Key words : Coronavirus disease 2019, Kidney transplantation, SARS-CoV-2

Introduction

The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, has emerged as a global pandemic^1,2 with multifaceted repercussions worldwide, challenging the sustainability of national health systems. On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a pandemic,³ and it has become one of the deadliest pandemics.⁴ The burden of COVID-19 extends far beyond that of a contagious disease. COVID-19 has affected the entire health system through its direct effect as a communicable disease, as well as its ability to alter the overall mortality and burden of disease through impact on noncommunicable diseases.

The first 2 cases of the COVID-19 in the state of Gujarat, India were confirmed on March 19, 2020. Despite the implementation of a stringent nationwide lockdown on March 24, 2020, to halt the spread of disease, the cases crossed the mark of 2000 by mid-April and reached around 15 000 by the end of May 2020. From June 1, 2020, our state entered into a phase of gradual “unlockdown,” and there was a steep decline in the number of COVID-19 cases. In November 2020, a second peak of COVID-19 was witnessed in our state, with a rapid surge of COVID-19 cases. By December 2020, COVID-19 had infected around 88.2 million people, that is, around 0.1% of the Earth’s population. Gujrat had reported around 250 000 cases and 4300 deaths from COVID-19 by December 2020.⁵

The surge of COVID-19 has also affected the 850 million people with kidney-related ailments, including the 3.9 million on regular dialysis and the recipients of kidney transplant.⁶ The pandemic led to a shutdown of public and private transport, preventing patients from reaching dialysis centers⁷; the availability of consumables for hemodialysis and peritoneal dialysis and essential medicines was also affected. Regular outpatient services were suspended, and inpatient services were severely curtailed.

For this study, we aimed to analyze the effects of the COVID-19 pandemic on nephrology and transplant services and clinical training at our center. The present study is pertinent and timely considering the current pandemic scenario and the alarming growth in the number of cases in India as well as worldwide.

Materials and Methods

We conducted this prospective observational study at the Institute of Kidney Disease and Research Centre, Ahmedabad, India. Our institute is one of the largest tertiary care centers of its kind in Gujarat, with around 400 total inpatient beds for nephrology, urology, and transplant patients. More than 6000 renal transplants, which include both living donor and deceased donor transplants, have been conducted at our institute, with around 412 renal transplants done in 2019. Apart from transplant facilities, we have a well-equipped hemodialysis unit at our center and around 50 peripheral satellite dialysis units at district levels in civil hospitals and community health centers.

For the present study, we collected and analyzed monthly data on outpatients, inpatients, and number of patients undergoing renal transplant (both living and deceased donor) in 2019 and 2020. We also compared the number of procedures, like arterio­venous fistulas and renal biopsies, conducted in 2019 and 2020. We also analyzed the impact of the COVID-19 pandemic on various non-COVID-19-related health care facilities and clinical training at our institute. This study received approval from our ethics committee.

Results

Table 1 shows a comparison of data from before the pandemic to during the pandemic at our nephrology and transplant institute. Our hospital was converted into a dedicated COVID-19 hospital, with 200 beds assigned to COVID-19 patients during the COVID-19 peaks in April and November 2020. At our Institute, we routinely have general outpatient numbers (that is, nontransplant patients) of 9099 ± 650 patients per month and outpatient transplant numbers of 1853 ± 106 per month. In 2019, there was consistency in outpatient numbers until March 2020. This consistency was followed by a steep decline in general outpatients (5702 ± 1083) and transplant outpatients (822 ± 102) from April 2020 to June 2020 (Figure 1 and Figure 2), that is, almost reduced by 50% after the imposition of nationwide lockdown due to the COVID-19 pandemic. After the lockdown, from July 2020, the outpatient numbers gradually increased until October 2020. During the second COVID-19 peak (from November 2020), we again observed a drastic decline in general outpatients (6712 ± 80) and transplant outpatients (1214 ± 51). A similar pattern was observed in inpatient numbers, as shown in Figure 3. There was a consistent number of admissions from January 2019 to March 2020, with a decline in patients from April to June 2020 and then a gradual increase observed from July 2020 to October 2010. This gradual increase was followed by a reduction in number of outpatients (357 ± 52) from November 2020 until the present.

Among patients on regular follow-up, around 640 ± 80 patients per month utilized telemedicine services, including internet consultation, instant message tools, telephone consultation, and E-mail consultations, in order to communicate with their previous doctors. From April 2020 to December 2020, around 2030 transplant patients used our drug delivery system and received home delivery of drugs.

Apart from results to outpatient and inpatient departments, day care facilities like hemodialysis were also affected by the COVID-19 pandemic. In 2019, we had around 4541 ± 497 dialysis sessions per month, which was consistent with that shown from January to March 2020; however, these numbers were reduced (4041 ± 443) from April to June 2020 (Figure 4). The numbers increased from July 2020 to October 2020 but suddenly declined (4686 ± 160) during the second wave. Although there was a decrease in the number of patients undergoing hemodialysis at our institute, a substantial increase was observed in the number of patients undergoing hemodialysis at our satellite dialysis centers (Figure 5).

The COVID-19 pandemic had severely affected the number of patients undergoing living donor and deceased donor transplant procedures at our institute. In 2019, we were conducting roughly 33 ± 8 transplants per month. In 2020, during January and February, the rate of transplants was the same; however, in March, due to fear of COVID-19, we had a reduction in the numbers of both living donor and deceased donor transplants, with only 15 transplants conducted during March 2020. There was a further decline in the number of transplants, in concordance with spread of COVID-19 pandemic (Figure 6). From June 2020, when we restarted our transplant program, there was an increase in the number of transplants conducted from July 2020 to October 2020. From November 2020, the number of transplants dropped again (10.5 ± 7.6) due to the second COVID-19 wave.

A similar pattern was observed in various procedures, including arteriovenous fistulas and renal biopsies, at our center. In 2019, we performed around 140 ± 16 arteriovenous fistulas and 104 ± 22 renal biopsies. We observed a fall in the number of procedures from February 2020, with only 65 ± 45 arteriovenous fistulas and 22 ± 10 renal biopsies performed during April to June 2020 (Figure 7 and Figure 8). There was an increase in the number of procedures from July 2020 to October 2020, which was followed by a second decline from November 2020 (82 ± 15.5 arteriovenous fistulas and 16.5 ± 3.5 renal biopsies).

The COVID-19 pandemic had affected academic activities at our institute. In 2019, we had regular case discussions, seminars, and journal reviews, focused on both general nephrology and renal transplant. However, during the COVID pandemic, with more focus on health care, we only had online sessions pertaining to efficient management of the COVID-19 pandemic.

Discussion

The current COVID-19 pandemic has impacted health care systems and the way that health care practices are conducted in an unprecedented manner. Governments across the world have placed varying restrictions on the activity of populations to limit the spread of COVID-19. Similar restrictions were imposed in our state of Gujarat, India. One by-product of these emergency measures was a dramatic decline in the number of outpatients and inpatients, as patients from outside the city could not reach our center. Apart from government advisories on travel restrictions, we had fewer patients in the initial months of the COVID-19 pandemic, especially in April, due to shortages of masks, personal protective equipment kits, and sanitizers. A substantial decline was also seen in routine follow-up of transplant patients because of fear of getting exposed to COVID-19.

Although we could not provide direct consultations to patients, telemedicine was conducted with outpatients to determine and address their concerns, reducing their need to visit the hospital. With regard to changes in the COVID-19 era, telemedicine can play a crucial role to ensure patient follow-up. Telemedicine was legalized in India on March 25, 2020.⁸ Because patients can be remotely followed, better standards of medical care can be ensured, as well as simultaneously ensuring social distancing. At our institute, there were few patients who opted for telemedicine, as there was no established operative telemedicine unit at our institute. There is need of more involvement of physicians, institutional telemedicine units, and patient education to further increase its efficacy. The development of digital tools and the set-up of virtual clinics may be hugely beneficial to our health care system⁹; these measures could guarantee clinical care while minimizing physical gatherings at hospitals or clinics. In a study on follow-up care in patients with chronic kidney disease, Chen and colleagues¹⁰ found that routine medical care was disrupted during the pandemic and that telemedicine could be a reasonable alternative method. Apart from teleconsultation, we have developed a drug delivery system that ensured the timely delivery of drugs to transplant patients. In a developing country like India, a large number of patients depend on various government services for public health care; therefore, this system also decreased noncompliance among patients who could not purchase drugs from private medical stores.

From April 2020 onward during the COVID-19 pandemic, we found that the number of patients undergoing hemodialysis per month at our center had decreased compared with data from 2019. This reduction could be attributed to a large number of patients shifting to nearby satellite dialysis centers due to strict travel restrictions. Indeed, there was an increase in the number of patients undergoing hemodialysis at satellite dialysis units. This increase was also because private sector clinics were converted into COVID-19 centers; hence, patients undergoing maintenance hemodialysis at those centers were being directed to our satellite units. There is a lack of data describing the impact of COVID-19 on patients on hemodialysis from resource-limited countries. Arslan and colleagues¹¹ reported a lower COVID-19 incidence in patients on hemodialysis.

The COVID-19 pandemic has affected the whole chain of organ donation and transplantation. Kidney transplant services were suspended throughout our country as part of the suspension of all nonessential surgeries, as done in other countries.^12,13 This resulted in a decrease in the number of renal transplants conducted at our center. Apart from government guidelines, this lowered number of renal transplant could have been also because of fear of COVID-19 infection and the decline in social support. In a survey study, Vistoli and colleagues¹⁴ reported that, starting from March 2020, there was a decline in kidney transplant activity in Italy, especially for living-related donor transplant procedures. At present, new national guidelines on organ donation, test requirements for potential donors and organ recipients, and national rules on acceptance of organs by transplant centers have been developed. Together, these have resulted in a gradual increase in the number of renal transplants from July 2020. In their study, Akdur and colleagues¹⁵ concluded that that the effect of COVID-19 on transplant patients was the same as that shown in the general population. The pandemic will have an ongoing effect in the long term; therefore, there is a need to put an effort toward fully restoring transplant programs.

We had also observed a reduction in patients undergoing nonurgent elective procedures like arteriovenous fistulas and renal biopsies during this period. This was as a result of a nearly full stop of nonurgent elective surgeries, as health care workers, essential system resources, and hospital care space had to be reorganized and reserved for the high-acuity care of COVID-19 patients in view of the sudden surge of COVID-19 infections. A systematic review done by Simone and colleagues¹⁶ emphasized a postponement of elective surgeries, until they were deemed necessary. At our center, we conducted renal biopsies only for patients who presented with rapid progressive renal failure or immune-mediated injury, with attempts to treat patients with acute kidney injury or nephrotic syndrome on clinical suspicion. In their review, Ulu and colleagues¹⁷ advised that patients who require renal biopsy should be evaluated individually in a risk-benefit way, with biopsies performed only in urgent cases.

The COVID-19 pandemic had a severe impact on both clinical and academic training of residents undergoing postgraduate degrees in nephrology at our institute. Clinical training was affected because of the dramatic decline in number of outpatients and inpatients and because of postponement of nonurgent procedures. Apart from this, academic training was also affected because of the increase in use of virtual case studies and discussions concentrating on COVID-19, with little focus on nephrology and transplant medicine. Similar impacts were reported on interventional cardiology fellowship training in New York¹⁸ and pediatric gastroenterology fellow training in North America.¹⁹

Conclusions

The COVID-19 pandemic continues to have a significant impact on health care systems worldwide. Many of our practice, service, education, and research efforts have been affected. There was a drastic decline in non-COVID-19-related care and services due to COVID-19 management being our priority. The effects of reduced numbers of outpatients and inpatients on workflow, as well as the reduced numbers of renal transplants and nonelective procedures on the health of our patients, are unknown. The COVID-19 pandemic had similar effects on other nephrology and transplant units across the country. Hence, it is the need of the hour to plan a strategic scheme. More emphasis should be given to enhance telemedicine and drug delivery systems. Furthermore, new policies to increase the number of renal transplants and protocols to conduct nonelective procedures are needed. The findings of this study could help us to understand the limitations during the present COVID-19 surge and could help prepare for any future waves, with digital reforms in health care system and regular updates in health care policies.

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