COVID-19 has thrown into stark relief the fragile state of healthcare for many vulnerable communities and exacerbated existing disparities that are jeopardizing access to care. 

Thirty-seven million American adults are living with chronic kidney disease and are at increased risk for severe COVID-19. Supply chain and medical staffing shortages brought on by COVID-19 have decreased access to treatments for many of the 800,000 individuals requiring dialysis or a kidney transplant to live. With hurricane season quickly approaching, these disruptions could be made worse if policymakers do not take actions to protect kidney patients in the face of emergencies.

For people living with kidney failure and their families, disruptions to dialysis treatments are more than just inconveniences. The typical patient requires three treatments per week, each lasting about four hours. Without timely care, they can develop high potassium in the bloodstream and fluid overload, leading to severe complications and, in some cases, death. Given the current stress on our healthcare system, every unexpected medical supply chain shock can create additional treatment delays and reduced access to health-sustaining medications.

Before the pandemic, kidney dialysis programs were already stretched to capacity. An influx of people needing treatments in the hospitals due to COVID-19 exacerbated existing shortages in trained staff. This was compounded by the fact that substantial numbers of COVID-19 patients developed acute kidney injury, and among COVID-19 patients requiring ICU care more than 50 percent with kidney injury may have required dialysis. 

During surges in cases of COVID-19, hospital shortages of staff, equipment and supplies limited the capacity to provide acute dialysis. Similarly, outpatient dialysis facilities also experienced staffing shortages as patients and care professionals became infected with COVID-19 and as many experienced staff left the workforce, resulting in closures of some dialysis facilities. Recent supply chain woes have also caused shortages of dialysate and other supplies essential to the provision of dialysis treatments. A major dialysis supplier stated that due to a severe labor shortage, workers could not keep up with the manufacturing and transportation needs for supplies. As a result, dialysis chains reduced patient treatments to compensate. 

COVID-19 is not the first time a public emergency has disrupted the dialysis delivery system. Hurricane Maria devasted Puerto Rico in 2017, leaving thousands of patients without access to nearby healthcare facilities. As seen with shortages in Puerto Rico and throughout the COVID-19 pandemic, marginalized communities tend to be disproportionately impacted. Studies have shown that African Americans are more than four times as likely to require dialysis than white Americans, while Hispanics are 1.3 times more likely. This is yet another example of healthcare inequities that must be addressed.

Chronic kidney disease patients face many challenges, but there are actions the federal government and other policymakers can take to better protect this population.

First, as the Biden administration considers ending the COVID-19 public health emergency declaration, kidney treatment facilities should be prioritized to continue receiving high-level, government-approved personal protective equipment. The Food and Drug Administration and Centers for Disease Control and Prevention should also provide additional specific guidance for prescribing and prioritizing the distribution of oral and monoclonal antibody therapies and vaccines for individuals on dialysis and those with moderate to severe chronic kidney disease not using dialysis who, while moderately immunocompromised, have not been prioritized in the same way as those living with a kidney transplant.

Second, Congress should work with the Department of Health and Human Services to replenish dialysis supplies at the Strategic National Stockpile — the federal government’s medical response infrastructure housed within the Office of the Assistant Secretary for Preparedness and Response — to reduce staff burden and mitigate the chances of future shortages. Additionally, lawmakers should urge better utilization of the Assistant Secretary for Preparedness and Response to provide mobile dialysis units during public health emergencies. These systems were specifically created to operate in disaster zones and overcome staffing and medical supply shortages, as was seen in states like New York, where mobile units were deployed from the Strategic National Stockpile to ICUs to assist COVID-19 patients requiring treatments.

Finally, policymakers at all levels should explore and adopt practices that address staffing shortages, such as permitting reciprocity for nurses to allow for interstate practice, regardless of whether the state is a compact state.

While federal and state governments are working to resolve current challenges around dialysis delivery, more can be done. Failure to act means that natural disasters and public health emergencies will continue to plague the system, potentially delaying critical, life-saving care for hundreds of thousands of Americans, especially the most vulnerable amongst us.

Paul M. Palevsky M.D. is president of the National Kidney Foundation and is a professor of Medicine in the Renal-Electrolyte Division at the University of Pittsburgh School of Medicine.

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