Empty chairs tell the story of pandemic's toll at Texas kidney dialysis centers

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Artemio Martinez noticed a stranger in the chair next to his when he showed up for kidney dialysis last April. Usually, the same woman sat there, and he would chat with her during the four-hour-long treatment.

“She was by me, like my dialysis partner,” Martinez said. “We told each other stories, we talked about life .... and the people that are going through the same thing you’re going through are like your family.”

Martinez, 55, soon received the devastating news. The woman had contracted COVID-19 and died after a two-week stay in the hospital.

The community of patients at Fresenius Kidney Care in Alamo — bonded over the need for dialysis treatments three times a week to stay alive — was crushed.

As the pandemic continued, patients at Martinez’s center continued disappearing, their chairs sometimes remaining empty for days before others claimed them. Some of the absent patients returned after hospital stays fighting the virus. Others didn’t. No one would know what happened unless relatives told them, because the center couldn’t share confidential medical information about other patients.

The more than 50,000 Texans whose survival depends on dialysis, which filters toxins and waste out of their blood because their kidneys do not function, have remained at high risk during the pandemic. Though they have preexisting conditions, they don’t have the choice to stay home. Without dialysis, they could die within days.

But more than half of dialysis patients with COVID-19 are hospitalized and over 20% of them die from it. Even though the 756 dialysis centers in Texas are supposed to follow a strict set of precautions, COVID-19 transmission in dialysis centers exploded when the pandemic began. Transmission has decreased since, but has remained inevitable over the past year. And the empty chairs remind other patients of a "dialysis family member" they may have lost.

“If I get sick from COVID, I pass away,” Martinez said. “If I skip my dialysis treatment, I'm going to pass away. I have to go to dialysis, regardless, no matter what.”

The Biden administration announced a new partnership Thursday with dialysis clinics to provide COVID-19 vaccinations directly to people receiving dialysis and health care workers in these clinics. As patients wait on these vaccinations, they remain at high risk.

Coronavirus spread in dialysis clinics was rampant for the first six weeks of the pandemic in places like the Rio Grande Valley, which has one of the highest rates of dialysis per capita in Texas, said Ivan Melendez, Hidalgo County health authority.

“Hemodialysis units were a source of rapid wildfire for coronavirus down here,” Melendez said. “It was dramatic. It was our focal point. In Hidalgo County, it was worse, initially, than the nursing homes. We had hemodialysis technicians that passed away, hemodialysis nurses that passed away.”

The numbers have improved over the past year, Melendez said, but dialysis providers have mainly tracked their own virus cases since the beginning of the pandemic. Neither the Texas Health and Human Services Commission or End Stage Renal Network of Texas tracked outbreak information in clinics.

U.S. Renal Care, a major dialysis provider, reported March 5 that almost 20% of its patients nationwide have contracted COVID-19, with over half of their facilities having more than 10 patients infected and larger facilities having more than 50 patients infected. Any transmission of COVID-19 in a dialysis clinic is considered an outbreak, according to guidelines from the U.S. Centers for Disease Control and Prevention.

The spread in dialysis centers was lower than spread in the general population, but mirrored its patterns, especially in Texas, according to a recent study from the Journal of the American Society of Nephrology.

“Ideally, we wouldn't bring all these patients together in these rooms,”said Mary Dittrich, chief medical officer for U.S. Renal Care. “But this is a non-elective, life saving treatment that if our patients miss, they can die from that.”

Her company, as well as major providers Davita Dialysis and Fresenius Kidney Care, said guidelines to protect patients have included spacing out treatment chairs, requiring masks at all times and prohibiting eating or visitors. Since Gov. Greg Abbott’s order rescinding statewide mandates for protective masks, major dialysis providers have continued requiring masks and safety protocols in their clinics.

They also test patients for COVID-19 weekly, if not more often, and screen them for the virus before letting them enter treatment rooms. If patients have symptoms or test positive, some clinics will send them to hospitals for dialysis.

Other clinics have so many positive patients that they split treatment into shifts throughout the day, and the positive patients all receive dialysis together on separate shifts or days.

The changes have made attending to patients more intensive for dialysis nurses and technicians. Normally, they monitor blood pressure dips in patients and ensure the right amount of fluid is circulating. During the pandemic, some were forced to work shifts with all COVID-19 positive patients.

“I actually have a heart condition, so I was having anxiety,” said Angela Metcalf, a former Davita dialysis nurse from North Texas. “And then, it was a lot of long hours. If a teammate got COVID, you would pick up their shifts. There's just a lot of stress involved with everything.”

As staff numbers fluctuated because of the virus, the number of dialysis patients started increasing because the coronavirus destroys organ function. Forty-six percent of people hospitalized with COVID-19 left the hospital in a stage of kidney disease, and 70% of those people had never had kidney disease before, said Tiffany Smith, president of the Texas Kidney Foundation.

People often overlook the mental suffering patients on dialysis have to endure, Smith said, which escalated during the pandemic. Dialysis is considered a temporary treatment for many, in between waiting for a kidney transplant or prolonging the end of people’s lives until they decide to stop.

“Sometimes, I hate to even think about it. It makes me cry watching the happiness, the joy, draining away,” Smith said. “It's not that it's completely gone … but it's watching them lose physical strength.”

Nine of Smith's family members have died from kidney disease, and both her brother and cousin received kidney transplants last year after months on dialysis. Black and Hispanic communities often have higher rates of kidney disease because of multiple factors. As COVID-19 has also ravaged communities of color at higher rates, Smith said the pandemic has further unveiled health inequities.

Martinez — a father of two living in Edinburg, where 88% of residents are Hispanic or Latino — still hopes for a kidney transplant. He said whenever something happens to a patient at the clinic he visits, other patients are there to support and help.

“Before the pandemic, a lot of people used to ask, ‘Why don’t you do dialysis at home?’” Martinez said. “Really, the one thing keeping me sane is talking to different people, seeing what they're going through and how we can help each other out.”

Despite the discomfort of the treatment, many older patients across the state have even started looking forward to dialysis during the pandemic. It’s one of their only outlets to socialize, said Gail Dewald, a nephrology nurse for 36 years.

“These patients get to see each other, at least say hello through their mask, and get to see their nurses and technicians,” Dewald said. “They really have been more compliant than they had been before the pandemic.”

For those who don’t find a community in their centers, many have moved to home dialysis, some switching to different types such as peritoneal dialysis, where a machine filters blood with fluid through an area in the stomach. There has been a 10% increase in U.S. Renal Care's percentage of home dialysis patients, said Dittrich.

Those physically unable to switch to home dialysis hope the vaccine will prevent further spread in centers and allow dialysis clinics to become safe again.

Michelle Adams-Walton, 58, has remained on dialysis for the past 17 years and hopes all dialysis patients receive the vaccine soon to prevent more death. Adams-Walton said she recently received the first dose of her vaccine, but many of her fellow patients are still waiting.

“Most of the people in my dialysis center have not had their vaccine yet, and that includes the staff, too,” she said. “It's a little worrying. Maybe we would be a little calmer about the mask business if we knew that people were vaccinated. But right now, that hasn't happened."

Brad Puffer, a spokesperson for Fresenius, said the company advocated with the federal government to prioritize dialysis patients for vaccines. As of Tuesday, Texas has opened up vaccine eligibility to include all adults, but only about 7 million of the state’s population of 30 million has received at least one dose. More than 3 million have been fully vaccinated, according to state health officials.

“I didn't know to what extent COVID was going to run through our clinics,” Adams-Walton said. “I'm very pleased that it hasn't been as devastating as it could have been. But we're not quite out of the woods yet.”