Patient groups have expressed concern at reports of a critical shortage of supplies for the provision of dialysis treatment in ICU for people with acute kidney injury caused by COVID-19.
On Wednesday, the Medicines and Healthcare products Regulatory Agency (MHRA) and NHS England warned of severe disruption to the supply of kits and fluids to perform continuous vein-to-vein haemofiltration, including haemodiafiltration (CVVH and CVVHD).
The alert, distributed to trusts, warned of limited supplies of certain haemofiltration sets and fluids in the system, due to the recent increase in demand during the COVID-19 pandemic.
It said that Baxter Health Care Limited, Fresenius Medical Care (UK) Ltd, and B Braun Medical Ltd, which together account for 70% of the NHS market, reported that there were now limited supplies of haemofiltration sets and fluids in the system.
It said the supply issue was likely to be further complicated because sets in particular, and probably fluids, were not interchangeable between different manufacturers' equipment.
Last week, the Intensive Care National Audit and Research Centre (ICNARC) reported that 1 in 5 critically ill coronavirus patients needed renal replacement therapy (RRT) for an average of 4 days, rising to 28.8% among patients needing advanced respiratory support after hospital admission because of SARS-CoV-2.
The alert explained that patients appeared to have a hyper coagulopathy that was causing CVVH and CVVHD sets to clot, both before the filter and within the filter.
Sharing Stocks of Units and Fluid
In response, clinical teams have been asked to take a number of steps. These included sharing stocks with other units and using sets for longer than usually recommended when conditions were appropriate.
A letter, quoted in The Guardian yesterday, and attributed to James Palmer, the national medical director of specialised services at NHS England, said: "The revised strategy should be to conserve both fluids and sets used in CVVH and it is recommended that the following actions are taken. In contrast to previous guidance, sets should be used for 24-48 hours. If the supply of machines allows, the use of the set may continue longer up to the recommended time permitted."
It continued: "To further conserve fluid stocks, CVVH is preferred to CVVHD, but individualised case by case. During the current clinical scenario, the addition dialysis (CVVHD mode) should be rarely needed."
Another letter, also quoted in The Guardian, said that providers should be limited to ordering 4 days of supply. "On Monday 27 April the supply chain constraints will be reviewed so further ordering frequency can be defined, aiming to move to weekly orders as soon as stocks allow," it said.
NHS England declined a request by Medscape News UK to see the full contents of the letters.
However, an NHS spokesperson told us: "There is significant global pressure on the supplies of the particular types of renal replacement therapies being used to treat COVID-19 patients who develop kidney problems, and the NHS is working with Government and our partners to ensure supplies are maintained."
Kidney Care UK said it alerted the Department of Health and Social Care to the potential problem on 7th April and was continuing to monitor the situation.
It urged the Government to make public its immediate and short-term contingency plans.
Fiona Loud, policy director at the charity, said: "No patients in ICUs should be put at risk due to a shortage of supplies and any proposed solution must not impact detrimentally on the care and treatment provided to existing long-term kidney patients or their recommended dialysis treatment."