The purpose of NG176 is to maximise the safety of adults with chronic kidney disease during the COVID-19 pandemic, to protect staff from infection and to make the best use of available resources during the pandemic.
The guideline offers advice on what should be either stopped or started during the pandemic though healthcare staff need to use the guidance in conjunction with any other professional guidelines, standards and relevant laws in line with advice on decision-making when using NICE guidance.
Patient communication and minimising infection risk
NG176 discusses the importance of communicating with patients, their families and carers to support their mental wellbeing during the COVID-19 pandemic to alleviate any anxieties or concerns they might have about the virus. The guideline suggests signposting patients to relevant sources of information such as Kidney Care UK coronavirus guidance, the National Kidney Federation, any local kidney patient organisations and the UK government guidance mental health and wellbeing aspects of COVID-19.
NG176 advises staff to remind patients who have received a letter from the government to follow advice on shielding and that their risk may change over time based on advice from either primary care teams or their specialist kidney units.
For those with booked appointments, it is recommended that they do not to stop any current medicines unless advised to do so and to maintain a current list of treatments if they require treatment for COVID-19. Where patients have been advised to self-isolate, they should follow the government stay at home advice for anyone with possible coronavirus infection.
NG176 advises on the need to minimise face-to-face consultations and to make use of either telephone or video instead or to contact patients via email or text messaging and to issue electronic rather than paper prescriptions. It is also recommended that teams explore alternative delivery routes for prescriptions and medicines such as pharmacy delivery services, via the post, using NHS volunteers or drive through medicine pick-up points.
Patients should be advised to contact both their renal teams and the NHS111 online coronavirus service if they believe that they are infected with COVID-19, but if seriously ill to contact emergency services.
In cases where patients are required to attend for blood tests, they should attempt to reduce the risk of contracting COVID-19 by following the relevant advice on social distancing, attending appointments alone or with only one other and to avoid public transport if possible but if this is unavoidable to wear face covering. If face-to-face appointments are necessary, staff should minimise the time patients spend in the waiting area through careful scheduling of appointments, discouraging early attendance and by asking patients to remain in their transport vehicle until they receive a text message informing them that they are ready to be seen. NG176 strongly recommends a “clean route” through the hospital and that treatments and prescriptions are delivered and dispensed rapidly.
Managing the underlying condition in patients known or suspected of having COVID-19
Where a patient is known or suspected of having COVID-19, NG176 advises staff to follow the UK government guidance on infection prevention and control. However, if COVID-19 is detected at a later stage and the patient was not initially isolated, the NG176 suggests following the UK government guidance on the management of exposed healthcare workers and patients.
In contrast, if a patient not known to be infected displays COVID-19 symptoms when first presenting, NG176 advises staff to follow the UK government guidance on investigation and initial clinical management of possible cases.
Managing chronic kidney disease (CKD)
Changes to usual care
NG176 recommends specialist centres modify usual care to reduce patient exposure to COVID-19 and to make best use of available resources. Any modification to a patient’s treatment should be undertaken by a multi-disciplinary team and in light of clinical circumstances and any relevant preferences and the reasoning behind the changes fully documented. The risks and benefits of any changes to treatment or care should be fully discussed with the patient.
NG176 recommends that patients continue with all current medicines unless or until, advised to do so by a member of their specialist team and this includes patients with COVID-19 infection. The guideline notes advice from the Renal Association UK that ACE inhibitors and angiotensin receptor blockers can be continued. Moreover, NG176 signposts healthcare staff to advice from the Renal Association on the use of immunosuppressive therapy for autoimmune conditions.
It is advised in NG176 that staff review current medication taken by those with CKD, irrespective of COVID-19 status to determine whether any of their treatments have an adverse effect on renal function.
Monitoring of those with CKD
For those who have recovered from COVID-19 infection, NG176 recommends that renal function is reassessed and that the urgency of this assessment is prioritised based on glomerular filtration rate (GFR) category, relevant comorbidities and clinical circumstances.
Where patients are deemed to be stable, the frequency of routine blood & urine tests can be reduced during the pandemic though any decisions should also consider if the patient’s CKD is progressive. Healthcare staff are advised to refer to the NICE guidance on chronic kidney disease for further information.
Self-monitoring and self-management (for example, blood pressure) with appropriate advice on safety netting is encouraged in NG176 as is a recommendation that patients should access their medical data via PatientView.
Referrals to renal services
NG176 recommends that non-urgent referrals to specialist services are delayed, for example, if the patient has only mild to moderate proteinuria and a stable GFR. However, the guidance makes clear that referrals should continue in cases where:
- The patient has accelerated progression of CKD defined by a sustained decrease in GFR of 25% of more and a change of GFR category within 12 months or a sustained decrease in GFR of 15ml/min/1.73m2 per year.
- Nephrotic syndrome or very severe proteinuria (urinary ACR > 300mg/mmol)
- A new diagnosis of GFR category G5 (that is, GFR < 15ml/min/1.73m2).
It is advisable to contact the renal team via telephone or virtually if there is any uncertainty about the need for an urgent outpatient referral.
It is recommended that renal ultrasounds are delayed if the result is unlikely to lead to immediate changes to management. For instance:
- where the patient has a family history of polycystic kidney disease and that ultrasound is required to exclude this disease
- if the patient has a GFR < 30ml/min/17.3m2 (GFR category G4 or G5) that has been stable for at least six months
- where a nephrologist has identified that the patient has a non-urgent renal biopsy.
However, NG176 suggest that patients SHOULD be referred for renal ultrasound where:
- They have an accelerated progression of CKD
- Visible or persistent invisible haematuria
- Symptoms of urinary tract obstruction.
NG176 advises that where staff are considering a hospital admission, they consider:
- The patient’s preferences and the severity of the CKD and associated comorbidities
- Whether the patient is taking any immunosuppressants
- The relative risks and benefits of an admission compared with the care that can be provided at home.
Advanced chronic kidney disease
For a patient starting dialysis, NG176 advises that staff continue to plan for this, for example, to perform procedures to create vascular and peritoneal access but to also consider whether it is safe to delay dialysis during the pandemic. It is also advised that referrals continue for patients who require transplantation but explain how some tests and assessments might be delayed due to the pandemic.
NG176 makes clear that all patients with advanced CKD are given the opportunity to participate in care planning and that all decisions and discussions are fully documented.
NG176 proposes that all NHS staff involved in all aspects of patient care (including receiving, assessing and caring) who have known/suspected COVID-19 infection, follow the UK government guidance for infection prevention and control.
In cases where staff are known/suspected of having COVID-19, or live in a household where another person is known/suspected of having the virus, they should self-isolate and only return to work in accordance with the UK government guidance on stay at home for households with possible COVID-19 infection.
If self-isolating staff are still able to work, recommended roles include undertaking telephone or video consultations and participation in virtual multidisciplinary meetings, helping to identify patients who can be monitored remotely and those who might require more support as well as performing any routine tasks which can be done remotely.
NG176 is available online and interested readers should check this version for further updates.