Re: Yu Xiao, Kaiyu Qian, Yongwen Luo, et al. Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Renal Failure Patients: A Potential Covert Source of Infection. Eur Urol. In press. https://doi.org/10.1016/j.eururo.2020.03.025.

We read the article by Xiao et al [1] on chronic kidney disease (CKD) patients during the coronavirus disease 2019 (COVID-19) pandemic. Clinical research and autopsies have revealed that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is common among individuals with conditions that include renal failure, diabetes, Parkinson’s disease, and physical and mental disabilities [2].

In 2003, an outbreak of SARS occurred among residents of Amoy Gardens, Hong Kong SAR, China. It had been speculated that a patient with renal failure might have carried an extraordinarily high viral load because of immunosuppression, which might then have been transmitted via aerosol formation through the sewers and could have led to a large outbreak [3]. This small case series served as a cautionary tale, highlighting that close attention to SARS-CoV-2 infection in CKD patients is warranted.

As reported by the authors, patients with CKD may be more susceptible to SARS-CoV-2 infection compared to the general normal population [1]. In patients with CKD, impairment of the immune system could result in greater susceptibility to bacterial and viral infections. Moreover, these patients need routine hemodialysis (HD) in hospital two to three times per week. Some symptoms in HD patients with COVID-19 may be difficult to distinguish from other symptoms common in the HD population.

Our hospital is one of the designated hospitals for patients with COVID-19 in Wuhan, China. To add to the report by Xiao et al [1], we noted in our HD center dozens of new patients with end-stage renal disease undergoing HD, and more than 20% tested positive for SARS-CoV-2 from February to March 2020. Moreover, several patients did not seem to present with obvious respiratory symptoms before dyspnea, but their condition deteriorated rapidly after dyspnea occurred. Another HD center in Wuhan reported that 37/230 HD patients (16.09%) and four/33 medical staff (12.12%) were diagnosed with COVID-19, most with mild symptoms [4], suggesting that HD patients have higher susceptibility to SARS-CoV-2 infection and HD centers are high-risk areas during the COVID-19 pandemic.

In addition, researchers in Italy published recommendations for HD patients and HD centers during the pandemic [5], suggesting that HD patients should maximize social distancing, efforts should focus on early detection of infected cases, and the need for hospitalization should be minimized. They also provided recommendations for the safety of medical staff in HD centers.

In summary, HD patients are susceptible to SARS-CoV-2 with mild or no symptoms. Medical staff should take preventive measures to detect patients with COVID-19 as early as possible with the aim of reducing the probability of infection of health care providers and other patients.

The authors have nothing to disclose.

We are grateful for grant B2014070 from the Scientific Research Project of Hubei Education Department.