As doctors see coronavirus-kidney link, worry grows over dialysis machines
當醫生們看到冠狀病毒和腎臟之間的聯繫時，對透析機數量的擔憂與日俱增
The novel coronavirus exposes another potential shortage in U.S. healthcare.
新型冠狀病毒暴露了美國醫療保健的另一個潛在短缺。
Lucien Bruggeman
呂西安布萊格曼
22 April 2020, 16:00
2020年4月22日16:00
11 min read
11分鐘閱讀
Jamal Uddin’s coronavirus story began like many others: His health deteriorated, he was hospitalized, he tested positive for COVID-19, and he was treated. Then his health began improving. He was going to be taken off the ventilator -- until his potassium levels spiked.
賈馬爾•烏丁(Jamal Uddin)感染冠狀病毒的經歷和其他許多人一樣:他的健康狀況惡化，住院治療，covid19檢測呈陽性，並接受了治療。然後他的健康狀況開始好轉。他本來要停止呼吸機——直到他體內的鉀含量飆升。
A sudden increase in potassium levels, a result of kidney damage, can be treated with a dialysis machine. But at the hospital in hard-hit New York City where Uddin was being treated, his family says every dialysis machine was already in use – a sign, experts say, of the growing connection between COVID-19 and kidney problems.
鉀水平的突然升高是腎臟損傷的結果，可以用透析機來治療。但是在紐約市受災最嚴重的一家醫院，烏丁的家人說，每一臺透析機都已經投入使用了。專家說，這是一個跡象，說明了covid19和腎臟問題之間的聯繫越來越緊密。
Doctors attempted creative workarounds to treat Uddin – including peritoneal dialysis, which removes fluid through a tube coming from the abdomen – but to no avail. He died within days.
醫生們嘗試了各種創造性的方法來治療烏丁，包括通過一根管子從腹部抽走液體的腹膜透析，但都無濟於事。幾天後他就死了。
Jamal Uddin, 68, passed away last week in a New York City hospital after testing positive for COVID-19, according to his wife, Jesmin. 68歲的賈邁勒烏丁(Jamal Uddin)的妻子傑斯明(Jesmin)說，烏丁上週在紐約市一家醫院去世，之前他的COVID-19檢測呈陽性。
Jamal Uddin, 68, passed away last week in a New York City hospital after testing positive for COVID-19, according to his wife, Jesmin.68歲的賈邁勒烏丁(Jamal Uddin)的妻子傑斯明(Jesmin)說，烏丁上週在紐約市一家醫院去世，之前他的COVID-19檢測呈陽性。
Courtesy Shehran Uddin 禮貌Shehran Uddin
“They said that other patients are doing a lot worse than him,” said Uddin’s wife, Jesmin, who recounted his story to ABC News. “Everyone is advertising there are not enough ventilators, that's what I was afraid of -- whether he was going to have a ventilator or not. People are getting better from the ventilator. The lung is getting clearer, but they're not getting dialysis. And that's why people are dying."
“他們說其他病人的情況比他糟糕得多，”烏丁的妻子傑斯明(Jesmin)說，她向美國廣播公司新聞頻道(ABC News)講述了他的故事。“每個人都在宣傳說沒有足夠的通風機，這就是我所擔心的——不管他是否會有通風機。呼吸機使人們的病情好轉了。肺越來越清晰了，但他們沒有做透析。這就是人們死亡的原因。”
Tune into ABC at 1 p.m. ET and ABC News Live at 4 p.m. ET every weekday for special coverage of the novel coronavirus with the full ABC News team, including the latest news, context and analysis. 在美國東部時間下午1點和東部時間下午4點收聽美國廣播公司新聞頻道的新冠狀病毒特別報道，包括最新的新聞、背景和分析。
The hospital was not able to return ABC News' request for comment because of patient privacy rules, and the Uddin family did not authorize the hospital to speak about his ordeal.
由於患者隱私規定，醫院無法回覆ABC新聞的置評請求，烏丁的家人也沒有授權醫院談論他的遭遇。
MORE: More than 300 US hospitals warn of supply shortages in coronavirus fight, watchdog says 更多:超過300家美國醫院發出警告，在與冠狀病毒的戰鬥中，供應短缺，看門狗說
A possible dearth of various life-saving equipment has for weeks nipped at the heels of the novel coronavirus’ spread. But as the disease has begun to appear linked to kidney issues, a new round of ethical questions are being raised about who gets treatment and who doesn’t – and Uddin’s case illustrates fears that otherwise potentially preventable deaths might occur as a result of dialysis equipment shortages.
在新型冠狀病毒傳播之後的幾周內，各種救生設備可能出現的短缺已經對病毒的傳播造成了影響。但是，隨著這種疾病開始與腎臟問題聯繫起來，關於誰接受治療，誰不接受治療的新一輪倫理問題被提了出來——烏丁的案例說明了人們的擔憂，即本來可以避免的死亡可能會因為透析設備短缺而發生。
There's also the question of how to balance the use of dialysis machines for coronavirus patients with the needs of the more than 500,000 Americans with pre-existing kidney disease who already rely on them.
還有一個問題是如何平衡使用透析儀治療冠狀病毒患者和50多萬已經患有腎病的美國人的需求。
Guidelines developed at the state level are meant to provide a framework for healthcare providers to prioritize care for certain patients in the event of a crisis that could lead to a scarcity of resources. Critics say some states use broad rules and algorithms -- rather than the on-the-ground opinion of doctors -- that could put patients with chronic kidney disease at risk of not getting the care they need.
在州一級制定的指導方針旨在為衛生保健提供者提供一個框架，以便在發生可能導致資源短缺的危機時優先照顧某些患者。批評人士說，一些州使用廣泛的規則和算法，而不是醫生的實際意見，這可能會讓患有慢性腎病的病人面臨得不到他們需要的治療的風險。
A doctor operates a dialysis machine in an intensive care unit. 醫生在重症監護病房操作透析機。
A doctor operates a dialysis machine in an intensive care unit.醫生在重症監護病房操作透析機。
Picture Alliance/dpa/picture alliance via Getty I 圖片聯盟/dpa/通過Getty I圖片聯盟
Concern among experts is so grave that two leading advocacy organizations for kidney illness penned a letter in recent days to state leaders calling on a shift in policy.
專家們的擔憂如此嚴重，以至於兩家主要的腎臟疾病倡導組織近日致信各州領導人，呼籲改變政策。
“A one-size-fits-all category that denies care to all patients with kidney failure is short-sighted, arbitrary, unethical, and discriminatory,” the presidents of the American Society of Nephrology (ASN) and the National Kidney Foundation in a letter to the National Governors Association and the National Conference of State Legislatures wrote last week. Nephrology refers to medical specialization in kidneys.
“放之四海而皆準的類別,否認保健腎衰竭患者都是短視的,任意的,不道德的,和歧視性的,”總統的美國腎臟病學會(ASN)和國家腎臟基金會在一封致全國州長協會和全國各州立法機構會議上週寫道。腎臟學是指腎臟的醫學特化。
“Blanket policies that categorically restrict the access of kidney patients, and other vulnerable populations, to critical care are scientifically unfounded and inappropriately interfere with the trusted patient-physician relationship as well as disregard basic principles of medical ethics,” the groups added. “Unilateral guidance should never outweigh sound, individualized medical judgment.”
這些組織還說:“那些明確限制腎病患者和其他弱勢群體接受重症監護的一攬子政策是沒有科學依據的，而且不恰當地干擾了值得信任的醫患關係，並且無視醫學倫理的基本原則。”“單方面的指導永遠不應該超過合理的、個性化的醫療判斷。”
MORE: Doctors fear shortage of drug critical to ventilator treatment for coronavirus 更多:醫生擔心呼吸機治療冠狀病毒的關鍵藥物短缺
An estimated 40 million adults in the U.S. have chronic kidney disease, according to the Centers for Disease Control and Prevention (CDC). Experts anticipate even more Americans will develop kidney ailments as a result of the coronavirus pandemic, but the extent of the kidney damage in confirmed coronavirus patients remains unclear.
據美國疾病控制與預防中心(CDC)估計，美國約有4000萬成年人患有慢性腎病。專家預計，由於冠狀病毒大流行，更多的美國人將患上腎病，但確診的冠狀病毒患者的腎臟損害程度仍不清楚。
The ASN and U.S. Department of Health and Human Services (HHS) are “working to get better numbers – harder numbers – than the impressions of nephrologists,” according to Dr. Alan Kliger, a Yale nephrologist and co-chairman of the ASN coronavirus task force.
愛生公司和美國衛生與公眾服務部(HHS)正在“努力獲得更好的數字——更準確的數字——而不是腎病學家的印象，”耶魯大學腎病學家、愛生冠狀病毒工作組聯合主席阿蘭·克里格博士說。
Medics and hospital workers prepare to lift a COVID-19 patient onto a hospital stretcher outside the Montefiore Medical Center... 醫務人員和醫院工作人員準備將一名covid19患者抬上醫院的擔架，該擔架位於Montefiore醫療中心外。
more更多的
Medics and hospital workers prepare to lift a COVID-19 patient onto a hospital stretcher outside the Montefiore Medical Center Moses Campus on April 07, 2020, in the Bronx borough of New York.2020年4月7日，紐約布朗克斯區，醫務人員和醫院工作人員準備將一名covid19患者抬上醫院的擔架。
John Moore/Getty Images 約翰摩爾/蓋蒂圖片社
What is clear, experts say, is that a substantial proportion of critically ill coronavirus patients – those on ventilators in the intensive care unit – require dialysis machines. The number of those needing dialysis range from 20-40% of that severely ill subgroup of positive cases, according to Kliger.
專家們說，有一點是清楚的，在重症監護病房使用呼吸機的重症患者中，有相當比例的冠狀病毒患者需要透析機。Kliger說，需要透析治療的人數在20-40%的重症陽性者亞組中。
Studies and clinical anecdotes indicate that the coronavirus can attack the kidneys, leading to kidney failure or, in patients with existing kidney disease, exacerbate matters. Compounding the issue is that kidney disease is made worse in patients who require mechanical ventilation, like many patients with severe cases of the coronavirus. Without dialysis, fluid can accumulate in the lung when the kidneys can't remove enough fluid and toxins from the body.
研究和臨床趣聞表明，冠狀病毒可攻擊腎臟，導致腎功能衰竭，或使已有腎臟疾病的患者病情惡化。更糟糕的是，需要機械通氣的患者的腎臟疾病會惡化，就像許多冠狀病毒重症患者一樣。如果沒有透析，當腎臟不能從體內排出足夠的液體和毒素時，液體就會在肺部積聚。
MORE: Lawsuit filed against WHO over its handling of coronavirus outbreak 更多:對世界衛生組織處理冠狀病毒爆發的訴訟
“These patients generate the toxins that are removed by dialysis at a phenomenal rate – a rate that will make your eyes pop out,” said Dr. Joel Topf, the medical director of St. Clair Nephrology Research in Detroit, Michigan. “We are finding we need to dialyze these patients every day using high doses of the dialysis to clear off these toxins … and that really adds to the stress on resources.”
密歇根州底特律市聖克萊爾腎病研究中心的醫學主任喬爾·託普夫博士說:“這些病人體內產生的毒素會以驚人的速度通過透析排出體外——這種速度會讓你的眼睛突出來。”“我們發現，我們需要每天對這些患者進行高劑量透析，以清除這些毒素……這確實增加了對資源的壓力。”
Experts cited a growing need for both dialysis machines and the fluid required to dialyze patients. Because manufacturing new machines can be an arduous process, Dr. Sunny Jha, a USC anesthesiologist, suggested states with fewer cases donate machines to the “hot spots” – not unlike the reallocation of ventilators in recent weeks.
專家指出，對透析機和透析液的需求越來越大。由於製造新機器可能是一個艱難的過程，南加州大學麻醉學家Sunny Jha博士建議病例較少的州捐贈機器給“熱點地區”——這與最近幾周呼吸器的重新分配沒有什麼不同。
“We have had trouble getting the fluids needed for dialysis. Machines are needed as well but getting them can be complicated,” said Dr. Jha. “One way that we can address this is by asking those not seeing as much kidney disease and coronavirus to reallocate their supplies to the hot spots.”
“我們在獲得透析所需的液體方面遇到了麻煩。機器也是需要的，但獲得它們可能是複雜的，”Jha博士說。“我們可以解決這個問題的一個方法是，讓那些沒有那麼多腎病和冠狀病毒的人重新分配他們的供應到熱點地區。”
STOCK PHOTO: Hemodialysis machines with tubing and installations. 庫存照片:血液透析機與管道和安裝。
STOCK PHOTO: Hemodialysis machines with tubing and installations.庫存照片:血液透析機與管道和安裝。
STOCK PHOTO/Getty Images 股票照片/蓋蒂圖片社
The creative spirit hospitals are exercising to preserve resources extends beyond supplies, experts suggest. Staffing shortages – nurses and dialysis machine technicians – are also being stretched thin.
專家建議，創新精神醫院正在努力保護供應以外的資源。人員短缺——護士和透析機技術人員——也在不斷減少。
“Physicians are having to be creative in these circumstances and other types of dialysis machines require specifically trained dialysis nurses which are hard to find,” said Dr. Nwamaka Eneanya, Nephrologist and Assistant Professor of Medicine at the University of Pennsylvania.
賓夕法尼亞大學(University of Pennsylvania)腎病學家、醫學助理教授Nwamaka Eneanya博士說:“在這種情況下，醫生必須發揮創造力，而其他類型的透析機需要經過專門培訓的透析護士，而這是很難找到的。”
MORE: The coronavirus dilemma: Are we using ventilators too much? 更多:冠狀病毒困境:我們是不是用了太多的呼吸器?
Topf echoed that sentiment, noting that the coronavirus “is just wearing down the nurses, and we are really asking a lot of them.”
Topf也表達了同樣的觀點，指出冠狀病毒“正在讓護士們疲憊不堪，我們真的問了他們很多問題。”
“If you focus on machines and fluids and filters, you’re not talking about the real story,” Topf added. “The real story is people.”
“如果你關注的是機器、液體和過濾器，你談論的不是真實的故事，”Topf補充說。“真正的故事是人。”
Taken together, the strain on resources – both human and logistical – remains a threat to those at risk of contracting kidney ailments. And with guidelines in place in some states that might push those resources out of reach of those on dialysis, nephrologists and medical experts hope to spread awareness of the risks.
綜上所述，人力和後勤資源的緊張對那些有患腎病風險的人來說仍然是一個威脅。隨著一些州出臺的指導方針可能會使這些資源超出透析患者的承受能力，腎病學家和醫學專家希望能傳播對這些風險的認識。
“Given the discussions we have been having about using ventilators and crisis standards of care, as well as scare resource allocation, it might be time to start tracking the use of dialysis treatment in critical care and if we have the skilled nurses we need to deliver care to patients with kidney failure,” said Dr. Kelly Michelson, director of the Center for Bioethics and Medical Humanities at Northwestern University. “This can help us get in front of the issue and provide insight to help inform ethics conversations.”
“鑑於我們一直在討論使用呼吸器和危機的護理標準,以及恐慌資源分配,它可能是時候開始跟蹤使用透析治療在重症監護和如果我們有我們需要的技能的護士提供護理患者腎衰竭,”凱利邁克耳遜博士說,中心主任生物倫理學和醫學人文在西北大學。“這可以幫助我們站在這個問題的前沿，為道德對話提供洞見。”
