#AskRenal about this scenario (answer at the end):
pt on dialysis shows up with upper respiratory symptoms c/w COVID19. Entire household has same symptoms and they all got tested. Everyone is +ve except the patient. How would you approach the pt for infection control purposes

Two days have passed after your decision. Pt is now visibly short of breath and is sent to hospital to be admitted (family members have also deteriorated so they all travel to ED). Pt sent to dialysis for urgent HD and PCR is sent. How do you handle their 1st inpatient dialysis:

Pt stabilizes after the first emergency dialysis and a CXR is obtained. It shows multilobar pneumonia; PCR results within 16hrs (yeah we can do that in #NewMexico) & is negative. IM labels the patient as HCAP & IV ABx are initiated; condition improves somewhat & ABx stepped down

We are now 4 days after the onset of symptoms and 36 hrs after admission - time for the second dialysis!
How do you handle infection control during the 2nd hospital dialysis:

Pt improves even more after second dialysis, everyone is talking discharge (including pt who is concerned about the nonhospitalized family members with COVID19). A third PCR is performed and is -ve. What infection precautions do you take upon return to the outpt unit:

We are now 10 days after the initial PCR, pt on dialysis unit per the RN still looks bad. Decision is made to swab the patient and sent to the corporate lab. PCR results -ve. How do you handle the subsequent dialysis sessions:

We are now 14 days after the symptom of symptoms, pt still whooping and an antibody test is sent out. This is a total quant Ab test (measures IgM+IgG) against the nucleocapcid protein. It it comes back strongly positive.
How do you handle the subsequent dialysis session:

This is actually a story from one of our units and has played out over the last 2.5 weeks. The Medical Director appropriately gave more weight to the clinical history and assigned a rather high pretest probability to this pt having COVID19 given high risk exposures.

Pt was treated as PUI and dialyzed in iso throughout this period, even when per hospital protocols the patients was not treated as a COVID19 case (3 negative PCRs!!). The high community transmission rate meant that the negative predictive value of the test wasnt impressive

Subsequent decisions about when to take the patient off iso will be based on clinical symptoms (can't rely on PCR) and following antibody titers have little utility. We will aim for 2 weeks of zero respiratory symptoms before d/c iso.
Moral: clinical judgement is not overatted