Neil Turner graduated in Medicine in 1980. He was Professor of Nephrology in Edinburgh when this article was written in June 2020.
Yes we’d heard the warnings of the probability of future SARS-plus pandemics, and rolled eyes at Trump closing down the unit set up to plan and prepare for one in the USA. But the reality and speed of the global pandemic were astonishing. Medically, mostly only the East Asian countries that had experienced SARS were better prepared. Some other countries were lucky enough to encounter relatively few cases.
The UK seems to have been neither of those. But it is striking that our awful position in the world mortality league was not accompanied by such horrifying tales of overwhelmed health services as were heard from New York, New Orleans, and some locations in Italy and Spain.
Scotland was lucky in having a lower and later peak, but the effects were still profound. Many nephrologists became heavily involved in general medical care for those with COVID-19 as well as continuing their specialty practice. But in the hardest hit centres, suddenly there was unexpected pressure on provision of acute kidney support.
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Reports from China, and later Italy and Spain, led to recognition of an urgent need for ventilators, but the impact on kidneys was appreciated only later. In some centres over half of patients admitted to intensive care were reported also to have developed kidney failure. Although this isn’t a rare complication of serious illnesses in intensive care units at usual times, this was extreme, and occurred at a time when the number of intensive care beds had been tripled or more, and capacity was severely challenged. A shortage of dialysis machines, disposables (tubing, filters), and trained staff quickly became apparent. The mortality of patients with kidney as well as lung failure was chilling.
The unexpected incidence and severity of kidney failure in severe COVID-19 infection led to series of hypotheses, and some premature publications, about whether there were risks around exposure to particular drugs, direct infection of kidneys by coronavirus, or thrombosis occluding blood vessels in the kidneys. The better, but still emerging (in June 2020) publications around this, suggest not. It seems to be typical acute renal failure as seen in severe pneumonias. Patients become hot and dehydrated on top of other stresses.
As in every other stressed area in this crisis, the ability and willingness of staff to work differently, take personal risks, and be imaginative in finding solutions, was truly impressive.
A response in several of the most severely stressed centres was to revert to using acute peritoneal dialysis, a technique hardly used in intensive care settings for 30-40 years in the developed world. It is widely used in some long-term outpatients with kidney failure, but generally on a small scale.
Scaling it up and implementing it in intensive care required engaging and training a new cohort of staff very quickly. Experience was almost uniformly positive. After that, maybe its use will be reconsidered in other circumstances.
One of the privileges of being a nephrologist is that not only do you get involved in intensive care-level medicine, plus some fascinating and challenging less acute diseases, but you also have a large cohort of patients that you look after life-long. These include the nearly 70,000 patients in the UK who are kept alive by dialysis or kidney transplantation, an average of about 1,000 associated with each main Renal Unit. Then there is a cohort of maybe two to three times as many with lesser chronic kidney disease under nephrological follow-up. We know them and their families over decades.
Many of these are at increased risk of more serious COVID-19 infection. Although few transplant patients have died from it, they have probably been particularly assiduous about self-isolation. Long-term haemodialysis patients have fared less well, with very sad figures reported from some local units. However patients on haemodialysis are on average older, more likely to be frail, have a high rate of other conditions apart from kidney disease, and most have to travel to a dialysis unit three times a week for treatment, raising the risk of exposure to the virus. Many patients with less severe kidney disease are at intermediate risk.
Renal patients are generally a very realistic group. Many older or sicker patients were clear that they didn’t want intensive treatment if they got COVID-19.
Early on, everything was unfamiliar, uncertain, and scary. There were strong suspicions that protective equipment was inadequate, but even with it, staff were afraid both of catching the infection themselves, and of taking it back to their families. These fears lessened with time, and many found that working reduced their anxiety. The diversion of work, but in particular a strong feeling of camaraderie, with all healthcare professions working together with common purpose, were powerful factors. There has been a strong feeling that the NHS is the right system to rise to the challenge.
It is a story for another place of how medical schools switched so quickly to remote teaching for early years students, and made efforts to return to workplace teaching as soon as possible for the later years, and to maintain authentic and robust assessments. This has required an enormous effort too.
Academic and research colleagues, and surgeons whose work had stopped, who stepped up to prop up medical services during the acute crisis, will need to go back. Clinical services need to return to doing their routine tasks efficiently in new, distanced and protected ways of working. These are not built into the system at the moment – every encounter and virtual encounter takes much longer. This is a huge challenge if we are to prevent a long slow wave of illness and mortality from reduced recognition and care of other diseases.
Will there be lasting benefits from some of the things that have been rapidly implemented for the crisis? We must hope so. Much more use of electronic media to communicate with patients and with each other. Rapid routes to mounting important research studies. Remote ways to manage consultations.
Remote consultations can reduce attendances, but take as long or longer for staff, and don’t work nearly as well if you don’t know the patient. Consistency of practitioner looks expensive to managers, but longitudinal studies suggest the opposite, and patients with chronic conditions consistently rate ‘seeing a practitioner who knows you’ amongst their highest priorities.
Discussing individual risks and compromises with patients has been an important element of the pandemic – most conducted by phone and messaging. That’s much harder if you don’t know the person you’re talking to. Let’s be optimistic about how all this will go.
Written for a medical school alumni journal in June 2020, posted here November 2025.
Last Updated on November 5, 2025 by neilturn