Chronic Kidney Disease (CKD) is characterized by the irreversible reduction of the number of nephrons, functional units of the kidneys. In this way, the organ becomes unable to perform its multiples and essential homeostatic activitie= s⁽¹⁾. For its magnitude, for affecting so many individuals and having lasting consequences, CKD is considered a public health problem⁽²⁾. In Brazil, the prevalence of people with kidney failure is increasing, the dis= ease has an unfavorable prognosis and costs costly dialysis treatment^(3).

The numb= ers of people undergoing hemodialysis are growing, as well as a high mortality = rate, which is alarming the scientific community in both last decades^{(3).
In July 2018, the estimated total number of dialysis patients in the country
was 133,464, while the annual rate of gross mortality was 9.5%. Of these, 9=
2.3%
were on hemodialysis, 7.7% in peritoneal dialysis and 22.1% on the waiting =
list
for transplant⁽⁴⁾.}

Patients undergoing hemodialysis treatment face many challenges and health-related complications. In addition to this problem, the current pandemic for the new coronavirus (or Covid-19) as a possible aggravating factor to the health of this group. That disease can compromise several tissues and organs of the b= ody, the impairment of kidney function can occur at any moment during the course= of the disease, being more described as late. The pathogenesis of kidney injur= y in Covid-19 has not yet been defined, but it was observed that the presence of comorbidities can favor a more serious course of the disease⁽⁵⁾.

SARS-CoV= -2 is the etiologic agent of the disease called new coronavirus or Covid-19. T= he first cases were registered at the end of 2019 in China, featuring worldwide dissemination months later⁽⁶⁾. Covid-19 can cause the Severe Acu= te Respiratory Syndrome (SARS), a condition that compromises the lungs, causing inflammatory cell infiltration, fluid accumulation (edema) and pulmonary destruction, making it difficult to perform gas exchange⁽⁷⁾.

Until December 7, 2020, the Covid-19 infection reached 67,940,946 people in the w= orld and 6,623,911 in Brazil. Among the most vulnerable people and considered as= a risk group for the worsening of the disease are the carriers of chronic diseases such as diabetes and hypertension, asthma, kidney disease, among others⁽⁸⁾.

It is important to address the hemodialysis services and precautions related to i= nfection. Logistic factors such as transport and the functioning of hemodialysis cent= ers in closed places, allied to the clinical vulnerabilities of the patients wi= th kidney disease, hemodialysis patients in Crema, in Italy, a risk of coronav= irus infection 12.7 times greater than in the local population⁽⁹⁾. In= a hemodialysis center in Spain that attends ninety patients, the prevalence of disease was 41% and mortality was around 16.2% in the first half of 2020(10).

Even with the imminent risk of infection, dialysis treatment could not be interrupted= , as it is essential for the survival of these patients, who maintain an average frequency of going to these places three times a week. Given this context, = the hemodialysis centers of the world adapted their routines following the heal= th protocols recommended by the Ministries of Health, World Organization of He= alth and Specialist Societies, to minimize the risk of infection in these servic= es^(11-12).

In Brazi= l, the first recommendation concerning the care of dialysis patients was publi= shed on March 1, 2020 by Brazilian Society of Nephrology (SBN). As it is a new virus, the recommendations walked along with the evolution of knowledge abo= ut the disease and followed the recommendations and determinations of the Fede= ral Council of Medicine (CFM) and the Ministry of Health⁽¹³⁾. Several countries also issued recommendations that were applied in the context of i= ts services, taking into account regional specifici= ties.

Given th= is reality and the new challenges imposed in dialysis centers to ensure the continuity of the treatment of patients safely, it was necessary to adapt service routines to adopt these recommendations. The professionals of health faced the enormous challenge of dealing with an unknown scenario and fear of death, at the same time, they had to remain active to ensure survival of th= ese patients⁽¹⁴⁾.

Developm= ent is necessary for scientific studies that explore the reality of hemodialysis centers in context of the pandemic. This work has as a goal to identify the= adaptations occurring in hemodialysis centers for the prevention of new coronavirus infection. The study was guided by the following research question: what adaptations have been made in hemodialysis centers for prevention of the new coronavirus infection?

&nb= sp;

METHOD

The pres= ent study consists of an integrative review, a method that provides the synthes= is of knowledge and the incorporation of applicability of study results significantly⁽¹⁵⁾. This type of study allows the combination of primary and secondary studies, evaluating the methodological quality in ord= er to propose new results according to the objective intended⁽¹⁶⁾.<= o:p>

The Integrative Review (IR) is consisting of six distinct phases: 1) identifica= tion of the theme and selection of the hypothesis or research question for the elaboration of the integrative review; 2) establishment of criteria for inclusion and exclusion of studies/sampling or literature search; 3) defini= tion of the information to be extracted from the studies, selecting the categorization of studies; 4) evaluation of studies included in the integra= tive review; 5) interpretation of results; 6) presentation review/synthesis of knowledge⁽¹⁷⁾.

In the f= irst stage, the research question was: what adaptations performed in hemodialysis centers for the prevention of infection by the new coronavirus? Later, in t= he second stage, the strategies for searches were defined, in which the follow= ing Health Sciences Descriptors (DeCS) combined with operators Booleans AND and OR: "infections by coronavirus", "= hospital units of hemodialysis", "hemodialysis centers", “renal dialysis”, hemodialysis, “failure chronic kidney disease", "peritoneal dialysis", "disease by the new coronavirus"= and "measures of security”, as shown in Figure 1.<= /span>

The data collection step was held in December 2020, through electronic searches in Latino Literature-American and Caribbean in Health Sciences (LILACS), in Medical Literature Analysis and Retrieval System Online (MEDLINE) and in the Bibliographic Index Español en Ciencias de la Salud (IBECS). Studies were included w= hen published from December 2019 to November 2020, available in Portuguese, Eng= lish or Spanish and that dealt with adjustments made in the centers of hemodialy= sis due to the new coronavirus pandemic. Studies of review, technical notes, manuals or other recommendations for prevention of Covid-19 in hemodialysis centers were excluded.

In the selection step, initially 486 studies were found, then with the application= of the filter from the year 2019 to 2020, remained 421. After reading all titl= es, 41 studies continued. The reading of the abstracts continued, with the permanence of 30 studies. At the end, after reading the articles in full, 16 studies were selected, which two of them got eliminated, because they were duplicated in more than one database. Therefore, the final study sample consisted of 14 articles, as shown in Figure 1. After the careful reading of the studies in the sample, data were extracted on its characterization, as = well as those who answered the question of research.

Table 1<= /span>- Characterization of selected studies regarding a= uthors' names, month and year of publication, type of study, country and study sett= ing, indexed databases and journal of Publication, Macei&oa= cute;, Brazil, 2020.

AUTHOR= S/ MONTH/ YEAR OF

PUBLIC= ATION

TYPE O= F

STUDY / LEVEL

OF EVIDENCE

SCENARIO/

COUNTRY<= /span>

BASES/

JOURNAL<= /span>

¹⁸ S&aac= ute;nchez - Pérez et al., 08- 09/2020

Report of

experience/VI

Tertiary hospital/<= /span>

Spain=

IBECS/ MEDLINE/

Journal of Nephrology

¹⁹Arribas ̵= 1; Cobo et al., 07/2020

Repor<= /span>t of<= /p>

experience/VI

Hospital Unit/

Spain

IBECS/ Enfermería

Nefrológica

²⁰Andreu-Periz

et al., 10/2020

Phenomenological Qualitat= ive/ IV

Hemodialysis Hospital Units/ Spain

IBECS/ Journal of

Nephrology

¹⁰Albalate et

al., 05- 06/ 2020

Report of

experience/VI

Hospital Unit/

Spain

IBECS/ Journal of

Nephrology

⁹Depetri et al.,

05/2020.

Report of

experience

Dialysis Center of<= /span>

Crema, Italy=

MEDLINE/ G Ital

Nefrol

²¹Bharati et al.,

07/ 2020

Report of

experience/VI

Reference Center

tertiary hemodialysis/

South and Southeast Asia<= /o:p>

MEDLINE/ Journal of

Nephrology

²²Ippolito et al.,

06/2020

Report of

experience/VI

Dialysis unit/ Italy

MEDLIN/ Giornale

Italiano di Nefrologia

²³Yau et al., 11/2020

Cohort Study/IV

Hospital Unit/

Toronto, Canada

MEDLINE/ American

Journal of Kidney

²⁴ Cho et al., 12/2020

Cohort Study/IV

Hemodialysis Units/ Korea

MEDLINE/ Journal of=

the American=

²⁵ Li e Xu, 05/2020

Report of

experience/VI

Dialysis Centers / Wuhan in Ch= ina

MEDLINE/ Clinical

Journal of American=

Society of Nephro= logy

²⁶ Arenas et al.,

04/ 2020

Report of

experience/VI

Hemodialysis unit/

Spain

IBECS/ J. Nefrol

²⁷Ossareh et al.,

09/2020

Report of

experience/VI

Hospital Unit/

Wuhan China

MEDLINE/ Iranian

Journal of kidney

Diseases

²⁸ Ulrich et al.,

03- 04/ 2020

Report of

experience/VI

Hemodialysis unit/

U.S

MEDLINE/ Nephrol

Nurs J.

²⁹ Wei et al.

06/2020

Report of

experience/VI

Dialysis Center / Wuhan, China

MEDLINE/ Renal

Failure

Source: Authors (2020).

Table 2 – Main adjustments adopte= d in hemodialysis centers of the studies analyzed after the Covid-19 pandemic, <= span class=3DSpellE>Maceió, Brazil – 2020.=

I) HOMECARE AND TRANSPORT

II) NEW ROUTINES IN HEMODIALYS= IS CENTERS

III) CHANGES IN HUMAN/MATERIALS RESOURCES

Genera= l:

✔ Washing hands before the exit from home^{(19, 26)};=

✔ Avoid contact with sick peop= le/ symptomatic^{<=
span
lang=3DEN-US style=3D'font-family:"Times New Roman",serif;mso-fareast-fon=
t-family:
"Times New Roman";mso-ansi-language:EN-US'>(23,26)};=

✔ Keep up at home in eminence = of symptoms of Covid and call to the center of dialysis for<= /o:p>

guidelines⁽²⁶⁾.

Transp= ort:=

✔ Sanitize the hands before en= ter the ambulance(26) and w= ear mask during the

transport^{(18, 19)};<= o:p>

✔ Offer of written instruction= s to the operators and patients about the measures to be followed at home and = on travels from/to the center dialysis^{(9, 27=
)};=

✔ The transport in collective ambulance was discour= aged; oriented to use

own vehicle^{(10, 18)}.=

Screen= ing:

✔ Hand wash with hydroalcoholic solution^{(19,20,10,26,27)} and in a continuous way^{(=
23, 27,
29)};

✔ Washing the fistula with hydroalcoholic solution^{(19, 20,27)};=

✔ Mandatory use of mask includ= ing by escorts in the waiting room^(18,19) and constant use of surgical mask by patients^{(19, 20, 10, 22, 23, 27, 29=
)};

✔ Patient screenings: 1st) by phone on the prior day to the dialysis session; 2nd) upon arrival in the waiting area for the unit of dialysis⁽²³⁾;=

✔ Protocol implementation<= /o:p>

screening for patients and

professionals of health ^{(=
18,10,22,23,24)} which included the monitoring of vital signs ^{(18,19,23,24)} and questions about the symptoms or contact with confirmed cases or suspects<= sup>(18, 23, 24);

✔ Creating a clinic triage for patients with suggestive diagnosis with blood tests immunoglobulin (IgG/I= gM) and computed chest tomography

(CCT)⁽²⁷⁾;

✔ Implementation of physical distance in the waiting roo= m⁽²³⁾= .

Dialysis:

✔ Acce= ss prohibition to the dialysis room by escorts and shift changes of dialysis= ^{(19,20,29,24)} with distance between the machines^{(19, 20, 23)} of two meters⁽²¹⁾;<= /span>

Common:<= /span>

✔ Corr= ect use of PPE ^{<=
span
lang=3DEN-US style=3D'font-family:"Times New Roman",serif;mso-fareast-fon=
t-family:
"Times New Roman";mso-ansi-language:EN-US'>(18,19,22,24,26,27,28,21)} and dispensers of disinfectant⁽⁹⁾ were installed;

✔ Crea= tion of a care protocol with patients in dialysis⁽²⁴⁾=

&= nbsp;

Health education:

✔ Implementation of protocols with guidel= ines on the disease/prevention^(10,23,25);<= /p>
✔ Guidelines for patients about infection, prevention and measures in the face of symptoms<= span style=3D'mso-bookmark:_Hlk74668380'>^(10,21) and every turn on the care for the disease⁽²⁹⁾;

✔ Social distancing within the rooms of dialysis and= out⁽²⁹⁾= ;

✔ Vaccination for seasonal flu= (Haemop= hilus influenzae<= span style=3D'mso-bookmark:_Hlk74668380'>)^=
(26) and implantation of biosecurity protocol ^{(10, 19)};<= /span>

Precau= tions/biosafety:

✔ Constant use of surgical mas= k^{(19,20,10,27,29)} and strict hand hygiene^{(=
21,
25, 27, 28, 21)} before, during and after each procedure^{(24);
creation of an exchange area adequate⁽²¹⁾;}

✔ Adoption of effective protec= tive measures and precautions, including the use of masks, hats and aprons that meet to requirements⁽²⁵⁾ and standard precautions: pre-examination, invasive operations, vascular acce= ss connection, injections, collection of blood and other operations through contact with blood and patient's bodily fluids⁽²⁵⁾;=

✔ Professionals are always well protected with all PPE⁽²⁸⁾, including personal goggles, closed shoes, suitable clothes and mask N95(27). Assiduous use whenever they are in dialysis rooms and especially in patie= nt contact⁽²⁸⁾;

Traini= ng/continuing education/motivation:

✔ Training professionals in the hemodialysis unit on the use of PPE, with an emphasis on proper removal⁽²⁹⁾= and contamination prevention<= sup>(24) and identification of signs of Covid-19 symptoms⁽²⁶⁾;

✔ Correct handling of surgical masks and N95(28) and guidance on patient care^(18,29);

✔ Strategies to deal with the = new scenario and the practice of clinical look^(28,29), leading and examining patien= ts with the discussion of cases and reduction of fear with the intensificati= on of prevention measures⁽²¹⁾

Resour= ce and routine management:

✔ Expansion of human resources= and awareness of interpersonal relationships for nurses in order to facilitate adaptation to tasks⁽²⁰⁾;=

✔ High availability of personal protect equipment (PPE) and encouragement for the adoption of surgical ma= sks, coveralls, gowns, water repellents, glasses, shoe protectors, gloves and harness for the assistance of the patients⁽⁹⁾<= span lang=3DEN-US style=3D'font-family:"Times New Roman",serif;mso-fareast-fon= t-family: "Times New Roman";mso-ansi-language:EN-US'> and availability of kits with goggles, N95 mask and plastic apron, in addition to the cotton smock, glo= ves, cap and usual shoe protectors⁽²¹⁾. The gaps of supply were man= aged with the internal production of 3D printing visors⁽²¹⁾;

✔ Cluster medical activities w= ith large groups such as study groups and discussion with the patient were carried out by phone or inter= net⁽²⁵⁾= .

Source: = Authors (2020).

The hemodialysis centers had to adapt to Covid-19's pandemic scenario to ensure continuity of treatment of patients safely⁽¹⁹⁾. They deepened th= eir knowledge and sought to transform the scenario with the implementation of n= ew routines and incentives for patients and professionals, in order to ensure = the continuity of hemodialysis⁽²⁰⁾.

Among the measures cited for the prevention of Covid-19 in studies, highlights are ha= nd washing^{(19, 26, 20, 10, 27)}, recommended to patients and professionals of continuous form^{(23, 27, 29)}. It is a low cost a= nd high effectiveness measure, because the hands are the main vehicle of cross contamination⁽³⁰⁾, becoming a fundamental measure of Sanitary protocols. Its correct execution removes transient skin flora and desquamat= ed cells, reducing the risk of infection. Hand hygiene can be performed with s= oap and water or alcoholic and antiseptic solution⁽³¹⁾.

Another measure adopted in the centers of hemodialysis consists of the mandatory us= e of masks by patients since leaving house^(18-19), as well as by professionals and escorts, when present^{(10,19,20,22,23,27,29)}. T= he masks are mechanical barriers for the prevention of droplet dispersion with= the purpose of self-protection against diseases, and also to prevent the transmission of pathogens between sick and healthy individuals, masks have = been used as a popular public health intervention⁽³²⁾.

The stud= ies also highlighted important recommendations aimed at patients and profession= als involved in the transport of patients to hemodialysis centers. In addition = to the guidelines on the washing hands before entering the ambulance^{(26)<=
/sup>
and the use of a mask^{(18, 19)}, there was also the distribution of
instructions written about the measures to be followed at home and during t=
he
journey^(9,27). In two centers of Spain, transport in collective
ambulances were discouraged, being recommended the use of own vehicles^=
(10,
18). This aspect represents a critical point, especially in Brazil, s=
ince
many patients reside in cities far from services and are not able to afford=
the
expenses of private transport.}

The hemodialysis centers modified the service flow with the implementation of mandatory routines in screening the patient before entering the room dialys= is, which included: hygiene of hands^{(19,20,10,26,27,23,27,29)}, use of masks^{(18,19, 20, 10, 22, 23, 27, 29)}, operationalization of a screening protocol for the identification of healthcare professionals or symptomatic patients through the investigation of symptoms and check vitals sign^{(18,10,22,23,24)}. In addition, a hemodialysis center in Wuhan has implemented a clinical screening with the provision of immunoglobulin a= nd tomography tests for patients with diagnoses suggestive of Covid-19. <= /o:p>

In addit= ion to patient screening after the entrance to the dialysis unit, a center in Canada inserted a telephone triage, performed the day before dialysis, with= the objective of evaluating the patient and providing the necessary guidance and support⁽²³⁾. In this sense, the importance of initial evaluation/screening done by health professionals to the patient on dialysi= s, because this allows the detection of flu symptoms and the targeting of susp= ect patients to a more detailed evaluation, following a different service flow = to guarantee your safety and of other patients and professionals^(33).

The measurement of vital signs during the screening of patients, professionals = and family members who arrive at the center of hemodialysis is crucial to reduce the risks of Covid-19 infection as it allows the comparison with patterns a= nd bodily trends and directs the= conduct of professionals⁽³⁴⁾. The washing of the arm of the arteriovenous fistula in patient screening was implemented in two centers in Spain and of China^{(19, 20, 27)} and there is also a purpose to reduce the risk= of infection, being performed by prior cleaning of the puncture site using mild soap and antiseptic⁽³⁵⁾.

Dialysis services changed routines inside the dialysis rooms too. Between identified measurements, the prohibition of access to room by companions, being allowed only in strictly necessary situations⁽⁹⁾. Changes in shifts of dialysis were implemented in two centers of dialysis from Spain, one from K= orea and one from China^(19,20,24), to minimize agglomeration of patie= nts. The distance between the stations of hemodialysis were also observed^(1=
9,20,23), two meters between them⁽²¹⁾. These conducts are aligned with the main recommendations of the World Organization of Health⁽³⁶⁾.

Some com= mon measures were implemented in all sectors of the units of dialysis, such as = the use of individual protection of form correct^{(18,19,22,24,26,27,28,21)<=
/sup>,
implantation of biosafety protocol^(19,10) and the creation of a
patient care protocol on dialysis⁽²⁴⁾. There was also the
implementation of alcohol gel dispensers⁽⁹⁾ for patients, escorts
and professionals. Due to its antiseptic properties, the alcohol use in gel
became indispensable in the fight against the pandemic, with wide availabil=
ity
in various spaces and at the main entrances to buildings, public transport =
and
health services⁽³⁷⁾.}

Some dialysis centers carried out various educational actions aimed at self-care= of patients, with emphasis on preventive measures to minimize risks of infecti= on by the new coronavirus^(10,21). At the dialysis center in Wuhan, China⁽²⁵⁾, educational actions were promoted on the Covid-19 on = all shifts, with the purpose of promoting a greater availability of information= and to solve doubts about the infection. They also included guidelines on social distancing inside and outside the rooms. In a center of dialysis from Spain= ⁽²⁶⁾, the patients too were instructed to receive the seasonal flu vaccine, becau= se although this one doesn't check protection against Covid-19, it prevents the seasonal flu, which can be an aggravating factor to the clinical picture of these patients.

There we= re significant changes regarding human resources and availability of materials= in the services of hemodialysis in the face of the pandemic. One of adaptations that should be highlighted are the intensification of strategies for biosaf= ety, such as the constant use of masks^{(19,20,10,27,29)}, strict sanita= tion of the hands^{(21,25,27,28,21)} before and after each procedure(24), protective measures and effective standard precautions, including use of ma= sks, hats and aprons that meet the requirements by the workers⁽²⁵⁾. T= he glasses of personal protection, closed shoes, appropriate clothing and N95 masks also became more rigorously used⁽²⁷⁾. In one dialysis unit= ⁽²⁸⁾, health professionals were instructed to stay assiduously with all PPE whene= ver they were inside the rooms and mainly in direct contact with the patients. = These strategies are paramount to give greater security to the performance professional⁽³⁸⁾.

Hemodial= ysis services organized to ensure the greatest supply of PPE, as with the change= s in routines and the intensification of biosafety actions, the consumption of t= hese inputs was increasing. Beyond the standard precautionary equipment already used, were added some high protection, such as overalls, repellent coats of water, harness⁽⁹⁾, N95 mask and cap⁽²¹⁾.

The management of gaps in supply was a problem experienced by all countries and= in all health services. To deal with these gaps, a tertiary referral center of Asian hemodialysis⁽²¹⁾ produced visors by 3D printing, using pla= stic sheets of protection. A study also pointed out that there was an increase in the availability of human resources in the service, given the overload of w= ork that professionals have been and are being exposed to during the pandemic(20). The same center also cited the insertion of team training in order to foste= r a better relationship between nurses, enabling greater adaptation to new challenges imposed by the pandemic⁽²⁰⁾. Covid-19 imposes a work routine on the professional which requires greater dedication, responsibili= ty, skill and emotional balance⁽³⁹⁾.

There was also investment by some centers in training/qualification for the teams on = the use of PPE, patient management, as well as personal motivation to reduce insecurity in acting in this context⁽²¹⁾. These professional empowerment/training moments were fundamental for the planning of care, to discuss cases and create service flowcharts/strategies⁽⁴⁰⁾.=

A study = at a center in Crema, Italy, reported the experience of 13 patients on peritoneal dialysis at home. At the beginning of the pandemic, they received guidance = and participated in online consultations through chats with doctors. These pati= ents had no additional risks and specific aspects of hemodialysis subjects (home-hospital displacement) regarding the exposure to infection by the new coronavirus, since they were isolated in the home. Only one of the patients= on peritoneal dialysis tested positive for Covid-19. Peritoneal dialysis is a viable alternative in the midst of the pandemic, in addition to requiring l= ower costs in the treatment of the patient⁽⁹⁾.

CONCLUSI= ON

The study achieved its objective, since it identified the adaptations performed in hemodialysis services of several countries for the prevention of the infect= ion of the new coronavirus for chronic kidney patients.

The arti= cles addressed a range of adjustments; one of the main ones was the reinforcemen= ts to the guidelines on washing the hands. Were also implemented guidance on m= ask use by patients during transport and in the room of waiting, the importance= of PPE for the professionals who are directly counting with the patients, the rotation in the shifts of dialysis and the distance of equipment.

The implementation of these measures was crucial for patients to continue their treatment and minimize the risks of exposure. It is important to emphasize = that all these changes that have taken place in the centers of hemodialysis reinforce the importance of more intensive implementation of standards and biosafety routines, because often, in the daily lives of professionals, they are neglected, and should be applied regardless of the context of the pande= mic. The adjustments that occurred also lead to reflection on peritoneal dialysi= s as a possible treatment to be further explored and investable both in the pand= emic as in the daily lives of patients, as it can be performed at home, reducing costs and wear and tear with the displacement.

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<= /p>

Submission: 2021-04-01

Approval: 2021-05-11