortality). This is way higher than the rate among non-nephropathic patients in Italy (around 10%) – and an unacceptable price to pay [6].

All transplanted patients in home care (118) and those treated with peritoneal dialysis (34) were discouraged from visiting the hospital but were contacted via telephone on a daily basis by our doctors and nurses. We have currently 4 transplanted patients who tested positive to Covid-19; two of them are hospitalised at the Transplant Center in Bologna, while the others are quarantined at home and are being monitored very closely for any pharmacological interactions. Luckily, only one PD patient has tested positive so far and is also at home, closely monitored.

In line with what has been reported by a few other authors, we observed only a small percentage of Covid-19-related cases of acute kidney injury (AKI) (<3%) [7]. To date, we have 5 AKI patients that have required intensive care treatment with CRRT; 4 of them, all men with existing comorbidities whose average age is 60 and age range is 39-71, are still being treated.

Looking back, the strict containment measures that we have adopted early on have certainly helped minimise the spread of the disease, although the mortality rate has remained unacceptably high among nephropathic patents. We are now waiting for new results to shed light on the renin-angiotensin blockade as a potential functional receptor for the virus [8, 9], on the use of immunomodulating drugs inhibiting IL-6 as a mean to reduce the progression of respiratory failure and inflammation, and on the use of other antiviral medications (or perhaps even a vaccine) that may reduce the rate of infection and the prognosis, which is currently extremely negative in 8-10% of cases. While we wait to know more, however, we must invest in preventing the spread of Covid-19. Prevention through social distancing is imperative, especially for older patients with renal disease, but cannot be enforced in all cases as many of them need to come to the Center for life-saving treatment up to three times per week. The low rate of infection among patients in home care further confirms the effectiveness of self-isolation.



  1. Zhu N, Zhang D, Wang W, et al. A novel Coronavirus from patients with pneumonia in China, 2019. N Eng J Med 2020; 382(8):727-33.
  2. Carinci F. Covid-19: preparedness, decentralisation, and the hunt for patient zero. BMJ 2020; 368:bmj.m799.
  3. Ministero della Salute (ultimo accesso 25/03/2020).
  4. Center for Disease Control and Prevention. Interim Additional Guidance for Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed COVID-19 in Outpatient Hemodialysis Facilities: (ultimo accesso 15/03/2020).
  5. Naicker S, Yang C-W, Hwang S-J, et al. The Novel Coronavirus 2019 Epidemic and Kidneys. Kidney Int 2020; in press.
  6. Xianghong Y, Renhua S, Dechang C. Diagnosis and treatment of COVID-19: acute kidney injury cannot be ignored. Natl Med J China 2020; epub ahead of print.
  7. Guan W, Ni Z, Yu Hu, Liang W, et al for the China Medical Treatment Expert Group for Covid-19. Clinical Characteristics of Coronavirus Disease 2019 in China. New Engl Journ Med 2020;
  8. Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular System. Nat Rev Cardiol 2020;
  9. Perico L, Benigni A, Remuzzi G. Should COVID-19 Concern Nephrologists? Why and to What Extent? The Emerging Impasse of Angiotensin Blockade. Nephron. 2020 Mar 23:1-9.

An account of the first hours of the Covid-19 epidemic at the Nephrology Unit in Lodi (Lombardy)


Marco Farina and colleagues give us their account of the first days of the Covid-19 epidemic in the Nephrology Unit of the Ospedale Maggiore in Lodi. From the news trickling through from Codogno on the 20th of February to the hospitalization, the following day, of the first dialytic patient with signs of pneumonia, who later tested positive to the virus.

They tell us of how the hospital has been completely restructured in the wake of the epidemic, at remarkable speed and providing an example for others to follow, and the great sense self-sacrifice displayed by all medical personnel. After an overview of the clinical conditions of the 7 patients positive to the virus hospitalised in the following few days, they describe in some detail how symptomatic Covid+ patients are currently managed at the Ospedale Maggiore in Lodi.

Keywords: Covid-19, Ospedale Maggiore di Lodi, nephrology, dialysis


The Covid-19 epidemic suddenly hit us on the 20th of February, the day the news started trickling through that the first case of SARS-CoV-2 had been isolated in Codogno, far out in the province. After being all over the news because of a nasty high-speed train accident only a few days before, the Lodi area was once again in the spotlight as the theatre, this time, of a health emergency.

In those first confusing hours we spent plenty of time and energy trying to find the case 1 and case 0, and doing all we could to pinpoint the starting point of the epidemic — apparently a dinner between co-workers, one of which had just returned from China. Both patient 1 and his pregnant wife, for whom we were all particularly worried, had just been hospitalised. It was then clear that the virus had arrived in Italy, in all likelihood destined to spread from our own region to the rest of the country, and that there was no point in trying to find links between infected people and China any longer. We have since been witnessing an exponential growth that, up to this day, has not shown any signs of a slowdown.


The first case

When I got to work on the 21st I was told that our Nephrology department had just received a 62-year-old hemodialysis patient showing signs of pneumonia at a chest X-rays. Showing a commendable insight, our local Health Care System had published on the 5th of February a detailed plan on how to identify, signal and manage either potential, probable or confirmed cases of Covid-19. This is not to say we were ready for what was to come – who could have been? – but at least we had criteria in place to recognise and assess the problem. The patient described above, who had arrived from the small town that would soon become the main cluster of cases in the country, was immediately isolated and we all started using the protective equipment described in detail in the management plan. We sent blood samples and a nasopharyngeal swab to the Microbiology Lab at the Sacco Hospital in Milan and we waited the results with apprehension; as it was still early days, we received them the same evening: positive. We alerted the Crisis Unit created by the Region for this purpose and, in the night between the 21st and the 22nd, the patient was transferred to the Infective Disease Unit at S. Anna Hospital in Como. He was then transferred to the Intensive Care Unit not because of any worsening of his conditions (he did not need a ventilator during transfer) but because he needed dialysis, which cannot be administered in Infective Disease wards. However, within a day, we witnessed a sudden worsening of the patient’s respiratory conditions (something we have grown accustomed to seeing in this type of patients), followed by death. This announcement, that reached our Nephrology Unit through mainstream news channels, was met with bewilderment: we all knew that the patient, albeit young, had several comorbidities but we were nonetheless greatly distressed to learn of his death; as a pre-emptive measure we had to quarantine the entire medical personnel, as the very first contacts with the patient had, quite understandably, taken place without the necessary protections.


Re-structuring the Hospital

This is our account of the first hours of this ordeal; the rest, the local and national directives that have been published in quick succession and that keep being fine-tuned hour by hour, is well known to all of us. From the creation of the “red zone” in Lodi, later extended to the entire Lombardy area, to the strict quarantine measures required across the entire Region (DPCM 21 February, 8 March and 11 March, respectively).

Since the spike in the infection rate has started (as we write there has been no inversion in this trend, and we wait for it anxiously) our Hospital in Lodi has undergone a complete overhaul and its re-structuring has been used as a model by other institutes. On the 26th of February the “blue area” was created, with 18 hospital beds previously belonging to Neurology, to hold Covid+ patients necessitating ventilation; on the 28th the “yellow area” was opened, allowing for 37 additional beds for Covid+ patients without the need for ventilation or simply requiring oxygen therapy. On the 4th of March we opened an “orange area” (previously General Medicine) with 38 more beds; on the same date we started setting up a hemodialysis room devoted to patients positive to Covid+. On the 6th we opened, within Nephrology, a “red area” with 13 beds and a drywall-delimited space devoted exclusively to the dressing and undressing of healthcare personnel. On the 7th of March Covid+ pneumonia cases started being hospitalised in the Orthopedics Unit, under supervision of the surgeon.

Doctors and nurses have been assigned to any type of duty according to pressing and ever-changing needs, impossible to predict. At the helm, a multi-disciplinary team composed by the Directors of critical care, resuscitation, pneumology and infectiology and by a number of nurses; working closely with the Biochemical and Microbiology Labs, they constituted the Hospital’s Crisis Unit, gathered in a virtually permanent assembly. Everybody has been displaying a great sense self-sacrifice, working incredibly long shifts, often in silence. This same situation seems to repeat in most of Lombardy, but also in Veneto and in many other places.


Other cases

By looking at preliminary data, we clearly have yet to see the huge wave of hospitalizations described by initial projections (this, however, may change or might have already changed since I wrote this piece). Patients arriving from the “red zone” have been immediately treated with the utmost care and attention, and all necessary protections have been used both in local health care facilities and in hospitals. Those of them needing dialysis have been treated in a separate room, used exclusively to this purpose, and they have been closely monitored through anamnesis and the measuring of saturation and body temperature. Of the 18 tests administered to all patients who had been in contact with the first Covid+ case deceased at S. Anna Hospital only 3 turned out positive (about 15%); the rate is actually unexpectedly good, although in the present situation it is very difficult to make any statements with an acceptable degree of confidence.

As I write, there are 7 dialytic patients who resulted positive to SARS-CoV-2, although this number is certainly destined to go up; as we have a total of 162 patients in hemodialysis or peritoneal dialysis, the current number of infections accounts for around 4%. In addition to the case described above, where the patient was initially in good conditions but presented several comorbidities, 2 more have died. An 84-year-old patient, also with many underlying conditions, that had been hospitalized for other reasons but started testing positive during his hospital stay; X-rays showed signs of pneumonia, to be added to a recent diagnosis of pulmonary neoplasms. Then a female patient with stage 5 kidney disease who was not in dialysis but presented severe cardiac problems. She also caught the infection during the hospital stay; palliative care was the only viable option, as general conditions were already heavily compromised.

In the table below we try to summarise the clinical characteristics and outcomes of the patients who tested positive to the virus, while we wait to be able to collect and publish more precise data.


Table I: Clinical characteristics and outcomes of patients positive to the virus


Addendum and conclusions

We have been the first to be hit by the epidemic and, as such, we have also been the first to put in place stringent protocols and regulations. Although we have been doing our absolute best, there is sometimes a mismatch between the regulations and the actual situation on the ground. Until now, all nurses have been using FFP2 masks, counted and distributed at the beginning of the shift. Nurses assisting the dialysis of patients that are not confirmed cases wear single use garments and, in one of the two centers in the “red area”, also a waterproof vest. All nurses wear a hat and, since the FFP2 mask can be an obstacle to the use of the visor, we have equipped each room with goggles that are sanitized with 70% alcohol at the end of each shift. Leaving aside the FFP2 mask and the waterproof vest, these are for the most part standard sanitary measures.

Patients, on the other hand, wear a chirurgical mask that is changed at the beginning of each new shift. Most of them also use it during transportation, although it is probably the same one they were given the night before. While waiting, all patients are invited to stand at least a meter apart from each other and wash thoroughly their hands and the arm where the vascular access is located.

To date, at our Hospital in Lodi, patients testing positive to the virus and showing symptoms are treated in one of the following ways (as decided by the multidisciplinary team we have previously described):

  1. If invasive ventilation is needed, they are transferred to Intensive Care, where CRRT or hemodialysis is started immediately; a portable osmosis filtration system is also available.
  2. If non-invasive ventilation is needed, they are transferred to the “yellow area”, where CPAP is available, as well as water filtration systems.
  3. Regardless of ventilation needs they can also be assigned to the “red area” created within our Nephrology, where we have 3 rooms with 3 beds each that have also been fitted with systems to filtrate water.

We have very recently implemented a new water management system that allows for two patients to undergo dialysis at the same time. Together with the system available in the yellow area, which caters for one patient at the time, is therefore possible to dialyse 3 patients at the time, maintaining the ratio between nurses and patients to 1:3.

If the patient is a suspected case but has no symptoms, the hemodialysis can be carried out in a hospital room specifically set up for this purpose. It now has 2 beds that could easily become 6 with very minor changes to the set-up.

All considered, the system we have put in place seems currently up to the task. However, as the epidemiological landscape keeps changing, this evaluation could suddenly turn out to be wrong.

Managing patients in dialysis and with kidney transplant infected with Covid-19


We are in the midst of a health emergency that is totally new for us all and that requires a concerted effort, especially when it comes to safeguarding patients on hemodialysis, and kidney transplant recipients. Brescia is currently a very active cluster of infections (2918 cases on the 17/03/2020), second only to Bergamo. The way our structure is organised has allowed us to treat nephropathic patients directly within the Nephrology Unit, following of course a great deal of reshuffling; at the moment, we are treating 21 transplanted patients and 17 on hemodialysis. This has led us to adopt a systematic approach to handling this emergency, not only in managing inpatients, but also in researching the
new disease. Our approach is mirrored in the guidelines attached to this article, originally intended for internal use only but potentially very useful to our colleagues, as they face the same exact problems.
We have also started collecting data on our positive patients with the aim of understanding better the functioning of this disease and how best to manage it. If anyone is interested, we ask you to please get in touch with us, so we can coordinate our efforts.


Keywords: Covid-19, Brescia, nephrology, dialysis, transplants, guidelines

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L’epidemia da Covid-19 in Lombardia richiede la messa a punto di un protocollo nei pazienti nefropatici, in particolare nei pazienti in trattamento dialitico e in quelli portatori di trapianto renale.

Recentemente, il China CDC ha pubblicato la più ampia casistica di Covid-19, che includeva 44672 casi; da questo studio emerge una mortalità totale del 2.3%. I fattori di rischio principali sembrano essere, oltre all’età (mortalità dell’1.3% nella fascia 50-59, 3.6% nella fascia 60-69, 8% nella fascia 70-79 e 14.8% nella fascia ≥80 anni), la presenza di malattie cardiovascolari (mortalità 10.5%), diabete (mortalità 7.3%), malattie respiratorie croniche (mortalità 6.3%), ipertensione arteriosa (mortalità 6%) e neoplasie (mortalità 5.6%) [1,2]. Nella regione Lombardia, tuttavia, la malattia sembra avere una mortalità decisamente maggiore di quella riportata in Cina, e questo deve indurci a studiare con attenzione tutti i fattori potenzialmente responsabili di questo andamento.

Le comorbidità associate ad aumentata mortalità in corso d’infezione da Covid-19 sono molto frequenti nei pazienti affetti da Insufficienza Renale Cronica (IRC) e nei pazienti in corso di terapia sostitutiva della funzione renale mediante emodialisi. Non esistono inoltre, al momento, dati solidi sui pazienti Covid-19 positivi in trattamento dialitico e nei portatori di trapianto di rene in cui, oltre ai vari fattori di rischio cardiovascolare, esiste una condizione di ridotta immunocompetenza.


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