HOPKINS PHYSICIAN SAYS KIDNEY DISEASE PATIENTS FACE SPECIAL CHALLENGES FROM COVID-19

When SARS-CoV-2, the virus that causes COVID-19, attacks the body, the kidneys are among the earliest organs to be affected. Viral damage to kidney cells can lead to fluid imbalance, electrolyte loss, lack of blood pressure regulation and many other negative consequences that can make recovery more difficult to achieve. However, for the thousands of Americans with kidney disease, the hazards of COVID-19 are even greater.

In a viewpoint article in the April 6, 2020 issue of the Journal of Clinical Investigation, Johns Hopkins Medicine nephrologist Hamid Rabb, M.D., examines the major challenges that kidney patients face when dealing with COVID-19 and suggests ways to address them. For example, Rabb notes that the 500,000 hemodialysis patients in the United States are at high risk for contracting COVID-19 because they are immunocompromised and have to “visit densely populated outpatient units three times per week” for treatment. He says that increasing the use of home dialysis — a goal of the U.S. Department of Health and Human Services even before the pandemic — “should be hastened to reduce incidence of COVID-19 infections.”

Patients who have undergone kidney transplants are another group vulnerable to COVID-19 and its complications because they often take immunosuppressive medications to prevent rejection of the received organ.

Rabb, who is available for interviews, also urges physicians to look for signs of acute kidney injury in patients being treated for COVID-19, especially the elderly. The condition can be a consequence of the virus, he warns, and it increases the risk of death during hospitalization.

MENTAL HEALTH CHALLENGES IN RECOVERY FROM SEVERE COVID-19 INFECTION

Up to 20% of patients hospitalized in an intensive care unit (ICU) experience symptoms of post-traumatic stress disorder (PTSD), which may include fear, anxiety, agitation and isolation when subjected to a triggering memory of the event. Early reports from China suggest that rates of PTSD may be particularly high in patients recovering from COVID-19.

Psychiatrist O. Joseph Bienvenu, M.D., Ph.D., says that particular circumstances surrounding the pandemic may be contributing to this increase. Patients being treated for COVID infections are in quarantine situations with visitor restrictions in place on hospitals and physical separation from loved ones when they return home. People who have recovered COVID may also face a stigma related to their physical illness as well as their mental health, and there may be a lack of access to social support.

Bienvenu is available to speak about the unique mental health challenges that COVID patients face during their recovery and ways that we can address these challenges.

CORONAVIRUS DRUG DEVELOPMENT

Current drug development efforts for COVID-19 mostly focus on repurposing existing drugs to prevent the virus from making more copies of itself. However, these available drugs may not be as effective as drugs targeting coronaviruses more specifically. In addition, different approaches may be needed in the event of drug resistance. Cocktail therapy with multiple drugs targeting different viral proteins will likely increase efficiency and thwart resistance, as is the case for HIV treatment.

Johns Hopkins Bloomberg School of Public Health molecular biologist Anthony Leung, Ph.D., and virologist Diane Griffin, M.D., Ph.D., are applying their research on a class of viral enzymes to potentially develop coronavirus treatments. They have shown that a class of enzymes are critical for virus replication and may play a role in disease development. In collaboration with the Johns Hopkins Drug Discovery and ChemCore groups, the research team will screen a library of 100,000 compounds to identify ones that block the activities of these enzymes. This library will consist of FDA-approved drugs, clinical trial drug candidates and natural products. They will then test the drug leads in cell culture and animal models for their effectiveness against coronaviruses.

The specific viral enzymes under investigation remove the chemical ADP-ribose — a combination of an energy molecule and a sugar — off of proteins known as ADP-ribosylation hydrolases. Added when a protein is made, these chemical ADP-riboses give the proteins a function in the cell, and then the ADP-ribose-remover enzymes take off the chemicals so they can be recycled when the protein has finished its job.

Leung and Griffin are available to discuss this very early-stage project.

TREATMENT FOR OPIOID USE DISORDER DURING THE PANDEMIC

People with opioid use disorder are one of the populations that shouldn’t be overlooked during the pandemic. Patients with substance use disorders face multiple challenges aside from being able to gain access to medications necessary for their treatment, including poverty, a lack of access to affordable housing and difficulties from other chronic health conditions.

Kenneth Stoller, M.D., director of the Johns Hopkins Broadway Center for Addiction, is available for comment on clinical and provider measures being used to care for substance use disorder patients during the coronavirus crisis.

He says that accessing care for new individuals seeking treatment may be more challenging at this time, as fewer treatment programs are accepting new patients, and those that are may be limiting numbers due to logistics involved with distancing precautions and conservation of personal protective equipment. Opioid treatment programs that are accepting new patients may be less likely to offer methadone as opposed to buprenorphine due to the requirement for an in-person exam. In-person meetings are being avoided, and alternatives may include consultations via phone or audiovisual technologies. More take-home doses of medication are being offered to minimize travel to and from programs. This also results in less patient contact.

With the hope of decreasing risk for drug relapse, overdose and social isolation due to the limited face-to-face patient/provider interaction and altered medication regimen, health care providers such as Stoller recommend patients connect with family and friends who contribute to positive behaviors and can encourage them during their drug recovery process. Patients are also encouraged to connect with mutual support groups virtually, as well as with peer recovery specialists, spiritual communities, and other people or groups that can support their efforts to create a strong recovery in these challenging circumstances.

Brendan Saloner, Ph.D., is available to discuss policy and systems regarding opioid use disorder treatment during the coronavirus crisis.

Newly updated federal guidelines implemented during the crisis allow patients facing opioid use disorder to take advantage of benefits and flexible services offered virtually by Medicaid and private insurance programs. In addition to the new telemedicine options for virtual health care visits, some of the public policies enacted for treating people facing opioid use disorder include safer delivery of treatments for patients and staff and waiving required in-person urine drug testing to adhere to social distancing guidelines. Based on recommendations from the Substance Abuse and Mental Health Services Administration, some patients who are on a stable medication regimen can receive up to 28 days of medication for at-home use, including being prescribed naloxone to reverse potential drug overdoses.

Saloner says that additional funding and incentives for telehealth visits, phone outreach and access to other services such as food and housing would lift a heavy burden from patients facing substance use disorder amid the coronavirus crisis.

REHABILITATION AT A DISTANCE AFTER STROKE DURING A PANDEMIC

After suffering from a stroke or another brain injury, patients require targeted physical rehabilitation to aid their recovery, which can include physical, occupational, speech and psychological therapy. The coronavirus pandemic has had a tremendous impact on the way care is provided to these patients as well as how and when they are discharged home to the care of their loved ones.

When a patient is discharged from the hospital, it is just the beginning of their journey toward recovery. They are usually still frail and vulnerable to medical complications. In addition, there are often safety concerns due to new disability. Doctors including Preeti Raghavan, M.B.B.S., director of the Center of Excellence in Stroke Treatment, Recovery and Rehabilitation at the Sheikh Khalifa Stroke Institute, and her team are working diligently to provide care for their patients within the hospital setting while determining how patients can receive adequate rehab at a distance once the patient has been discharged from the hospital.

The teams have set up a stroke interdisciplinary telemedicine clinic to ensure that patients are evaluated in a timely fashion. Patients are seen by the stroke neurology team and physical therapist in a telemedicine visit within a week after discharge to address any safety concerns — these may be medical, pharmaceutical or physical needs. Within two weeks after discharge, patients are seen by the physical medicine and rehabilitation physician and an occupational therapist to assess function and determine a plan of action. Individuals with language and/or swallowing deficits may also be seen by a speech therapist.

These collaborative physician-therapy visits help therapist familiar with the patient’s medical issues ensure the patient receives the rehabilitation they need. Physical, occupational and speech therapists plan the patient’s telerehabilitation visits and assemble kits to facilitate telerehabilitation at home to aid patients during their path to recovery.

Raghavan is available to discuss how rehabilitation experts are addressing the challenges of social and physical distancing when rehabilitation care is needed. She is also able to comment on how — during a pandemic — experts might still provide the needed continuum of care for non-COVID-19 healthcare needs, such as stroke recovery.

PAIN MANAGEMENT DURING THE CORONAVIRUS PANDEMIC

As our medical systems are strained by COVID-19, health care providers find themselves weighing the risk of exposure for front-line care workers against the benefits of patients receiving treatment in the clinic. This is especially salient for an estimated 50 million Americans with chronic pain. A panel of experts in pain treatment convened to create guidelines for best practices in pain management during times of public health crisis such as the COVID-19 pandemic. Johns Hopkins Medicine pain expert Steven P. Cohen, M.D., chaired the panel and is available to speak about the proposed guidelines and moral and ethical conundrums pain management physicians are facing each day.

• Link to Recommendations: https://www.asra.com/content/documents/pnaa127.pdf.
• ‘Pain Rounds’ video interview with Cohen, who is also the director of medical education - Pain Medicine Division at the Johns Hopkins University School of Medicine, and Friedhelm Sandbrink, M.D., national program director for pain management at the Veterans Health Administration: https://www.asra.com/news/250/asra-joins-multiple-societies-in-endorsi
• Downloadable infographic on recommendations: https://www.asra.com/content/documents/paingdlnsinfograph04070444p.pdf

For more information about coronavirus disease (COVID-19) from Johns Hopkins Medicine, visit hopkinsmedicine.org/coronavirus. For information on coronavirus disease (COVID-19) from around the Johns Hopkins enterprise, including from the Johns Hopkins Bloomberg School of Public Health and The Johns Hopkins University, visit coronavirus.jhu.edu.