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                  Managing your health during the COVID-19 outbreak

                  What are my rights as a kidney patient if my employer wants me to return to work

                  There are laws to protect people with chronic conditions and illnesses from discrimination in the workplace. Your legal rights may be protected by one of the following federal acts.

                  Americans with Disabilities Act (ADA)

                  If you work for a company with 15 or more employees, the Americans with Disabilities Act (ADA) requires your employer to make any “reasonable accommodations” that you might need in order to perform your work duties.

                  Examples include:

                  • Making parking lots, bathrooms, and work areas handicapped accessible
                  • Allowing you to work from home if possible, in your current role
                  • Having flexible work schedules (to schedule around dialysis treatments for example)
                  • Designating a sterile area to exchange cleansing fluid bags for PD
                  • Reassigning you to a less strenuous job if you request one and one is available
                  • Assigning any of your non-essential tasks to other employees, at your request

                  The Equal Employment Opportunity Commission (EEOC) handles complaints under the ADA.

                  Family and Medical Leave Act (FMLA)

                  If you work at least 20 weeks of the year for an employer with 50 or more employees, you may qualify for the Family and Medical Leave Act (FMLA). The FMLA allows for 12 weeks of unpaid, job-protected leave for medical reasons.

                  If you had group health insurance coverage before taking leave, it will continue under the same terms or conditions.

                  Your employer can ask for medical certification stating that you have a serious illness but cannot punish you for taking leave to have surgery or begin treatment. Your spouse, children, or parents may also be eligible for FMLA leave if you need them to provide you with care or transportation.

                  The Department of Labor (DOL) handles complaints under FMLA.

                  Families First Coronavirus Response Act

                  You may also have protected rights under the new Families First Coronavirus Response Act – which includes the Emergency Family Medical Leave Expansion Act (EFMLEA) and the Emergency Paid Sick Leave Act (EPSLA) – or other state and local laws.

                  The FMLA Expansion Act provides 12 weeks of leave. If you are a full-time employee, the Emergency Paid Sick Leave Act provides 80 hours of leave. If you are a part-time employee, the law provides leave for the average number of hours you work in a two-week period. Currently these provisions expire December 31, 2020.

                  For more information, including suggestions for writing a letter to your employer requesting work accommodations because you are at high risk for severe disease from COVID-19, click here.

                  Should I go to my doctors appointments?

                  You should first call your doctor’s office to see if they have regular office hours or if they’re doing phone, Skype, or other types of remote visits.

                  If you can’t have a phone or remote visit because you need a treatment, vaccine, or test, then you should ask if it’s possible to do them at a later time when it might be safer.

                  How do I balance my health goals with the realities of COVID-19?

                  Stay in touch with your healthcare team as often as possible, especially if you have any new signs or symptoms of illness. You should also reach out to them if you can’t get the medicines or foods you need.

                  Your main health goal is to avoid exposure to COVID-19 by staying inside and keeping a safe distance from others if you need to go out. While inside, you can relieve stress with hobbies such as reading, sewing, drawing, or board games. You should also talk with friends and family by phone, or by exercise, if allowed by your healthcare team. Be realistic with your exercise goals, and find ways to keep fit when not at the gym. For example, use stairs for a good cardio workout and look for exercise classes online. Find great tips on exercise and meditation during the outbreak here.

                  In time you’ll be able to return to your normal routine. But for now, you can do things you would because you were busy outside of your home. Just think how good you’ll feel if you finally clean that basement or closet–not only will you burn a lot of calories, you’ll also feel a sense of accomplishment that is very good for your health!

                  What is telemedicine and what do I need to know about it?

                  Telemedicine, also known as telehealth, allows for virtual appointments (remote visits, but in real time) with your healthcare professional using your computer, tablet, or smartphone. Check with your provider to see if they offer virtual appointments so you can reduce your exposure to the coronavirus. Many insurance plans cover telemedicine, including Medicare. Veterans also have access to telemedicine through the Veterans Administration.

                  Telemedicine can also include remote monitoring of your health by a healthcare professional, most often a telehealth nurse. By using a special monitor that’s connected to a blood pressure machine or other device, the nurse can check on you at any time.

                  Healthcare professionals can’t diagnose COVID-19 through telemedicine, but they can provide medical advice, tell patients how to quarantine and when they should go to the hospital, order tests, and write prescriptions. For more information contact the American Telemedicine Association.

                  Use this worksheet when at a telemedicine appointment with your healthcare professional.

                  Can COVID-19 cause kidney failure in otherwise healthy adults?

                  There have been recent reports of nonelderly adults infected with COVID-19 who have developed an acute kidney injury (AKI) — sudden loss of kidney function. These adults did not have underlying medical conditions. With proper treatment, including dialysis in severe cases, AKI can be reversible.

                  Acute kidney injury (AKI) and chronic kidney disease (CKD)

                  " COVID-19 also attacks the kidneys, not just the lungs."

                  — Professor Carmine Zoccali, MD, President of the European Renal Association–European Dialysis and Transplantation Association (ERA–EDTA)

                  Acute kidney injury (AKI), also known as acute renal failure (ARF), is not the same as chronic kidney disease (CKD), which will eventually lead to chronic kidney failure (CKF). Neither CKD or CKF are reversible diseases. Detecting proteins and/or blood in urine labs is an early sign of kidney involvement in people with confirmed COVID-19.

                  AKI and COVID-19

                  A new comprehensive report shows that people hospitalized with COVID-19 are at significant risk of AKI, which can lead to serious illness, dialysis, and even death. The study found patients with COVID-19, who were hospitalized between March 11 and April 26, were twice as likely to develop AKI as compared to non-COVID patients who developed AKI during the same time period in 2019 – 56.9% versus 25.1% respectively. AKI appears to be a marker of COVID-19 infection severity and the mortality rate is higher for these patients.

                  Various COVID-19-related effects that are thought to contribute to AKI include kidney tubular injury (acute tubular necrosis) with septic shock, microinflammation, increased blood clotting, and probable direct infection of the kidney. Most patients with COVID-19-related AKI who recover continue to have low kidney function after discharge from the hospital.

                  Long term implications of AKI

                  It’s recommended that recovered COVID-19 patients who had an AKI or ARF should be seen regularly by a kidney doctor, because their risk of developing chronic kidney disease is higher than others. COVID-19 patients who did not develop an AKI, but who had blood and/or protein in their urine, should be monitored since they are at increased risk of developing chronic- and end-stage-kidney disease.

                  What should I know about miracle cures and treatments?

                  " The FDA considers the sale and promotion of fraudulent COVID-19 products to be a threat to the public health."

                  Stephen H Hahn, MD, FDA Commissioner

                  Unfortunately, in times of uncertainty, there are people who look to prey upon those who are vulnerable. The US Food and Drug Administration (FDA) reports there are unscrupulous companies and individuals looking to fraudulently profit by scamming people who want to prevent and/or treat COVID-19.

                  Knowledge is power

                  The best way to avoid becoming a victim of fraud is to know the facts. According to the latest guidance from the CDC, there no vaccines or drugs approved to treat or prevent COVID-19. And, while there are investigational COVID-19 vaccines and treatments in development, these investigational products are still in the early stages of development and have not yet been fully tested for safety or effectiveness.

                  Beware of false promises

                  Products that claim to cure, mitigate, treat, or prevent disease, but are not proven safe and effective for those purposes, defraud consumers of money and can place consumers at risk for serious harm. Fraudulent COVID-19 products may come in many varieties, including dietary supplements, such as vitamins and minerals, foods (garlic), as well as questionable products purporting to be drugs, herbal remedies, immune boosters, medical devices, or vaccines. Using these products may lead to delays in getting proper diagnosis and treatment for COVID-19.

                  The FDA urges consumers and patients to talk to their healthcare providers and to follow the advice from federal public health agencies about how to prevent the spread and treatment options for people with COVID-19.

                  How can I protect myself if I need a blood test or other labs?

                  " Keep in mind that you may need a new “order” from your doctor if you use a new lab."

                  For routine blood draws or other kinds of labs, contact your healthcare provider to determine if the test can be postponed. If your doctor feels the test is necessary to do now, contact your lab to see if it can be done at home. Check if your lab is accepting urine samples dropped off at their site or sent through the mail. Sterile specimen cups can be purchased online or may be in stock at a local pharmacy.

                  If home testing is not an option, you should ask your lab, doctor, or transplant coordinator if there are any local labs that can provide in-home testing services. Not all health insurance plans cover lab visits at home, so you should contact your insurance provider to learn about your coverage.

                  Staying safe at the lab

                  If the test cannot be postponed or done in your home, you should know that medical facilities are taking precautions to keep you healthy. Hospitals, labs, doctors’ offices, and dialysis centers are evaluating patients and staff, such as checking temperatures and asking questions, to assess each person for active COVID-I9. If it is suspected that someone has the virus, then those people are kept isolated from all healthy people.

                  Prevention tips

                  It is also important that you take measures to help keep yourself safe and reduce the chance of getting COVID-19. Be sure to wear a mask when you go outside your home. Keep at least 6 feet distance between you and other people. Remember to wash your hands frequently and use hand sanitizer if there are no washing facilities. Avoid touching your eyes, mouth, and nose.

                  Be well prepared

                  Have extra supplies on hand, including surgical masks, hand sanitizer, and disposable gloves, so that if you come into contact with someone at a medical facility or if a technician comes to your home, you are both well protected. For in-home visits be sure to disinfect any surfaces that another person may have touched, such as doorknobs and countertops.

                  For National home testing programs click here:
                  CareDx
                  Natera

                  Are transplant recipients at higher risk of getting COVID-19?

                  Because transplant recipients take immunosuppressive drugs, they have a higher risk of infection from viruses such as cold or flu. To lower the chance of getting the coronavirus that causes COVID-19, transplant patients should follow the CDC’s guidance on how to avoid catching or spreading germs, and contact their health care professional if they develop symptoms of COVID-19.

                  Statement from the American Society of Transplantation (AST):
                  We do not have specific information on whether COVID-19 infection will be more severe in transplant recipients compared to healthy people; however, other viruses often cause more severe disease in people whose immune system is low, such as transplant recipients.

                  Are people born with one kidney at higher risk for COVID-19?

                  No specific information exists about there being a higher risk for COVID-19 in people who have a single kidney as compared with the general population.

                  Can I be denied dialysis treatment if I have COVID-19?

                  No. People who are on dialysis and who have also contracted COVID-19 are considered to be at high-risk. If there is availability, these patients may even be admitted to a hospital. In the event your symptoms are mild, you should be able to go to your dialysis center for your scheduled treatments.

                  The Centers for Disease Control has already issued interim guidance for patients on dialysis who have COVID-19 and all centers should be following these guidelines.

                  If you have a confirmed case of COVID-19, or have symptoms of COVID-19, or believe you may have been exposed to the coronavirus, then call your dialysis center prior to your scheduled appointment as there may be new procedures they would like you to follow.

                  How to cope with loneliness

                  " A near-constant stream of news reports about an outbreak can cause anyone to feel anxious or distressed. "

                  World Health Organization, March 2020

                  If you are like most people in America, you are now practicing social distancing to keep you and your loved ones and other people in your community safe from contracting COVID-19. However, it’s important to remember that social distancing is not the same thing as social isolation. At the same time, feeling lonely and anxious when you need to remain isolated is a very normal reaction.

                  World Health Organization Recommendations

                  According to the World Health Organization, if you are under quarantine staying or staying home as instructed by government officials, you should try to keep up your personal daily routines. WHO recommends that you pay attention to your own needs and feelings and engage in healthy activities that you enjoy and find relaxing, to exercise regularly, keep regular sleep routines, and eat healthy foods.

                  It is recommended that people seek out COVID-19 updates and practical guidance from health professionals and the WHO website.

                  Staying occupied

                  While staying home, there are many things you can do keep active and mentally stimulated. Here are just a few suggestions:

                  • Stay in touch with friends and family through technology – video conference, play online games, or post cute animal photos on Facebook and Instagram
                  • Haven’t been to Broadway in a while? Stream shows for free at insider.com
                  • Upcoming new movies are either already available (or will be soon) on demand instead of opening in theaters – they will be released for purchase. Learn more by contacting your cable provider, streaming services, and at ET Live
                  • Tackle a DIY project, trying a new recipe, or spring-cleaning
                  • Become an armchair scholar, traveler, private detective – or anything else!
                  • Spend quality time with your pet

                  Whatever you choose to do, know that you are contributing to the health and well-being of yourself, and everyone else in our country and world.

                  What does "shelter in place" mean?

                  Shelter in place means to stay at home. Exceptions to go out may include tasks that are essential to the health and safety of your family and pets.

                  If you are at higher risk for serious illness from COVID-19 because of your age or other serious health problems such as kidney disease, you should not go out except for essential medical appointments and treatments such as dialysis.

                  Additionally, non-essential businesses are closed such as dine-in restaurants, bars and nightclubs, entertainment venues, fitness centers, hair salons, public events, and convention centers. The purpose is to avoid large groups of people from gathering to prevent spread of COVID-19.

                  Businesses that may be open include stores that sell groceries, take-out and delivery restaurants, gas stations, pharmacies, laundromats, banks, and government offices and services. Check on local information for shelter in place rules in your area.

                  What does "lock-down" mean?

                  In the context of COVID-19, “lock-down” and “shelter in place” (see above) are being used interchangeably. Check on local information for lock-down rules in your area.

                  When should I leave my home?

                  The best practice is to stay at home except for essential medical appointments and treatments, such as dialysis. You may also have to leave your home for other health-related issues. If you have symptoms of COVID-19, call your healthcare provider immediately. If you have a medical emergency call 911.

                  In some areas, supermarkets are offering special shopping hours for senior citizens to shop without additional crowds in the store. This may be a good option for older adults if grocery delivery is not available. Check on local information about when to leave your home.

                  Should I use public transportation?

                  Public transportation such as buses, subways, and trains will increase your chances of close contact with more people which may increase your exposure to COVID-19. In some areas, public transportation is reserved for essential workers. You may choose to use a taxi or ride share service to limit your exposure to large numbers of people.

                  How can I protect myself if I have to use a taxi or ride share?

                  You can protect yourself in a taxi or ride share by wiping down the seat, seat belt and anything else you may touch in the vehicle with a disinfectant wipe. Don’t shake hands with anyone in the vehicle and don’t touch your face. Wash your hands or use hand sanitizer after paying for the ride.

                  Learn more about how to protect yourself from COVID-19 on the Centers for Disease Control (CDC).

                  How can I help prevent my loved one from getting COVID-19?

                  Older people and those with underlying medical conditions, such as chronic kidney failure or people have had a kidney transplant and take immunosuppressive drugs, are at increased risk of contracting COVID-19 and developing serious complications.

                  Take stock of your supplies

                  If you are caregiver for a family member or friend who is at an increased risk of serious disease, now’s the time to make sure you are prepared by doing the following.

                  • Know what medications your loved one is taking and see if you can help them have extra on hand.
                  • Monitor food and other medical supplies (oxygen, incontinence, dialysis, wound care) needed and create a back-up plan.
                  • Stock up on non-perishable food to have on hand in your home to minimize trips to stores.
                  • If your loved one is a resident in a care facility, check whether any residents have tested positive and know what will happen should an outbreak occur.

                  How can COVID-19 affect transplant surgeries?

                  Statement from the American Society of Transplantation: The risk of acquiring COVID-19 from organ donation is low. Donors are screened for COVID-19 symptoms and exposure history. Living donors who have been to high-risk areas or exposed to someone diagnosed or being evaluated for COVID-19 infection are generally being asked to postpone donation for 14 to 28 days after returning. Some organ procurement organizations are testing some or all donors for COVID-19. The Center for Disease Control (CDC) made recommendations about elective surgeries and non-essential procedures that include transplantation. Transplants should not be postponed in “high acuity/unhealthy patients.” Some centers may still need to look at temporarily putting elective living donor transplantation or non-urgent deceased donor transplants on hold. Transplant centers will base these decisions on issues such as the level of circulating COVID-19 infection in their areas and/or operational issues (such as testing availability, bed space, availability of basic supplies and equipment, including personal protective equipment).

                  Also, living donors are being asked to not travel to high-risk areas for at least 14 days before donation and monitor for symptoms. Information about recent travel and possible exposure is also asked about deceased donors to help determine if it is safe to use them for organ and tissue donation.

                  The Center for Disease Control (CDC) made recommendations about elective surgeries and non-essential procedures that include transplantation. Transplants should not be postponed in “high acuity/unhealthy patients.” Some centers may still need to look at temporarily putting elective living donor transplantation or non-urgent deceased donor transplants on hold. Transplant centers will base these decisions on issues such as the level of circulating COVID-19 infection in their areas and/or operational issues (such as testing availability, bed space, availability of basic supplies and equipment, including personal protective equipment).

                  Where can I get tested?

                  The US Department of Health & Human Services has partnered with pharmacies and retail companies in an effort to make COVID-19 testing more available and accessible to Americans in many areas of the country. The goal of this partnership is to expand testing to communities across the US especially in populations that are under-tested and socially vulnerable.

                  Americans will have access to faster, less invasive, and more convenient testing for active COVID-19 infection, while protecting healthcare personnel by eliminating direct contact with symptomatic individuals.

                  It is important to remember that a negative test result means that the virus that causes COVID-19 was not found in a person’s sample. In the early stages of infection, it is possible the virus will not be detected especially in those who do not have any symptoms.

                  Click here to find a testing location near you.

                  Can I recover from COVID-19 and then get it again?

                  " With regards to recovery and then reinfection…we do not have the answers to that. That is an unknown."

                  Dr Mike Ryan, Executive Director, WHO Health Emergencies Programme

                  According to the CDC, the immune response to COVID-19 infection is not yet understood. It is believed, in the short-term, that people who recover from COVID-19 are unlikely to be reinfected with the virus. However, the length of time that someone may be immune is uncertain.

                  WHO guidance

                  In a recent statement, WHO officials have reported there is no evidence that people who have recovered from COVID-19 and have antibodies are protected from a second infection. In addition, no study has evaluated whether the presence of COVID-19 antibodies confers immunity to subsequent infection by this virus in humans.

                  COVID-19 testing accuracy

                  There is also some concern regarding the test for COVID-19 antibodies. A negative test result means that there were no detectable antibodies found in the specimen. However, not all people with confirmed COVID-19 infection have antibodies above the detectable level. The sensitivity of the test to detect virus antibodies determines the accuracy of the results. There have been reports of false positive results, leading people to think they have some measure of protection, when in fact, they do not.

                  Are young transplant recipients at increased risk from COVID-19?

                  " The idea that COVID-19 is sparing of young people is just false. Parents need to continue to take the virus seriously."

                  Lawrence C Kleinman, MD, MPH
                  Professor and Vice Chair for Academic Development/
                  Chief, Division of Population Health, Quality, and Implementation Sciences
                  Department of Pediatrics at Rutgers Robert Wood Johnson Medical School

                  Recent reports indicate that children, teens, and young adults are at greater risk for severe complications from COVID-19 and most of the children admitted to pediatric intensive care units have underlying conditions, such as kidney transplant recipients who are immunosuppressant medication.

                  Published findings -
                  A newly published study followed 48 children and young adults (newborns to 21 years old) who were admitted to pediatric intensive care units (PICUs) in the United States and Canada for COVID-19 in March and April. Over 80% of the patients had chronic underlying conditions.

                  During the 3-week study period, over 20% of these patients experienced failure of 2 or more organ systems due to COVID-19, and nearly 40% required a breathing tube and ventilator. At the end of the follow-up period, nearly 33% of the children were still hospitalized due to COVID-19, with 3 still needing ventilator support, 1 child on life support, and 2 children died.

                  New developments -
                  Even more recently, a growing number of children have been identified who appear to have a different response to COVID-19, which doctors are calling Pediatric Multi-System Inflammatory Syndrome. The symptoms of Pediatric Multi-System Inflammatory Syndrome include a persistent fever, rash, as well as gastrointestinal symptoms such as vomiting and diarrhea. Patients can also suffer from cardiac inflammation. In the coming days, the CDC is expected to issue guidance with information for treatment.

                  What can parents of young transplant recipients do?

                  The best way to keep children on immunosuppressant treatment well is to prevent their exposure to the virus. Continue to practice everyday preventive actions to help reduce your risk of getting sick and infecting your child and

                  • Avoid close contact with people who are sick
                  • Stay home when you are sick, except to get medical care
                  • Cover your coughs and sneezes with a tissue and throw the tissue in the trash
                  • Wash your hands often with soap and water for at least 20 seconds, especially after blowing your nose, coughing, or sneezing; going to the bathroom; and before eating or preparing food
                  • Use an alcohol-based hand sanitizer with at least 60% alcohol, if you’re unable to wash your hands (eg, using a gas pump)
                  • Clean and disinfect frequently touched surfaces and objects (eg, tables, countertops, light switches, doorknobs, and cabinet handles)
                  • Wear a cloth mask when around your child

                  Contact your child’s transplant center for more information.

                  Reference: Shekerdemian LS, Mahmood NR, Wolfe KK, et al. Characteristics and outcomes of children with coronavirus disease 2019 (COVID-19) infection admitted to US and Canadian pediatric intensive care units. JAMA Pediatr. Published online May 11, 2020. doi:10.1001/jamapediatrics.2020.1948.

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