Hemodialysis shake-up on the front lines of the Covid-19 pandemic: the Treviglio Hospital experience


The new coronavirus disease (Covid-19) pandemic in Italy formally started on 21st February 2020, when a 38-years old man was established as the first Italian citizen with Covid-19 in Codogno, Lombardy region. In a few days, the deadly coronavirus swept beyond expectations across the city of Bergamo and its province, claiming thousands of lives and putting the hospital in Treviglio under considerable strain.

Since designated Covid-dialysis hospitals to centrally manage infected hemodialysis patients were not set up in the epidemic areas, we arranged to treat all our patients. We describe the multiple strategies we had to implement fast to prevent/control Covid-19 infection and spread resources in our Dialysis Unit during the first surge of the pandemic in one of the worst-hit areas in Italy. The recommendations provided by existing guidelines and colleagues with significant experience in dealing with Covid-19 were combined with the practical judgement of our dialysis clinicians, nurses and nurse’s aides.

KEYWORDS: COVID-19, hemodialysis, end-stage kidney disease, coronavirus, pandemic.


Since December 2019, an outbreak of new coronavirus disease (Covid-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has developed into a global pandemic [1]. Its outburst in Italy officially dates back to February 21st, 2020. In a few days, the number of detected cases increased beyond expectations [2]. The deadly coronavirus swept across the city of Bergamo and its province, claiming thousands of lives and putting the hospital in Treviglio under considerable strain; all departments had to be readapted and most beds were rapidly occupied by infected patients.

Droplet spread and close contact are the main routes of Covid-19 transmission [3]. Hemodialysis centers have an exceptionally high risk of infection exposure due to patients’ recurring attendance at the facilities, physical proximity and several times a week mobility; their co-morbidities and suppressed immunity enhance the risk of infection further, endangering the staff unit in close contact [4]. Since designated Covid-dialysis hospitals to centrally manage infected hemodialysis patients were not set up in our area, we had to implement local strategies to prevent/control the infection and spread resources during the emergency from February to May 2020, in one of the worst-hit areas in Italy. We took into account the Institute of Medicine definition of ‘crisis surge’ that states “Adaptive spaces, staff, and supplies are not consistent with usual standards of care, but provide sufficiency of care in the setting of a catastrophic disaster (i.e., provide the best possible care to patients given the circumstances and resources available). Crisis capacity activation constitutes a significant adjustment to standards of care.” [5]. The recommendations provided by guidelines and colleagues with significant experience in dealing with Covid-19 [6-9] were combined with our staff’s practical judgement (Table I).

Area management

Avoid crossing areas

Create staff filter zones

Create a check-in area to welcome and screen patients

Create different paths for patients

Dialyze patients in separate hemodialysis rooms or group them in a proper area

Apply environmental cleaning and disinfection of the areas

Management of healthcare team members

Educate staff

Avoid cluster activities

Screen and protect staff

Cohort manpower

Use PPE judiciously

Implement contingency plans

Work with local Covid-19 Response Team to apply best practice changes

Management of hemodialysis patients

Screen patients

Educate patients

Create an environment where patients feel safe

Table I: Our guiding principles for the Covid-19 outburst

Area management

The usual entry to the dialysis center gave access to a large waiting room, where patients used to meet before entering the aisle and reach their changing rooms. Hence this zone was closed to avoid movement across different areas and a new outside entrance was established directly from the outdoor parking. Team members wore personal protective equipment (PPE) in a tiny passage which became the filter zone to enter the hemodialysis area. Stable patients waited outside the facility in their private vehicle/ambulance or standing in line keeping proper distances. Patients with symptoms or those who had had contact with Covid-19 infected people were asked to inform the staff by phone before arrival, so we could be prepared to anticipate their entrance. Accompanying people, including ambulance personnel and relatives, were not allowed to enter the center, being potential vectors of the disease. A check-in was set up at the entrance to welcome patients one-by-one, require them to use hand sanitizer, wear supplied surgical face mask and gloves, take the temperature with a temperature gun and ask about their epidemiologic contact history and state of health, with a focus on fever, cough, dyspnoea, rhinorrhoea, conjunctivitis, diarrhoea. According to their medical status, they were accompanied one-by-one to distinct changing and waiting rooms, equipped with given numbered lockers and well-spaced armchairs to avoid gatherings; patients with mild symptoms were screened one-by-one in a dedicated room, whereas those with dyspnoea and signs of organ dysfunction were referred to the emergency ward. Hospitalized hemodialysis patients were accompanied to the facility by dedicated paths according to their infection status. Separate hemodialysis rooms, with separate access serving as both entrance and exit, were used for suspected or confirmed Covid-19 patients; early in the pandemic, our dialysis operating room was turned into a two-bed Covid-19 room, but as the epidemic spread, infected patients were clustered in a designated seven-bed room. In our dialysis facility in Romano di Lombardia a separate room was not available, thus patients were grouped during the same shift at the end-of row stations, away from the main flow and spaced from the others in all directions. Assigned healthcare teams entered the isolation room/cohort area. Staff members took off PPE in a dedicated zone before getting out of the hemodialysis area. Environmental cleaning and disinfection of the areas were carried out at the end of each shift by personnel equipped with PPE. The medical waste from suspected or confirmed Covid-19 patients was considered as infectious material and disposed of accordingly. Uremic critical patients with Covid-19 were treated separately by dedicated portable reverse osmosis systems in the Covid-19 Sub-Intensive Care Unit.

During the pandemic, almost all operating rooms were converted into Intensive Care Units and creation/revision of arteriovenous fistulas became impracticable. We quickly replaced short term in use hemodialysis central venous catheters (CVC) with tunnelled ones. A designated room was identified at the Department of Interventional Cardiology for catheters placement in non-infected patients. Covid-19 infected patients who needed CVC placement were managed in dedicated areas. During the first surge of the pandemic, we observed only two arteriovenous fistula thrombosis; they occurred in two infected patients a few hours before their died.

Management of healthcare team members

Dialysis physicians, nurses and nurse’s aides received instructions in SARS-CoV-2 infection prevention and control. Nurses were trained to take nasopharynx swabs for Covid-19 polymerase chain reaction. Cluster activities (i.e., large shifts, group studies, patient discussion, coffee breaks) were cancelled; when gathering was essential, it was mandatory to wear protective equipment. Staff members were required to take body temperature at the beginning of their shift and inform the team leader. If the body temperature was ≥ 37.5°C, they were suspended from duty and examined by nasopharynx swabs and chest x-ray; they could return to work only after the evaluations proved negative. Hand hygiene was strictly implemented. Hemodialysis staff wore appropriate PPE putting on filtering face piece (FFP2) masks, goggles or shields, hats, gloves, long-sleeved waterproof isolation clothing, shoe covers during check-in, nasopharynx swab collection and hemodialysis sessions. Manpower was divided in separate teams for the management of suspected or confirmed COVID-19 and non-infected patients. We established policies to optimize PPE use, as these precious resources had to be deployed for many weeks: only the minimum required team entered the hemodialysis restricted area and all non-scheduled colleagues were excluded; patients were grouped according to their infective status in order to plan full shifts; reusable shields and goggles were cleaned and disinfected. Contingency plans were continuously implemented as Covid-19 infections curtailed the staff available to dialyse patients; the shortage of qualified personnel was due to illness. Physicians communicated daily with the local Covid-19 Response Team to apply best practice changes.

Healthcare workers experience severe emotional stress on the front lines of a pandemic, knowing that some of them might die. The Impact of Events Scale-Revised (IES-R) [10] and the Hospital Anxiety and Depression Scale (HADS) [11-13] were administered to assess their psychological impact and immediate stress. Of the 40 renal healthcare staff members who were on duty during the Covid-19 outbreak, 14 completed the survey. The total response rate was 35.0%. The response rates stratified by employment group were as follows: doctor, 57.1% (100% of total medical staff); nurse’s aide, 7.1% (50% of total nurse’s aide staff); nurse, 35.8% (17% of total nurse staff). The mean IES-R score was 30.50 ± 17.02; of all responders, 6 (42.8%) received a score of 33 or higher, indicating the presence of PTSD (post-traumatic stress disorder). In the HADS 7 staff members (50.0%) scored 8 or above on the anxiety item and 5 (35.7%) scored 8 or above on the depression item (Table II). Prompt psychological help was provided as needed.


Employment role

(1=nurse’s aide;

2= nurse; 3=doctor)

HADS D (cut-off >8)

HADS A (cut-off >8)


(cut-off >=33)

IES-R Intrusion





IES-R Hyperarousal


1 1 14* 14* 44* 2.33 2.00 1.71
2 2 7 7 19 0.57 1.25 0.71
3 2 7 10* 27 1.14 1.13 1.43
4 2 5 7 18 0.71 0.88 0.86
5 2 10* 12* 36* 2.00 0.88 2.14
6 2 11* 13* 55* 2.43 2.63 2.43
7 3 7 5 10 0.71 0.50 0.14
8 3 11* 15* 53* 3.14 1.88 2.29
9 3 3 4 20 1.57 0.63 0.57
10 3 12* 16* 59* 3.57 2.04 2.57
11 3 7 6 15 0.57 0.88 0.57
12 3 1 4 10 0.57 0.75 0.00
13 3 8 11* 39* 2.00 1.50 1.86
14 3 5 9 22 1.43 0.50 1.14

7.71 9.50 30.50 1.62 1.24 1.31
(3.60) (4.11) (17.02) (0.99) (0.66) (0.86)
Table II: IES-R and HADS measurements in renal healthcare staff members

Our infection rates were 12.5% for medical staff (1 out of 8), 20% for nurses (6 out of 30) and 50% for nurse’s aides (1 out of 2); most infections and subsequent absences from duty occurred in March 2020. Nobody needed hospitalization and everyone had a benign course.

Management of hemodialysis patients

We drew up a triaging plan to identify infected patients before they entered the treatment area. Subjects with signs and symptoms (fever, cough, dyspnoea, rhinorrhoea, conjunctivitis or diarrhoea) or those who had had contact with the new coronavirus infected people were asked to inform staff by phone to anticipate their arrival. Stable patients waited in the outdoor parking. They were welcomed and screened one-by-one by staff members at the new entry, as described in detail above. According to their medical status, patients were accompanied one by one to distinct changing and waiting rooms, equipped with given numbered lockers. We had two available changing rooms: one was dedicated to asymptomatic patients, the other to infected ones. The latter was also outfitted as waiting room for infected patients with suitably spaced armchairs. While time-consuming, the procedure allowed to avoid moving across areas and increased safety; Collective Patient Transport personnel was very cooperative in managing travel management despite some delay.

In absence of positive finding, the patient proceeded to normal dialysis treatment. If an abnormal body temperature (≥ 37.5°C) or any signs and symptoms or contact history were detected, the patient was screened for Covid-19 in a dedicated room and submitted to nasopharyngeal swab, thoracic X-ray, and biochemical determinations. If the first swab came back negative but thoracic X-ray and clinical criteria were highly suspected for Covid-19, patients were treated as if they were infected and re-examined for SARS-CoV-2 nucleic acid [14]; most of them turned out positive. Patients with dyspnoea and signs of organ dysfunction were referred to the emergency ward. If Covid-19 was excluded, the patient came back for routine dialysis. Patients with suspected or confirmed Covid-19 were clustered in designated hemodialysis rooms or grouped during the same shift at the end-of row stations.

During the dialysis session, nurses provided education on keeping social distances, coughing and sneezing etiquette, how to use face masks, how to dispose of contaminated items, and how and when to perform hand hygiene. Patient snack time during the session was cancelled.

Discontinuation of isolation was determined on a case-by-case basis, depending on the resolution of the symptoms, imaging improvement (thoracic x-ray and/or computed tomography) and the detection of two consecutive negative nasopharynx swabs.

The world pandemic created concern in many hemodialysis patients. Hence, IES-R [10] and HADS [11-13] were administered to assess their psychological impact and immediate stress. Of the 130 hemodialysis patients, 29 completed the survey. The total response rate was 22.3% (13 female and 16 male). The mean IES-R score was 26.93 ± 17.61; of all responders, 10 (34.4%) received a score of 33 or higher, indicating the presence of PTSD (post-traumatic stress disorder). In the HADS, 5 patients (17.2%) scored 8 or above on the anxiety item and 4 (13.7%) scored 8 or above on the depression item (Table III). Psychological help was provided as needed by phone or appropriate electronic means.





(1=Male; 2=Female)

HADS Depression (cut-off >8) HADS Anxiety (cut-off >8) IES-R     (cut-off >=33)




IES_R Avoidance


IES-R Hyperarousal


1 75 2 3 4 15 0.75 0.57 0.67
2 67 1 0 1 25 0.75 1.88 0.67
3 56 1 1 2 23 0.88 1.25 1.00
4 76 2 12* 8 53* 2.38 2.13 2.83
5 79 2 16* 15* 58* 3.00 2.00 3.00
6 49 1 4 4 18 1.13 0.88 0.33
7 30 2 15* 14* 59* 2.50 2.38 3.33
8 57 1 2 4 20 0.75 0.88 1,17
9 67 1 6 5 34* 1.63 1.75 1.17
10 81 1 1 2 12 0.75 0,75 0.00
11 51 1 6 4 27 1.58 1.00 1.00
12 68 2 1 2 14 1.00 0.29 0.67
13 61 2 5 1 20 0.50 1.25 0.83
14 71 2 7 8 54* 0.63 0.50 0.17
15 74 1 2 5 20 3.00 1.88 2.33
16 49 2 3 3 36* 1.50 0.63 0.50
17 49 2 3 4 18 3.38 2.04 2.67
18 81 1 2 3 17 0.50 0.88 0.67
19 75 1 7 8 21 0.75 0.88 1.17
20 62 2 10* 12* 57* 2.75 2.50 2.00
21 54 1 7 8 55* 1.25 0.38 1.17
22 64 2 1 1 8 1.00 1.13 1.67
23 52 2 3 7 19 0.75 0.88 0.83
24 69 1 7 14* 37* 2.29 2.00 1.67
25 89 1 5 5 0 1.75 0.88 2.50
26 67 1 0 3 20 0.50 0.75 0.00
27 38 2 4 10* 34* 2.38 2.63 2.50
28 68 1 1 0 7 2.00 1.50 1.83
29 73 1 0 0 0 1.38 0.50 1.17

Mean 63.86
4.62 5.41 26.93 1.49 1.27 1.36
(SD) (13.59)
(4.26) (4.28) (17.61) (0.87) (0.69) (0.94)
Table III: IES-R and HADS measurements in hemodialysis patients

Covid-19 was diagnosed from 10th to 30th March 2020 in 23 people out of a population of 130 hemodialysis patients (infection rate 17.6%, mean age 68±14 years, dialysis vintage 52±47 months, 14 male and 9 female). Infected patients’ hospitalization rate was 61%. Seven patients died (mean age 71±10 years, 6 male and 1 female); at the initial presentation of the disease, their White Blood Cells Count (6.5±2.1 vs 4.9±1.6 103/mcL, p<0.05), Neutrophils (80.9±8.8 vs 69.9±13.7 %, p < 0.05) and C-reactive Protein level (153.9±57.9 vs 47.5±49.4 mg/L, p<0.05), tested by Student’s t-test for paired data, were significantly higher than in recovered Covid-19 patients. Detailed data are provided in Table IV.





(1=Male; 2=Female)

Dialysis vintage (months) Presenting symptoms/signs


(x-ray or CT scan)

Laboratory Findings Treatment Hospitalization


(1=death; 2=recovery)

Fever Cough Dyspnea GI Myalgia





D-dimer (ng/ml)



Antiviral HCQ LMWH
1 60 1 24 X
X 5.7 87.7
118.6 X X
X 1
2 84 1 28 X X

X 7.6 70.0
128.1 X

X 1
3 84 1 26 X

X 9.1 76.4

X 1
4 60 2 65 X X

X 3.7 73.8 651 90.1 X X
X 1
5 84 2 26 X X

X 3.5 73.7 6122 90
X 2
6 60 1 2 X

3.6 50.6 578 28.4
X 2
7 69 1 57 X

X 6.4 82.3 2006 255.7 X X
X 1
8 73 2 37 X

X 2.3 58.4

9 65 1 55 X

4.9 72.2 306 10.5

10 65 1 210 X

X 4.3 80.0 859 124.5 X X
X 1
11 83 1 138 X

X 3.1 70.6 1720 14.2
12 61 2 8 X

X 7.3 88.5 3835 40.4 X X
X 2
13 74 1 68 X

X 5.8 82.9 1838 77.8

X X 2
14 82 2 73 X

X 5.8 38.7 1012 6.4

15 78 1 8 X

X 9.2 96.1 20000 153 X X
X 1
16 37 2 45 X

X X 4.6 59.6 1356 2.9
17 76 1 21 X

X 4.4 88.8 2016 87.7

18 47 2 58 X

5.7 69.2 1083 23.2
19 66 1 106 X

X 3.0 67.7 4715 84.3
X X X 2
20 86 1 5 X

X 8.4 86.2 1620 194.2

X X 2
21 73 1 38 X

6.5 65.5 1027 21.5
22 38 2 73 X

X 4.6 68.1 481 36.9
23 67 2 26 X

X 5.3 78 1002 15

X X 2
Table IV: Clinical features of hemodialysis patients with Covid-19 infection in order of disease onset
Abbreviations: GI: gastrointestinal symptoms; WBC: white blood cells count; N: neutrophils; CRP: C-reactive Protein; Antiviral: lopinavir/ritonavir; HCQ: hydroxychloroquine; LMWH: low molecular weight heparin.

Home hemodialysis and peritoneal dialysis

Patients continued the treatment at home using electronic systems for clinical management. None of them (21 patients on peritoneal dialysis and 3 on home hemodialysis) developed symptomatic infection.


COVID-19 is a major global human threat that has turned into a pandemic. Being prepared for a surge of patients, suspected or confirmed, is crucial to minimize the risk for other patients and personnel taking care of them. We are currently facing a new, bigger wave; cases are surging mainly in other provinces and our hospital is supporting them.

The best reward. Courtesy of Simona Zerbi


The author thanks all the nurses and nurse’s aides of their Dialysis Centres of Treviglio Hospital and Romano di Lombardia Hospital for their suggestions and invaluable effort.

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Influenza da Covid-19 e impatto sui pazienti con nefropatia: l’esperienza del Centro di Piacenza


Roberto Scarpioni e colleghi riportano qui in breve l’esperienza del Centro di Nefrologia e Dialisi dell’Ospedale “Guglielmo da Saliceto” di Piacenza in questo difficile momento, che vede tutti ancora impegnati nella prevenzione e nel fronteggiare una situazione clinica correlata all’infezione da Covid-19, difficile da sostenere. A causa del forte afflusso di pazienti dalla zona rossa del basso lodigiano, a soli 15 Km di distanza, l’Ospedale di Piacenza si è trovato a fronteggiare un’escalation di pazienti con diagnosi di Covid-19. Gli autori descrivono la riorganizzazione del reparto di Nefrologia e i presidi utilizzati per contenere l’infezione tra i pazienti in emodialisi, soprattutto. Riportano anche le informazioni disponibili al 25/03/2020 sui pazienti positivi al virus, e sul tasso di mortalità, purtroppo molto elevato. Lo fanno sperando che sia di utilità per chi non è stato per fortuna ancora travolto dall’infezione come è accaduto in Emilia, Lombardia, Veneto, Marche ed altre zone.

Parole chiave: Covid-19, coronavirus, malattia renale, dialisi, nefrologia, Piacenza, Emilia Romagna

Il 31 dicembre 2019 è stato segnalato un focolaio di episodi di polmonite ad eziologia sconosciuta presso la città cinese di Wuhan; successivamente è stato identificato da ricercatori cinesi (China CDC) l’agente eziologico di questa infezione, un nuovo coronavirus denominato SARS-CoV-2 o Covid-19 [1]. Un mese dopo, il 31 gennaio, sono stati individuati e trattati in Italia i primi pazienti con infezione da Covid-19, due turisti Cinesi dalla città di Wuhan in vacanza a Roma. Il 21 febbraio primo paziente italiano con malattia da Covid-19 è stato ricoverato l’Ospedale di Codogno (Lodi), a soli 15 km di distanza da Piacenza [2]. Nelle settimane successive si è assistito a una crescita esponenziale dei casi di infezione da Covid-19 nel nostro Paese. L’Italia è, in queste ore, il Paese più colpito a livello globale dalla pandemia dopo la Repubblica Popolare Cinese, con 57.521 casi accertati; di questi, più di 8.256 nella sola Emilia Romagna, ove 1.077 pazienti sono deceduti e 721 sono stati dichiarati guariti [3].

Riportiamo qui in breve l’esperienza del Centro di Nefrologia e Dialisi in questo difficile momento, che vede tutti ancora impegnati tanto nella prevenzione che nel fronteggiare una situazione clinica difficile da sostenere. Speriamo che possa essere di utilità in chi, per fortuna, non è ancora stato travolto dall’onda dell’infezione come è accaduto in Emilia e in Lombardia. A causa del forte afflusso di pazienti dalla zona rossa del basso lodigiano, a soli 15 Km da Piacenza, nei giorni seguenti la chiusura dell’Ospedale di Codogno, l’Ospedale di Piacenza si è trovato a fronteggiare un’escalation di pazienti afferenti in pronto soccorso con diagnosi di Covid-19 (vedi Fig. 1).


Fig. 1: Accesso al pronto soccorso per polmonite-Covid-19


Nei giorni successivi abbiamo assistito a un esponenziale incremento del numero di pazienti nefropatici con infezione da Covid-19, che ci ha imposto di adottare rigide misure per contenere l’infezione tra i nostri pazienti ambulatoriali che accedevano direttamente al Centro per eseguire l’emodialisi. A partire dalla 3a e 4a giornata abbiamo autonomamente adottato delle misure di contenimento del virus sia tra i pazienti che tra il personale sanitario. Alla data odierna (25/03/2020), nessun medico è per fortuna stato trovato positivo, mentre tre infermieri positivi per contatto sono attualmente in isolamento al domicilio, per fortuna in buone condizioni.

I pazienti, accolti prima dell’ingresso in reparto con la misurazione della temperatura corporea, venivano invitati a indossare mascherine, lavarsi le mani con amuchina o soluzione alcolica e sostituire gli abiti e le calzature. Il personale indossava maschere sul volto, visiere e guanti, e disinfettava le sale e gli apparecchi prima di ogni turno [4].

Inizialmente i pazienti in emodialisi cronica sono stati trattati presso i reparti di ricovero con metodiche CRRT (Continuous Renal Replacement Therapy) o con emofiltrazione ad alti volumi (6 L/ora), associate a membrane adsorbenti allo scopo di rimuovere endotossine oltre a citokine infiammatorie (IL-6); una sola infermiera ha gestito contemporaneamente due trattamenti, nella stessa stanza e con trasporti dedicati, al fine di isolare il più possibile l’eventuale contagio. Successivamente, visto che l’incremento del numero di pazienti positivi non ci ha più permesso la gestione in reparto, distante dalle sale dialisi, abbiamo ‘sacrificato’ una sala contumaciale dedicata a pazienti con documentata infezione. In attesa dei tamponi, tutti i pazienti sono stati trattati come potenzialmente infetti da un personale bardato con mascherine, occhiali, guanti e sovracamice. Svuotando le sale del materiale non indispensabile, i posti dialisi sono stati distanziati di almeno 1-1,5 m; tutto il personale è stato obbligato ad utilizzare maschere e cuffie e si sono evitate le riunioni al chiuso. Con non poche difficoltà è stato anche organizzato un percorso dedicato specificatamente per i pazienti Covid positivi, con trasporti dedicati, sanificati a fine trasporto.

Alla data in cui scrivo la triste fotografia dimostra come tanti pazienti nefropatici siano stati colpiti da infezione da Covid-19: 41 pazienti, il 16% dei pazienti in dialisi, di età media 73±11 anni e range 52-90 anni, 31M/10F, tutti di razza caucasica. La diagnosi è stata data dal tampone oro-rino-faringeo, quando disponibile, o dal quadro TAC polmonare (infiltrato interstiziale a vetro smerigliato diffuso con eventuali focolai confluenti). Paradossalmente, la quantità di pazienti contagiati a Piacenza è uguale a quella del Renmin Hospital di Wuhan (16%) [5], anche se vi è un bias dovuto al numero selezionato di tamponi, eseguiti nei primi giorni solo ai pazienti sintomatici.

Tutti i pazienti con insufficienza respiratoria e febbre sono stati trattati empiricamente con 5-OH-clorochina e terapia anti-retro virale, quando ritenuto opportuno dell’infettivologo. Purtroppo, il tasso di mortalità è stato assai elevato nei pazienti nefropatici, anziani e fragili per definizione, spesso con comorbidità associate. Al momento in cui scrivo la metà dei pazienti in emodialisi cronica colpiti dal virus sono deceduti, ben 18/41 (41% mortalità grezza a Piacenza) versus circa 10% dei decessi totali in Italia (3), un prezzo assolutamente inaccettabile e di molto maggiore rispetto ai soggetti non-nefropatici [6].

In merito ai pazienti domiciliari trapiantati (118 in totale) ed a quelli in dialisi peritoneale (34), che sono stati invitati a recarsi in ospedale il meno possibile, abbiamo attivato contatti telefonici pressoché quotidiani da parte dei medici ed infermieri dell’ambulatorio. Al momento contiamo 4 pazienti trapiantati affetti da Covid-19: due sono ricoverato presso il Centro trapianti a Bologna e gli altri due si trovano a domicilio, con stretto monitoraggio clinico anche per le interazioni farmacologiche tra la terapia empirica anti-retrovirale e quella immunomodulatrice (dove somministrata). Fortunatamente solo un paziente in dialisi peritoneale domiciliare è risultato positivo e prosegue la terapia domiciliare sotto stretto monitoraggio.

Ad oggi sono solo 5 i casi di insufficienza renale acuta (IRA) che hanno richiesto trattamento in Rianimazione con CRRT, tuttora in corso per 4 pazienti maschi di età media 60 anni e range 39-71, tutti con comorbidità; la nostra esperienza è in linea coi pochi dati in letteratura che indicano una percentuale di IRA Covid-correlate relativamente scarsa (<3%) [7].

La nostra pesante esperienza legata all’infezione da Covid-19 ci dimostra come le rigide misure di vestizione e precauzioni abbiano verosimilmente consentito di limitare i danni dal contagio, anche in considerazione dell’elevatissimo tasso di mortalità nei pazienti nefropatici. Siamo in attesa di verificare i punti ancora controversi, come il ruolo del blocco dell’enzima di conversione dell’angiotensina in pazienti con Covid-19 quale potenziale ipotetico recettore funzionale del virus [8, 9]. Siamo in attesa di sapere se l’utilizzo su ampie casistiche di farmaci immunomodulatori inibenti IL-6 quali il tocilizumab (usato nell’artrite reumatoide) possano ridurre la progressione dell’insufficienza respiratoria, inibendo la cascata infiammatoria; oppure se altri nuovi farmaci anti-virali, o persino un ipotetico vaccino, possano ridurre l’incidenza di infezione e migliorare la prognosi, ad oggi infausta in circa l’8-10%. Per il momento, tuttavia, dobbiamo puntare soprattutto sulla prevenzione dell’infezione da Covid-19; essa è tanto più imperativa per i nostri pazienti fragili con insufficienza renale ed elevatissimo rischio di mortalità, che sono purtroppo esposti al contagio dovendo venire in Centro tre volte la settimana. L’efficacia dell’isolamento è peraltro dimostrata dallo scarso numero di contagiati tra i pazienti a domicilio.



  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. https://doi.org/10.1056/NEJMoa2001017
  2. Carinci F. Covid-19: preparedness, decentralisation, and the hunt for patient zero. BMJ 2020; 368:bmj.m799. https://doi.org/10.1136/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. https://doi.org/10.1016/j.kint.2020.03.001
  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. https://doi.org/10.3760/cma.j.cn112137-20200229-00520
  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; https://doi.org/10.1056/NEJMoa2002032
  8. Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular System. Nat Rev Cardiol 2020; https://doi.org/10.1038/s41569-020-0360-5
  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. https://doi.org/10.1159/000507305