Background: Hemodialysis patients have faced unique challenges during the COVID-19 pandemic. They face high risk of death if infected, and have unavoidable exposure to others when they come to hospital three times weekly for their life-saving treatments. The objective of this study was to gain a better understanding of the scope and magnitude of the impacts of the pandemic on the lived experience of patients receiving in-center hemodialysis. Methods: We conducted semi-structured interviews with 22 patients who were undergoing dialysis treatments in five hemodialysis centers in Montreal from Nov 2020 to May 2021. Interviews were transcribed and then analyzed using thematic content analysis. Results: Most participants reported no negative impacts of the COVID-19 pandemic on their hemodialysis care. Several patients had negative feelings related to forced changes in their dialysis schedules, and this was especially pronounced for indigenous patients in a shared living situation. Some patients were concerned about contracting COVID-19, especially during public transportation, while others expressed confidence that the physical distancing and screening measures implemented at the hospital would protect them and their loved ones. Some participants reported that masks negatively impacted their interactions with healthcare workers, and for many others, the pandemic was associated with feelings of loneliness. Finally, some respondents reported some positive impacts of the pandemic, including use of telemedicine, and creating a sense of solidarity. Conclusion: Patients undergoing hemodialysis reported no negative impacts on their medical care, but faced significant disruptions in their routines and social interactions due to the COVID-19 pandemic. Nevertheless, they showed great resilience in their ability to adapt to the new reality of their hemodialysis treatments. We also show that studies focused on understanding the lived experiences of indigenous patients and patients from different ethnic backgrounds are needed in order reduce inequities in care during public health emergencies.

ince March 2020, the COVID-19 pandemic has completely disrupted the lives of Canadians; for the 24 000 vulnerable Canadians receiving in-centre hemodialysis, 1 its effects are especially grave. Case-fatality rates from COVID-19 are reported at 20%-30% in patients receiving hemodialysis -10 times that in the general population. [2][3][4][5][6][7][8] Yet self-isolation to avoid exposure is impossible. Most patients must leave their homes 3 times a week to receive their life-saving treatments. Each treatment is typically performed for 3-5 hours in an open space shared with several other patients 9 and involves frequent contact with health care workers. Exposure to SARS-CoV-2 may also occur during transport and in the waiting area before and after dialysis.Outbreaks of COVID-19 within hemodialysis units can have disastrous consequences. 10,11 Although the risk of outbreaks in dialysis units was recognized early on during the pandemic, 10 implementation of strict infection prevention and control (IPAC) measures in hemodialysis units is challenging. Most North American installations were not designed to prevent respiratory virus transmission. Many are crowded, with minimal distance between treatment stations and few, if any, single-patient rooms.

Transportation is a key element of access to healthcare. The COVID-19 pandemic posed unique and unforeseen challenges to patients receiving hemodialysis who rely on three times weekly transportation to receive their life-saving treatments, but there is little data on the problems they faced. This study explores the attitudes, fears, and concerns of hemodialysis patients during the pandemic with a focus on their travel to/from dialysis treatments. A mixed methods travel survey was distributed to hemodialysis patients from three urban centers in Montréal, Canada, during the pandemic (n= 43). The survey included closed questions that were analysed through descriptive statistics as well as open-ended questions that were assessed through thematic analysis. Descriptive statistics show that hemodialysis patients are more fearful of contracting COVID-19 in transit than they are at the treatment center. Patients taking paratransit, public transportation, and taxis are more fearful of COVID-19 while traveling than those who drive, who are driven, or who walk to the clinic. In the open-ended questions, patients reported struggling with confusing COVID-19 protocols in public transport, including conflicting information on whether paratransit taxis allowed one or multiple passengers. Paratransit was the most used travel mode to access treatment (n = 30), with problems identified in the open-ended questions, such as long and unreliable pickup windows, and extended travel times. To limit COVID-19 exposure and stress for paratransit users, agencies should consider sitting one patient per paratransit taxi, clearly communicating COVID-19 protocols online and in the vehicles, and tracking vehicles for more efficient pickups.

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Objective To identify determinants and outcomes associated with infection in paediatric systemic lupus erythematosus (SLE) patients at admission and during hospitalization in intensive care units (ICUs). Patients and methods A retrospective cohort study of paediatric SLE patients admitted to two ICUs was conducted. Frequency and risk factors of infection as well as mortality were studied. Results Seventy-three infection episodes amongst 55 patients were analysed. The median age was 14.4 years (IQR 12.5–16). The median SLEDAI was 16 (IQR 12–20). Twenty-nine episodes were documented at admission; the CRP was higher in these patients (6.58 versus 1.04 mg/dl, p<0.001) than in non-infected patients, even after multivariate adjustment (OR 8.6, 95% CI = 2.1–34.8, p = 0.003). Twenty-five (34.7%) episodes occurred during hospitalization. Lupus activity (OR 1.14, 95% CI = 1.01–1.27, p = 0.029), cyclophosphamide (OR 17.9, 95% CI = 2–156, p = 0.009) and mechanical ventilation (OR 16, 95% CI = 2.1–122, p = 0.008) were associated with infection. Ten episodes (14%) led to death. Admission to the ICU due to infection was strongly associated with mortality (90% versus 31.8%, OR 19.4, 95% CI = 2.3–163, p = 0.006). Conclusion In paediatric lupus patients admitted to the ICU, elevated CRP should alert clinicians to possible infection. During hospitalization, SLE activity and cyclophosphamide were associated with infection. Infection at admission to the ICU was strongly associated with mortality.

Background: The COVID-19 pandemic has disrupted health systems and created numerous challenges in hospitals worldwide for patients and healthcare workers (HCWs). Hemodialysis centers are at risk of COVID-19 outbreaks given the difficulty of maintaining social distancing and the fact that hemodialysis patients are at higher risk of being infected with COVID-19. During the COVID-19 pandemic, HCWs have had to face many challenges and stressors. Our study was designed to gain HCWs' perspectives on their experiences of the impacts of the COVID-19 pandemic in hemodialysis units. Methods: Semi-structured interviews were conducted with 22 HCWs (nurses, nephrologists, pharmacists, social workers, patient attendants, security agents) working in five hemodialysis centers in Montreal, between November 2020 and May 2021. The content of the interviews was analyzed using thematic analysis. Results: Four themes were identified during the interviews. The first was the impact of COVID-19 on work organization, regarding which participants reported an increased workload, a need for a consistent information strategy, and positive innovations such as telemedicine. The second theme was challenges associated with communicating and caring for dialysis patients during the pandemic. The third theme was psychological distress experienced by hemodialysis staff and the psychosocial impact of COVID-19 on their personal lives. The fourth theme was recommendations made by participants for future public health emergencies, such as maintaining public health measures, ensuring an adequate supply of protective equipment and developing a consistent communication strategy. Conclusions: During the first and second waves of the COVID-19 pandemic, HCWs working in hemodialysis units faced multiple challenges that impacted their wellbeing and their work. In order to minimize challenges for HCWs in hemodialysis during a future pandemic, the healthcare system should provide an adequate supply of protective equipment, develop effective communication strategies and take into account the psychological distress related to HCWs' professional and personal lives.

Cellular immune defects associated with suboptimal responses to SARS-CoV-2 mRNA vaccination in people receiving hemodialysis (HD) are poorly understood. We longitudinally analyzed antibody, B cell, CD4+ and CD8+ T cell vaccine responses in 27 HD patients and 26 low-risk control individuals (CI). The first two doses elicit weaker B cell and CD8+ T cell responses in HD than in CI, while CD4+ T cell responses are quantitatively similar. In HD, a third dose robustly boosts B cell responses, leads to convergent CD8+ T cell responses and enhances comparatively more Thelper (TH) immunity. Unsupervised clustering of single-cell features reveals phenotypic and functional shifts over time and between cohorts. The third dose attenuates some features of TH cells in HD (TNFα/IL-2 skewing), while others (CCR6, CXCR6, PD-1 and HLA-DR overexpression) persist. Therefore, a third vaccine dose is critical to achieve robust multifaceted immunity in hemodialysis patients, although some distinct TH characteristics endure.

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